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

Logical Model: LongitudinalCareWoundObservation - Detailed Descriptions

Draft as of 2024-12-19

Definitions for the LongitudinalCareWoundObservation logical model.

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

0. Observation
Logical ContainerClinicalDocument (CDA Class)
ValidationInstance of this type are validated by templateId
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
2. Observation.templateId
Control2..?
4. Observation.templateId:Longitudinal-care-wound-obs
Slice NameLongitudinal-care-wound-obs
Control1..1
6. Observation.templateId:Longitudinal-care-wound-obs.root
Control1..?
Pattern Value2.16.840.1.113883.10.20.22.4.114
8. Observation.templateId:Longitudinal-care-wound-obs.extension
Control1..?
Pattern Value2015-08-01
10. Observation.classCode
Comments

SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1198-31012).

12. Observation.moodCode
Comments

SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1198-31013).

14. Observation.code
Comments

SHALL contain exactly one [1..1] code (CONF:1198-29476).

16. Observation.code.code
Comments

This code SHALL contain exactly one [1..1] @code="ASSERTION" assertion (CONF:1198-29477).

Control1..?
Pattern ValueASSERTION
18. Observation.code.codeSystem
Comments

This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.5.4" (CodeSystem: HL7ActCode urn:oid:2.16.840.1.113883.5.4) (CONF:1198-31010).

Control1..?
Pattern Value2.16.840.1.113883.5.4
20. Observation.value
Comments

SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Wound Type urn:oid:2.16.840.1.113883.1.11.20.2.6 DYNAMIC (CONF:1198-29485).

BindingThe codes SHOULD be taken from Wound Type .
(preferred to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.20.2.6)
22. Observation.targetSiteCode
Comments

SHOULD contain zero or one [0..1] targetSiteCode, which SHOULD be selected from ValueSet Body Site Value Set urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:1198-29488) such that it

Control0..1
BindingThe codes SHOULD be taken from Body Site Value Set .
(preferred to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9)
24. Observation.targetSiteCode.qualifier
ShortIf targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality.
Comments

MAY contain zero or more [0..*] qualifier (CONF:1198-29490).

26. Observation.targetSiteCode.qualifier.name
Comments

The qualifier, if present, SHALL contain exactly one [1..1] name (CONF:1198-29491).

Control1..?
28. Observation.targetSiteCode.qualifier.name.code
Comments

This name SHALL contain exactly one [1..1] @code="272741003" laterality (CONF:1198-29492).

Control1..?
Pattern Value272741003
30. Observation.targetSiteCode.qualifier.name.codeSystem
Comments

This name SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT urn:oid:2.16.840.1.113883.6.96) (CONF:1198-31524).

Control1..?
Pattern Value2.16.840.1.113883.6.96
32. Observation.targetSiteCode.qualifier.value
Comments

The qualifier, if present, SHALL contain exactly one [1..1] value (CONF:1198-29493).

Control1..?
34. Observation.targetSiteCode.qualifier.value.nullFlavor
Control0..0
36. Observation.targetSiteCode.qualifier.value.code
Control1..?
BindingThe codes SHOULD be taken from TargetSite Qualifiers .
(preferred to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.37)
38. Observation.author
Comments

SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1198-31542).

40. Observation.entryRelationship
ShortWhen the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage.
42. Observation.entryRelationship:woundMeasurementObservation
Slice NamewoundMeasurementObservation
Comments

SHOULD contain zero or more [0..*] entryRelationship (CONF:1198-29495) such that it

Control0..*
44. Observation.entryRelationship:woundMeasurementObservation.typeCode
Comments

SHALL contain exactly one [1..1] @typeCode="COMP" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1198-29496).

Fixed ValueCOMP
46. Observation.entryRelationship:woundMeasurementObservation.observation
Comments

SHALL contain exactly one [1..1] Wound Measurement Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.133) (CONF:1198-29497).

Control1..?
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Wound Measurement Observation)
48. Observation.entryRelationship:woundCharacteristic
Slice NamewoundCharacteristic
Comments

SHOULD contain zero or more [0..*] entryRelationship (CONF:1198-29503) such that it

Control0..*
50. Observation.entryRelationship:woundCharacteristic.typeCode
Comments

SHALL contain exactly one [1..1] @typeCode="COMP" (CONF:1198-29504).

Fixed ValueCOMP
52. Observation.entryRelationship:woundCharacteristic.observation
Comments

SHALL contain exactly one [1..1] Wound Characteristic (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.134) (CONF:1198-29505).

Control1..?
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Wound Characteristic)
54. Observation.entryRelationship:numberofPressureUlcersObservation
Slice NamenumberofPressureUlcersObservation
ShortWhen the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers.
Comments

MAY contain zero or more [0..*] entryRelationship (CONF:1198-31890) such that it

Control0..*
56. Observation.entryRelationship:numberofPressureUlcersObservation.typeCode
Comments

SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31891).

Fixed ValueCOMP
58. Observation.entryRelationship:numberofPressureUlcersObservation.observation
Comments

SHALL contain exactly one [1..1] Number of Pressure Ulcers Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.76:2015-08-01) (CONF:1198-31892).

Control1..?
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Number of Pressure Ulcers Observation)
60. Observation.entryRelationship:highestPressureUlcerStage
Slice NamehighestPressureUlcerStage
Comments

MAY contain zero or one [0..1] entryRelationship (CONF:1198-31893) such that it

Control0..1
62. Observation.entryRelationship:highestPressureUlcerStage.typeCode
Comments

SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31894).

Fixed ValueCOMP
64. Observation.entryRelationship:highestPressureUlcerStage.observation
Comments

SHALL contain exactly one [1..1] Highest Pressure Ulcer Stage (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.77) (CONF:1198-31919).

Control1..?
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Highest Pressure Ulcer Stage)