Consolidated CDA (C-CDA)
3.0.0 - STU
Consolidated CDA (C-CDA)
3.0.0 - STU
Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 3.0.0 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/MedicationAdherence | Version: 3.0.0 | |||
| Draft as of 2024-05-07 | Computable Name: MedicationAdherence | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.508:2023-05-01 | ||||
This profile represents whether a medication has been consumed according to instructions.
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, 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 Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-informant: SHOULD contain informant |
  Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:med-adherence |
1..1 | II | ||
  @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.508 | |
  @extension |
1..1 | st | Required Pattern: 2023-05-01 | |
 @moodCode |
1..1 | cs | Fixed Value: EVN | |
| id |
1..* | II | ||
| code |
1..1 | CD | Adherence to prescribed medication instructions [Reported] | |
| @code |
1..1 | cs | Required Pattern: 71799-1 | |
 @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| 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 | ||
| effectiveTime |
1..1 | IVL_TS | ||
 value |
1..1 | CD | ||
| @nullFlavor |
0..0 | |||
| @code |
1..1 | cs | Binding: Medication Adherence  (preferred) | |
 informant |
0..* | Informant | (USCDI) The person or organization that provided the information about the medication adherence. | |
| assignedEntity |
1..1 | AssignedEntity | ||
| code |
0..1 | CE | Binding: Information Source for Medication Adherence (preferred) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Observation.value.code | preferred | MedicationAdherence http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.8 | |
| Observation.informant.assignedEntity.code | preferred | InformationSourceForMedicationAdherence http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.11 |
| Id | Grade | Path(s) | Details | Requirements |
| should-informant | warning | Observation | SHOULD contain informant : informant.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, 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 Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-informant: SHOULD contain informant |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:med-adherence |
1..1 | II | ||
 @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.508 | |
| @extension |
1..1 | st | Required Pattern: 2023-05-01 | |
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) | |
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
| id |
1..* | II | ||
| code |
1..1 | CD | Adherence to prescribed medication instructions [Reported] Binding: ObservationType (example) | |
| @code |
1..1 | cs | Required Pattern: 71799-1 | |
| @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| 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) | |
| effectiveTime |
1..1 | IVL_TS | ||
| value |
1..1 | CD | ||
| @code |
1..1 | cs | Binding: Medication Adherence (preferred) | |
| informant |
0..* | Informant | (USCDI) The person or organization that provided the information about the medication adherence. | |
| assignedEntity |
1..1 | AssignedEntity | ||
| id |
1..* | II | ||
| code |
0..1 | CE | Binding: Information Source for Medication Adherence (preferred) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.classCode | required | CDAActClassObservationhttp://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.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.value.code | preferred | MedicationAdherence http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.8 | |
| Observation.informant.assignedEntity.code | preferred | InformationSourceForMedicationAdherence http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.11 |
| Id | Grade | Path(s) | Details | Requirements |
| should-informant | warning | Observation | SHOULD contain informant : informant.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, 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 Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-informant: SHOULD contain informant |
| @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:med-adherence |
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: 2.16.840.1.113883.10.20.22.4.508 | |
| @extension |
1..1 | st | Required Pattern: 2023-05-01 | |
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) | |
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
| @negationInd |
0..1 | bl | ||
| id |
1..* | II | ||
| code |
1..1 | CD | Adherence to prescribed medication instructions [Reported] Binding: ObservationType (example) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 71799-1 | |
| @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 | ||
| 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) | |
| effectiveTime |
1..1 | IVL_TS | ||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| value |
1..1 | CD | ||
| @code |
1..1 | cs | Binding: Medication Adherence (preferred) | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @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 | ||
| 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 | (USCDI) The person or organization that provided the information about the medication adherence. | |
| @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: CDAParticipationType (required) Fixed Value: INF | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| assignedEntity |
1..1 | AssignedEntity | ||
| @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 | ||
| @classCode |
0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id |
1..* | II | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: Information Source for Medication Adherence (preferred) | |
| addr |
0..* | AD | ||
| telecom |
0..* | TEL | ||
| assignedPerson |
0..1 | Person | ||
| representedOrganization |
0..1 | Organization | ||
 sdtcPatient |
0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id |
1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| relatedEntity |
0..1 | RelatedEntity | ||
| 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:med-adherence.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.classCode | required | CDAActClassObservationhttp://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.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.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Observation.value.code | preferred | MedicationAdherence http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.8 | |
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
| Observation.informant.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.informant.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.informant.typeCode | required | Fixed Value: INFhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| Observation.informant.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| Observation.informant.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.informant.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.informant.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
| Observation.informant.assignedEntity.code | preferred | InformationSourceForMedicationAdherence http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.11 | |
| 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-informant | warning | Observation | SHOULD contain informant : informant.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('#') |
This structure is derived from Observation
Summary
Mandatory: 11 elements(1 nested mandatory element)
Fixed: 1 element
Prohibited: 1 element
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, 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 Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-informant: SHOULD contain informant |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:med-adherence |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.508 | |
| @extension |
1..1 | st | Required Pattern: 2023-05-01 | |
| @moodCode |
1..1 | cs | Fixed Value: EVN | |
| id |
1..* | II | ||
| code |
1..1 | CD | Adherence to prescribed medication instructions [Reported] | |
| @code |
1..1 | cs | Required Pattern: 71799-1 | |
| @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| 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 | ||
| effectiveTime |
1..1 | IVL_TS | ||
| value |
1..1 | CD | ||
| @nullFlavor |
0..0 | |||
| @code |
1..1 | cs | Binding: Medication Adherence (preferred) | |
| informant |
0..* | Informant | (USCDI) The person or organization that provided the information about the medication adherence. | |
| assignedEntity |
1..1 | AssignedEntity | ||
| code |
0..1 | CE | Binding: Information Source for Medication Adherence (preferred) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Observation.value.code | preferred | MedicationAdherence http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.8 | |
| Observation.informant.assignedEntity.code | preferred | InformationSourceForMedicationAdherence http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.11 |
| Id | Grade | Path(s) | Details | Requirements |
| should-informant | warning | Observation | SHOULD contain informant : informant.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, 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 Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-informant: SHOULD contain informant |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:med-adherence |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.508 | |
| @extension |
1..1 | st | Required Pattern: 2023-05-01 | |
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) | |
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
| id |
1..* | II | ||
| code |
1..1 | CD | Adherence to prescribed medication instructions [Reported] Binding: ObservationType (example) | |
| @code |
1..1 | cs | Required Pattern: 71799-1 | |
| @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| 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) | |
| effectiveTime |
1..1 | IVL_TS | ||
| value |
1..1 | CD | ||
| @code |
1..1 | cs | Binding: Medication Adherence (preferred) | |
| informant |
0..* | Informant | (USCDI) The person or organization that provided the information about the medication adherence. | |
| assignedEntity |
1..1 | AssignedEntity | ||
| id |
1..* | II | ||
| code |
0..1 | CE | Binding: Information Source for Medication Adherence (preferred) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.classCode | required | CDAActClassObservationhttp://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.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.value.code | preferred | MedicationAdherence http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.8 | |
| Observation.informant.assignedEntity.code | preferred | InformationSourceForMedicationAdherence http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.11 |
| Id | Grade | Path(s) | Details | Requirements |
| should-informant | warning | Observation | SHOULD contain informant : informant.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('#') |
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, 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 Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-informant: SHOULD contain informant |
| @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:med-adherence |
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: 2.16.840.1.113883.10.20.22.4.508 | |
| @extension |
1..1 | st | Required Pattern: 2023-05-01 | |
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) | |
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
| @negationInd |
0..1 | bl | ||
| id |
1..* | II | ||
| code |
1..1 | CD | Adherence to prescribed medication instructions [Reported] Binding: ObservationType (example) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 71799-1 | |
| @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 | ||
| 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) | |
| effectiveTime |
1..1 | IVL_TS | ||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| value |
1..1 | CD | ||
| @code |
1..1 | cs | Binding: Medication Adherence (preferred) | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @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 | ||
| 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 | (USCDI) The person or organization that provided the information about the medication adherence. | |
| @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: CDAParticipationType (required) Fixed Value: INF | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| assignedEntity |
1..1 | AssignedEntity | ||
| @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 | ||
| @classCode |
0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id |
1..* | II | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: Information Source for Medication Adherence (preferred) | |
| addr |
0..* | AD | ||
| telecom |
0..* | TEL | ||
| assignedPerson |
0..1 | Person | ||
| representedOrganization |
0..1 | Organization | ||
| sdtcPatient |
0..1 | Base | XML Namespace: urn:hl7-org:sdtc XML: patient (urn:hl7-org:sdtc) | |
| id |
1..1 | II | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| relatedEntity |
0..1 | RelatedEntity | ||
| 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:med-adherence.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.classCode | required | CDAActClassObservationhttp://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.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.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Observation.value.code | preferred | MedicationAdherence http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.8 | |
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
| Observation.informant.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.informant.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.informant.typeCode | required | Fixed Value: INFhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| Observation.informant.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| Observation.informant.assignedEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.informant.assignedEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.informant.assignedEntity.classCode | required | Fixed Value: ASSIGNEDhttp://terminology.hl7.org/ValueSet/v3-RoleClassAssignedEntity | |
| Observation.informant.assignedEntity.code | preferred | InformationSourceForMedicationAdherence http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.11 | |
| 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-informant | warning | Observation | SHOULD contain informant : informant.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('#') |
This structure is derived from Observation
Summary
Mandatory: 11 elements(1 nested mandatory element)
Fixed: 1 element
Prohibited: 1 element
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#3.0.0 based on FHIR 5.0.0. Generated 2024-05-07
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