Consolidated CDA (C-CDA)
4.0.0-ballot - STU4 Ballot
Consolidated CDA (C-CDA)
4.0.0-ballot - STU4 Ballot
Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 4.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentScaleObservation | Version: 4.0.0-ballot | |||
| Draft as of 2024-12-19 | 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.
Usage:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
  Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value | ||||||
  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 | ||||||||
| code |
C | 1..1 | CD | survey should-translation: SHOULD contain translation | ||||||
| @code |
1..1 | cs | Required Pattern: survey | |||||||
| @codeSystem |
1..1 | oid, uuid, ruid | Observation Category Codes Required Pattern: 2.16.840.1.113883.4.642.1.1125 | |||||||
 translation |
0..* | CD | Binding: Screening and Assesment Survey Codes  (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 | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| 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 | Intended 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 | |||||||
| 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 | Base for all types and resources | |||||||
 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 | should-text: SHOULD contain text should-text-ref-value: SHOULD contain text/reference/@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 | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet | URI |
| Observation.code.translation | preferred | ScreeningAndAssesmentSurveyCodes http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.13 |
| Id | Grade | Path(s) | Details | Requirements |
| 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 | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value | ||||||
 @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
| @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 | ||||||||
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |||||||
| code |
C | 1..1 | CD | survey Binding: ObservationType (example) should-translation: SHOULD contain translation | ||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code |
1..1 | cs | Required Pattern: survey | |||||||
| @codeSystem |
1..1 | oid, uuid, ruid | Observation Category Codes 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 | Binding: Screening and Assesment Survey Codes (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 | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| thumbnail |
0..1 | ED | ||||||||
| statusCode |
1..1 | CS | 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 | Intended 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 | ||||||||
 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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
 @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 |
C | 1..1 | AssessmentScaleSupportingObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| 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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
| @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 | should-text: SHOULD contain text should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
| @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 | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| 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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: PRCN | |||||||
| conjunctionCode |
1..1 | CS | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc Binding: RelationshipConjunction (2.0.0) (required) | |||||||
| criterion1 |
1..1 | Criterion | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |||||||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.templateId:assessment-scale-obs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
| Observation.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.code.translation | preferred | ScreeningAndAssesmentSurveyCodes http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.13 | |
| Observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.interpretationCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
| Observation.entryRelationship:supportingObs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:supportingObs.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:supportingObs.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.referenceRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.typeCode | required | Fixed Value: REFVhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
| Observation.referenceRange.observationRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.classCode | required | CDAActClassObservationhttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.referenceRange.observationRange.moodCode | required | Fixed Value: EVN.CRThttp://terminology.hl7.org/ValueSet/v3-ActMoodPredicate | |
| Observation.referenceRange.observationRange.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Observation.referenceRange.observationRange.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Observation.referenceRange.observationRange.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Observation.referenceRange.observationRange.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Observation.referenceRange.observationRange.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Observation.referenceRange.observationRange.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.typeCode | required | Fixed Value: PRCNhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.conjunctionCode | required | RelationshipConjunctionhttp://terminology.hl7.org/ValueSet/v3-RelationshipConjunction|2.0.0 |
| Id | Grade | Path(s) | Details | Requirements |
| 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() | |
| 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-text-ref-value | warning | Observation.entryRelationship:supportingObs.observation | 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 | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
| @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 | ||||||||
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |||||||
| code |
C | 1..1 | CD | survey Binding: ObservationType (example) should-translation: SHOULD contain translation | ||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code |
1..1 | cs | Required Pattern: survey | |||||||
| @codeSystem |
1..1 | oid, uuid, ruid | Observation Category Codes 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 | Binding: Screening and Assesment Survey Codes (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 | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| thumbnail |
0..1 | ED | ||||||||
| statusCode |
1..1 | CS | 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 | Intended 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 | ||||||||
| 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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
| @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 |
C | 1..1 | AssessmentScaleSupportingObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| 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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
| @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 | should-text: SHOULD contain text should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
| @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 | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| 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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: PRCN | |||||||
| conjunctionCode |
1..1 | CS | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc Binding: RelationshipConjunction (2.0.0) (required) | |||||||
| criterion1 |
1..1 | Criterion | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |||||||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.templateId:assessment-scale-obs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
| Observation.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.code.translation | preferred | ScreeningAndAssesmentSurveyCodes http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.13 | |
| Observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.interpretationCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
| Observation.entryRelationship:supportingObs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:supportingObs.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:supportingObs.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.referenceRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.typeCode | required | Fixed Value: REFVhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
| Observation.referenceRange.observationRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.classCode | required | CDAActClassObservationhttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.referenceRange.observationRange.moodCode | required | Fixed Value: EVN.CRThttp://terminology.hl7.org/ValueSet/v3-ActMoodPredicate | |
| Observation.referenceRange.observationRange.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Observation.referenceRange.observationRange.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Observation.referenceRange.observationRange.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Observation.referenceRange.observationRange.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Observation.referenceRange.observationRange.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Observation.referenceRange.observationRange.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.typeCode | required | Fixed Value: PRCNhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.conjunctionCode | required | RelationshipConjunctionhttp://terminology.hl7.org/ValueSet/v3-RelationshipConjunction|2.0.0 |
| Id | Grade | Path(s) | Details | Requirements |
| 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() | |
| 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-text-ref-value | warning | Observation.entryRelationship:supportingObs.observation | 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: 11 elements(1 nested mandatory element)
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 | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| 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 | ||||||||
| code |
C | 1..1 | CD | survey should-translation: SHOULD contain translation | ||||||
| @code |
1..1 | cs | Required Pattern: survey | |||||||
| @codeSystem |
1..1 | oid, uuid, ruid | Observation Category Codes Required Pattern: 2.16.840.1.113883.4.642.1.1125 | |||||||
| translation |
0..* | CD | Binding: Screening and Assesment Survey Codes (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 | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| 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 | Intended 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 | |||||||
| 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 | Base for all types and resources | |||||||
| 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 | should-text: SHOULD contain text should-text-ref-value: SHOULD contain text/reference/@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 | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet | URI |
| Observation.code.translation | preferred | ScreeningAndAssesmentSurveyCodes http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.13 |
| Id | Grade | Path(s) | Details | Requirements |
| 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 | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
| @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 | ||||||||
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |||||||
| code |
C | 1..1 | CD | survey Binding: ObservationType (example) should-translation: SHOULD contain translation | ||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code |
1..1 | cs | Required Pattern: survey | |||||||
| @codeSystem |
1..1 | oid, uuid, ruid | Observation Category Codes 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 | Binding: Screening and Assesment Survey Codes (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 | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| thumbnail |
0..1 | ED | ||||||||
| statusCode |
1..1 | CS | 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 | Intended 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 | ||||||||
| 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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
| @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 |
C | 1..1 | AssessmentScaleSupportingObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| 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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
| @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 | should-text: SHOULD contain text should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
| @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 | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| 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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: PRCN | |||||||
| conjunctionCode |
1..1 | CS | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc Binding: RelationshipConjunction (2.0.0) (required) | |||||||
| criterion1 |
1..1 | Criterion | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |||||||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.templateId:assessment-scale-obs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
| Observation.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.code.translation | preferred | ScreeningAndAssesmentSurveyCodes http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.13 | |
| Observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.interpretationCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
| Observation.entryRelationship:supportingObs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:supportingObs.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:supportingObs.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.referenceRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.typeCode | required | Fixed Value: REFVhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
| Observation.referenceRange.observationRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.classCode | required | CDAActClassObservationhttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.referenceRange.observationRange.moodCode | required | Fixed Value: EVN.CRThttp://terminology.hl7.org/ValueSet/v3-ActMoodPredicate | |
| Observation.referenceRange.observationRange.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Observation.referenceRange.observationRange.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Observation.referenceRange.observationRange.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Observation.referenceRange.observationRange.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Observation.referenceRange.observationRange.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Observation.referenceRange.observationRange.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.typeCode | required | Fixed Value: PRCNhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.conjunctionCode | required | RelationshipConjunctionhttp://terminology.hl7.org/ValueSet/v3-RelationshipConjunction|2.0.0 |
| Id | Grade | Path(s) | Details | Requirements |
| 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() | |
| 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-text-ref-value | warning | Observation.entryRelationship:supportingObs.observation | 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 | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
| @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 | ||||||||
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |||||||
| code |
C | 1..1 | CD | survey Binding: ObservationType (example) should-translation: SHOULD contain translation | ||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code |
1..1 | cs | Required Pattern: survey | |||||||
| @codeSystem |
1..1 | oid, uuid, ruid | Observation Category Codes 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 | Binding: Screening and Assesment Survey Codes (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 | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| thumbnail |
0..1 | ED | ||||||||
| statusCode |
1..1 | CS | 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 | Intended 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 | ||||||||
| 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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
| @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 |
C | 1..1 | AssessmentScaleSupportingObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| 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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
| @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 | should-text: SHOULD contain text should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. | ||||||
| @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 | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| 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 | II-1: An II instance must have either a root or an nullFlavor. | ||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: PRCN | |||||||
| conjunctionCode |
1..1 | CS | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc Binding: RelationshipConjunction (2.0.0) (required) | |||||||
| criterion1 |
1..1 | Criterion | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |||||||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.templateId:assessment-scale-obs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
| Observation.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.code.translation | preferred | ScreeningAndAssesmentSurveyCodes http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.13 | |
| Observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.interpretationCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
| Observation.entryRelationship:supportingObs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:supportingObs.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:supportingObs.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.referenceRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.typeCode | required | Fixed Value: REFVhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
| Observation.referenceRange.observationRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.classCode | required | CDAActClassObservationhttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.referenceRange.observationRange.moodCode | required | Fixed Value: EVN.CRThttp://terminology.hl7.org/ValueSet/v3-ActMoodPredicate | |
| Observation.referenceRange.observationRange.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Observation.referenceRange.observationRange.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Observation.referenceRange.observationRange.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Observation.referenceRange.observationRange.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Observation.referenceRange.observationRange.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Observation.referenceRange.observationRange.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.typeCode | required | Fixed Value: PRCNhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.conjunctionCode | required | RelationshipConjunctionhttp://terminology.hl7.org/ValueSet/v3-RelationshipConjunction|2.0.0 |
| Id | Grade | Path(s) | Details | Requirements |
| 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() | |
| 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-text-ref-value | warning | Observation.entryRelationship:supportingObs.observation | 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: 11 elements(1 nested mandatory element)
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-ballot based on FHIR 5.0.0. Generated 2024-12-19
Links: Table of Contents |
QA Report
| Version History |
|
Propose a change