Consolidated CDA (C-CDA)
4.0.0-ballot - STU4
Consolidated CDA (C-CDA)
4.0.0-ballot - STU4
Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 4.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ResultObservation | Version: 4.0.0-ballot | |||
| Draft as of 2024-11-21 | Computable Name: ResultObservation | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.2:2023-05-01 | ||||
This template represents the results of a laboratory, radiology, or other study performed on a patient.
The result observation includes a statusCode to allow recording the status of an observation. Pending results (e.g., a test has been run but results have not been reported yet) should be represented as active ActStatus.
If code contains a valid non-null LOINC then the xsi:type value SHOULD match the LOINC Scale Part based on the table below:
| LOINC Scale Part | Value xsi:type |
|---|---|
| Qn - Quantitative | INT, IVL_INT, MO, IVL_MO, REAL, IVL_REAL, PQ, IVL_PQ, RTO, TS, IVL_TS |
| Ord - Ordinal | CD |
| Nom - Nominal | CD |
| Nar - Narrative | ED, ST |
| OrdQn - Quantitative or Ordinal | CD, INT, IVL_INT, MO, IVL_MO, REAL, IVL_REAL, PQ, IVL_PQ, RTO, TS, IVL_TS |
| Multi - Multi | ED |
| Doc - Document | ED |
The Result Observation template is a versatile template designed to represent any type of finding resulting from various types of tests. Value set bindings for Observation.code have been created to support implementers, covering three categories: 1) Common Laboratory Tests, 2) Radiology Tests, and 3) Clinical Tests. If a suitable code is not available within these value sets, first use another LOINC code. If no LOINC code is appropriate, a local code may be used.
Usage:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
| Name | Flags | Card. | Type | Description & Constraints | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
  Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-interpretationCode: SHOULD contain interpretationCode should-author: SHOULD contain author should-referenceRange: SHOULD contain referenceRange | ||||||||||||
  Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||||||||
   templateId:result-obs |
1..1 | II | ||||||||||||||
  @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |||||||||||||
  @extension |
1..1 | st | Required Pattern: 2023-05-01 | |||||||||||||
 @classCode |
1..1 | cs | Fixed Value: OBS | |||||||||||||
| @moodCode |
1..1 | cs | Fixed Value: EVN | |||||||||||||
| id |
1..* | II | ||||||||||||||
| code |
C | 1..1 | CD | 𝗨𝗦𝗖𝗗𝗜: Tests Binding: ObservationType (example)
shall-code-or-nullflavor: SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. 4537-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). | ||||||||||||
  (Choice of one) |
1..1 | |||||||||||||||
 @nullFlavor |
0..1 | cs | ||||||||||||||
 @code |
0..1 | cs | ||||||||||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||||||||
 reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||||||||
| statusCode |
1..1 | CS | 𝗨𝗦𝗖𝗗𝗜: Result Status | |||||||||||||
| @nullFlavor |
0..0 | |||||||||||||||
| @code |
1..1 | cs | Binding: Result Status  (required) | |||||||||||||
| effectiveTime |
1..1 | IVL_TS | Represents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |||||||||||||
| Slices for value |
1..1 | ANY, BL, ED, ST, CD, CV, CE, CO, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | 𝗨𝗦𝗖𝗗𝗜: Values/Results - Value can be any type, but certain types have additional rules. Slice: Unordered, Open by type:$this | |||||||||||||
 value:physical-quantity |
0..1 | PQ | ||||||||||||||
 @unit |
1..1 | cs | 𝗨𝗦𝗖𝗗𝗜: Result Unit of Measure Binding: UnitsOfMeasureCaseSensitive (preferred) | |||||||||||||
| translation |
0..1 | PQR | Can be used to represent the original results as output by the lab | |||||||||||||
| value:coded |
C | 0..1 | CD | 4537-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). | ||||||||||||
| translation |
0..1 | CD | Can be used to represent the original results as output by the lab | |||||||||||||
| interpretationCode |
0..* | CE | 𝗨𝗦𝗖𝗗𝗜: Result Interpretation | |||||||||||||
| methodCode |
0..1 | CE | ||||||||||||||
| targetSiteCode |
0..1 | CD | ||||||||||||||
 author |
0..* | AuthorParticipation | Base for all types and resources | |||||||||||||
| referenceRange |
0..* | InfrastructureRoot | 𝗨𝗦𝗖𝗗𝗜: Result Reference Range | |||||||||||||
| observationRange |
1..1 | ObservationRange | ||||||||||||||
| value |
1..1 | BL, ED, ST, CD, CV, CE, CO, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS | When the value is a quantity, then the unit SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive. | |||||||||||||
| Documentation for this format | ||||||||||||||||
| Path | Conformance | ValueSet | URI |
| Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
| Observation.statusCode.code | required | ResultStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39 | |
| Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive |
| Id | Grade | Path(s) | Details | Requirements |
| 4537-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). : codeSystem = '2.16.840.1.113883.6.1' | |
| 4537-32610 | warning | Observation.value:coded | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). : codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.1' | |
| shall-code-or-nullflavor | error | Observation.code | SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. : (code | nullFlavor).count() = 1 | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-interpretationCode | warning | Observation | SHOULD contain interpretationCode : interpretationCode.exists() | |
| should-referenceRange | warning | Observation | SHOULD contain referenceRange : referenceRange.exists() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Name | Flags | Card. | Type | Description & Constraints | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-interpretationCode: SHOULD contain interpretationCode should-author: SHOULD contain author should-referenceRange: SHOULD contain referenceRange | ||||||||||||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||||||||
| templateId:result-obs |
1..1 | II | ||||||||||||||
 @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |||||||||||||
| @extension |
1..1 | st | Required Pattern: 2023-05-01 | |||||||||||||
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |||||||||||||
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||||||||
| id |
1..* | II | ||||||||||||||
| code |
C | 1..1 | CD | 𝗨𝗦𝗖𝗗𝗜: Tests Binding: ObservationType (example)
shall-code-or-nullflavor: SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. 4537-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). | ||||||||||||
| (Choice of one) |
1..1 | |||||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @code |
0..1 | cs | ||||||||||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||||||||
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||||||||
| statusCode |
1..1 | CS | 𝗨𝗦𝗖𝗗𝗜: Result Status Binding: ActStatus (required) | |||||||||||||
| @code |
1..1 | cs | Binding: Result Status (required) | |||||||||||||
| effectiveTime |
1..1 | IVL_TS | Represents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |||||||||||||
| Slices for value |
1..1 | 𝗨𝗦𝗖𝗗𝗜: Values/Results - Value can be any type, but certain types have additional rules. Slice: Unordered, Open by type:$this | ||||||||||||||
 value |
ANY | |||||||||||||||
| value |
BL | |||||||||||||||
| value |
ED | |||||||||||||||
| value |
ST | |||||||||||||||
| value |
CD | |||||||||||||||
| value |
CV | |||||||||||||||
| value |
CE | |||||||||||||||
| value |
CO | |||||||||||||||
| value |
SC | |||||||||||||||
| value |
II | |||||||||||||||
| value |
TEL | |||||||||||||||
| value |
AD | |||||||||||||||
| value |
EN | |||||||||||||||
| value |
INT | |||||||||||||||
| value |
REAL | |||||||||||||||
| value |
PQ | |||||||||||||||
| value |
MO | |||||||||||||||
| value |
TS | |||||||||||||||
| value |
IVL_PQ | |||||||||||||||
| value |
IVL_TS | |||||||||||||||
| value |
PIVL_TS | |||||||||||||||
| value |
EIVL_TS | |||||||||||||||
| value |
SXPR_TS | |||||||||||||||
| value |
RTO_PQ_PQ | |||||||||||||||
| value:physical-quantity |
0..1 | PQ | ||||||||||||||
| @unit |
1..1 | cs | 𝗨𝗦𝗖𝗗𝗜: Result Unit of Measure Binding: UnitsOfMeasureCaseSensitive (preferred) | |||||||||||||
| translation |
0..1 | PQR | Can be used to represent the original results as output by the lab | |||||||||||||
| value:coded |
C | 0..1 | CD | 4537-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). | ||||||||||||
| translation |
0..1 | CD | Can be used to represent the original results as output by the lab | |||||||||||||
| interpretationCode |
0..* | CE | 𝗨𝗦𝗖𝗗𝗜: Result Interpretation Binding: CDAObservationInterpretation (required) | |||||||||||||
| methodCode |
0..1 | CE | Binding: ObservationMethod (example) | |||||||||||||
| targetSiteCode |
0..1 | CD | ||||||||||||||
| author |
0..* | AuthorParticipation | Base for all types and resources | |||||||||||||
| referenceRange |
0..* | InfrastructureRoot | 𝗨𝗦𝗖𝗗𝗜: Result Reference Range | |||||||||||||
| observationRange |
1..1 | ObservationRange | ||||||||||||||
| value |
1..1 | When the value is a quantity, then the unit SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive. | ||||||||||||||
| value |
BL | |||||||||||||||
| value |
ED | |||||||||||||||
| value |
ST | |||||||||||||||
| value |
CD | |||||||||||||||
| value |
CV | |||||||||||||||
| value |
CE | |||||||||||||||
| value |
CO | |||||||||||||||
| value |
SC | |||||||||||||||
| value |
II | |||||||||||||||
| value |
TEL | |||||||||||||||
| value |
AD | |||||||||||||||
| value |
EN | |||||||||||||||
| value |
INT | |||||||||||||||
| value |
REAL | |||||||||||||||
| value |
PQ | |||||||||||||||
| value |
MO | |||||||||||||||
| value |
TS | |||||||||||||||
| value |
IVL_PQ | |||||||||||||||
| value |
IVL_TS | |||||||||||||||
| value |
PIVL_TS | |||||||||||||||
| value |
EIVL_TS | |||||||||||||||
| value |
SXPR_TS | |||||||||||||||
| Documentation for this format | ||||||||||||||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
| Observation.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.statusCode.code | required | ResultStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39 | |
| Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod |
| Id | Grade | Path(s) | Details | Requirements |
| 4537-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). : codeSystem = '2.16.840.1.113883.6.1' | |
| 4537-32610 | warning | Observation.value:coded | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). : codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.1' | |
| shall-code-or-nullflavor | error | Observation.code | SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. : (code | nullFlavor).count() = 1 | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-interpretationCode | warning | Observation | SHOULD contain interpretationCode : interpretationCode.exists() | |
| should-referenceRange | warning | Observation | SHOULD contain referenceRange : referenceRange.exists() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Name | Flags | Card. | Type | Description & Constraints | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-interpretationCode: SHOULD contain interpretationCode should-author: SHOULD contain author should-referenceRange: SHOULD contain referenceRange | ||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| realmCode |
0..* | CS | ||||||||||||||
| typeId |
0..1 | II | ||||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @assigningAuthorityName |
0..1 | st | ||||||||||||||
| @displayable |
0..1 | bl | ||||||||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||||||||
| @extension |
1..1 | st | ||||||||||||||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||||||||
| templateId:result-obs |
1..1 | II | ||||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @assigningAuthorityName |
0..1 | st | ||||||||||||||
| @displayable |
0..1 | bl | ||||||||||||||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |||||||||||||
| @extension |
1..1 | st | Required Pattern: 2023-05-01 | |||||||||||||
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |||||||||||||
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||||||||
| @negationInd |
0..1 | bl | ||||||||||||||
| id |
1..* | II | ||||||||||||||
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |||||||||||||
| code |
C | 1..1 | CD | 𝗨𝗦𝗖𝗗𝗜: Tests Binding: ObservationType (example)
shall-code-or-nullflavor: SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. 4537-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). | ||||||||||||
| (Choice of one) |
1..1 | |||||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @code |
0..1 | cs | ||||||||||||||
| @codeSystem |
0..1 | oid, uuid, ruid | ||||||||||||||
| @codeSystemName |
0..1 | st | ||||||||||||||
| @codeSystemVersion |
0..1 | st | ||||||||||||||
| @displayName |
0..1 | st | ||||||||||||||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |||||||||||||
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |||||||||||||
| originalText |
0..1 | ED | ||||||||||||||
| qualifier |
0..* | CR | ||||||||||||||
| translation |
0..* | CD | ||||||||||||||
| derivationExpr |
0..1 | ST | ||||||||||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @compression |
0..1 | cs | Binding: CDACompressionAlgorithm (required) | |||||||||||||
| @integrityCheck |
0..1 | bin | ||||||||||||||
| @integrityCheckAlgorithm |
0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |||||||||||||
| @language |
0..1 | cs | ||||||||||||||
| @mediaType |
0..1 | cs | Binding: MediaType (example) | |||||||||||||
| @representation |
0..1 | cs | Binding: CDABinaryDataEncoding (required) | |||||||||||||
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |||||||||||||
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||||||||
| thumbnail |
0..1 | ED | ||||||||||||||
| statusCode |
1..1 | CS | 𝗨𝗦𝗖𝗗𝗜: Result Status Binding: ActStatus (required) | |||||||||||||
| @code |
1..1 | cs | Binding: Result Status (required) | |||||||||||||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |||||||||||||
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |||||||||||||
| effectiveTime |
1..1 | IVL_TS | Represents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |||||||||||||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |||||||||||||
| repeatNumber |
0..1 | IVL_INT | ||||||||||||||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |||||||||||||
| Slices for value |
1..1 | 𝗨𝗦𝗖𝗗𝗜: Values/Results - Value can be any type, but certain types have additional rules. Slice: Unordered, Open by type:$this | ||||||||||||||
| value |
ANY | |||||||||||||||
| value |
BL | |||||||||||||||
| value |
ED | |||||||||||||||
| value |
ST | |||||||||||||||
| value |
CD | |||||||||||||||
| value |
CV | |||||||||||||||
| value |
CE | |||||||||||||||
| value |
CO | |||||||||||||||
| value |
SC | |||||||||||||||
| value |
II | |||||||||||||||
| value |
TEL | |||||||||||||||
| value |
AD | |||||||||||||||
| value |
EN | |||||||||||||||
| value |
INT | |||||||||||||||
| value |
REAL | |||||||||||||||
| value |
PQ | |||||||||||||||
| value |
MO | |||||||||||||||
| value |
TS | |||||||||||||||
| value |
IVL_PQ | |||||||||||||||
| value |
IVL_TS | |||||||||||||||
| value |
PIVL_TS | |||||||||||||||
| value |
EIVL_TS | |||||||||||||||
| value |
SXPR_TS | |||||||||||||||
| value |
RTO_PQ_PQ | |||||||||||||||
| value:physical-quantity |
0..1 | PQ | ||||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @unit |
1..1 | cs | 𝗨𝗦𝗖𝗗𝗜: Result Unit of Measure Binding: UnitsOfMeasureCaseSensitive (preferred) | |||||||||||||
| @value |
0..1 | real | ||||||||||||||
| translation |
0..1 | PQR | Can be used to represent the original results as output by the lab | |||||||||||||
| value:coded |
C | 0..1 | CD | 4537-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). | ||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @code |
0..1 | cs | ||||||||||||||
| @codeSystem |
0..1 | oid, uuid, ruid | ||||||||||||||
| @codeSystemName |
0..1 | st | ||||||||||||||
| @codeSystemVersion |
0..1 | st | ||||||||||||||
| @displayName |
0..1 | st | ||||||||||||||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |||||||||||||
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |||||||||||||
| originalText |
0..1 | ED | ||||||||||||||
| qualifier |
0..* | CR | ||||||||||||||
| translation |
0..1 | CD | Can be used to represent the original results as output by the lab | |||||||||||||
| interpretationCode |
0..* | CE | 𝗨𝗦𝗖𝗗𝗜: Result Interpretation Binding: CDAObservationInterpretation (required) | |||||||||||||
| methodCode |
0..1 | CE | Binding: ObservationMethod (example) | |||||||||||||
| targetSiteCode |
0..1 | CD | ||||||||||||||
| subject |
0..1 | Subject | ||||||||||||||
| specimen |
0..* | Specimen | ||||||||||||||
| performer |
0..* | Performer2 | ||||||||||||||
| author |
0..* | AuthorParticipation | Base for all types and resources | |||||||||||||
| informant |
0..* | Informant | ||||||||||||||
| participant |
0..* | Participant2 | ||||||||||||||
| entryRelationship |
0..* | EntryRelationship | ||||||||||||||
| reference |
0..* | Reference | ||||||||||||||
| precondition |
0..* | Precondition | ||||||||||||||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |||||||||||||
| referenceRange |
0..* | InfrastructureRoot | 𝗨𝗦𝗖𝗗𝗜: Result Reference Range | |||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| realmCode |
0..* | CS | ||||||||||||||
| typeId |
0..1 | II | ||||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @assigningAuthorityName |
0..1 | st | ||||||||||||||
| @displayable |
0..1 | bl | ||||||||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||||||||
| @extension |
1..1 | st | ||||||||||||||
| templateId |
0..* | II | ||||||||||||||
| @typeCode |
0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: REFV | |||||||||||||
| observationRange |
1..1 | ObservationRange | ||||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| realmCode |
0..* | CS | ||||||||||||||
| typeId |
0..1 | II | ||||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @assigningAuthorityName |
0..1 | st | ||||||||||||||
| @displayable |
0..1 | bl | ||||||||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||||||||
| @extension |
1..1 | st | ||||||||||||||
| templateId |
0..* | II | ||||||||||||||
| @classCode |
0..1 | cs | Binding: CDAActClassObservation (required) | |||||||||||||
| @moodCode |
0..1 | cs | Binding: ActMoodPredicate (required) Fixed Value: EVN.CRT | |||||||||||||
| code |
0..1 | CD | Binding: v3 Code System ActCode (example) | |||||||||||||
| text |
0..1 | ED | ||||||||||||||
| value |
1..1 | When the value is a quantity, then the unit SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive. | ||||||||||||||
| value |
BL | |||||||||||||||
| value |
ED | |||||||||||||||
| value |
ST | |||||||||||||||
| value |
CD | |||||||||||||||
| value |
CV | |||||||||||||||
| value |
CE | |||||||||||||||
| value |
CO | |||||||||||||||
| value |
SC | |||||||||||||||
| value |
II | |||||||||||||||
| value |
TEL | |||||||||||||||
| value |
AD | |||||||||||||||
| value |
EN | |||||||||||||||
| value |
INT | |||||||||||||||
| value |
REAL | |||||||||||||||
| value |
PQ | |||||||||||||||
| value |
MO | |||||||||||||||
| value |
TS | |||||||||||||||
| value |
IVL_PQ | |||||||||||||||
| value |
IVL_TS | |||||||||||||||
| value |
PIVL_TS | |||||||||||||||
| value |
EIVL_TS | |||||||||||||||
| value |
SXPR_TS | |||||||||||||||
| interpretationCode |
0..1 | CE | Binding: CDAObservationInterpretation (required) | |||||||||||||
| sdtcPrecondition1 |
0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: precondition1 (urn:hl7-org:sdtc) | |||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| realmCode |
0..* | CS | ||||||||||||||
| typeId |
0..1 | II | ||||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @assigningAuthorityName |
0..1 | st | ||||||||||||||
| @displayable |
0..1 | bl | ||||||||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||||||||
| @extension |
1..1 | st | ||||||||||||||
| templateId |
0..* | II | ||||||||||||||
| @typeCode |
0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: PRCN | |||||||||||||
| conjunctionCode |
1..1 | CS | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc Binding: RelationshipConjunction (2.0.0) (required) | |||||||||||||
| criterion1 |
1..1 | Criterion | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |||||||||||||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |||||||||||||
| Documentation for this format | ||||||||||||||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.templateId:result-obs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
| Observation.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.statusCode.code | required | ResultStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39 | |
| Observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Observation.value:physical-quantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| Observation.value:coded.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
| Observation.referenceRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.typeCode | required | Fixed Value: REFVhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
| Observation.referenceRange.observationRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.classCode | required | CDAActClassObservationhttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.referenceRange.observationRange.moodCode | required | Fixed Value: EVN.CRThttp://terminology.hl7.org/ValueSet/v3-ActMoodPredicate | |
| Observation.referenceRange.observationRange.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Observation.referenceRange.observationRange.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.typeCode | required | Fixed Value: PRCNhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.conjunctionCode | required | RelationshipConjunctionhttp://terminology.hl7.org/ValueSet/v3-RelationshipConjunction|2.0.0 |
| Id | Grade | Path(s) | Details | Requirements |
| 4537-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). : codeSystem = '2.16.840.1.113883.6.1' | |
| 4537-32610 | warning | Observation.value:coded | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). : codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.1' | |
| shall-code-or-nullflavor | error | Observation.code | SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. : (code | nullFlavor).count() = 1 | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-interpretationCode | warning | Observation | SHOULD contain interpretationCode : interpretationCode.exists() | |
| should-referenceRange | warning | Observation | SHOULD contain referenceRange : referenceRange.exists() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from Observation
Summary
Mandatory: 9 elements(2 nested mandatory elements)
Fixed: 2 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Observation
| Name | Flags | Card. | Type | Description & Constraints | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-interpretationCode: SHOULD contain interpretationCode should-author: SHOULD contain author should-referenceRange: SHOULD contain referenceRange | ||||||||||||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||||||||
| templateId:result-obs |
1..1 | II | ||||||||||||||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |||||||||||||
| @extension |
1..1 | st | Required Pattern: 2023-05-01 | |||||||||||||
| @classCode |
1..1 | cs | Fixed Value: OBS | |||||||||||||
| @moodCode |
1..1 | cs | Fixed Value: EVN | |||||||||||||
| id |
1..* | II | ||||||||||||||
| code |
C | 1..1 | CD | 𝗨𝗦𝗖𝗗𝗜: Tests Binding: ObservationType (example)
shall-code-or-nullflavor: SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. 4537-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). | ||||||||||||
| (Choice of one) |
1..1 | |||||||||||||||
| @nullFlavor |
0..1 | cs | ||||||||||||||
| @code |
0..1 | cs | ||||||||||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||||||||
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||||||||
| statusCode |
1..1 | CS | 𝗨𝗦𝗖𝗗𝗜: Result Status | |||||||||||||
| @nullFlavor |
0..0 | |||||||||||||||
| @code |
1..1 | cs | Binding: Result Status (required) | |||||||||||||
| effectiveTime |
1..1 | IVL_TS | Represents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |||||||||||||
| Slices for value |
1..1 | ANY, BL, ED, ST, CD, CV, CE, CO, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | 𝗨𝗦𝗖𝗗𝗜: Values/Results - Value can be any type, but certain types have additional rules. Slice: Unordered, Open by type:$this | |||||||||||||
| value:physical-quantity |
0..1 | PQ | ||||||||||||||
| @unit |
1..1 | cs | 𝗨𝗦𝗖𝗗𝗜: Result Unit of Measure Binding: UnitsOfMeasureCaseSensitive (preferred) | |||||||||||||
| translation |
0..1 | PQR | Can be used to represent the original results as output by the lab | |||||||||||||
| value:coded |
C | 0..1 | CD | 4537-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). | ||||||||||||
| translation |
0..1 | CD | Can be used to represent the original results as output by the lab | |||||||||||||
| interpretationCode |
0..* | CE | 𝗨𝗦𝗖𝗗𝗜: Result Interpretation | |||||||||||||
| methodCode |
0..1 | CE | ||||||||||||||
| targetSiteCode |
0..1 | CD | ||||||||||||||
| author |
0..* | AuthorParticipation | Base for all types and resources | |||||||||||||
| referenceRange |
0..* | InfrastructureRoot | 𝗨𝗦𝗖𝗗𝗜: Result Reference Range | |||||||||||||
| observationRange |
1..1 | ObservationRange | ||||||||||||||
| value |
1..1 | BL, ED, ST, CD, CV, CE, CO, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS | When the value is a quantity, then the unit SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive. | |||||||||||||
| Documentation for this format | ||||||||||||||||
| Path | Conformance | ValueSet | URI |
| Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
| Observation.statusCode.code | required | ResultStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39 | |
| Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive |
| Id | Grade | Path(s) | Details | Requirements |
| 4537-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). : codeSystem = '2.16.840.1.113883.6.1' | |
| 4537-32610 | warning | Observation.value:coded | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). : codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.1' | |
| shall-code-or-nullflavor | error | Observation.code | SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. : (code | nullFlavor).count() = 1 | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-interpretationCode | warning | Observation | SHOULD contain interpretationCode : interpretationCode.exists() | |
| should-referenceRange | warning | Observation | SHOULD contain referenceRange : referenceRange.exists() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-interpretationCode: SHOULD contain interpretationCode should-author: SHOULD contain author should-referenceRange: SHOULD contain referenceRange | ||||||||||||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||||||||
| templateId:result-obs |
1..1 | II | ||||||||||||||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |||||||||||||
| @extension |
1..1 | st | Required Pattern: 2023-05-01 | |||||||||||||
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |||||||||||||
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||||||||
| id |
1..* | II | ||||||||||||||
| code |
C | 1..1 | CD | 𝗨𝗦𝗖𝗗𝗜: Tests Binding: ObservationType (example)
shall-code-or-nullflavor: SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. 4537-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). | ||||||||||||
| (Choice of one) |
1..1 | |||||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @code |
0..1 | cs | ||||||||||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||||||||
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||||||||
| statusCode |
1..1 | CS | 𝗨𝗦𝗖𝗗𝗜: Result Status Binding: ActStatus (required) | |||||||||||||
| @code |
1..1 | cs | Binding: Result Status (required) | |||||||||||||
| effectiveTime |
1..1 | IVL_TS | Represents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |||||||||||||
| Slices for value |
1..1 | 𝗨𝗦𝗖𝗗𝗜: Values/Results - Value can be any type, but certain types have additional rules. Slice: Unordered, Open by type:$this | ||||||||||||||
| value |
ANY | |||||||||||||||
| value |
BL | |||||||||||||||
| value |
ED | |||||||||||||||
| value |
ST | |||||||||||||||
| value |
CD | |||||||||||||||
| value |
CV | |||||||||||||||
| value |
CE | |||||||||||||||
| value |
CO | |||||||||||||||
| value |
SC | |||||||||||||||
| value |
II | |||||||||||||||
| value |
TEL | |||||||||||||||
| value |
AD | |||||||||||||||
| value |
EN | |||||||||||||||
| value |
INT | |||||||||||||||
| value |
REAL | |||||||||||||||
| value |
PQ | |||||||||||||||
| value |
MO | |||||||||||||||
| value |
TS | |||||||||||||||
| value |
IVL_PQ | |||||||||||||||
| value |
IVL_TS | |||||||||||||||
| value |
PIVL_TS | |||||||||||||||
| value |
EIVL_TS | |||||||||||||||
| value |
SXPR_TS | |||||||||||||||
| value |
RTO_PQ_PQ | |||||||||||||||
| value:physical-quantity |
0..1 | PQ | ||||||||||||||
| @unit |
1..1 | cs | 𝗨𝗦𝗖𝗗𝗜: Result Unit of Measure Binding: UnitsOfMeasureCaseSensitive (preferred) | |||||||||||||
| translation |
0..1 | PQR | Can be used to represent the original results as output by the lab | |||||||||||||
| value:coded |
C | 0..1 | CD | 4537-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). | ||||||||||||
| translation |
0..1 | CD | Can be used to represent the original results as output by the lab | |||||||||||||
| interpretationCode |
0..* | CE | 𝗨𝗦𝗖𝗗𝗜: Result Interpretation Binding: CDAObservationInterpretation (required) | |||||||||||||
| methodCode |
0..1 | CE | Binding: ObservationMethod (example) | |||||||||||||
| targetSiteCode |
0..1 | CD | ||||||||||||||
| author |
0..* | AuthorParticipation | Base for all types and resources | |||||||||||||
| referenceRange |
0..* | InfrastructureRoot | 𝗨𝗦𝗖𝗗𝗜: Result Reference Range | |||||||||||||
| observationRange |
1..1 | ObservationRange | ||||||||||||||
| value |
1..1 | When the value is a quantity, then the unit SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive. | ||||||||||||||
| value |
BL | |||||||||||||||
| value |
ED | |||||||||||||||
| value |
ST | |||||||||||||||
| value |
CD | |||||||||||||||
| value |
CV | |||||||||||||||
| value |
CE | |||||||||||||||
| value |
CO | |||||||||||||||
| value |
SC | |||||||||||||||
| value |
II | |||||||||||||||
| value |
TEL | |||||||||||||||
| value |
AD | |||||||||||||||
| value |
EN | |||||||||||||||
| value |
INT | |||||||||||||||
| value |
REAL | |||||||||||||||
| value |
PQ | |||||||||||||||
| value |
MO | |||||||||||||||
| value |
TS | |||||||||||||||
| value |
IVL_PQ | |||||||||||||||
| value |
IVL_TS | |||||||||||||||
| value |
PIVL_TS | |||||||||||||||
| value |
EIVL_TS | |||||||||||||||
| value |
SXPR_TS | |||||||||||||||
| Documentation for this format | ||||||||||||||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
| Observation.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.statusCode.code | required | ResultStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39 | |
| Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod |
| Id | Grade | Path(s) | Details | Requirements |
| 4537-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). : codeSystem = '2.16.840.1.113883.6.1' | |
| 4537-32610 | warning | Observation.value:coded | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). : codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.1' | |
| shall-code-or-nullflavor | error | Observation.code | SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. : (code | nullFlavor).count() = 1 | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-interpretationCode | warning | Observation | SHOULD contain interpretationCode : interpretationCode.exists() | |
| should-referenceRange | warning | Observation | SHOULD contain referenceRange : referenceRange.exists() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-interpretationCode: SHOULD contain interpretationCode should-author: SHOULD contain author should-referenceRange: SHOULD contain referenceRange | ||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| realmCode |
0..* | CS | ||||||||||||||
| typeId |
0..1 | II | ||||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @assigningAuthorityName |
0..1 | st | ||||||||||||||
| @displayable |
0..1 | bl | ||||||||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||||||||
| @extension |
1..1 | st | ||||||||||||||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||||||||
| templateId:result-obs |
1..1 | II | ||||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @assigningAuthorityName |
0..1 | st | ||||||||||||||
| @displayable |
0..1 | bl | ||||||||||||||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |||||||||||||
| @extension |
1..1 | st | Required Pattern: 2023-05-01 | |||||||||||||
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |||||||||||||
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||||||||
| @negationInd |
0..1 | bl | ||||||||||||||
| id |
1..* | II | ||||||||||||||
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |||||||||||||
| code |
C | 1..1 | CD | 𝗨𝗦𝗖𝗗𝗜: Tests Binding: ObservationType (example)
shall-code-or-nullflavor: SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. 4537-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). | ||||||||||||
| (Choice of one) |
1..1 | |||||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @code |
0..1 | cs | ||||||||||||||
| @codeSystem |
0..1 | oid, uuid, ruid | ||||||||||||||
| @codeSystemName |
0..1 | st | ||||||||||||||
| @codeSystemVersion |
0..1 | st | ||||||||||||||
| @displayName |
0..1 | st | ||||||||||||||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |||||||||||||
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |||||||||||||
| originalText |
0..1 | ED | ||||||||||||||
| qualifier |
0..* | CR | ||||||||||||||
| translation |
0..* | CD | ||||||||||||||
| derivationExpr |
0..1 | ST | ||||||||||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @compression |
0..1 | cs | Binding: CDACompressionAlgorithm (required) | |||||||||||||
| @integrityCheck |
0..1 | bin | ||||||||||||||
| @integrityCheckAlgorithm |
0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |||||||||||||
| @language |
0..1 | cs | ||||||||||||||
| @mediaType |
0..1 | cs | Binding: MediaType (example) | |||||||||||||
| @representation |
0..1 | cs | Binding: CDABinaryDataEncoding (required) | |||||||||||||
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |||||||||||||
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||||||||
| thumbnail |
0..1 | ED | ||||||||||||||
| statusCode |
1..1 | CS | 𝗨𝗦𝗖𝗗𝗜: Result Status Binding: ActStatus (required) | |||||||||||||
| @code |
1..1 | cs | Binding: Result Status (required) | |||||||||||||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |||||||||||||
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |||||||||||||
| effectiveTime |
1..1 | IVL_TS | Represents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |||||||||||||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |||||||||||||
| repeatNumber |
0..1 | IVL_INT | ||||||||||||||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |||||||||||||
| Slices for value |
1..1 | 𝗨𝗦𝗖𝗗𝗜: Values/Results - Value can be any type, but certain types have additional rules. Slice: Unordered, Open by type:$this | ||||||||||||||
| value |
ANY | |||||||||||||||
| value |
BL | |||||||||||||||
| value |
ED | |||||||||||||||
| value |
ST | |||||||||||||||
| value |
CD | |||||||||||||||
| value |
CV | |||||||||||||||
| value |
CE | |||||||||||||||
| value |
CO | |||||||||||||||
| value |
SC | |||||||||||||||
| value |
II | |||||||||||||||
| value |
TEL | |||||||||||||||
| value |
AD | |||||||||||||||
| value |
EN | |||||||||||||||
| value |
INT | |||||||||||||||
| value |
REAL | |||||||||||||||
| value |
PQ | |||||||||||||||
| value |
MO | |||||||||||||||
| value |
TS | |||||||||||||||
| value |
IVL_PQ | |||||||||||||||
| value |
IVL_TS | |||||||||||||||
| value |
PIVL_TS | |||||||||||||||
| value |
EIVL_TS | |||||||||||||||
| value |
SXPR_TS | |||||||||||||||
| value |
RTO_PQ_PQ | |||||||||||||||
| value:physical-quantity |
0..1 | PQ | ||||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @unit |
1..1 | cs | 𝗨𝗦𝗖𝗗𝗜: Result Unit of Measure Binding: UnitsOfMeasureCaseSensitive (preferred) | |||||||||||||
| @value |
0..1 | real | ||||||||||||||
| translation |
0..1 | PQR | Can be used to represent the original results as output by the lab | |||||||||||||
| value:coded |
C | 0..1 | CD | 4537-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). | ||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @code |
0..1 | cs | ||||||||||||||
| @codeSystem |
0..1 | oid, uuid, ruid | ||||||||||||||
| @codeSystemName |
0..1 | st | ||||||||||||||
| @codeSystemVersion |
0..1 | st | ||||||||||||||
| @displayName |
0..1 | st | ||||||||||||||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |||||||||||||
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |||||||||||||
| originalText |
0..1 | ED | ||||||||||||||
| qualifier |
0..* | CR | ||||||||||||||
| translation |
0..1 | CD | Can be used to represent the original results as output by the lab | |||||||||||||
| interpretationCode |
0..* | CE | 𝗨𝗦𝗖𝗗𝗜: Result Interpretation Binding: CDAObservationInterpretation (required) | |||||||||||||
| methodCode |
0..1 | CE | Binding: ObservationMethod (example) | |||||||||||||
| targetSiteCode |
0..1 | CD | ||||||||||||||
| subject |
0..1 | Subject | ||||||||||||||
| specimen |
0..* | Specimen | ||||||||||||||
| performer |
0..* | Performer2 | ||||||||||||||
| author |
0..* | AuthorParticipation | Base for all types and resources | |||||||||||||
| informant |
0..* | Informant | ||||||||||||||
| participant |
0..* | Participant2 | ||||||||||||||
| entryRelationship |
0..* | EntryRelationship | ||||||||||||||
| reference |
0..* | Reference | ||||||||||||||
| precondition |
0..* | Precondition | ||||||||||||||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |||||||||||||
| referenceRange |
0..* | InfrastructureRoot | 𝗨𝗦𝗖𝗗𝗜: Result Reference Range | |||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| realmCode |
0..* | CS | ||||||||||||||
| typeId |
0..1 | II | ||||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @assigningAuthorityName |
0..1 | st | ||||||||||||||
| @displayable |
0..1 | bl | ||||||||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||||||||
| @extension |
1..1 | st | ||||||||||||||
| templateId |
0..* | II | ||||||||||||||
| @typeCode |
0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: REFV | |||||||||||||
| observationRange |
1..1 | ObservationRange | ||||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| realmCode |
0..* | CS | ||||||||||||||
| typeId |
0..1 | II | ||||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @assigningAuthorityName |
0..1 | st | ||||||||||||||
| @displayable |
0..1 | bl | ||||||||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||||||||
| @extension |
1..1 | st | ||||||||||||||
| templateId |
0..* | II | ||||||||||||||
| @classCode |
0..1 | cs | Binding: CDAActClassObservation (required) | |||||||||||||
| @moodCode |
0..1 | cs | Binding: ActMoodPredicate (required) Fixed Value: EVN.CRT | |||||||||||||
| code |
0..1 | CD | Binding: v3 Code System ActCode (example) | |||||||||||||
| text |
0..1 | ED | ||||||||||||||
| value |
1..1 | When the value is a quantity, then the unit SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive. | ||||||||||||||
| value |
BL | |||||||||||||||
| value |
ED | |||||||||||||||
| value |
ST | |||||||||||||||
| value |
CD | |||||||||||||||
| value |
CV | |||||||||||||||
| value |
CE | |||||||||||||||
| value |
CO | |||||||||||||||
| value |
SC | |||||||||||||||
| value |
II | |||||||||||||||
| value |
TEL | |||||||||||||||
| value |
AD | |||||||||||||||
| value |
EN | |||||||||||||||
| value |
INT | |||||||||||||||
| value |
REAL | |||||||||||||||
| value |
PQ | |||||||||||||||
| value |
MO | |||||||||||||||
| value |
TS | |||||||||||||||
| value |
IVL_PQ | |||||||||||||||
| value |
IVL_TS | |||||||||||||||
| value |
PIVL_TS | |||||||||||||||
| value |
EIVL_TS | |||||||||||||||
| value |
SXPR_TS | |||||||||||||||
| interpretationCode |
0..1 | CE | Binding: CDAObservationInterpretation (required) | |||||||||||||
| sdtcPrecondition1 |
0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: precondition1 (urn:hl7-org:sdtc) | |||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| realmCode |
0..* | CS | ||||||||||||||
| typeId |
0..1 | II | ||||||||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||||||||
| @assigningAuthorityName |
0..1 | st | ||||||||||||||
| @displayable |
0..1 | bl | ||||||||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||||||||
| @extension |
1..1 | st | ||||||||||||||
| templateId |
0..* | II | ||||||||||||||
| @typeCode |
0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: PRCN | |||||||||||||
| conjunctionCode |
1..1 | CS | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc Binding: RelationshipConjunction (2.0.0) (required) | |||||||||||||
| criterion1 |
1..1 | Criterion | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |||||||||||||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |||||||||||||
| Documentation for this format | ||||||||||||||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.templateId:result-obs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
| Observation.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.statusCode.code | required | ResultStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39 | |
| Observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Observation.value:physical-quantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| Observation.value:coded.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
| Observation.referenceRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.typeCode | required | Fixed Value: REFVhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
| Observation.referenceRange.observationRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.classCode | required | CDAActClassObservationhttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.referenceRange.observationRange.moodCode | required | Fixed Value: EVN.CRThttp://terminology.hl7.org/ValueSet/v3-ActMoodPredicate | |
| Observation.referenceRange.observationRange.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Observation.referenceRange.observationRange.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.typeCode | required | Fixed Value: PRCNhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.conjunctionCode | required | RelationshipConjunctionhttp://terminology.hl7.org/ValueSet/v3-RelationshipConjunction|2.0.0 |
| Id | Grade | Path(s) | Details | Requirements |
| 4537-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). : codeSystem = '2.16.840.1.113883.6.1' | |
| 4537-32610 | warning | Observation.value:coded | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). : codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.1' | |
| shall-code-or-nullflavor | error | Observation.code | SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. : (code | nullFlavor).count() = 1 | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-interpretationCode | warning | Observation | SHOULD contain interpretationCode : interpretationCode.exists() | |
| should-referenceRange | warning | Observation | SHOULD contain referenceRange : referenceRange.exists() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from Observation
Summary
Mandatory: 9 elements(2 nested mandatory elements)
Fixed: 2 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#4.0.0-ballot based on FHIR 5.0.0. Generated 2024-11-21
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