Consolidated CDA Release 2.2
2.2 - CI Build

Consolidated CDA Release 2.2, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.2). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.2/ and changes regularly. See the Directory of published versions

## Resource Profile: Health Status Evaluations and Outcomes Section

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.61 | Version: 2.2
Active as of 2022-05-13 | Computable Name: HealthStatusEvaluationsandOutcomesSection
Other Identifiers: : urn:oid:2.16.840.1.113883.10.20.22.2.61

This template represents observations regarding the outcome of care from the interventions used to treat the patient. These observations represent status, at points in time, related to established care plan goals and/or interventions.

Usage:

- Use this Resource Profile: Care Plan

### Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

- Text Summary
- Differential Table
- Snapshot Table
- Snapshot Table (Must Support)
- All

This structure is derived from CDAR2.Section

Summary

Mandatory: 9 elements

Structures

This structure refers to these other structures:

- Outcome Observation (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.144)

Slices

This structure defines the following Slices:

- The element Section.templateId is sliced based on the value of value:root
- The element Section.entry is sliced based on the value of value:observation

This structure is derived from CDAR2.Section

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Section |  | 1..1 | CDAR2.Section |
nullFlavor |  | 0..1 | code | Required Pattern: NI
Slices for templateId |  | 0..* | II | Slice: Unordered, Open by value:root
templateId:primary |  | 1..1 | II |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.2.61
code |  | 1..1 | CE |
code |  | 1..1 | string | Required Pattern: 11383-7
codeSystem |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1
title |  | 1..1 | ED |
text |  | 1..1 | xhtml |
Slices for entry |  | 0..* | Element | If section/@nullFlavor is not present: Slice: Unordered, Open by value:observation
entry:outcome |  | 1..* | Element |
observation |  | 1..1 | OutcomeObservation |
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Section |  | 1..1 | CDAR2.Section |
ID |  | 0..1 | string |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required) Required Pattern: NI
classCode |  | 1..1 | code | ​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required) Fixed Value: DOCSECT
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
Slices for templateId |  | 0..* | II | Slice: Unordered, Open by value:root
templateId:primary |  | 1..1 | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.2.61
extension |  | 0..1 | string |
id |  | 0..1 | II |
code |  | 1..1 | CE | Binding: DocumentSectionType (extensible)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | Required Pattern: 11383-7
codeSystem |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
title |  | 1..1 | ED |
text | S | 1..1 | xhtml |
confidentialityCode |  | 0..1 | CE |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
subject |  | 0..1 | Element |
typeCode |  | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ
contextControlCode |  | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP
awarenessCode |  | 0..1 | CE | Binding: TargetAwareness (extensible)
relatedSubject |  | 1..1 | RelatedSubject |
author |  | 0..* | Author |
informant |  | 0..* | Element |
typeCode |  | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF
contextControlCode |  | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP
assignedEntity |  | 0..1 | AssignedEntity |
relatedEntity |  | 0..1 | RelatedEntity |
Slices for entry | I | 0..* | Element | If section/@nullFlavor is not present: Slice: Unordered, Open by value:observation
entry:All Slices |  |  |  | Content/Rules for all slices
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
(Choice of one) |  | 1..1 |  |
observation |  | 0..1 | Observation |
regionOfInterest |  | 0..1 | RegionOfInterest |
observationMedia |  | 0..1 | ObservationMedia |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
procedure |  | 0..1 | Procedure |
encounter |  | 0..1 | Encounter |
organizer |  | 0..1 | Organizer |
act |  | 0..1 | Act |
entry:outcome | I | 1..* | Element |
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
observation | I | 1..1 | OutcomeObservation |
component |  | 0..* | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | Section |
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Section |  | 1..1 | CDAR2.Section |
text |  | 1..1 | xhtml |
Documentation for this format

This structure is derived from CDAR2.Section

Summary

Mandatory: 9 elements

Structures

This structure refers to these other structures:

- Outcome Observation (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.144)

Slices

This structure defines the following Slices:

- The element Section.templateId is sliced based on the value of value:root
- The element Section.entry is sliced based on the value of value:observation

Differential View

This structure is derived from CDAR2.Section

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Section |  | 1..1 | CDAR2.Section |
nullFlavor |  | 0..1 | code | Required Pattern: NI
Slices for templateId |  | 0..* | II | Slice: Unordered, Open by value:root
templateId:primary |  | 1..1 | II |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.2.61
code |  | 1..1 | CE |
code |  | 1..1 | string | Required Pattern: 11383-7
codeSystem |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1
title |  | 1..1 | ED |
text |  | 1..1 | xhtml |
Slices for entry |  | 0..* | Element | If section/@nullFlavor is not present: Slice: Unordered, Open by value:observation
entry:outcome |  | 1..* | Element |
observation |  | 1..1 | OutcomeObservation |
Documentation for this format

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Section |  | 1..1 | CDAR2.Section |
ID |  | 0..1 | string |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required) Required Pattern: NI
classCode |  | 1..1 | code | ​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required) Fixed Value: DOCSECT
moodCode |  | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN
Slices for templateId |  | 0..* | II | Slice: Unordered, Open by value:root
templateId:primary |  | 1..1 | II |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
assigningAuthorityName |  | 0..1 | string |
displayable |  | 0..1 | boolean |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.2.61
extension |  | 0..1 | string |
id |  | 0..1 | II |
code |  | 1..1 | CE | Binding: DocumentSectionType (extensible)
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
code |  | 1..1 | string | Required Pattern: 11383-7
codeSystem |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1
codeSystemName |  | 0..1 | string |
codeSystemVersion |  | 0..1 | string |
displayName |  | 0..1 | string |
sdtcValueSet |  | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion |  | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
translation |  | 0..* | CD |
title |  | 1..1 | ED |
text | S | 1..1 | xhtml |
confidentialityCode |  | 0..1 | CE |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
subject |  | 0..1 | Element |
typeCode |  | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ
contextControlCode |  | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP
awarenessCode |  | 0..1 | CE | Binding: TargetAwareness (extensible)
relatedSubject |  | 1..1 | RelatedSubject |
author |  | 0..* | Author |
informant |  | 0..* | Element |
typeCode |  | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF
contextControlCode |  | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP
assignedEntity |  | 0..1 | AssignedEntity |
relatedEntity |  | 0..1 | RelatedEntity |
Slices for entry | I | 0..* | Element | If section/@nullFlavor is not present: Slice: Unordered, Open by value:observation
entry:All Slices |  |  |  | Content/Rules for all slices
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
(Choice of one) |  | 1..1 |  |
observation |  | 0..1 | Observation |
regionOfInterest |  | 0..1 | RegionOfInterest |
observationMedia |  | 0..1 | ObservationMedia |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
procedure |  | 0..1 | Procedure |
encounter |  | 0..1 | Encounter |
organizer |  | 0..1 | Organizer |
act |  | 0..1 | Act |
entry:outcome | I | 1..* | Element |
typeCode |  | 1..1 | code |
contextConductionInd |  | 1..1 | boolean |
observation | I | 1..1 | OutcomeObservation |
component |  | 0..* | Element |
typeCode |  | 1..1 | code | Fixed Value: COMP
contextConductionInd |  | 1..1 | boolean |
section |  | 1..1 | Section |
Documentation for this format

Other representations of profile: CSV, Excel, Schematron

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Section.nullFlavor | required | Pattern: NI
Section.classCode | required | Fixed Value: DOCSECT
Section.moodCode | required | Fixed Value: EVN
Section.templateId:primary.nullFlavor | required | NullFlavor
Section.code | extensible | DocumentSectionType
Section.code.nullFlavor | required | NullFlavor
Section.languageCode | required | HumanLanguage
Section.subject.typeCode | required | Fixed Value: SBJ
Section.subject.contextControlCode | required | Fixed Value: OP
Section.subject.awarenessCode | extensible | TargetAwareness
Section.informant.typeCode | required | Fixed Value: INF
Section.informant.contextControlCode | required | Fixed Value: OP

#### Constraints

Id | Grade | Path | Details | Requirements
only-one-statement | error | Section.entry | SHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act. : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
only-one-statement | error | Section.entry:outcome | SHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act. : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
1098-32782 | error | Section.entry:outcome.observation | SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). : |