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/InstructionObservation | Version: 4.0.0-ballot | |||
Draft as of 2024-11-12 | Computable Name: InstructionObservation | |||
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.515:2025-05-01 |
The Instruction observation template can be used in several ways, such as to record patient instructions within a Medication Activity or to record fill instructions within a supply order. Though not defined in this template, a Vaccine Information Statement (VIS) document could be referenced through observation/reference/externalDocument, and patient awareness of the instructions can be represented with the generic participant and the participant/awarenessCode.
The value element represents the actual instructions given to the patient. Typically recorded as a string or a narrative reference, the value may also be coded, though this template enforces no limits on the set of codes that can be used.
Usage:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:instruction | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.515 | |
@extension | 1..1 | st | Required Pattern: 2025-05-01 | |
@classCode | 1..1 | cs | Fixed Value: OBS | |
@moodCode | 1..1 | cs | Fixed Value: EVN | |
code | 1..1 | CD | Instructions Provided | |
@code | 1..1 | cs | Required Pattern: 89187-7 | |
@codeSystem | 1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
translation | 0..* | CD | Can further classify the type of instructions provided Binding: Patient Education (preferred) | |
text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
statusCode | 1..1 | CS | ||
@code | 1..1 | cs | Fixed Value: completed | |
effectiveTime | C | 0..1 | IVL_TS | value-only: Interval fields SHALL NOT be present |
@value | 0..1 | ts | value should be used instead of low/high | |
value | 1..1 | The actual instructions provided | ||
value | ED | |||
value | ST | |||
value | CD | |||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.code.translation | preferred | PatientEducation http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.34 |
Id | Grade | Path(s) | Details | Requirements |
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
value-only | error | Observation.effectiveTime | Interval fields SHALL NOT be present : (low | high | width | center).empty() | |
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 |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:instruction | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.515 | |
@extension | 1..1 | st | Required Pattern: 2025-05-01 | |
@classCode | 1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |
@moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
code | 1..1 | CD | Instructions Provided Binding: ObservationType (example) | |
@code | 1..1 | cs | Required Pattern: 89187-7 | |
@codeSystem | 1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
translation | 0..* | CD | Can further classify the type of instructions provided Binding: Patient Education (preferred) | |
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 | Binding: ActStatus (required) | |
@code | 1..1 | cs | Fixed Value: completed | |
effectiveTime | C | 0..1 | IVL_TS | value-only: Interval fields SHALL NOT be present |
@value | 0..1 | ts | value should be used instead of low/high Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
value | 1..1 | The actual instructions provided | ||
value | ED | |||
value | ST | |||
value | CD | |||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
Observation.code.translation | preferred | PatientEducation http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.34 | |
Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus |
Id | Grade | Path(s) | Details | Requirements |
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
value-only | error | Observation.effectiveTime | Interval fields SHALL NOT be present : (low | high | width | center).empty() | |
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 |
@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 | ||
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:instruction | 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: 2.16.840.1.113883.10.20.22.4.515 | |
@extension | 1..1 | st | Required Pattern: 2025-05-01 | |
@classCode | 1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |
@moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
@negationInd | 0..1 | bl | ||
id | 0..* | II | ||
sdtcCategory | 0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |
code | 1..1 | CD | Instructions Provided Binding: ObservationType (example) | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 1..1 | cs | Required Pattern: 89187-7 | |
@codeSystem | 1..1 | oid, uuid, ruid | LOINC 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 | ||
qualifier | 0..* | CR | ||
translation | 0..* | CD | Can further classify the type of instructions provided Binding: Patient Education (preferred) | |
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) | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 1..1 | cs | Fixed Value: completed | |
@sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
@sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
effectiveTime | C | 0..1 | IVL_TS | value-only: Interval fields SHALL NOT be present |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@value | 0..1 | ts | value should be used instead of low/high Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
@operator | 0..1 | cs | Binding: CDASetOperator (required) | |
low | 0..1 | IVXB_TS | ||
center | 0..1 | TS | ||
width | 0..1 | PQ | ||
high | 0..1 | IVXB_TS | ||
priorityCode | 0..1 | CE | Binding: ActPriority (example) | |
repeatNumber | 0..1 | IVL_INT | ||
languageCode | 0..1 | CS | Binding: AllLanguages (required) | |
value | 1..1 | The actual instructions provided | ||
value | ED | |||
value | ST | |||
value | CD | |||
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..* | Author | ||
informant | 0..* | Informant | ||
participant | 0..* | Participant2 | ||
entryRelationship | 0..* | EntryRelationship | ||
reference | 0..* | Reference | ||
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 | 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: 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:instruction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
Observation.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.code.translation | preferred | PatientEducation http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.34 | |
Observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
Observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
Observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
Observation.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.effectiveTime.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.effectiveTime.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
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.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
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 |
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
value-only | error | Observation.effectiveTime | Interval fields SHALL NOT be present : (low | high | width | center).empty() | |
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: 9 elements
Fixed: 3 elements
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:instruction | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.515 | |
@extension | 1..1 | st | Required Pattern: 2025-05-01 | |
@classCode | 1..1 | cs | Fixed Value: OBS | |
@moodCode | 1..1 | cs | Fixed Value: EVN | |
code | 1..1 | CD | Instructions Provided | |
@code | 1..1 | cs | Required Pattern: 89187-7 | |
@codeSystem | 1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
translation | 0..* | CD | Can further classify the type of instructions provided Binding: Patient Education (preferred) | |
text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
statusCode | 1..1 | CS | ||
@code | 1..1 | cs | Fixed Value: completed | |
effectiveTime | C | 0..1 | IVL_TS | value-only: Interval fields SHALL NOT be present |
@value | 0..1 | ts | value should be used instead of low/high | |
value | 1..1 | The actual instructions provided | ||
value | ED | |||
value | ST | |||
value | CD | |||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.code.translation | preferred | PatientEducation http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.34 |
Id | Grade | Path(s) | Details | Requirements |
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
value-only | error | Observation.effectiveTime | Interval fields SHALL NOT be present : (low | high | width | center).empty() | |
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 |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:instruction | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.515 | |
@extension | 1..1 | st | Required Pattern: 2025-05-01 | |
@classCode | 1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |
@moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
code | 1..1 | CD | Instructions Provided Binding: ObservationType (example) | |
@code | 1..1 | cs | Required Pattern: 89187-7 | |
@codeSystem | 1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
translation | 0..* | CD | Can further classify the type of instructions provided Binding: Patient Education (preferred) | |
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 | Binding: ActStatus (required) | |
@code | 1..1 | cs | Fixed Value: completed | |
effectiveTime | C | 0..1 | IVL_TS | value-only: Interval fields SHALL NOT be present |
@value | 0..1 | ts | value should be used instead of low/high Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
value | 1..1 | The actual instructions provided | ||
value | ED | |||
value | ST | |||
value | CD | |||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
Observation.code.translation | preferred | PatientEducation http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.34 | |
Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus |
Id | Grade | Path(s) | Details | Requirements |
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
value-only | error | Observation.effectiveTime | Interval fields SHALL NOT be present : (low | high | width | center).empty() | |
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 |
@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 | ||
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:instruction | 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: 2.16.840.1.113883.10.20.22.4.515 | |
@extension | 1..1 | st | Required Pattern: 2025-05-01 | |
@classCode | 1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |
@moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
@negationInd | 0..1 | bl | ||
id | 0..* | II | ||
sdtcCategory | 0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |
code | 1..1 | CD | Instructions Provided Binding: ObservationType (example) | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 1..1 | cs | Required Pattern: 89187-7 | |
@codeSystem | 1..1 | oid, uuid, ruid | LOINC 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 | ||
qualifier | 0..* | CR | ||
translation | 0..* | CD | Can further classify the type of instructions provided Binding: Patient Education (preferred) | |
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) | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 1..1 | cs | Fixed Value: completed | |
@sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
@sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
effectiveTime | C | 0..1 | IVL_TS | value-only: Interval fields SHALL NOT be present |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@value | 0..1 | ts | value should be used instead of low/high Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
@operator | 0..1 | cs | Binding: CDASetOperator (required) | |
low | 0..1 | IVXB_TS | ||
center | 0..1 | TS | ||
width | 0..1 | PQ | ||
high | 0..1 | IVXB_TS | ||
priorityCode | 0..1 | CE | Binding: ActPriority (example) | |
repeatNumber | 0..1 | IVL_INT | ||
languageCode | 0..1 | CS | Binding: AllLanguages (required) | |
value | 1..1 | The actual instructions provided | ||
value | ED | |||
value | ST | |||
value | CD | |||
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..* | Author | ||
informant | 0..* | Informant | ||
participant | 0..* | Participant2 | ||
entryRelationship | 0..* | EntryRelationship | ||
reference | 0..* | Reference | ||
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 | 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: 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:instruction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
Observation.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.code.translation | preferred | PatientEducation http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.34 | |
Observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
Observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
Observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
Observation.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.effectiveTime.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.effectiveTime.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
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.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
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 |
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
value-only | error | Observation.effectiveTime | Interval fields SHALL NOT be present : (low | high | width | center).empty() | |
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: 9 elements
Fixed: 3 elements
Slices
This structure defines the following Slices: