Consolidated CDA (C-CDA)
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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

Logical Model: AssessmentScaleObservation - Detailed Descriptions

Draft as of 2024-12-19

Definitions for the AssessmentScaleObservation logical model.

Guidance on how to interpret the contents of this table can be found here

0. Observation
Logical ContainerClinicalDocument (CDA Class)
ValidationInstance of this type are validated by templateId
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
Invariantsshould-text-ref-value: SHOULD contain text/reference/@value (text.reference.value.exists())
2. Observation.templateId
Control1..?
SlicingThis element introduces a set of slices on Observation.templateId. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ root
  • value @ extension
  • 4. Observation.templateId:assessment-scale-obs
    Slice Nameassessment-scale-obs
    Control1..1
    6. Observation.templateId:assessment-scale-obs.root
    Control1..?
    Pattern Value2.16.840.1.113883.10.20.22.4.69
    8. Observation.templateId:assessment-scale-obs.extension
    Control1..?
    Pattern Value2022-06-01
    10. Observation.classCode
    Comments

    SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:4515-14434).

    Fixed ValueOBS
    12. Observation.moodCode
    Comments

    SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:4515-14435).

    Fixed ValueEVN
    14. Observation.id
    Comments

    SHALL contain at least one [1..*] id (CONF:4515-14438).

    Control1..?
    16. Observation.code
    Shortsurvey
    Invariantsshould-translation: SHOULD contain translation (translation.exists())
    18. Observation.code.code
    Control1..?
    Pattern Valuesurvey
    20. Observation.code.codeSystem
    ShortObservation Category Codes
    Control1..?
    Pattern Value2.16.840.1.113883.4.642.1.1125
    22. Observation.code.translation
    BindingThe codes SHOULD be taken from Screening and Assesment Survey Codes .
    (preferred to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.13)
    24. Observation.derivationExpr
    ShortSuch derivation expression can contain a text calculation of how the components total up to the summed score
    Comments

    MAY contain zero or one [0..1] derivationExpr (CONF:4515-14637).

    26. Observation.text
    ShortSHOULD reference the portion of section narrative text corresponding to this entry
    28. Observation.text.reference
    Invariantsvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative (value.exists() implies value.startsWith('#'))
    30. Observation.statusCode
    Comments

    SHALL contain exactly one [1..1] statusCode (CONF:4515-14444).

    Control1..?
    32. Observation.statusCode.code
    Comments

    This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: HL7ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:4515-19088).

    Control1..?
    Fixed Valuecompleted
    34. Observation.effectiveTime
    ShortRepresents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards)
    Comments

    SHALL contain exactly one [1..1] effectiveTime (CONF:4515-14445).

    Control1..?
    36. Observation.value
    ShortIntended to hold the calculated score, if a calculated score exists in the originating questionaire or scale from the contained Assessment Scale Observations, and the associated answer integer will be at observation.value.translationCode, if present
    Comments

    SHALL contain exactly one [1..1] value (CONF:4515-14450).

    Control1..1
    38. Observation.interpretationCode
    Comments

    MAY contain zero or more [0..*] interpretationCode (CONF:4515-14459).

    40. Observation.interpretationCode.translation
    Comments

    The interpretationCode, if present, MAY contain zero or more [0..*] translation (CONF:4515-14888).

    42. Observation.author
    Comments

    MAY contain zero or more [0..*] author (CONF:4515-14460).

    44. Observation.entryRelationship
    Comments

    SHOULD contain zero or more [0..*] entryRelationship (CONF:4515-14451) such that it

    SlicingThis element introduces a set of slices on Observation.entryRelationship. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • profile @ observation
    • value @ typeCode
    • 46. Observation.entryRelationship:supportingObs
      Slice NamesupportingObs
      ShortentryRelationship
      Control0..*
      48. Observation.entryRelationship:supportingObs.typeCode
      Comments

      SHALL contain exactly one [1..1] @typeCode="COMP" has component (CONF:4515-16741).

      Fixed ValueCOMP
      50. Observation.entryRelationship:supportingObs.observation
      Comments

      SHALL contain exactly one [1..1] Assessment Scale Supporting Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.86) (CONF:4515-16742).

      Control1..?
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Assessment Scale Supporting Observation)
      52. Observation.referenceRange
      ShortThe referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7 = moderate pain, 8 to 10 = severe pain)
      Comments

      MAY contain zero or more [0..*] referenceRange (CONF:4515-16799).

      54. Observation.referenceRange.observationRange
      Comments

      The referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:4515-16800).

      Invariantsshould-text: SHOULD contain text (text.exists())
      should-text-ref-value: SHOULD contain text/reference/@value (text.reference.value.exists())
      56. Observation.referenceRange.observationRange.text
      ShortThe text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain)
      Comments

      This observationRange SHOULD contain zero or one [0..1] text (CONF:4515-16801).

      58. Observation.referenceRange.observationRange.text.reference
      Invariantsvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative (value.exists() implies value.startsWith('#'))