Consolidated CDA (C-CDA)
4.0.0 - STU4
Consolidated CDA (C-CDA)
4.0.0 - 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 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/AssessmentScaleObservation | Version: 4.0.0 | |||
| Draft as of 2025-10-02 | Computable Name: AssessmentScaleObservation | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.69:2022-06-01 | ||||
An assessment scale is a collection of observations that together can yield a calculated or non-calculated summary evaluation of a one or more conditions. Examples include the Braden Scale (assesses pressure ulcer risk), APACHE Score (estimates mortality in critically ill patients), Mini-Mental Status Exam (assesses cognitive function), APGAR Score (assesses the health of a newborn), Glasgow Coma Scale (assesses coma and impaired consciousness), and WE CARE (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education - a clinic-based screening and referral system developed for pediatric settings).
When an Assessment Scale Observation is contained in a Problem Observation, a Social History Observation or a Procedure instance that is Social Determinant of Health focused, that Assessment scale MAY contain assessment scale observations that represent question and answer pairs from SDOH screening instruments that are represented in LOINC. Note that guidance on the use of LOINC in assessment scales already exists in Assessment Scale Observation constraints and Assessment Scale Supporting Observations constraints.
The Observation value is used to record a calculated score using an integer. A LOINC answer concept is used when the assessment is non-calculated result.
Although open templates may contain any valid CDA content, the following templates are specifically called out by this template:
Optional EntryRelationships: AssessmentScaleSupportingObservation
Usages:
You can also check for usages in the FHIR IG Statistics
Changes since version 3.0.0:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value, should-sdtcCategory, category-survey |
  Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:assessment-scale-obs |
1..1 | II | ||
  @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.69 | |
  @extension |
1..1 | st | Required Pattern: 2022-06-01 | |
 @classCode |
1..1 | cs | Fixed Value: OBS | |
| @moodCode |
1..1 | cs | Fixed Value: EVN | |
| id |
1..* | II | ||
| Slices for sdtcCategory |
0..* | CD | Category is optional, but if present it SHALL contain a category with code=survey. Slice: Unordered, Open by value:code, value:codeSystem | |
| sdtcCategory:survey |
0..1 | CD | Survey | |
| @code |
1..1 | cs | Required Pattern: survey | |
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.642.1.1125 | |
| code |
C | 1..1 | CD | For Social Determinant of Health Assessments Binding: Screening and Assessment Survey Codes  (required)Constraints: should-translation |
 translation |
0..* | CD | Binding: Social Determinants of Health Screening Assessments And Questions (preferred) | |
| derivationExpr |
0..1 | ST | Such derivation expression can contain a text calculation of how the components total up to the summed score | |
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference |
C | 0..1 | TEL | Constraints: value-starts-octothorpe |
| statusCode |
1..1 | CS | ||
| @code |
1..1 | cs | Fixed Value: completed | |
| effectiveTime |
1..1 | IVL_TS | Represents 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) | |
| 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 | This is intended to hold the overall assessment score. This could be calculated from the contained Assessment Scale Supporting Observations | |
| interpretationCode |
0..* | CE | ||
| translation |
0..* | CD | ||
| author |
0..* | Author | ||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, value:typeCode | |
| entryRelationship:supportingObs |
0..* | EntryRelationship | entryRelationship | |
| @typeCode |
1..1 | cs | Fixed Value: COMP | |
 observation |
1..1 | AssessmentScaleSupportingObservation | ||
 referenceRange |
0..* | InfrastructureRoot | The 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) | |
| observationRange |
C | 1..1 | ObservationRange | Constraints: should-text, should-text-ref-value |
| text |
0..1 | ED | The 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) | |
| reference |
C | 0..1 | TEL | Constraints: value-starts-octothorpe |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Observation.code | Base | required |
Screening and Assessment Survey Codes
|
📦20241008 | VSAC v0.23 |
| Observation.code.translation | Base | preferred |
Social Determinants of Health Screening Assessments And Questions
|
📦20241214 | VSAC v0.23 |
| Id | Grade | Path(s) | Description | Expression |
| category-survey | error | Observation | If category is present, then there shall be a category with code 'survey'. |
sdtcCategory.empty() or sdtcCategory.exists(code = 'survey' and codeSystem = '2.16.840.1.113883.4.642.1.1125')
|
| should-sdtcCategory | warning | Observation | SHOULD contain sdtcCategory |
sdtcCategory.exists()
|
| should-text | warning | Observation.referenceRange.observationRange | SHOULD contain text |
text.exists()
|
| should-text-ref-value | warning | Observation, Observation.referenceRange.observationRange | SHOULD contain text/reference/@value |
text.reference.value.exists()
|
| should-translation | warning | Observation.code | SHOULD contain translation |
translation.exists()
|
| value-starts-octothorpe | error | Observation.text.reference, Observation.referenceRange.observationRange.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 Filter: |
|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value, should-sdtcCategory, category-survey |
 @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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:assessment-scale-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: 2.16.840.1.113883.10.20.22.4.69 | |
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |
| @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 | ||
| Slices for sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc Category is optional, but if present it SHALL contain a category with code=survey. Slice: Unordered, Open by value:code, value:codeSystem XML: category (urn:hl7-org:sdtc) | |
| sdtcCategory:survey |
0..1 | CD | XML Namespace: urn:hl7-org:sdtc Survey XML: category (urn:hl7-org:sdtc) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: survey | |
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.642.1.1125 | |
| @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 | ||
| code |
C | 1..1 | CD | For Social Determinant of Health Assessments Binding: Screening and Assessment Survey Codes (required)Constraints: should-translation |
| @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 | Binding: Social Determinants of Health Screening Assessments And Questions (preferred) | |
| derivationExpr |
0..1 | ST | Such derivation expression can contain a text calculation of how the components total up to the summed score | |
| 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 | Constraints: value-starts-octothorpe |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| @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 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) | |
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
 value |
1..1 | This is intended to hold the overall assessment score. This could be calculated from the contained Assessment Scale Supporting Observations | ||
 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 | |||
| interpretationCode |
0..* | CE | Binding: CDAObservationInterpretation (required) | |
| @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 | ||
| translation |
0..* | CD | ||
| methodCode |
0..* | CE | Binding: ObservationMethod (example) | |
| targetSiteCode |
0..* | CD | ||
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | Author | ||
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, value:typeCode | |
| entryRelationship:supportingObs |
0..* | EntryRelationship | entryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
 typeId |
C | 0..1 | II | Constraints: II-1 |
 @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd |
0..1 | bl | ||
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
1..1 | AssessmentScaleSupportingObservation | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| referenceRange |
0..* | InfrastructureRoot | The 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) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
C | 1..1 | ObservationRange | Constraints: should-text, should-text-ref-value |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 | The 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) | |
| @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 | Constraints: value-starts-octothorpe |
| thumbnail |
0..1 | ED | ||
| value |
0..1 | |||
| 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 |
C | 0..1 | II | Constraints: II-1 |
| @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 | Status | Usage | ValueSet | Version | Source |
| Observation.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.templateId:assessment-scale-obs.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.classCode | Base | required | CDAActClassObservation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.moodCode | Base | required | x_ActMoodDocumentObservation | 📍2.0.0 | THO v5.2 |
| Observation.sdtcCategory:survey.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.code | Base | required |
Screening and Assessment Survey Codes
|
📦20241008 | VSAC v0.23 |
| Observation.code.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.code.translation | Base | preferred |
Social Determinants of Health Screening Assessments And Questions
|
📦20241214 | VSAC v0.23 |
| Observation.text.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.text.compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.text.integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2 |
| Observation.text.mediaType | Base | example | MediaType | 📦3.0.0 | THO v6.5 |
| Observation.text.representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5 |
| Observation.statusCode.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5 |
| Observation.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std. |
| Observation.interpretationCode | Base | required | CDAObservationInterpretation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.interpretationCode.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.methodCode | Base | example | ObservationMethod | 📦3.0.0 | THO v6.5 |
| Observation.entryRelationship:supportingObs.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:supportingObs.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:supportingObs.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​typeCode | Base | required | CDAActRelationshipType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.classCode | Base | required | CDAActClassObservation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.moodCode | Base | required | ActMoodPredicate | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​observationRange.code | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​observationRange.text.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.text.​compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.text.​integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2 |
| Observation.referenceRange.​observationRange.text.​mediaType | Base | example | MediaType | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​observationRange.text.​representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.interpretationCode | Base | required | CDAObservationInterpretation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.sdtcPrecondition1.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.sdtcPrecondition1.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.sdtcPrecondition1.​typeCode | Base | required | CDAActRelationshipType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.sdtcPrecondition1.​conjunctionCode | Base | required | RelationshipConjunction | 📍2.0.0 | THO v5.2 |
| Id | Grade | Path(s) | Description | Expression |
| II-1 | error | Observation.typeId, Observation.entryRelationship:supportingObs.typeId, Observation.referenceRange.typeId, Observation.referenceRange.observationRange.typeId, Observation.referenceRange.observationRange.sdtcPrecondition1.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
| category-survey | error | Observation | If category is present, then there shall be a category with code 'survey'. |
sdtcCategory.empty() or sdtcCategory.exists(code = 'survey' and codeSystem = '2.16.840.1.113883.4.642.1.1125')
|
| should-sdtcCategory | warning | Observation | SHOULD contain sdtcCategory |
sdtcCategory.exists()
|
| should-text | warning | Observation.referenceRange.observationRange | SHOULD contain text |
text.exists()
|
| should-text-ref-value | warning | Observation, Observation.referenceRange.observationRange | SHOULD contain text/reference/@value |
text.reference.value.exists()
|
| should-translation | warning | Observation.code | SHOULD contain translation |
translation.exists()
|
| value-starts-octothorpe | error | Observation.text.reference, Observation.referenceRange.observationRange.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 Filter: |
|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value, should-sdtcCategory, category-survey |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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:assessment-scale-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: 2.16.840.1.113883.10.20.22.4.69 | |
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |
| @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 | ||
| Slices for sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc Category is optional, but if present it SHALL contain a category with code=survey. Slice: Unordered, Open by value:code, value:codeSystem XML: category (urn:hl7-org:sdtc) | |
| sdtcCategory:survey |
0..1 | CD | XML Namespace: urn:hl7-org:sdtc Survey XML: category (urn:hl7-org:sdtc) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: survey | |
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.642.1.1125 | |
| @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 | ||
| code |
C | 1..1 | CD | For Social Determinant of Health Assessments Binding: Screening and Assessment Survey Codes (required)Constraints: should-translation |
| @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 | Binding: Social Determinants of Health Screening Assessments And Questions (preferred) | |
| derivationExpr |
0..1 | ST | Such derivation expression can contain a text calculation of how the components total up to the summed score | |
| 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 | Constraints: value-starts-octothorpe |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| @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 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) | |
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| value |
1..1 | This is intended to hold the overall assessment score. This could be calculated from the contained Assessment Scale Supporting Observations | ||
| 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 | |||
| interpretationCode |
0..* | CE | Binding: CDAObservationInterpretation (required) | |
| @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 | ||
| translation |
0..* | CD | ||
| methodCode |
0..* | CE | Binding: ObservationMethod (example) | |
| targetSiteCode |
0..* | CD | ||
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | Author | ||
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, value:typeCode | |
| entryRelationship:supportingObs |
0..* | EntryRelationship | entryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd |
0..1 | bl | ||
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
1..1 | AssessmentScaleSupportingObservation | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| referenceRange |
0..* | InfrastructureRoot | The 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) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
C | 1..1 | ObservationRange | Constraints: should-text, should-text-ref-value |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 | The 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) | |
| @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 | Constraints: value-starts-octothorpe |
| thumbnail |
0..1 | ED | ||
| value |
0..1 | |||
| 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 |
C | 0..1 | II | Constraints: II-1 |
| @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 | Status | Usage | ValueSet | Version | Source |
| Observation.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.templateId:assessment-scale-obs.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.classCode | Base | required | CDAActClassObservation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.moodCode | Base | required | x_ActMoodDocumentObservation | 📍2.0.0 | THO v5.2 |
| Observation.sdtcCategory:survey.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.code | Base | required |
Screening and Assessment Survey Codes
|
📦20241008 | VSAC v0.23 |
| Observation.code.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.code.translation | Base | preferred |
Social Determinants of Health Screening Assessments And Questions
|
📦20241214 | VSAC v0.23 |
| Observation.text.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.text.compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.text.integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2 |
| Observation.text.mediaType | Base | example | MediaType | 📦3.0.0 | THO v6.5 |
| Observation.text.representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5 |
| Observation.statusCode.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5 |
| Observation.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std. |
| Observation.interpretationCode | Base | required | CDAObservationInterpretation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.interpretationCode.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.methodCode | Base | example | ObservationMethod | 📦3.0.0 | THO v6.5 |
| Observation.entryRelationship:supportingObs.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:supportingObs.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:supportingObs.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​typeCode | Base | required | CDAActRelationshipType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.classCode | Base | required | CDAActClassObservation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.moodCode | Base | required | ActMoodPredicate | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​observationRange.code | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​observationRange.text.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.text.​compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.text.​integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2 |
| Observation.referenceRange.​observationRange.text.​mediaType | Base | example | MediaType | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​observationRange.text.​representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.interpretationCode | Base | required | CDAObservationInterpretation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.sdtcPrecondition1.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.sdtcPrecondition1.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.sdtcPrecondition1.​typeCode | Base | required | CDAActRelationshipType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.sdtcPrecondition1.​conjunctionCode | Base | required | RelationshipConjunction | 📍2.0.0 | THO v5.2 |
| Id | Grade | Path(s) | Description | Expression |
| II-1 | error | Observation.typeId, Observation.entryRelationship:supportingObs.typeId, Observation.referenceRange.typeId, Observation.referenceRange.observationRange.typeId, Observation.referenceRange.observationRange.sdtcPrecondition1.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
| category-survey | error | Observation | If category is present, then there shall be a category with code 'survey'. |
sdtcCategory.empty() or sdtcCategory.exists(code = 'survey' and codeSystem = '2.16.840.1.113883.4.642.1.1125')
|
| should-sdtcCategory | warning | Observation | SHOULD contain sdtcCategory |
sdtcCategory.exists()
|
| should-text | warning | Observation.referenceRange.observationRange | SHOULD contain text |
text.exists()
|
| should-text-ref-value | warning | Observation, Observation.referenceRange.observationRange | SHOULD contain text/reference/@value |
text.reference.value.exists()
|
| should-translation | warning | Observation.code | SHOULD contain translation |
translation.exists()
|
| value-starts-octothorpe | error | Observation.text.reference, Observation.referenceRange.observationRange.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(3 nested mandatory elements)
Fixed: 4 elements
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 Filter: |
|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value, should-sdtcCategory, category-survey |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:assessment-scale-obs |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.69 | |
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |
| @classCode |
1..1 | cs | Fixed Value: OBS | |
| @moodCode |
1..1 | cs | Fixed Value: EVN | |
| id |
1..* | II | ||
| Slices for sdtcCategory |
0..* | CD | Category is optional, but if present it SHALL contain a category with code=survey. Slice: Unordered, Open by value:code, value:codeSystem | |
| sdtcCategory:survey |
0..1 | CD | Survey | |
| @code |
1..1 | cs | Required Pattern: survey | |
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.642.1.1125 | |
| code |
C | 1..1 | CD | For Social Determinant of Health Assessments Binding: Screening and Assessment Survey Codes (required)Constraints: should-translation |
| translation |
0..* | CD | Binding: Social Determinants of Health Screening Assessments And Questions (preferred) | |
| derivationExpr |
0..1 | ST | Such derivation expression can contain a text calculation of how the components total up to the summed score | |
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference |
C | 0..1 | TEL | Constraints: value-starts-octothorpe |
| statusCode |
1..1 | CS | ||
| @code |
1..1 | cs | Fixed Value: completed | |
| effectiveTime |
1..1 | IVL_TS | Represents 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) | |
| 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 | This is intended to hold the overall assessment score. This could be calculated from the contained Assessment Scale Supporting Observations | |
| interpretationCode |
0..* | CE | ||
| translation |
0..* | CD | ||
| author |
0..* | Author | ||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, value:typeCode | |
| entryRelationship:supportingObs |
0..* | EntryRelationship | entryRelationship | |
| @typeCode |
1..1 | cs | Fixed Value: COMP | |
| observation |
1..1 | AssessmentScaleSupportingObservation | ||
| referenceRange |
0..* | InfrastructureRoot | The 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) | |
| observationRange |
C | 1..1 | ObservationRange | Constraints: should-text, should-text-ref-value |
| text |
0..1 | ED | The 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) | |
| reference |
C | 0..1 | TEL | Constraints: value-starts-octothorpe |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Observation.code | Base | required |
Screening and Assessment Survey Codes
|
📦20241008 | VSAC v0.23 |
| Observation.code.translation | Base | preferred |
Social Determinants of Health Screening Assessments And Questions
|
📦20241214 | VSAC v0.23 |
| Id | Grade | Path(s) | Description | Expression |
| category-survey | error | Observation | If category is present, then there shall be a category with code 'survey'. |
sdtcCategory.empty() or sdtcCategory.exists(code = 'survey' and codeSystem = '2.16.840.1.113883.4.642.1.1125')
|
| should-sdtcCategory | warning | Observation | SHOULD contain sdtcCategory |
sdtcCategory.exists()
|
| should-text | warning | Observation.referenceRange.observationRange | SHOULD contain text |
text.exists()
|
| should-text-ref-value | warning | Observation, Observation.referenceRange.observationRange | SHOULD contain text/reference/@value |
text.reference.value.exists()
|
| should-translation | warning | Observation.code | SHOULD contain translation |
translation.exists()
|
| value-starts-octothorpe | error | Observation.text.reference, Observation.referenceRange.observationRange.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 Filter: |
|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value, should-sdtcCategory, category-survey |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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:assessment-scale-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: 2.16.840.1.113883.10.20.22.4.69 | |
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |
| @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 | ||
| Slices for sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc Category is optional, but if present it SHALL contain a category with code=survey. Slice: Unordered, Open by value:code, value:codeSystem XML: category (urn:hl7-org:sdtc) | |
| sdtcCategory:survey |
0..1 | CD | XML Namespace: urn:hl7-org:sdtc Survey XML: category (urn:hl7-org:sdtc) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: survey | |
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.642.1.1125 | |
| @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 | ||
| code |
C | 1..1 | CD | For Social Determinant of Health Assessments Binding: Screening and Assessment Survey Codes (required)Constraints: should-translation |
| @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 | Binding: Social Determinants of Health Screening Assessments And Questions (preferred) | |
| derivationExpr |
0..1 | ST | Such derivation expression can contain a text calculation of how the components total up to the summed score | |
| 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 | Constraints: value-starts-octothorpe |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| @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 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) | |
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| value |
1..1 | This is intended to hold the overall assessment score. This could be calculated from the contained Assessment Scale Supporting Observations | ||
| 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 | |||
| interpretationCode |
0..* | CE | Binding: CDAObservationInterpretation (required) | |
| @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 | ||
| translation |
0..* | CD | ||
| methodCode |
0..* | CE | Binding: ObservationMethod (example) | |
| targetSiteCode |
0..* | CD | ||
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | Author | ||
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, value:typeCode | |
| entryRelationship:supportingObs |
0..* | EntryRelationship | entryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd |
0..1 | bl | ||
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
1..1 | AssessmentScaleSupportingObservation | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| referenceRange |
0..* | InfrastructureRoot | The 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) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
C | 1..1 | ObservationRange | Constraints: should-text, should-text-ref-value |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 | The 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) | |
| @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 | Constraints: value-starts-octothorpe |
| thumbnail |
0..1 | ED | ||
| value |
0..1 | |||
| 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 |
C | 0..1 | II | Constraints: II-1 |
| @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 | Status | Usage | ValueSet | Version | Source |
| Observation.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.templateId:assessment-scale-obs.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.classCode | Base | required | CDAActClassObservation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.moodCode | Base | required | x_ActMoodDocumentObservation | 📍2.0.0 | THO v5.2 |
| Observation.sdtcCategory:survey.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.code | Base | required |
Screening and Assessment Survey Codes
|
📦20241008 | VSAC v0.23 |
| Observation.code.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.code.translation | Base | preferred |
Social Determinants of Health Screening Assessments And Questions
|
📦20241214 | VSAC v0.23 |
| Observation.text.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.text.compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.text.integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2 |
| Observation.text.mediaType | Base | example | MediaType | 📦3.0.0 | THO v6.5 |
| Observation.text.representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5 |
| Observation.statusCode.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5 |
| Observation.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std. |
| Observation.interpretationCode | Base | required | CDAObservationInterpretation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.interpretationCode.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.methodCode | Base | example | ObservationMethod | 📦3.0.0 | THO v6.5 |
| Observation.entryRelationship:supportingObs.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:supportingObs.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:supportingObs.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​typeCode | Base | required | CDAActRelationshipType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.classCode | Base | required | CDAActClassObservation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.moodCode | Base | required | ActMoodPredicate | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​observationRange.code | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​observationRange.text.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.text.​compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.text.​integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2 |
| Observation.referenceRange.​observationRange.text.​mediaType | Base | example | MediaType | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​observationRange.text.​representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.interpretationCode | Base | required | CDAObservationInterpretation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.sdtcPrecondition1.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.sdtcPrecondition1.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.sdtcPrecondition1.​typeCode | Base | required | CDAActRelationshipType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.sdtcPrecondition1.​conjunctionCode | Base | required | RelationshipConjunction | 📍2.0.0 | THO v5.2 |
| Id | Grade | Path(s) | Description | Expression |
| II-1 | error | Observation.typeId, Observation.entryRelationship:supportingObs.typeId, Observation.referenceRange.typeId, Observation.referenceRange.observationRange.typeId, Observation.referenceRange.observationRange.sdtcPrecondition1.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
| category-survey | error | Observation | If category is present, then there shall be a category with code 'survey'. |
sdtcCategory.empty() or sdtcCategory.exists(code = 'survey' and codeSystem = '2.16.840.1.113883.4.642.1.1125')
|
| should-sdtcCategory | warning | Observation | SHOULD contain sdtcCategory |
sdtcCategory.exists()
|
| should-text | warning | Observation.referenceRange.observationRange | SHOULD contain text |
text.exists()
|
| should-text-ref-value | warning | Observation, Observation.referenceRange.observationRange | SHOULD contain text/reference/@value |
text.reference.value.exists()
|
| should-translation | warning | Observation.code | SHOULD contain translation |
translation.exists()
|
| value-starts-octothorpe | error | Observation.text.reference, Observation.referenceRange.observationRange.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 Filter: |
|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value, should-sdtcCategory, category-survey |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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:assessment-scale-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: 2.16.840.1.113883.10.20.22.4.69 | |
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |
| @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 | ||
| Slices for sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc Category is optional, but if present it SHALL contain a category with code=survey. Slice: Unordered, Open by value:code, value:codeSystem XML: category (urn:hl7-org:sdtc) | |
| sdtcCategory:survey |
0..1 | CD | XML Namespace: urn:hl7-org:sdtc Survey XML: category (urn:hl7-org:sdtc) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: survey | |
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.4.642.1.1125 | |
| @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 | ||
| code |
C | 1..1 | CD | For Social Determinant of Health Assessments Binding: Screening and Assessment Survey Codes (required)Constraints: should-translation |
| @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 | Binding: Social Determinants of Health Screening Assessments And Questions (preferred) | |
| derivationExpr |
0..1 | ST | Such derivation expression can contain a text calculation of how the components total up to the summed score | |
| 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 | Constraints: value-starts-octothorpe |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| @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 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) | |
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| value |
1..1 | This is intended to hold the overall assessment score. This could be calculated from the contained Assessment Scale Supporting Observations | ||
| 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 | |||
| interpretationCode |
0..* | CE | Binding: CDAObservationInterpretation (required) | |
| @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 | ||
| translation |
0..* | CD | ||
| methodCode |
0..* | CE | Binding: ObservationMethod (example) | |
| targetSiteCode |
0..* | CD | ||
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | Author | ||
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, value:typeCode | |
| entryRelationship:supportingObs |
0..* | EntryRelationship | entryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd |
0..1 | bl | ||
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
1..1 | AssessmentScaleSupportingObservation | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| referenceRange |
0..* | InfrastructureRoot | The 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) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
C | 1..1 | ObservationRange | Constraints: should-text, should-text-ref-value |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 | The 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) | |
| @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 | Constraints: value-starts-octothorpe |
| thumbnail |
0..1 | ED | ||
| value |
0..1 | |||
| 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 |
C | 0..1 | II | Constraints: II-1 |
| @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 | Status | Usage | ValueSet | Version | Source |
| Observation.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.templateId:assessment-scale-obs.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.classCode | Base | required | CDAActClassObservation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.moodCode | Base | required | x_ActMoodDocumentObservation | 📍2.0.0 | THO v5.2 |
| Observation.sdtcCategory:survey.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.code | Base | required |
Screening and Assessment Survey Codes
|
📦20241008 | VSAC v0.23 |
| Observation.code.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.code.translation | Base | preferred |
Social Determinants of Health Screening Assessments And Questions
|
📦20241214 | VSAC v0.23 |
| Observation.text.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.text.compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.text.integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2 |
| Observation.text.mediaType | Base | example | MediaType | 📦3.0.0 | THO v6.5 |
| Observation.text.representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5 |
| Observation.statusCode.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5 |
| Observation.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std. |
| Observation.interpretationCode | Base | required | CDAObservationInterpretation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.interpretationCode.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.methodCode | Base | example | ObservationMethod | 📦3.0.0 | THO v6.5 |
| Observation.entryRelationship:supportingObs.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:supportingObs.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:supportingObs.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​typeCode | Base | required | CDAActRelationshipType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.classCode | Base | required | CDAActClassObservation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.moodCode | Base | required | ActMoodPredicate | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​observationRange.code | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​observationRange.text.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.text.​compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.text.​integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2 |
| Observation.referenceRange.​observationRange.text.​mediaType | Base | example | MediaType | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​observationRange.text.​representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.interpretationCode | Base | required | CDAObservationInterpretation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.sdtcPrecondition1.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.sdtcPrecondition1.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.sdtcPrecondition1.​typeCode | Base | required | CDAActRelationshipType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​observationRange.sdtcPrecondition1.​conjunctionCode | Base | required | RelationshipConjunction | 📍2.0.0 | THO v5.2 |
| Id | Grade | Path(s) | Description | Expression |
| II-1 | error | Observation.typeId, Observation.entryRelationship:supportingObs.typeId, Observation.referenceRange.typeId, Observation.referenceRange.observationRange.typeId, Observation.referenceRange.observationRange.sdtcPrecondition1.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
| category-survey | error | Observation | If category is present, then there shall be a category with code 'survey'. |
sdtcCategory.empty() or sdtcCategory.exists(code = 'survey' and codeSystem = '2.16.840.1.113883.4.642.1.1125')
|
| should-sdtcCategory | warning | Observation | SHOULD contain sdtcCategory |
sdtcCategory.exists()
|
| should-text | warning | Observation.referenceRange.observationRange | SHOULD contain text |
text.exists()
|
| should-text-ref-value | warning | Observation, Observation.referenceRange.observationRange | SHOULD contain text/reference/@value |
text.reference.value.exists()
|
| should-translation | warning | Observation.code | SHOULD contain translation |
translation.exists()
|
| value-starts-octothorpe | error | Observation.text.reference, Observation.referenceRange.observationRange.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(3 nested mandatory elements)
Fixed: 4 elements
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 based on FHIR 5.0.0. Generated 2025-10-02
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