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: Progress Toward Goal Observation

This template represents a patient's progress toward a goal. It can describe whether a goal has been achieved or not and can also describe movement a patient is making toward the achievement of a goal (e.g., "Goal not achieved - no discernible change", "Goal not achieved - progressing toward goal", "Goal not achieved - declining from goal").

In the Care Planning workflow, the judgment about how well the person is progressing towards the goal is based on the observations made about the status of the patient with respect to interventions performed in the pursuit of achieving that goal.

For example, an observation outcome of a blood oxygen saturation level of 95% is related to the goal of "Maintain Pulse Ox greater than 92" and in this case the Progress Toward Goal Observation template would record that the related goal has been achieved.

Usage:

• Use this Logical Model: Goal Observation and Outcome Observation

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 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
templateId:progress-toward-goal-obs		1..1	II
@root		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.10.20.22.4.110
@extension		0..0
@classCode		1..1	cs	Fixed Value: OBS
@moodCode		1..1	cs	Fixed Value: EVN
id		1..*	II
code		1..1	CD
@code		1..1	cs	Required Pattern: ASSERTION
@codeSystem		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.5.4
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	1..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	CD	Binding: Goal Achievement (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Observation.value	required	GoalAchievement http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.55 from https://vsac.nlm.nih.gov

Constraints

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
templateId:progress-toward-goal-obs		1..1	II
@root		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.10.20.22.4.110
@classCode		1..1	cs	Binding: CDAActClassObservation (required) Fixed Value: OBS
@moodCode		1..1	cs	Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN
id		1..*	II
code		1..1	CD	Binding: ObservationType (example)
@code		1..1	cs	Required Pattern: ASSERTION
@codeSystem		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.5.4
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	1..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	CD	Binding: Goal Achievement (required)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Observation.classCode	required	Fixed Value: OBS http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation
Observation.moodCode	required	Fixed Value: EVN http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Observation.code	example	ObservationType http://terminology.hl7.org/ValueSet/v3-ObservationType
Observation.statusCode	required	ActStatus http://terminology.hl7.org/ValueSet/v3-ActStatus
Observation.value	required	GoalAchievement http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.55 from https://vsac.nlm.nih.gov

Constraints

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
templateId:progress-toward-goal-obs		1..1	II
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
@assigningAuthorityName		0..1	st
@displayable		0..1	bl
@root		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.10.20.22.4.110
@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		1..*	II
sdtcCategory		0..*	CD	XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc)
code		1..1	CD	Binding: ObservationType (example)
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
@code		1..1	cs	Required Pattern: ASSERTION
@codeSystem		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.5.4
@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)
@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	1..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	CD	Binding: Goal Achievement (required)
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

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Observation.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.templateId:progress-toward-goal-obs.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.classCode	required	Fixed Value: OBS http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation
Observation.moodCode	required	Fixed Value: EVN http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Observation.code	example	ObservationType http://terminology.hl7.org/ValueSet/v3-ObservationType
Observation.code.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.text.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.text.compression	required	CDACompressionAlgorithm http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Observation.text.integrityCheckAlgorithm	required	IntegrityCheckAlgorithm http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Observation.text.mediaType	example	MediaType http://terminology.hl7.org/ValueSet/v3-MediaType
Observation.text.representation	required	BinaryDataEncoding http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Observation.statusCode	required	ActStatus http://terminology.hl7.org/ValueSet/v3-ActStatus
Observation.statusCode.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.effectiveTime.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.effectiveTime.operator	required	CDASetOperator http://hl7.org/cda/stds/core/ValueSet/CDASetOperator
Observation.priorityCode	example	ActPriority http://terminology.hl7.org/ValueSet/v3-ActPriority
Observation.languageCode	required	AllLanguages http://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard
Observation.value	required	GoalAchievement http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.55 from https://vsac.nlm.nih.gov
Observation.interpretationCode	required	CDAObservationInterpretation http://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation
Observation.methodCode	example	ObservationMethod http://terminology.hl7.org/ValueSet/v3-ObservationMethod
Observation.referenceRange.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.typeCode	required	Fixed Value: REFV http://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType

Constraints

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: 10 elements
Fixed: 3 elements
Prohibited: 1 element

Slices

This structure defines the following Slices:

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

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
templateId:progress-toward-goal-obs		1..1	II
@root		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.10.20.22.4.110
@extension		0..0
@classCode		1..1	cs	Fixed Value: OBS
@moodCode		1..1	cs	Fixed Value: EVN
id		1..*	II
code		1..1	CD
@code		1..1	cs	Required Pattern: ASSERTION
@codeSystem		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.5.4
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	1..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	CD	Binding: Goal Achievement (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Observation.value	required	GoalAchievement http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.55 from https://vsac.nlm.nih.gov

Constraints

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
templateId:progress-toward-goal-obs		1..1	II
@root		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.10.20.22.4.110
@classCode		1..1	cs	Binding: CDAActClassObservation (required) Fixed Value: OBS
@moodCode		1..1	cs	Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN
id		1..*	II
code		1..1	CD	Binding: ObservationType (example)
@code		1..1	cs	Required Pattern: ASSERTION
@codeSystem		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.5.4
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	1..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	CD	Binding: Goal Achievement (required)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Observation.classCode	required	Fixed Value: OBS http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation
Observation.moodCode	required	Fixed Value: EVN http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Observation.code	example	ObservationType http://terminology.hl7.org/ValueSet/v3-ObservationType
Observation.statusCode	required	ActStatus http://terminology.hl7.org/ValueSet/v3-ActStatus
Observation.value	required	GoalAchievement http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.55 from https://vsac.nlm.nih.gov

Constraints

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
templateId:progress-toward-goal-obs		1..1	II
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
@assigningAuthorityName		0..1	st
@displayable		0..1	bl
@root		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.10.20.22.4.110
@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		1..*	II
sdtcCategory		0..*	CD	XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc)
code		1..1	CD	Binding: ObservationType (example)
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
@code		1..1	cs	Required Pattern: ASSERTION
@codeSystem		1..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.5.4
@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)
@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	1..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	CD	Binding: Goal Achievement (required)
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

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Observation.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.templateId:progress-toward-goal-obs.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.classCode	required	Fixed Value: OBS http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation
Observation.moodCode	required	Fixed Value: EVN http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Observation.code	example	ObservationType http://terminology.hl7.org/ValueSet/v3-ObservationType
Observation.code.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.text.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.text.compression	required	CDACompressionAlgorithm http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Observation.text.integrityCheckAlgorithm	required	IntegrityCheckAlgorithm http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Observation.text.mediaType	example	MediaType http://terminology.hl7.org/ValueSet/v3-MediaType
Observation.text.representation	required	BinaryDataEncoding http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Observation.statusCode	required	ActStatus http://terminology.hl7.org/ValueSet/v3-ActStatus
Observation.statusCode.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.effectiveTime.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.effectiveTime.operator	required	CDASetOperator http://hl7.org/cda/stds/core/ValueSet/CDASetOperator
Observation.priorityCode	example	ActPriority http://terminology.hl7.org/ValueSet/v3-ActPriority
Observation.languageCode	required	AllLanguages http://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard
Observation.value	required	GoalAchievement http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.55 from https://vsac.nlm.nih.gov
Observation.interpretationCode	required	CDAObservationInterpretation http://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation
Observation.methodCode	example	ObservationMethod http://terminology.hl7.org/ValueSet/v3-ObservationMethod
Observation.referenceRange.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.typeCode	required	Fixed Value: REFV http://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType

Constraints

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: 10 elements
Fixed: 3 elements
Prohibited: 1 element

Slices

This structure defines the following Slices:

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

Other representations of profile: CSV, Excel