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

• Content
• Detailed Descriptions
• Mappings
• Examples
• XML
• JSON

Logical Model: Health Status Evaluations and Outcomes Section

This section represents observations regarding the evaluation or assessment of the patient, and the outcome of care from the interventions used to treat the patient. These observations represent status information, at points in time, related to established goals or related to new care plan goals and/or interventions.

Usage:

• Use this Logical Model: Care Plan

Formal Views of Template Content

Description of Template, Differentials, Snapshots and how the different presentations work.

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from Section

Name	Flags	Card.	Type	Description & Constraints
Section	C	1..1	Section	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) shall-outcome-obs: If section/@nullFlavor is not present, SHALL contain at least one Outcome Observation
@nullFlavor		0..1	cs	If a required section contains no information, the @nullFlavor MAY be set to NI
Slices for templateId		1..*	II	Slice: Unordered, Open by value:root
templateId:section		1..1	II
@root		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.10.20.22.2.61
@extension		0..0
code		1..1	CE	Patient problem outcome Narrative
@code		1..1	cs	Required Pattern: 11383-7
@codeSystem		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.6.1
title		1..1	ST
text		1..1	xhtml
Slices for entry		0..*	Entry	If section/@nullFlavor is not present: Slice: Unordered, Open by profile:observation
entry:outcome		0..*	Entry
observation		1..1	OutcomeObservation	Base for all types and resources
Documentation for this format

Constraints

Id	Grade	Path(s)	Details	Requirements
shall-outcome-obs	error	Section	If section/@nullFlavor is not present, SHALL contain at least one Outcome Observation : nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation')).exists()

Name	Flags	Card.	Type	Description & Constraints
Section	C	1..1	Section	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) shall-outcome-obs: If section/@nullFlavor is not present, SHALL contain at least one Outcome Observation
@nullFlavor		0..1	cs	If a required section contains no information, the @nullFlavor MAY be set to NI Binding: CDANullFlavor (required)
Slices for templateId		1..*	II	Slice: Unordered, Open by value:root
templateId:section		1..1	II
@root		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.10.20.22.2.61
code		1..1	CE	Patient problem outcome Narrative Binding: DocumentSectionType (example)
@code		1..1	cs	Required Pattern: 11383-7
@codeSystem		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.6.1
title		1..1	ST
text		1..1	xhtml
Slices for entry		0..*	Entry	If section/@nullFlavor is not present: Slice: Unordered, Open by profile:observation
entry:outcome		0..*	Entry
observation	C	1..1	OutcomeObservation	Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-value: SHOULD contain value should-author: SHOULD contain author
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Section.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.code	example	DocumentSectionType http://terminology.hl7.org/ValueSet/v3-DocumentSectionType

Constraints

Id	Grade	Path(s)	Details	Requirements
shall-outcome-obs	error	Section	If section/@nullFlavor is not present, SHALL contain at least one Outcome Observation : nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation')).exists()
should-author	warning	Section.entry:outcome.observation	SHOULD contain author : author.exists()
should-text-ref-value	warning	Section.entry:outcome.observation	SHOULD contain text/reference/@value : text.reference.value.exists()
should-value	warning	Section.entry:outcome.observation	SHOULD contain value : value.exists()

Name	Flags	Card.	Type	Description & Constraints
Section	C	1..1	Section	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) shall-outcome-obs: If section/@nullFlavor is not present, SHALL contain at least one Outcome Observation
@nullFlavor		0..1	cs	If a required section contains no information, the @nullFlavor MAY be set to NI Binding: CDANullFlavor (required)
realmCode		0..*	CS
typeId		0..1	II
@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
templateId:section		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: 2.16.840.1.113883.10.20.22.2.61
@ID		0..1	xs:ID
@classCode		0..1	cs	Binding: ActClassRecordOrganizer (required) Fixed Value: DOCSECT
@moodCode		0..1	cs	Binding: CDAActMood (required) Fixed Value: EVN
id		0..1	II
code		1..1	CE	Patient problem outcome Narrative Binding: DocumentSectionType (example)
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
@code		1..1	cs	Required Pattern: 11383-7
@codeSystem		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.6.1
@codeSystemName		0..1	st
@codeSystemVersion		0..1	st
@displayName		0..1	st
@sdtcValueSet		0..1	oid	XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion		0..1	st	XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText		0..1	ED
translation		0..*	CD
title		1..1	ST
text		1..1	xhtml
confidentialityCode		0..1	CE
languageCode		0..1	CS	Binding: AllLanguages (required)
subject		0..1	Subject
author		0..*	Author
informant		0..*	Informant
Slices for entry		0..*	Entry	If section/@nullFlavor is not present: Slice: Unordered, Open by profile:observation
entry:outcome		0..*	Entry
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
realmCode		0..*	CS
typeId		0..1	II
@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: x_ActRelationshipEntry (required)
@contextConductionInd		0..1	bl	Fixed Value: true
act		0..1	Act
encounter		0..1	Encounter
observation	C	1..1	OutcomeObservation	Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-value: SHOULD contain value 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
component		0..*	InfrastructureRoot
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
realmCode		0..*	CS
typeId		0..1	II
@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	Fixed Value: COMP
@contextConductionInd		0..1	bl	Fixed Value: true
section		1..1	Section
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Section.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.templateId:section.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.classCode	required	Fixed Value: DOCSECT http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.moodCode	required	Fixed Value: EVN http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.code	example	DocumentSectionType http://terminology.hl7.org/ValueSet/v3-DocumentSectionType
Section.code.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.languageCode	required	AllLanguages http://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard
Section.entry:outcome.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:outcome.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:outcome.typeCode	required	XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.component.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

Id	Grade	Path(s)	Details	Requirements
shall-outcome-obs	error	Section	If section/@nullFlavor is not present, SHALL contain at least one Outcome Observation : nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation')).exists()
should-author	warning	Section.entry:outcome.observation	SHOULD contain author : author.exists()
should-text-ref-value	warning	Section.entry:outcome.observation	SHOULD contain text/reference/@value : text.reference.value.exists()
should-value	warning	Section.entry:outcome.observation	SHOULD contain value : value.exists()

This structure is derived from Section

Summary

Mandatory: 8 elements(1 nested mandatory element)
Prohibited: 1 element

Structures

This structure refers to these other structures:

• Outcome Observation (http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Section.templateId
• The element 1 is sliced based on the value of Section.entry

Differential View

This structure is derived from Section

Name	Flags	Card.	Type	Description & Constraints
Section	C	1..1	Section	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) shall-outcome-obs: If section/@nullFlavor is not present, SHALL contain at least one Outcome Observation
@nullFlavor		0..1	cs	If a required section contains no information, the @nullFlavor MAY be set to NI
Slices for templateId		1..*	II	Slice: Unordered, Open by value:root
templateId:section		1..1	II
@root		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.10.20.22.2.61
@extension		0..0
code		1..1	CE	Patient problem outcome Narrative
@code		1..1	cs	Required Pattern: 11383-7
@codeSystem		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.6.1
title		1..1	ST
text		1..1	xhtml
Slices for entry		0..*	Entry	If section/@nullFlavor is not present: Slice: Unordered, Open by profile:observation
entry:outcome		0..*	Entry
observation		1..1	OutcomeObservation	Base for all types and resources
Documentation for this format

Constraints

Id	Grade	Path(s)	Details	Requirements
shall-outcome-obs	error	Section	If section/@nullFlavor is not present, SHALL contain at least one Outcome Observation : nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation')).exists()

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Section	C	1..1	Section	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) shall-outcome-obs: If section/@nullFlavor is not present, SHALL contain at least one Outcome Observation
@nullFlavor		0..1	cs	If a required section contains no information, the @nullFlavor MAY be set to NI Binding: CDANullFlavor (required)
Slices for templateId		1..*	II	Slice: Unordered, Open by value:root
templateId:section		1..1	II
@root		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.10.20.22.2.61
code		1..1	CE	Patient problem outcome Narrative Binding: DocumentSectionType (example)
@code		1..1	cs	Required Pattern: 11383-7
@codeSystem		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.6.1
title		1..1	ST
text		1..1	xhtml
Slices for entry		0..*	Entry	If section/@nullFlavor is not present: Slice: Unordered, Open by profile:observation
entry:outcome		0..*	Entry
observation	C	1..1	OutcomeObservation	Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-value: SHOULD contain value should-author: SHOULD contain author
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Section.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.code	example	DocumentSectionType http://terminology.hl7.org/ValueSet/v3-DocumentSectionType

Constraints

Id	Grade	Path(s)	Details	Requirements
shall-outcome-obs	error	Section	If section/@nullFlavor is not present, SHALL contain at least one Outcome Observation : nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation')).exists()
should-author	warning	Section.entry:outcome.observation	SHOULD contain author : author.exists()
should-text-ref-value	warning	Section.entry:outcome.observation	SHOULD contain text/reference/@value : text.reference.value.exists()
should-value	warning	Section.entry:outcome.observation	SHOULD contain value : value.exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Section	C	1..1	Section	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) shall-outcome-obs: If section/@nullFlavor is not present, SHALL contain at least one Outcome Observation
@nullFlavor		0..1	cs	If a required section contains no information, the @nullFlavor MAY be set to NI Binding: CDANullFlavor (required)
realmCode		0..*	CS
typeId		0..1	II
@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
templateId:section		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: 2.16.840.1.113883.10.20.22.2.61
@ID		0..1	xs:ID
@classCode		0..1	cs	Binding: ActClassRecordOrganizer (required) Fixed Value: DOCSECT
@moodCode		0..1	cs	Binding: CDAActMood (required) Fixed Value: EVN
id		0..1	II
code		1..1	CE	Patient problem outcome Narrative Binding: DocumentSectionType (example)
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
@code		1..1	cs	Required Pattern: 11383-7
@codeSystem		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.6.1
@codeSystemName		0..1	st
@codeSystemVersion		0..1	st
@displayName		0..1	st
@sdtcValueSet		0..1	oid	XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion		0..1	st	XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText		0..1	ED
translation		0..*	CD
title		1..1	ST
text		1..1	xhtml
confidentialityCode		0..1	CE
languageCode		0..1	CS	Binding: AllLanguages (required)
subject		0..1	Subject
author		0..*	Author
informant		0..*	Informant
Slices for entry		0..*	Entry	If section/@nullFlavor is not present: Slice: Unordered, Open by profile:observation
entry:outcome		0..*	Entry
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
realmCode		0..*	CS
typeId		0..1	II
@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: x_ActRelationshipEntry (required)
@contextConductionInd		0..1	bl	Fixed Value: true
act		0..1	Act
encounter		0..1	Encounter
observation	C	1..1	OutcomeObservation	Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-value: SHOULD contain value 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
component		0..*	InfrastructureRoot
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
realmCode		0..*	CS
typeId		0..1	II
@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	Fixed Value: COMP
@contextConductionInd		0..1	bl	Fixed Value: true
section		1..1	Section
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Section.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.templateId:section.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.classCode	required	Fixed Value: DOCSECT http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.moodCode	required	Fixed Value: EVN http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.code	example	DocumentSectionType http://terminology.hl7.org/ValueSet/v3-DocumentSectionType
Section.code.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.languageCode	required	AllLanguages http://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard
Section.entry:outcome.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:outcome.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:outcome.typeCode	required	XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.component.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

Id	Grade	Path(s)	Details	Requirements
shall-outcome-obs	error	Section	If section/@nullFlavor is not present, SHALL contain at least one Outcome Observation : nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation')).exists()
should-author	warning	Section.entry:outcome.observation	SHOULD contain author : author.exists()
should-text-ref-value	warning	Section.entry:outcome.observation	SHOULD contain text/reference/@value : text.reference.value.exists()
should-value	warning	Section.entry:outcome.observation	SHOULD contain value : value.exists()

This structure is derived from Section

Summary

Mandatory: 8 elements(1 nested mandatory element)
Prohibited: 1 element

Structures

This structure refers to these other structures:

• Outcome Observation (http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Section.templateId
• The element 1 is sliced based on the value of Section.entry

Other representations of profile: CSV, Excel