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: ResultObservation - Detailed Descriptions

Draft as of 2024-12-19

Definitions for the ResultObservation 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.
Invariantsshould-text-ref-value: SHOULD contain text/reference/@value (text.reference.value.exists())
should-interpretationCode: SHOULD contain interpretationCode (interpretationCode.exists())
should-author: SHOULD contain author (author.exists())
should-referenceRange: SHOULD contain referenceRange (referenceRange.exists())
2. Observation.templateId
Control1..?
SlicingThis element introduces a set of slices on Observation.templateId. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ root
  • value @ extension
  • 4. Observation.templateId:result-obs
    Slice Nameresult-obs
    Control1..1
    6. Observation.templateId:result-obs.root
    Control1..?
    Pattern Value2.16.840.1.113883.10.20.22.4.2
    8. Observation.templateId:result-obs.extension
    Control1..?
    Pattern Value2023-05-01
    10. Observation.classCode
    Comments

    SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:4537-7130).

    Fixed ValueOBS
    12. Observation.moodCode
    Comments

    SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:4537-7131).

    Fixed ValueEVN
    14. Observation.id
    Comments

    SHALL contain at least one [1..*] id (CONF:4537-7137).

    Control1..?
    16. Observation.code
    Short𝗨𝗦𝗖𝗗𝗜: Tests
    Comments

    SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4537-7133).

    BindingFor example codes, see ObservationType
    (example to http://terminology.hl7.org/ValueSet/v3-ObservationType)
    Invariantsshall-code-or-nullflavor: SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. ((code | nullFlavor).count() = 1)
    4537-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). (codeSystem = '2.16.840.1.113883.6.1')
    18. Observation.code.nullFlavor
    Comments

    Either code or nullFlavor MUST be present

    20. Observation.code.code
    Comments

    Either code or nullFlavor MUST be present

    22. Observation.text
    ShortSHOULD reference the portion of section narrative text corresponding to this entry
    24. Observation.text.reference
    Invariantsvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative (value.exists() implies value.startsWith('#'))
    26. Observation.statusCode
    Short𝗨𝗦𝗖𝗗𝗜: Result Status
    Comments

    SHALL contain exactly one [1..1] statusCode (CONF:4537-7134).

    Control1..?
    28. Observation.statusCode.nullFlavor
    Control0..0
    30. Observation.statusCode.code
    Control1..?
    BindingThe codes SHALL be taken from Result Status .
    (required to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39)
    32. Observation.effectiveTime
    ShortRepresents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test).
    Comments

    SHALL contain exactly one [1..1] effectiveTime (CONF:4537-7140).

    Control1..?
    34. Observation.value
    Short𝗨𝗦𝗖𝗗𝗜: Values/Results - Value can be any type, but certain types have additional rules.
    Control1..1
    SlicingThis element introduces a set of slices on Observation.value. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • type @ $this
    • 36. Observation.value:physical-quantity
      Slice Namephysical-quantity
      Control0..1
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/PQ
      38. Observation.value:physical-quantity.unit
      Short𝗨𝗦𝗖𝗗𝗜: Result Unit of Measure
      Control1..?
      BindingThe codes SHOULD be taken from UnitsOfMeasureCaseSensitive
      (preferred to http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive)
      40. Observation.value:physical-quantity.translation
      ShortCan be used to represent the original results as output by the lab
      Control0..1
      42. Observation.value:coded
      Slice Namecoded
      Control0..1
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
      Invariants4537-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). (codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.1')
      44. Observation.value:coded.translation
      ShortCan be used to represent the original results as output by the lab
      Control0..1
      46. Observation.interpretationCode
      Short𝗨𝗦𝗖𝗗𝗜: Result Interpretation
      Comments

      SHOULD contain zero or more [0..*] interpretationCode, which SHALL be selected from ValueSet Observation Interpretation (HL7) urn:oid:2.16.840.1.113883.1.11.78 DYNAMIC (CONF:4537-7147).

      48. Observation.methodCode
      Comments

      MAY contain zero or one [0..1] methodCode (CONF:4537-7148).

      Control0..1
      50. Observation.targetSiteCode
      Comments

      MAY contain zero or one [0..1] targetSiteCode (CONF:4537-7153).

      Control0..1
      52. 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:4537-7149).

      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Author(Author Participation)
      54. Observation.referenceRange
      Short𝗨𝗦𝗖𝗗𝗜: Result Reference Range
      Comments

      SHOULD contain zero or more [0..*] referenceRange (CONF:4537-7150).

      56. Observation.referenceRange.observationRange
      Comments

      The referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:4537-7151).

      58. Observation.referenceRange.observationRange.value
      ShortWhen the value is a quantity, then the unit SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive.
      Comments

      This observationRange SHALL contain exactly one [1..1] value (CONF:4537-32175).

      Control1..?