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: GoalObservation - Detailed Descriptions

Draft as of 2024-12-19

Definitions for the GoalObservation 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-effectiveTime: SHOULD contain effectiveTime (effectiveTime.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:goal-obs
    Slice Namegoal-obs
    Control1..1
    6. Observation.templateId:goal-obs.root
    Control1..?
    Pattern Value2.16.840.1.113883.10.20.22.4.121
    8. Observation.templateId:goal-obs.extension
    Control1..?
    Pattern Value2022-06-01
    10. Observation.classCode
    Comments

    SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:4515-30418).

    Fixed ValueOBS
    12. Observation.moodCode
    Comments

    SHALL contain exactly one [1..1] @moodCode="GOL" Goal (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:4515-30419).

    Fixed ValueGOL
    14. Observation.id
    Comments

    SHALL contain at least one [1..*] id (CONF:4515-32332).

    Control1..?
    16. Observation.code
    ShortWhen the Goal is Social Determinant of Health Goal, the observation/code SHOULD contain exactly one [1..1] code, which SHOULD contain exactly one [1..1] @code="8689-2 "History of Social function
    Comments

    This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1).

    18. Observation.text
    ShortSHOULD reference the portion of section narrative text corresponding to this entry
    20. 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('#'))
    22. Observation.statusCode
    Comments

    SHALL contain exactly one [1..1] statusCode (CONF:4515-32333).

    Control1..?
    24. Observation.statusCode.nullFlavor
    Control0..0
    26. Observation.statusCode.code
    Control1..?
    BindingThe codes SHALL be taken from ActStatus
    (required to http://terminology.hl7.org/ValueSet/v3-ActStatus)
    28. Observation.effectiveTime
    ShorteffectiveTime/low represents when to start working on the goal. effectiveTime/high or effectiveTime/value represents when the goal should be met (i.e. a due date)
    Comments

    SHOULD contain zero or one [0..1] effectiveTime (CONF:4515-32335).

    30. Observation.value
    Control0..1
    SlicingThis element introduces a set of slices on Observation.value. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • type @ $this
    • 32. Observation.value:coded
      Slice Namecoded
      Control0..1
      Binding

      See additional binding

      Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
      34. Observation.author
      ShortIf the author is the recordTarget (patient), this is a patient goal. If the author is a provider, this is a provider goal. If both patient and provider are authors, this is a negotiated goal. If no author is present, it is assumed the document or section author(s) is the author of this goal.
      Comments

      SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:4515-30995).

      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Author(Author Participation)
      36. Observation.entryRelationship
      Comments

      MAY contain zero or more [0..*] entryRelationship (CONF:4515-31559) such that it

      SlicingThis element introduces a set of slices on Observation.entryRelationship. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • profile @ act
      • profile @ observation
      • value @ typeCode
      • 38. Observation.entryRelationship:refersTo
        Slice NamerefersTo
        ShortThe following entryRelationship represents the relationship between a Goal Observation and another entry (usually a Health Concern Act) (Goal Observation REFERS TO Health Concern Act) already described in the CDA document instance. Rather than clone the whole entry, an Entry Reference may be used in this entryRelationship to reference this entry.
        Comments

        MAY contain zero or more [0..*] entryRelationship (CONF:4515-30701) such that it

        Control0..*
        40. Observation.entryRelationship:refersTo.typeCode
        Comments

        SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:4515-30702).

        Fixed ValueREFR
        42. Observation.entryRelationship:refersTo.act
        Comments

        SHALL contain exactly one [1..1] Entry Reference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.122) (CONF:4515-30703).

        Control1..?
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Act(Entry Reference)
        44. Observation.entryRelationship:componentEntry
        Slice NamecomponentEntry
        ShortThe following entryRelationship represents a planned component of the goal such as Planned Encounter (V2), Planned Procedure (V2), Planned Medication Activity (V2), Planned Supply (V2), Planned Act (V2) or Planned Immunization Activity. Because these entries are already described in the Interventions Section of the CDA document instance, rather than repeating the full content of the entries, the Entry Reference template may be used to reference the entries.
        Comments

        MAY contain zero or more [0..*] entryRelationship (CONF:4515-30704) such that it

        Control0..*
        46. Observation.entryRelationship:componentEntry.typeCode
        Comments

        SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:4515-30705).

        Fixed ValueCOMP
        48. Observation.entryRelationship:componentEntry.act
        Comments

        SHALL contain exactly one [1..1] Entry Reference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.122) (CONF:4515-32879).

        Control1..?
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Act(Entry Reference)
        50. Observation.entryRelationship:priorityPreference
        Slice NamepriorityPreference
        ShortThe following entryRelationship represents the priority that the patient or a provider puts on the goal.
        Comments

        SHOULD contain zero or one [0..1] entryRelationship (CONF:4515-30785) such that it

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

        SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:4515-30786).

        Fixed ValueREFR
        54. Observation.entryRelationship:priorityPreference.observation
        Comments

        SHALL contain exactly one [1..1] Priority Preference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.143) (CONF:4515-30787).

        Control1..?
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Priority Preference)
        56. Observation.entryRelationship:goal
        Slice Namegoal
        ShortThe following entryRelationship represents the relationship between two Goal Observations where the target is a component of the source (Goal Observation HAS COMPONENT Goal Observation). The component goal (target) is a Milestone.
        Comments

        MAY contain zero or more [0..*] entryRelationship (CONF:4515-31448) such that it

        Control0..*
        58. Observation.entryRelationship:goal.typeCode
        Comments

        SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:4515-31449).

        Fixed ValueCOMP
        60. Observation.entryRelationship:goal.observation
        Comments

        SHALL contain exactly one [1..1] Goal Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.121) (CONF:4515-32880).

        Control1..?
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Goal Observation)
        62. Observation.entryRelationship:progressTowardGoal
        Slice NameprogressTowardGoal
        ShortentryRelationship
        Comments

        MAY contain zero or more [0..*] entryRelationship such that it

        Control0..*
        64. Observation.entryRelationship:progressTowardGoal.typeCode
        Comments

        SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:4515-31560).

        Fixed ValueREFR
        66. Observation.entryRelationship:progressTowardGoal.observation
        Shortact
        Comments

        SHALL contain exactly one [1..1] Progress Toward Goal Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.110).

        Control1..?
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Progress Toward Goal Observation)
        68. Observation.reference
        ShortWhere it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument.
        Comments

        MAY contain zero or more [0..*] reference (CONF:4515-32754).

        70. Observation.reference.typeCode
        Comments

        The reference, if present, SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:4515-32755).

        Fixed ValueREFR
        72. Observation.reference.externalDocument
        Comments

        The reference, if present, SHALL contain exactly one [1..1] External Document Reference (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.115:2014-06-09) (CONF:4515-32756).

        Control1..?
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/ExternalDocument(External Document Reference)