Consolidated CDA (C-CDA)
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Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 4.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions

Logical Model: FunctionalStatusObservation - Detailed Descriptions

Draft as of 2024-12-19

Definitions for the FunctionalStatusObservation logical model.

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

0. Observation
Logical ContainerClinicalDocument (CDA Class)
ValidationInstance of this type are validated by templateId
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
Invariantsshould-text-ref-value: SHOULD contain text/reference/@value (text.reference.value.exists())
should-author: SHOULD contain author (author.exists())
2. Observation.templateId
Control1..?
SlicingThis element introduces a set of slices on Observation.templateId. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ root
  • value @ extension
  • 4. Observation.templateId:functional-status-obs
    Slice Namefunctional-status-obs
    Control1..1
    6. Observation.templateId:functional-status-obs.root
    Control1..?
    Pattern Value2.16.840.1.113883.10.20.22.4.67
    8. Observation.templateId:functional-status-obs.extension
    Control1..?
    Pattern Value2014-06-09
    10. Observation.classCode
    Comments

    SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-13905).

    Fixed ValueOBS
    12. Observation.moodCode
    Comments

    SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-13906).

    Fixed ValueEVN
    14. Observation.id
    Comments

    SHALL contain at least one [1..*] id (CONF:1098-13907).

    Control1..?
    16. Observation.code
    ShortFunctional status
    Comments

    This code SHALL contain exactly one [1..1] @code="54522-8" Functional status (CONF:1098-31522).

    18. Observation.code.code
    Control1..?
    Pattern Value54522-8
    20. Observation.code.codeSystem
    ShortLOINC
    Control1..?
    Pattern Value2.16.840.1.113883.6.1
    22. Observation.text
    ShortSHOULD reference the portion of section narrative text corresponding to this entry
    24. Observation.text.reference
    Invariantsvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative (value.exists() implies value.startsWith('#'))
    26. Observation.statusCode
    Comments

    SHALL contain exactly one [1..1] statusCode (CONF:1098-13929).

    Control1..?
    28. Observation.statusCode.code
    Comments

    This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: HL7ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:1098-19101).

    Control1..?
    Fixed Valuecompleted
    30. Observation.effectiveTime
    Comments

    SHALL contain exactly one [1..1] effectiveTime (CONF:1098-13930).

    Control1..?
    32. Observation.value
    Comments

    SHALL contain exactly one [1..1] value (CONF:1098-13932).

    Control1..1
    Invariants1098-14234: If coded, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1098-14234). (codeSystem.exists() implies codeSystem = '2.16.840.1.113883.6.96')
    34. Observation.author
    Comments

    SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-13936).

    Typehttp://hl7.org/cda/stds/core/StructureDefinition/Author(Author Participation)
    36. Observation.entryRelationship
    SlicingThis element introduces a set of slices on Observation.entryRelationship. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • profile @ supply
    • profile @ observation
    • value @ typeCode
    • 38. Observation.entryRelationship:nonMedSupply
      Slice NamenonMedSupply
      Comments

      MAY contain zero or one [0..1] entryRelationship (CONF:1098-13892) such that it

      Control0..1
      40. Observation.entryRelationship:nonMedSupply.typeCode
      Comments

      SHALL contain exactly one [1..1] @typeCode="REFR" refers to (CONF:1098-14596).

      Fixed ValueREFR
      42. Observation.entryRelationship:nonMedSupply.supply
      Comments

      SHALL contain exactly one [1..1] Non-Medicinal Supply Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.50:2014-06-09) (CONF:1098-14218).

      Control1..?
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Supply(Non-Medicinal Supply Activity)
      44. Observation.entryRelationship:caregiverCharacteristics
      Slice NamecaregiverCharacteristics
      Comments

      MAY contain zero or one [0..1] entryRelationship (CONF:1098-13895) such that it

      Control0..1
      46. Observation.entryRelationship:caregiverCharacteristics.typeCode
      Comments

      SHALL contain exactly one [1..1] @typeCode="REFR" refers to (CONF:1098-14597).

      Fixed ValueREFR
      48. Observation.entryRelationship:caregiverCharacteristics.observation
      Comments

      SHALL contain exactly one [1..1] Caregiver Characteristics (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.72) (CONF:1098-13897).

      Control1..?
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Caregiver Characteristics)
      50. Observation.entryRelationship:assessmentScaleObservation
      Slice NameassessmentScaleObservation
      Short𝗨𝗦𝗖𝗗𝗜: Functional Status
      Comments

      MAY contain zero or one [0..1] entryRelationship (CONF:1098-14465) such that it

      Control0..1
      52. Observation.entryRelationship:assessmentScaleObservation.typeCode
      Comments

      SHALL contain exactly one [1..1] @typeCode="COMP" has component (CONF:1098-14598).

      Fixed ValueCOMP
      54. Observation.entryRelationship:assessmentScaleObservation.observation
      Comments

      SHALL contain exactly one [1..1] Assessment Scale Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.69) (CONF:1098-14466).

      Control1..?
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Assessment Scale Observation)
      56. Observation.referenceRange
      ShortreferenceRange could be used to represent normal or expected capability for the function being evaluated.
      Comments

      MAY contain zero or more [0..*] referenceRange (CONF:1098-13937).