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: Text Observation

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.12 | Version: 2.2
Active as of 2022-05-13 | Computable Name: TextObservation
Other Identifiers: : urn:oid:2.16.840.1.113883.10.20.6.2.12

DICOM Template 2000 specifies that Imaging Report Elements of Value Type Text are contained in sections. The Imaging Report Elements are inferred from Basic Diagnostic Imaging Report Observations that consist of image references and measurements (linear, area, volume, and numeric). Text DICOM Imaging Report Elements in this context are mapped to CDA text observations that are section components and are related to the SOP Instance Observations (templateId 2.16.840.1.113883.10.20.6.2.8) or Quantity Measurement Observations (templateId 2.16.840.1.113883.10.20.6.2.14) by the SPRT (Support) act relationship.

A Text Observation is required if the findings in the section text are represented as inferred from SOP Instance Observations.

Usage:

- Use this Resource Profile: Diagnostic Imaging Report

### 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.Observation

Summary

Mandatory: 6 elements (4 nested mandatory elements)

Structures

This structure refers to these other structures:

- SOP Instance Observation (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.8)
- Quantity Measurement Observation (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.14)

Slices

This structure defines the following Slices:

- The element Observation.templateId is sliced based on the value of value:root
- The element Observation.entryRelationship is sliced based on the value of profile:observation

This structure is derived from CDAR2.Observation

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation |  | 1..1 | CDAR2.Observation |
classCode |  | 1..1 | code | Required Pattern: OBS
moodCode |  | 1..1 | code | Required Pattern: EVN
Slices for templateId |  | 0..* | II | Slice: Unordered, Open by value:root
templateId:primary |  | 1..1 | II |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.6.2.12
code |  | 1..1 | CD |
text |  | 0..1 | ED |
reference |  | 0..1 | TEL |
value | I | 0..1 | uri | 81-15940: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:81-15940).
effectiveTime |  | 0..1 | IVL_TS |
value |  | 1..1 | ED |
Slices for entryRelationship |  | 0..* | Element | Slice: Unordered, Open by profile:observation
entryRelationship:SOPInstanceObservation |  | 0..* | Element |
typeCode |  | 1..1 | code | Required Pattern: SPRT
observation |  | 1..1 | SOPInstanceObservation |
entryRelationship:quantityMeasurementObservation |  | 0..* | Element |
typeCode |  | 1..1 | code | Required Pattern: SPRT
observation |  | 1..1 | QuantityMeasurementObservation |
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation |  | 1..1 | CDAR2.Observation |
classCode |  | 1..1 | code | Binding: ActClassObservation (required) Required Pattern: OBS
moodCode |  | 1..1 | code | Required Pattern: EVN
negationInd |  | 0..1 | boolean |
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
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: 2.16.840.1.113883.10.20.6.2.12
extension |  | 0..1 | string |
id |  | 0..* | II |
code |  | 1..1 | CD | Binding: ObservationType (extensible)
derivationExpr |  | 0..1 | ED |
text |  | 0..1 | ED |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
charset |  | 0..1 | code |
compression |  | 0..1 | code | Binding: CompressionAlgorithm (required)
integrityCheck |  | 0..1 | base64Binary |
integrityCheckAlgorithm |  | 0..1 | code | Binding: IntegrityCheckAlgorithm (required)
language |  | 0..1 | code |
mediaType |  | 0..1 | code |
representation |  | 0..1 | code |
data[x] |  | 0..1 |  |
dataString |  |  | string |
dataBase64Binary |  |  | base64Binary |
reference |  | 0..1 | TEL |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value | I | 0..1 | uri | 81-15940: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:81-15940).
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
use |  | 0..* | code | Binding: AddressUse (required)
thumbnail |  | 0..1 | ED |
statusCode |  | 0..1 | CS | Binding: ActStatus (required)
effectiveTime |  | 0..1 | IVL_TS |
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
repeatNumber |  | 0..1 | IVL_INT |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
value |  | 1..1 | ED |
interpretationCode |  | 0..* | CE | Binding: ObservationInterpretation (required)
methodCode |  | 0..* | CE | Binding: ObservationMethod (extensible)
targetSiteCode |  | 0..* | CD |
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 |
specimen |  | 0..* | Specimen |
performer |  | 0..* | Performer2 |
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 |
participant |  | 0..* | Participant2 |
Slices for entryRelationship | I | 0..* | Element | Slice: Unordered, Open by profile:observation
entryRelationship:All Slices |  |  |  | Content/Rules for all slices
typeCode |  | 1..1 | code |
inversionInd |  | 0..1 | boolean |
contextConductionInd |  | 1..1 | boolean |
sequenceNumber |  | 0..1 | INT |
negationInd |  | 0..1 | boolean |
seperatableInd |  | 0..1 | BL |
(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 |
entryRelationship:SOPInstanceObservation | I | 0..* | Element |
typeCode |  | 1..1 | code | Required Pattern: SPRT
inversionInd |  | 0..1 | boolean |
contextConductionInd |  | 1..1 | boolean |
sequenceNumber |  | 0..1 | INT |
negationInd |  | 0..1 | boolean |
seperatableInd |  | 0..1 | BL |
observation |  | 1..1 | SOPInstanceObservation |
entryRelationship:quantityMeasurementObservation | I | 0..* | Element |
typeCode |  | 1..1 | code | Required Pattern: SPRT
inversionInd |  | 0..1 | boolean |
contextConductionInd |  | 1..1 | boolean |
sequenceNumber |  | 0..1 | INT |
negationInd |  | 0..1 | boolean |
seperatableInd |  | 0..1 | BL |
observation |  | 1..1 | QuantityMeasurementObservation |
reference |  | 0..* | Element |
typeCode |  | 1..1 | code |
seperatableInd |  | 0..1 | BL |
externalAct |  | 0..1 | ExternalAct |
externalObservation |  | 0..1 | ExternalObservation |
externalProcedure |  | 0..1 | ExternalProcedure |
externalDocument |  | 0..1 | ExternalDocument |
precondition |  | 0..* | Precondition |
referenceRange |  | 0..* | Element |
typeCode |  | 1..1 | code | Binding: ActRelationshipPertains (required) Fixed Value: REFV
observationRange |  | 1..1 | ObservationRange |
Documentation for this format

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

This structure is derived from CDAR2.Observation

Summary

Mandatory: 6 elements (4 nested mandatory elements)

Structures

This structure refers to these other structures:

- SOP Instance Observation (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.8)
- Quantity Measurement Observation (http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.14)

Slices

This structure defines the following Slices:

- The element Observation.templateId is sliced based on the value of value:root
- The element Observation.entryRelationship is sliced based on the value of profile:observation

Differential View

This structure is derived from CDAR2.Observation

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation |  | 1..1 | CDAR2.Observation |
classCode |  | 1..1 | code | Required Pattern: OBS
moodCode |  | 1..1 | code | Required Pattern: EVN
Slices for templateId |  | 0..* | II | Slice: Unordered, Open by value:root
templateId:primary |  | 1..1 | II |
root |  | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.6.2.12
code |  | 1..1 | CD |
text |  | 0..1 | ED |
reference |  | 0..1 | TEL |
value | I | 0..1 | uri | 81-15940: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:81-15940).
effectiveTime |  | 0..1 | IVL_TS |
value |  | 1..1 | ED |
Slices for entryRelationship |  | 0..* | Element | Slice: Unordered, Open by profile:observation
entryRelationship:SOPInstanceObservation |  | 0..* | Element |
typeCode |  | 1..1 | code | Required Pattern: SPRT
observation |  | 1..1 | SOPInstanceObservation |
entryRelationship:quantityMeasurementObservation |  | 0..* | Element |
typeCode |  | 1..1 | code | Required Pattern: SPRT
observation |  | 1..1 | QuantityMeasurementObservation |
Documentation for this format

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation |  | 1..1 | CDAR2.Observation |
classCode |  | 1..1 | code | Binding: ActClassObservation (required) Required Pattern: OBS
moodCode |  | 1..1 | code | Required Pattern: EVN
negationInd |  | 0..1 | boolean |
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
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: 2.16.840.1.113883.10.20.6.2.12
extension |  | 0..1 | string |
id |  | 0..* | II |
code |  | 1..1 | CD | Binding: ObservationType (extensible)
derivationExpr |  | 0..1 | ED |
text |  | 0..1 | ED |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
charset |  | 0..1 | code |
compression |  | 0..1 | code | Binding: CompressionAlgorithm (required)
integrityCheck |  | 0..1 | base64Binary |
integrityCheckAlgorithm |  | 0..1 | code | Binding: IntegrityCheckAlgorithm (required)
language |  | 0..1 | code |
mediaType |  | 0..1 | code |
representation |  | 0..1 | code |
data[x] |  | 0..1 |  |
dataString |  |  | string |
dataBase64Binary |  |  | base64Binary |
reference |  | 0..1 | TEL |
nullFlavor |  | 0..1 | code | Binding: NullFlavor (required)
value | I | 0..1 | uri | 81-15940: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:81-15940).
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
use |  | 0..* | code | Binding: AddressUse (required)
thumbnail |  | 0..1 | ED |
statusCode |  | 0..1 | CS | Binding: ActStatus (required)
effectiveTime |  | 0..1 | IVL_TS |
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
repeatNumber |  | 0..1 | IVL_INT |
languageCode |  | 0..1 | CS | Binding: HumanLanguage (required)
value |  | 1..1 | ED |
interpretationCode |  | 0..* | CE | Binding: ObservationInterpretation (required)
methodCode |  | 0..* | CE | Binding: ObservationMethod (extensible)
targetSiteCode |  | 0..* | CD |
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 |
specimen |  | 0..* | Specimen |
performer |  | 0..* | Performer2 |
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 |
participant |  | 0..* | Participant2 |
Slices for entryRelationship | I | 0..* | Element | Slice: Unordered, Open by profile:observation
entryRelationship:All Slices |  |  |  | Content/Rules for all slices
typeCode |  | 1..1 | code |
inversionInd |  | 0..1 | boolean |
contextConductionInd |  | 1..1 | boolean |
sequenceNumber |  | 0..1 | INT |
negationInd |  | 0..1 | boolean |
seperatableInd |  | 0..1 | BL |
(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 |
entryRelationship:SOPInstanceObservation | I | 0..* | Element |
typeCode |  | 1..1 | code | Required Pattern: SPRT
inversionInd |  | 0..1 | boolean |
contextConductionInd |  | 1..1 | boolean |
sequenceNumber |  | 0..1 | INT |
negationInd |  | 0..1 | boolean |
seperatableInd |  | 0..1 | BL |
observation |  | 1..1 | SOPInstanceObservation |
entryRelationship:quantityMeasurementObservation | I | 0..* | Element |
typeCode |  | 1..1 | code | Required Pattern: SPRT
inversionInd |  | 0..1 | boolean |
contextConductionInd |  | 1..1 | boolean |
sequenceNumber |  | 0..1 | INT |
negationInd |  | 0..1 | boolean |
seperatableInd |  | 0..1 | BL |
observation |  | 1..1 | QuantityMeasurementObservation |
reference |  | 0..* | Element |
typeCode |  | 1..1 | code |
seperatableInd |  | 0..1 | BL |
externalAct |  | 0..1 | ExternalAct |
externalObservation |  | 0..1 | ExternalObservation |
externalProcedure |  | 0..1 | ExternalProcedure |
externalDocument |  | 0..1 | ExternalDocument |
precondition |  | 0..* | Precondition |
referenceRange |  | 0..* | Element |
typeCode |  | 1..1 | code | Binding: ActRelationshipPertains (required) Fixed Value: REFV
observationRange |  | 1..1 | ObservationRange |
Documentation for this format

Other representations of profile: CSV, Excel, Schematron

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Observation.classCode | required | Pattern: OBS
Observation.templateId:primary.nullFlavor | required | NullFlavor
Observation.code | extensible | ObservationType
Observation.text.nullFlavor | required | NullFlavor
Observation.text.compression | required | CompressionAlgorithm
Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm
Observation.text.reference.nullFlavor | required | NullFlavor
Observation.text.reference.use | required | AddressUse
Observation.statusCode | required | ActStatus
Observation.priorityCode | extensible | ActPriority
Observation.languageCode | required | HumanLanguage
Observation.interpretationCode | required | ObservationInterpretation
Observation.methodCode | extensible | ObservationMethod
Observation.subject.typeCode | required | Fixed Value: SBJ
Observation.subject.contextControlCode | required | Fixed Value: OP
Observation.subject.awarenessCode | extensible | TargetAwareness
Observation.informant.typeCode | required | Fixed Value: INF
Observation.informant.contextControlCode | required | Fixed Value: OP
Observation.referenceRange.typeCode | required | Fixed Value: REFV

#### Constraints

Id | Grade | Path | Details | Requirements
81-15940 | error | Observation.text.reference.value | This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:81-15940). : |
obs-er-1 | error | Observation.entryRelationship | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
obs-er-1 | error | Observation.entryRelationship:SOPInstanceObservation | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
obs-er-1 | error | Observation.entryRelationship:quantityMeasurementObservation | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |