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/GoalObservation | Version: 4.0.0-ballot | |||
Draft as of 2024-12-19 | Computable Name: GoalObservation | |||
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.121:2022-06-01 |
This template represents a patient health goal. A Goal Observation template may have related components that are acts, encounters, observations, procedures, substance administrations, or supplies. A goal identifies a future desired condition or state. Goals are often related to physical or mental health conditions or diseases, but also may be related to a Social Determinant of Health (SDOH) risks or states. For example, to have adequate quality meals and snacks, gain transportation security - able to access health and social needs). SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes. A Goal is established by the patient or provider or both.
A goal may be a patient or provider goal. If the author is set to the recordTarget (patient), this is a patient goal. If the author is set to a provider, this is a provider goal. If both patient and provider are set as authors, this is called a negotiated or shared goal.
A goal usually has a related health concern and/or risk.
A goal may have components consisting of other goals (milestones). These milestones are related to the overall goal through entryRelationships.
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 should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
templateId:goal-obs | 1..1 | II | ||||||||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.121 | |||||||
@extension | 1..1 | st | Required Pattern: 2022-06-01 | |||||||
@classCode | 1..1 | cs | Fixed Value: OBS | |||||||
@moodCode | 1..1 | cs | Fixed Value: GOL | |||||||
id | 1..* | II | ||||||||
code | 1..1 | CD | When 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 | |||||||
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 | ||||||||
@nullFlavor | 0..0 | |||||||||
@code | 1..1 | cs | Binding: ActStatus (required) | |||||||
effectiveTime | 0..1 | IVL_TS | effectiveTime/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) | |||||||
Slices for value | 0..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 | Slice: Unordered, Open by type:$this | |||||||
value:coded | 0..1 | CD | Binding Description (No ValueSet): (example): See additional binding
| |||||||
author | 0..* | AuthorParticipation | If 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. | |||||||
Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation, value:typeCode | |||||||
entryRelationship:refersTo | 0..* | EntryRelationship | The 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. | |||||||
@typeCode | 1..1 | cs | Fixed Value: REFR | |||||||
act | 1..1 | EntryReference | Base for all types and resources | |||||||
entryRelationship:componentEntry | 0..* | EntryRelationship | The 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. | |||||||
@typeCode | 1..1 | cs | Fixed Value: COMP | |||||||
act | 1..1 | EntryReference | Base for all types and resources | |||||||
entryRelationship:priorityPreference | 0..1 | EntryRelationship | The following entryRelationship represents the priority that the patient or a provider puts on the goal. | |||||||
@typeCode | 1..1 | cs | Fixed Value: REFR | |||||||
observation | 1..1 | PriorityPreference | Base for all types and resources | |||||||
entryRelationship:goal | 0..* | EntryRelationship | The 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. | |||||||
@typeCode | 1..1 | cs | Fixed Value: COMP | |||||||
observation | 1..1 | GoalObservation | Base for all types and resources | |||||||
entryRelationship:progressTowardGoal | 0..* | EntryRelationship | entryRelationship | |||||||
@typeCode | 1..1 | cs | Fixed Value: REFR | |||||||
observation | 1..1 | ProgressTowardGoalObservation | act | |||||||
reference | 0..* | Reference | Where 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. | |||||||
@typeCode | 1..1 | cs | Fixed Value: REFR | |||||||
externalDocument | 1..1 | ExternalDocumentReference | Base for all types and resources | |||||||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.statusCode.code | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
Observation.value:coded | example |
|
Id | Grade | Path(s) | Details | Requirements |
should-author | warning | Observation | SHOULD contain author : author.exists() | |
should-effectiveTime | warning | Observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
value-starts-octothorpe | error | Observation.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 should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
@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:goal-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: 2.16.840.1.113883.10.20.22.4.121 | |||||||
@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: GOL | |||||||
@negationInd | 0..1 | bl | ||||||||
id | 1..* | II | ||||||||
sdtcCategory | 0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |||||||
code | 1..1 | CD | When 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 Binding: ObservationType (example) | |||||||
derivationExpr | 0..1 | ST | ||||||||
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) | |||||||
@code | 1..1 | cs | Binding: ActStatus (required) | |||||||
@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 | 0..1 | IVL_TS | effectiveTime/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) | |||||||
priorityCode | 0..1 | CE | Binding: ActPriority (example) | |||||||
repeatNumber | 0..1 | IVL_INT | ||||||||
languageCode | 0..1 | CS | Binding: AllLanguages (required) | |||||||
Slices for value | 0..1 | Slice: Unordered, Open by type:$this | ||||||||
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 | |||||||||
value:coded | 0..1 | CD | Binding Description (No ValueSet): (example): See additional binding
| |||||||
interpretationCode | 0..* | CE | Binding: CDAObservationInterpretation (required) | |||||||
methodCode | 0..* | CE | Binding: ObservationMethod (example) | |||||||
targetSiteCode | 0..* | CD | ||||||||
subject | 0..1 | Subject | ||||||||
specimen | 0..* | Specimen | ||||||||
performer | 0..* | Performer2 | ||||||||
author | 0..* | AuthorParticipation | If 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. | |||||||
informant | 0..* | Informant | ||||||||
participant | 0..* | Participant2 | ||||||||
Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation, value:typeCode | |||||||
entryRelationship:refersTo | 0..* | EntryRelationship | The 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. | |||||||
@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: REFR | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
encounter | 0..1 | Encounter | ||||||||
observation | 0..1 | Observation | ||||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:componentEntry | 0..* | EntryRelationship | The 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. | |||||||
@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 | C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
encounter | 0..1 | Encounter | ||||||||
observation | 0..1 | Observation | ||||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:priorityPreference | 0..1 | EntryRelationship | The following entryRelationship represents the priority that the patient or a provider puts on the goal. | |||||||
@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: REFR | |||||||
@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 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:goal | 0..* | EntryRelationship | The 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. | |||||||
@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 | GoalObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:progressTowardGoal | 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: REFR | |||||||
@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 | ProgressTowardGoalObservation | act 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 | Where 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. | |||||||
@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_ActRelationshipExternalReference (required) Fixed Value: REFR | |||||||
seperatableInd | 0..1 | BL | ||||||||
externalAct | 0..1 | ExternalAct | ||||||||
externalObservation | 0..1 | ExternalObservation | ||||||||
externalProcedure | 0..1 | ExternalProcedure | ||||||||
externalDocument | C | 1..1 | ExternalDocumentReference | Base for all types and resources should-setId: SHOULD contain setId should-versionNumber: SHOULD contain versionNumber | ||||||
precondition | 0..* | Precondition | ||||||||
sdtcPrecondition2 | 0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |||||||
referenceRange | 0..* | InfrastructureRoot | ||||||||
@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 | 1..1 | ObservationRange | ||||||||
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:goal-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: GOLhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
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.code | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
Observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Observation.value:coded | example | ||
Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
Observation.entryRelationship:refersTo.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:refersTo.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:refersTo.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.entryRelationship:componentEntry.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:componentEntry.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:componentEntry.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.entryRelationship:priorityPreference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:priorityPreference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:priorityPreference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.entryRelationship:goal.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:goal.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:goal.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.entryRelationship:progressTowardGoal.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:progressTowardGoal.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:progressTowardGoal.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.reference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.reference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.reference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipExternalReference | |
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 |
Id | Grade | Path(s) | Details | Requirements |
II-1 | error | Observation.typeId, Observation.entryRelationship:refersTo.typeId, Observation.entryRelationship:componentEntry.typeId, Observation.entryRelationship:priorityPreference.typeId, Observation.entryRelationship:goal.typeId, Observation.entryRelationship:progressTowardGoal.typeId, Observation.reference.typeId, Observation.referenceRange.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
should-author | warning | Observation, Observation.entryRelationship:goal.observation | SHOULD contain author : author.exists() | |
should-author | warning | Observation.entryRelationship:priorityPreference.observation | SHOULD contain author : author.exists() | |
should-effectiveTime | warning | Observation, Observation.entryRelationship:goal.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
should-effectiveTime | warning | Observation.entryRelationship:priorityPreference.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
should-setId | warning | Observation.reference.externalDocument | SHOULD contain setId : setId.exists() | |
should-text-ref-value | warning | Observation, Observation.entryRelationship:goal.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
should-text-ref-value | warning | Observation.entryRelationship:refersTo.act, Observation.entryRelationship:componentEntry.act, Observation.entryRelationship:priorityPreference.observation, Observation.entryRelationship:progressTowardGoal.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
should-versionNumber | warning | Observation.reference.externalDocument | SHOULD contain versionNumber : versionNumber.exists() | |
value-starts-octothorpe | error | Observation.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 should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
@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:goal-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: 2.16.840.1.113883.10.20.22.4.121 | |||||||
@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: GOL | |||||||
@negationInd | 0..1 | bl | ||||||||
id | 1..* | II | ||||||||
sdtcCategory | 0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |||||||
code | 1..1 | CD | When 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 Binding: ObservationType (example) | |||||||
derivationExpr | 0..1 | ST | ||||||||
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) | |||||||
@code | 1..1 | cs | Binding: ActStatus (required) | |||||||
@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 | 0..1 | IVL_TS | effectiveTime/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) | |||||||
priorityCode | 0..1 | CE | Binding: ActPriority (example) | |||||||
repeatNumber | 0..1 | IVL_INT | ||||||||
languageCode | 0..1 | CS | Binding: AllLanguages (required) | |||||||
Slices for value | 0..1 | Slice: Unordered, Open by type:$this | ||||||||
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 | |||||||||
value:coded | 0..1 | CD | Binding Description (No ValueSet): (example): See additional binding
| |||||||
interpretationCode | 0..* | CE | Binding: CDAObservationInterpretation (required) | |||||||
methodCode | 0..* | CE | Binding: ObservationMethod (example) | |||||||
targetSiteCode | 0..* | CD | ||||||||
subject | 0..1 | Subject | ||||||||
specimen | 0..* | Specimen | ||||||||
performer | 0..* | Performer2 | ||||||||
author | 0..* | AuthorParticipation | If 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. | |||||||
informant | 0..* | Informant | ||||||||
participant | 0..* | Participant2 | ||||||||
Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation, value:typeCode | |||||||
entryRelationship:refersTo | 0..* | EntryRelationship | The 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. | |||||||
@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: REFR | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
encounter | 0..1 | Encounter | ||||||||
observation | 0..1 | Observation | ||||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:componentEntry | 0..* | EntryRelationship | The 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. | |||||||
@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 | C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
encounter | 0..1 | Encounter | ||||||||
observation | 0..1 | Observation | ||||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:priorityPreference | 0..1 | EntryRelationship | The following entryRelationship represents the priority that the patient or a provider puts on the goal. | |||||||
@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: REFR | |||||||
@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 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:goal | 0..* | EntryRelationship | The 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. | |||||||
@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 | GoalObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:progressTowardGoal | 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: REFR | |||||||
@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 | ProgressTowardGoalObservation | act 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 | Where 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. | |||||||
@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_ActRelationshipExternalReference (required) Fixed Value: REFR | |||||||
seperatableInd | 0..1 | BL | ||||||||
externalAct | 0..1 | ExternalAct | ||||||||
externalObservation | 0..1 | ExternalObservation | ||||||||
externalProcedure | 0..1 | ExternalProcedure | ||||||||
externalDocument | C | 1..1 | ExternalDocumentReference | Base for all types and resources should-setId: SHOULD contain setId should-versionNumber: SHOULD contain versionNumber | ||||||
precondition | 0..* | Precondition | ||||||||
sdtcPrecondition2 | 0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |||||||
referenceRange | 0..* | InfrastructureRoot | ||||||||
@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 | 1..1 | ObservationRange | ||||||||
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:goal-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: GOLhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
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.code | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
Observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Observation.value:coded | example | ||
Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
Observation.entryRelationship:refersTo.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:refersTo.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:refersTo.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.entryRelationship:componentEntry.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:componentEntry.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:componentEntry.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.entryRelationship:priorityPreference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:priorityPreference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:priorityPreference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.entryRelationship:goal.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:goal.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:goal.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.entryRelationship:progressTowardGoal.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:progressTowardGoal.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:progressTowardGoal.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.reference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.reference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.reference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipExternalReference | |
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 |
Id | Grade | Path(s) | Details | Requirements |
II-1 | error | Observation.typeId, Observation.entryRelationship:refersTo.typeId, Observation.entryRelationship:componentEntry.typeId, Observation.entryRelationship:priorityPreference.typeId, Observation.entryRelationship:goal.typeId, Observation.entryRelationship:progressTowardGoal.typeId, Observation.reference.typeId, Observation.referenceRange.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
should-author | warning | Observation, Observation.entryRelationship:goal.observation | SHOULD contain author : author.exists() | |
should-author | warning | Observation.entryRelationship:priorityPreference.observation | SHOULD contain author : author.exists() | |
should-effectiveTime | warning | Observation, Observation.entryRelationship:goal.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
should-effectiveTime | warning | Observation.entryRelationship:priorityPreference.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
should-setId | warning | Observation.reference.externalDocument | SHOULD contain setId : setId.exists() | |
should-text-ref-value | warning | Observation, Observation.entryRelationship:goal.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
should-text-ref-value | warning | Observation.entryRelationship:refersTo.act, Observation.entryRelationship:componentEntry.act, Observation.entryRelationship:priorityPreference.observation, Observation.entryRelationship:progressTowardGoal.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
should-versionNumber | warning | Observation.reference.externalDocument | SHOULD contain versionNumber : versionNumber.exists() | |
value-starts-octothorpe | error | Observation.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: 7 elements(6 nested mandatory elements)
Fixed: 8 elements
Prohibited: 1 element
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 should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
templateId:goal-obs | 1..1 | II | ||||||||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.121 | |||||||
@extension | 1..1 | st | Required Pattern: 2022-06-01 | |||||||
@classCode | 1..1 | cs | Fixed Value: OBS | |||||||
@moodCode | 1..1 | cs | Fixed Value: GOL | |||||||
id | 1..* | II | ||||||||
code | 1..1 | CD | When 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 | |||||||
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 | ||||||||
@nullFlavor | 0..0 | |||||||||
@code | 1..1 | cs | Binding: ActStatus (required) | |||||||
effectiveTime | 0..1 | IVL_TS | effectiveTime/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) | |||||||
Slices for value | 0..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 | Slice: Unordered, Open by type:$this | |||||||
value:coded | 0..1 | CD | Binding Description (No ValueSet): (example): See additional binding
| |||||||
author | 0..* | AuthorParticipation | If 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. | |||||||
Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation, value:typeCode | |||||||
entryRelationship:refersTo | 0..* | EntryRelationship | The 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. | |||||||
@typeCode | 1..1 | cs | Fixed Value: REFR | |||||||
act | 1..1 | EntryReference | Base for all types and resources | |||||||
entryRelationship:componentEntry | 0..* | EntryRelationship | The 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. | |||||||
@typeCode | 1..1 | cs | Fixed Value: COMP | |||||||
act | 1..1 | EntryReference | Base for all types and resources | |||||||
entryRelationship:priorityPreference | 0..1 | EntryRelationship | The following entryRelationship represents the priority that the patient or a provider puts on the goal. | |||||||
@typeCode | 1..1 | cs | Fixed Value: REFR | |||||||
observation | 1..1 | PriorityPreference | Base for all types and resources | |||||||
entryRelationship:goal | 0..* | EntryRelationship | The 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. | |||||||
@typeCode | 1..1 | cs | Fixed Value: COMP | |||||||
observation | 1..1 | GoalObservation | Base for all types and resources | |||||||
entryRelationship:progressTowardGoal | 0..* | EntryRelationship | entryRelationship | |||||||
@typeCode | 1..1 | cs | Fixed Value: REFR | |||||||
observation | 1..1 | ProgressTowardGoalObservation | act | |||||||
reference | 0..* | Reference | Where 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. | |||||||
@typeCode | 1..1 | cs | Fixed Value: REFR | |||||||
externalDocument | 1..1 | ExternalDocumentReference | Base for all types and resources | |||||||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.statusCode.code | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
Observation.value:coded | example |
|
Id | Grade | Path(s) | Details | Requirements |
should-author | warning | Observation | SHOULD contain author : author.exists() | |
should-effectiveTime | warning | Observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
value-starts-octothorpe | error | Observation.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 should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
@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:goal-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: 2.16.840.1.113883.10.20.22.4.121 | |||||||
@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: GOL | |||||||
@negationInd | 0..1 | bl | ||||||||
id | 1..* | II | ||||||||
sdtcCategory | 0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |||||||
code | 1..1 | CD | When 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 Binding: ObservationType (example) | |||||||
derivationExpr | 0..1 | ST | ||||||||
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) | |||||||
@code | 1..1 | cs | Binding: ActStatus (required) | |||||||
@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 | 0..1 | IVL_TS | effectiveTime/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) | |||||||
priorityCode | 0..1 | CE | Binding: ActPriority (example) | |||||||
repeatNumber | 0..1 | IVL_INT | ||||||||
languageCode | 0..1 | CS | Binding: AllLanguages (required) | |||||||
Slices for value | 0..1 | Slice: Unordered, Open by type:$this | ||||||||
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 | |||||||||
value:coded | 0..1 | CD | Binding Description (No ValueSet): (example): See additional binding
| |||||||
interpretationCode | 0..* | CE | Binding: CDAObservationInterpretation (required) | |||||||
methodCode | 0..* | CE | Binding: ObservationMethod (example) | |||||||
targetSiteCode | 0..* | CD | ||||||||
subject | 0..1 | Subject | ||||||||
specimen | 0..* | Specimen | ||||||||
performer | 0..* | Performer2 | ||||||||
author | 0..* | AuthorParticipation | If 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. | |||||||
informant | 0..* | Informant | ||||||||
participant | 0..* | Participant2 | ||||||||
Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation, value:typeCode | |||||||
entryRelationship:refersTo | 0..* | EntryRelationship | The 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. | |||||||
@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: REFR | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
encounter | 0..1 | Encounter | ||||||||
observation | 0..1 | Observation | ||||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:componentEntry | 0..* | EntryRelationship | The 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. | |||||||
@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 | C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
encounter | 0..1 | Encounter | ||||||||
observation | 0..1 | Observation | ||||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:priorityPreference | 0..1 | EntryRelationship | The following entryRelationship represents the priority that the patient or a provider puts on the goal. | |||||||
@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: REFR | |||||||
@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 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:goal | 0..* | EntryRelationship | The 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. | |||||||
@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 | GoalObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:progressTowardGoal | 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: REFR | |||||||
@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 | ProgressTowardGoalObservation | act 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 | Where 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. | |||||||
@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_ActRelationshipExternalReference (required) Fixed Value: REFR | |||||||
seperatableInd | 0..1 | BL | ||||||||
externalAct | 0..1 | ExternalAct | ||||||||
externalObservation | 0..1 | ExternalObservation | ||||||||
externalProcedure | 0..1 | ExternalProcedure | ||||||||
externalDocument | C | 1..1 | ExternalDocumentReference | Base for all types and resources should-setId: SHOULD contain setId should-versionNumber: SHOULD contain versionNumber | ||||||
precondition | 0..* | Precondition | ||||||||
sdtcPrecondition2 | 0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |||||||
referenceRange | 0..* | InfrastructureRoot | ||||||||
@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 | 1..1 | ObservationRange | ||||||||
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:goal-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: GOLhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
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.code | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
Observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Observation.value:coded | example | ||
Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
Observation.entryRelationship:refersTo.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:refersTo.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:refersTo.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.entryRelationship:componentEntry.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:componentEntry.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:componentEntry.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.entryRelationship:priorityPreference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:priorityPreference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:priorityPreference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.entryRelationship:goal.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:goal.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:goal.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.entryRelationship:progressTowardGoal.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:progressTowardGoal.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:progressTowardGoal.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.reference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.reference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.reference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipExternalReference | |
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 |
Id | Grade | Path(s) | Details | Requirements |
II-1 | error | Observation.typeId, Observation.entryRelationship:refersTo.typeId, Observation.entryRelationship:componentEntry.typeId, Observation.entryRelationship:priorityPreference.typeId, Observation.entryRelationship:goal.typeId, Observation.entryRelationship:progressTowardGoal.typeId, Observation.reference.typeId, Observation.referenceRange.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
should-author | warning | Observation, Observation.entryRelationship:goal.observation | SHOULD contain author : author.exists() | |
should-author | warning | Observation.entryRelationship:priorityPreference.observation | SHOULD contain author : author.exists() | |
should-effectiveTime | warning | Observation, Observation.entryRelationship:goal.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
should-effectiveTime | warning | Observation.entryRelationship:priorityPreference.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
should-setId | warning | Observation.reference.externalDocument | SHOULD contain setId : setId.exists() | |
should-text-ref-value | warning | Observation, Observation.entryRelationship:goal.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
should-text-ref-value | warning | Observation.entryRelationship:refersTo.act, Observation.entryRelationship:componentEntry.act, Observation.entryRelationship:priorityPreference.observation, Observation.entryRelationship:progressTowardGoal.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
should-versionNumber | warning | Observation.reference.externalDocument | SHOULD contain versionNumber : versionNumber.exists() | |
value-starts-octothorpe | error | Observation.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 should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
@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:goal-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: 2.16.840.1.113883.10.20.22.4.121 | |||||||
@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: GOL | |||||||
@negationInd | 0..1 | bl | ||||||||
id | 1..* | II | ||||||||
sdtcCategory | 0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |||||||
code | 1..1 | CD | When 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 Binding: ObservationType (example) | |||||||
derivationExpr | 0..1 | ST | ||||||||
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) | |||||||
@code | 1..1 | cs | Binding: ActStatus (required) | |||||||
@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 | 0..1 | IVL_TS | effectiveTime/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) | |||||||
priorityCode | 0..1 | CE | Binding: ActPriority (example) | |||||||
repeatNumber | 0..1 | IVL_INT | ||||||||
languageCode | 0..1 | CS | Binding: AllLanguages (required) | |||||||
Slices for value | 0..1 | Slice: Unordered, Open by type:$this | ||||||||
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 | |||||||||
value:coded | 0..1 | CD | Binding Description (No ValueSet): (example): See additional binding
| |||||||
interpretationCode | 0..* | CE | Binding: CDAObservationInterpretation (required) | |||||||
methodCode | 0..* | CE | Binding: ObservationMethod (example) | |||||||
targetSiteCode | 0..* | CD | ||||||||
subject | 0..1 | Subject | ||||||||
specimen | 0..* | Specimen | ||||||||
performer | 0..* | Performer2 | ||||||||
author | 0..* | AuthorParticipation | If 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. | |||||||
informant | 0..* | Informant | ||||||||
participant | 0..* | Participant2 | ||||||||
Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation, value:typeCode | |||||||
entryRelationship:refersTo | 0..* | EntryRelationship | The 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. | |||||||
@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: REFR | |||||||
@inversionInd | 0..1 | bl | ||||||||
@contextConductionInd | 0..1 | bl | ||||||||
@negationInd | 0..1 | bl | ||||||||
sequenceNumber | 0..1 | INT | ||||||||
seperatableInd | 0..1 | BL | ||||||||
act | C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
encounter | 0..1 | Encounter | ||||||||
observation | 0..1 | Observation | ||||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:componentEntry | 0..* | EntryRelationship | The 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. | |||||||
@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 | C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
encounter | 0..1 | Encounter | ||||||||
observation | 0..1 | Observation | ||||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:priorityPreference | 0..1 | EntryRelationship | The following entryRelationship represents the priority that the patient or a provider puts on the goal. | |||||||
@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: REFR | |||||||
@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 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:goal | 0..* | EntryRelationship | The 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. | |||||||
@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 | GoalObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
observationMedia | 0..1 | ObservationMedia | ||||||||
organizer | 0..1 | Organizer | ||||||||
procedure | 0..1 | Procedure | ||||||||
regionOfInterest | 0..1 | RegionOfInterest | ||||||||
substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
supply | 0..1 | Supply | ||||||||
entryRelationship:progressTowardGoal | 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: REFR | |||||||
@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 | ProgressTowardGoalObservation | act 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 | Where 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. | |||||||
@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_ActRelationshipExternalReference (required) Fixed Value: REFR | |||||||
seperatableInd | 0..1 | BL | ||||||||
externalAct | 0..1 | ExternalAct | ||||||||
externalObservation | 0..1 | ExternalObservation | ||||||||
externalProcedure | 0..1 | ExternalProcedure | ||||||||
externalDocument | C | 1..1 | ExternalDocumentReference | Base for all types and resources should-setId: SHOULD contain setId should-versionNumber: SHOULD contain versionNumber | ||||||
precondition | 0..* | Precondition | ||||||||
sdtcPrecondition2 | 0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |||||||
referenceRange | 0..* | InfrastructureRoot | ||||||||
@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 | 1..1 | ObservationRange | ||||||||
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:goal-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: GOLhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
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.code | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
Observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Observation.value:coded | example | ||
Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
Observation.entryRelationship:refersTo.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:refersTo.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:refersTo.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.entryRelationship:componentEntry.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:componentEntry.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:componentEntry.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.entryRelationship:priorityPreference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:priorityPreference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:priorityPreference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.entryRelationship:goal.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:goal.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:goal.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.entryRelationship:progressTowardGoal.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:progressTowardGoal.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.entryRelationship:progressTowardGoal.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
Observation.reference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.reference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.reference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipExternalReference | |
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 |
Id | Grade | Path(s) | Details | Requirements |
II-1 | error | Observation.typeId, Observation.entryRelationship:refersTo.typeId, Observation.entryRelationship:componentEntry.typeId, Observation.entryRelationship:priorityPreference.typeId, Observation.entryRelationship:goal.typeId, Observation.entryRelationship:progressTowardGoal.typeId, Observation.reference.typeId, Observation.referenceRange.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
should-author | warning | Observation, Observation.entryRelationship:goal.observation | SHOULD contain author : author.exists() | |
should-author | warning | Observation.entryRelationship:priorityPreference.observation | SHOULD contain author : author.exists() | |
should-effectiveTime | warning | Observation, Observation.entryRelationship:goal.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
should-effectiveTime | warning | Observation.entryRelationship:priorityPreference.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
should-setId | warning | Observation.reference.externalDocument | SHOULD contain setId : setId.exists() | |
should-text-ref-value | warning | Observation, Observation.entryRelationship:goal.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
should-text-ref-value | warning | Observation.entryRelationship:refersTo.act, Observation.entryRelationship:componentEntry.act, Observation.entryRelationship:priorityPreference.observation, Observation.entryRelationship:progressTowardGoal.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
should-versionNumber | warning | Observation.reference.externalDocument | SHOULD contain versionNumber : versionNumber.exists() | |
value-starts-octothorpe | error | Observation.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: 7 elements(6 nested mandatory elements)
Fixed: 8 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices: