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/ResultObservation | Version: 3.0.0 | |||
| Draft as of 2024-05-07 | Computable Name: ResultObservation | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.2:2023-05-01 | ||||
This template represents the results of a laboratory, radiology, or other study performed on a patient.
The result observation includes a statusCode to allow recording the status of an observation. Pending results (e.g., a test has been run but results have not been reported yet) should be represented as active ActStatus.
If code contains a valid non-null LOINC then the xsi:type value SHOULD match the LOINC Scale Part based on the table below:
| LOINC Scale Part | Value xsi:type |
|---|---|
| Qn - Quantitative | INT, IVL_INT, MO, IVL_MO, REAL, IVL_REAL, PQ, IVL_PQ, RTO, TS, IVL_TS |
| Ord - Ordinal | CD |
| Nom - Nominal | CD |
| Nar - Narrative | ED, ST |
| OrdQn - Quantitative or Ordinal | CD, INT, IVL_INT, MO, IVL_MO, REAL, IVL_REAL, PQ, IVL_PQ, RTO, TS, IVL_TS |
| Multi - Multi | ED |
| Doc - Document | ED |
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-interpretationCode: SHOULD contain interpretationCode should-author: SHOULD contain author should-referenceRange: SHOULD contain referenceRange |
  Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:result-obs |
1..1 | II | ||
  @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
  @extension |
1..1 | st | Required Pattern: 2023-05-01 | |
 @classCode |
1..1 | cs | Fixed Value: OBS | |
| @moodCode |
1..1 | cs | Fixed Value: EVN | |
| id |
1..* | II | ||
| code |
C | 1..1 | CD | (USCDI) Tests shall-code-or-nullflavor: SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. 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). |
  (Choice of one) |
1..1 | |||
 @nullFlavor |
0..1 | cs | ||
 @code |
0..1 | cs | ||
| 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 | (USCDI) Result Status | |
| @nullFlavor |
0..0 | |||
| @code |
1..1 | cs | Binding: Result Status  (required) | |
| effectiveTime |
1..1 | IVL_TS | Represents 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). | |
| Slices for value |
1..1 | ANY, BL, ED, ST, CD, CV, CE, CO, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | (USCDI) Values/Results - Value can be any type, but certain types have additional rules. Slice: Unordered, Open by type:$this | |
 value:physical-quantity |
0..1 | PQ | ||
 @unit |
1..1 | cs | (USCDI) Result Unit of Measure Binding: UnitsOfMeasureCaseSensitive (preferred) | |
| translation |
0..1 | PQR | Can be used to represent the original results as output by the lab | |
| value:coded |
C | 0..1 | CD | 4537-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). |
| translation |
0..1 | CD | Can be used to represent the original results as output by the lab | |
| interpretationCode |
0..* | CE | (USCDI) Result Interpretation | |
| methodCode |
0..1 | CE | ||
| targetSiteCode |
0..1 | CD | ||
 author |
0..* | AuthorParticipation | Base for all types and resources | |
| referenceRange |
0..* | InfrastructureRoot | (USCDI) Result Reference Range | |
| observationRange |
1..1 | ObservationRange | ||
| value |
1..1 | BL, ED, ST, CD, CV, CE, CO, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS | When the value is a quantity, then the unit SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive. | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Observation.statusCode.code | required | ResultStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39 | |
| Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive |
| Id | Grade | Path(s) | Details | Requirements |
| 4537-19212 | warning | Observation.code | 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' | |
| 4537-32610 | warning | Observation.value:coded | 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' | |
| shall-code-or-nullflavor | error | Observation.code | SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. : (code | nullFlavor).count() = 1 | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-interpretationCode | warning | Observation | SHOULD contain interpretationCode : interpretationCode.exists() | |
| should-referenceRange | warning | Observation | SHOULD contain referenceRange : referenceRange.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-interpretationCode: SHOULD contain interpretationCode should-author: SHOULD contain author should-referenceRange: SHOULD contain referenceRange |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:result-obs |
1..1 | II | ||
 @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
| @extension |
1..1 | st | Required Pattern: 2023-05-01 | |
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
| id |
1..* | II | ||
| code |
C | 1..1 | CD | (USCDI) Tests Binding: ObservationType (example) shall-code-or-nullflavor: SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. 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). |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
0..1 | cs | ||
| 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 | (USCDI) Result Status Binding: ActStatus (required) | |
| @code |
1..1 | cs | Binding: Result Status (required) | |
| effectiveTime |
1..1 | IVL_TS | Represents 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). | |
| Slices for value |
1..1 | (USCDI) Values/Results - Value can be any type, but certain types have additional rules. Slice: Unordered, Open by type:$this | ||
 value |
ANY | |||
| value |
BL | |||
| value |
ED | |||
| value |
ST | |||
| value |
CD | |||
| value |
CV | |||
| value |
CE | |||
| value |
CO | |||
| value |
SC | |||
| value |
II | |||
| value |
TEL | |||
| value |
AD | |||
| value |
EN | |||
| value |
INT | |||
| value |
REAL | |||
| value |
PQ | |||
| value |
MO | |||
| value |
TS | |||
| value |
IVL_PQ | |||
| value |
IVL_TS | |||
| value |
PIVL_TS | |||
| value |
EIVL_TS | |||
| value |
SXPR_TS | |||
| value |
RTO_PQ_PQ | |||
| value:physical-quantity |
0..1 | PQ | ||
| @unit |
1..1 | cs | (USCDI) Result Unit of Measure Binding: UnitsOfMeasureCaseSensitive (preferred) | |
| translation |
0..1 | PQR | Can be used to represent the original results as output by the lab | |
| value:coded |
C | 0..1 | CD | 4537-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). |
| translation |
0..1 | CD | Can be used to represent the original results as output by the lab | |
| interpretationCode |
0..* | CE | (USCDI) Result Interpretation Binding: CDAObservationInterpretation (required) | |
| methodCode |
0..1 | CE | Binding: ObservationMethod (example) | |
| targetSiteCode |
0..1 | CD | ||
| author |
0..* | AuthorParticipation | Base for all types and resources | |
| referenceRange |
0..* | InfrastructureRoot | (USCDI) Result Reference Range | |
| observationRange |
1..1 | ObservationRange | ||
| value |
1..1 | When the value is a quantity, then the unit SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive. | ||
| value |
BL | |||
| value |
ED | |||
| value |
ST | |||
| value |
CD | |||
| value |
CV | |||
| value |
CE | |||
| value |
CO | |||
| value |
SC | |||
| value |
II | |||
| value |
TEL | |||
| value |
AD | |||
| value |
EN | |||
| value |
INT | |||
| value |
REAL | |||
| value |
PQ | |||
| value |
MO | |||
| value |
TS | |||
| value |
IVL_PQ | |||
| value |
IVL_TS | |||
| value |
PIVL_TS | |||
| value |
EIVL_TS | |||
| value |
SXPR_TS | |||
| 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.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.statusCode.code | required | ResultStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39 | |
| Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod |
| Id | Grade | Path(s) | Details | Requirements |
| 4537-19212 | warning | Observation.code | 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' | |
| 4537-32610 | warning | Observation.value:coded | 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' | |
| shall-code-or-nullflavor | error | Observation.code | SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. : (code | nullFlavor).count() = 1 | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-interpretationCode | warning | Observation | SHOULD contain interpretationCode : interpretationCode.exists() | |
| should-referenceRange | warning | Observation | SHOULD contain referenceRange : referenceRange.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-interpretationCode: SHOULD contain interpretationCode should-author: SHOULD contain author should-referenceRange: SHOULD contain referenceRange |
| @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:result-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: 2.16.840.1.113883.10.20.22.4.2 | |
| @extension |
1..1 | st | Required Pattern: 2023-05-01 | |
| @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 |
1..* | II | ||
| code |
C | 1..1 | CD | (USCDI) Tests Binding: ObservationType (example) shall-code-or-nullflavor: SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. 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). |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
0..1 | cs | ||
| @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 | ||
| 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 | (USCDI) Result Status Binding: ActStatus (required) | |
| @code |
1..1 | cs | Binding: Result Status (required) | |
| @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 |
1..1 | IVL_TS | Represents 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). | |
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| Slices for value |
1..1 | (USCDI) Values/Results - Value can be any type, but certain types have additional rules. Slice: Unordered, Open by type:$this | ||
| value |
ANY | |||
| value |
BL | |||
| value |
ED | |||
| value |
ST | |||
| value |
CD | |||
| value |
CV | |||
| value |
CE | |||
| value |
CO | |||
| value |
SC | |||
| value |
II | |||
| value |
TEL | |||
| value |
AD | |||
| value |
EN | |||
| value |
INT | |||
| value |
REAL | |||
| value |
PQ | |||
| value |
MO | |||
| value |
TS | |||
| value |
IVL_PQ | |||
| value |
IVL_TS | |||
| value |
PIVL_TS | |||
| value |
EIVL_TS | |||
| value |
SXPR_TS | |||
| value |
RTO_PQ_PQ | |||
| value:physical-quantity |
0..1 | PQ | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @unit |
1..1 | cs | (USCDI) Result Unit of Measure Binding: UnitsOfMeasureCaseSensitive (preferred) | |
| @value |
0..1 | real | ||
| translation |
0..1 | PQR | Can be used to represent the original results as output by the lab | |
| value:coded |
C | 0..1 | CD | 4537-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
0..1 | cs | ||
| @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..1 | CD | Can be used to represent the original results as output by the lab | |
| interpretationCode |
0..* | CE | (USCDI) Result Interpretation Binding: CDAObservationInterpretation (required) | |
| methodCode |
0..1 | CE | Binding: ObservationMethod (example) | |
| targetSiteCode |
0..1 | CD | ||
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | AuthorParticipation | Base for all types and resources | |
| 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 | (USCDI) Result Reference Range | |
| @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 | ||
| @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: CDAActClassObservation (required) | |
| @moodCode |
0..1 | cs | Binding: ActMoodPredicate (required) Fixed Value: EVN.CRT | |
| code |
0..1 | CD | Binding: v3 Code System ActCode (example) | |
| text |
0..1 | ED | ||
| value |
1..1 | When the value is a quantity, then the unit SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive. | ||
| value |
BL | |||
| value |
ED | |||
| value |
ST | |||
| value |
CD | |||
| value |
CV | |||
| value |
CE | |||
| value |
CO | |||
| value |
SC | |||
| value |
II | |||
| value |
TEL | |||
| value |
AD | |||
| value |
EN | |||
| value |
INT | |||
| value |
REAL | |||
| value |
PQ | |||
| value |
MO | |||
| value |
TS | |||
| value |
IVL_PQ | |||
| value |
IVL_TS | |||
| value |
PIVL_TS | |||
| value |
EIVL_TS | |||
| value |
SXPR_TS | |||
| interpretationCode |
0..1 | CE | Binding: CDAObservationInterpretation (required) | |
| sdtcPrecondition1 |
0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: precondition1 (urn:hl7-org:sdtc) | |
| @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: PRCN | |
| conjunctionCode |
1..1 | CS | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc Binding: RelationshipConjunction (2.0.0) (required) | |
| criterion1 |
1..1 | Criterion | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| 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:result-obs.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.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.code | required | ResultStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39 | |
| 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:physical-quantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| Observation.value:coded.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| 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 | |
| Observation.referenceRange.observationRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.classCode | required | CDAActClassObservationhttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.referenceRange.observationRange.moodCode | required | Fixed Value: EVN.CRThttp://terminology.hl7.org/ValueSet/v3-ActMoodPredicate | |
| Observation.referenceRange.observationRange.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Observation.referenceRange.observationRange.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.typeCode | required | Fixed Value: PRCNhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.conjunctionCode | required | RelationshipConjunctionhttp://terminology.hl7.org/ValueSet/v3-RelationshipConjunction|2.0.0 |
| Id | Grade | Path(s) | Details | Requirements |
| 4537-19212 | warning | Observation.code | 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' | |
| 4537-32610 | warning | Observation.value:coded | 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' | |
| shall-code-or-nullflavor | error | Observation.code | SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. : (code | nullFlavor).count() = 1 | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-interpretationCode | warning | Observation | SHOULD contain interpretationCode : interpretationCode.exists() | |
| should-referenceRange | warning | Observation | SHOULD contain referenceRange : referenceRange.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: 9 elements(2 nested mandatory elements)
Fixed: 2 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
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-interpretationCode: SHOULD contain interpretationCode should-author: SHOULD contain author should-referenceRange: SHOULD contain referenceRange |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:result-obs |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
| @extension |
1..1 | st | Required Pattern: 2023-05-01 | |
| @classCode |
1..1 | cs | Fixed Value: OBS | |
| @moodCode |
1..1 | cs | Fixed Value: EVN | |
| id |
1..* | II | ||
| code |
C | 1..1 | CD | (USCDI) Tests shall-code-or-nullflavor: SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. 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). |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | ||
| @code |
0..1 | cs | ||
| 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 | (USCDI) Result Status | |
| @nullFlavor |
0..0 | |||
| @code |
1..1 | cs | Binding: Result Status (required) | |
| effectiveTime |
1..1 | IVL_TS | Represents 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). | |
| Slices for value |
1..1 | ANY, BL, ED, ST, CD, CV, CE, CO, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | (USCDI) Values/Results - Value can be any type, but certain types have additional rules. Slice: Unordered, Open by type:$this | |
| value:physical-quantity |
0..1 | PQ | ||
| @unit |
1..1 | cs | (USCDI) Result Unit of Measure Binding: UnitsOfMeasureCaseSensitive (preferred) | |
| translation |
0..1 | PQR | Can be used to represent the original results as output by the lab | |
| value:coded |
C | 0..1 | CD | 4537-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). |
| translation |
0..1 | CD | Can be used to represent the original results as output by the lab | |
| interpretationCode |
0..* | CE | (USCDI) Result Interpretation | |
| methodCode |
0..1 | CE | ||
| targetSiteCode |
0..1 | CD | ||
| author |
0..* | AuthorParticipation | Base for all types and resources | |
| referenceRange |
0..* | InfrastructureRoot | (USCDI) Result Reference Range | |
| observationRange |
1..1 | ObservationRange | ||
| value |
1..1 | BL, ED, ST, CD, CV, CE, CO, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS | When the value is a quantity, then the unit SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive. | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Observation.statusCode.code | required | ResultStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39 | |
| Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive |
| Id | Grade | Path(s) | Details | Requirements |
| 4537-19212 | warning | Observation.code | 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' | |
| 4537-32610 | warning | Observation.value:coded | 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' | |
| shall-code-or-nullflavor | error | Observation.code | SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. : (code | nullFlavor).count() = 1 | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-interpretationCode | warning | Observation | SHOULD contain interpretationCode : interpretationCode.exists() | |
| should-referenceRange | warning | Observation | SHOULD contain referenceRange : referenceRange.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-interpretationCode: SHOULD contain interpretationCode should-author: SHOULD contain author should-referenceRange: SHOULD contain referenceRange |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:result-obs |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
| @extension |
1..1 | st | Required Pattern: 2023-05-01 | |
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
| id |
1..* | II | ||
| code |
C | 1..1 | CD | (USCDI) Tests Binding: ObservationType (example) shall-code-or-nullflavor: SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. 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). |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
0..1 | cs | ||
| 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 | (USCDI) Result Status Binding: ActStatus (required) | |
| @code |
1..1 | cs | Binding: Result Status (required) | |
| effectiveTime |
1..1 | IVL_TS | Represents 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). | |
| Slices for value |
1..1 | (USCDI) Values/Results - Value can be any type, but certain types have additional rules. Slice: Unordered, Open by type:$this | ||
| value |
ANY | |||
| value |
BL | |||
| value |
ED | |||
| value |
ST | |||
| value |
CD | |||
| value |
CV | |||
| value |
CE | |||
| value |
CO | |||
| value |
SC | |||
| value |
II | |||
| value |
TEL | |||
| value |
AD | |||
| value |
EN | |||
| value |
INT | |||
| value |
REAL | |||
| value |
PQ | |||
| value |
MO | |||
| value |
TS | |||
| value |
IVL_PQ | |||
| value |
IVL_TS | |||
| value |
PIVL_TS | |||
| value |
EIVL_TS | |||
| value |
SXPR_TS | |||
| value |
RTO_PQ_PQ | |||
| value:physical-quantity |
0..1 | PQ | ||
| @unit |
1..1 | cs | (USCDI) Result Unit of Measure Binding: UnitsOfMeasureCaseSensitive (preferred) | |
| translation |
0..1 | PQR | Can be used to represent the original results as output by the lab | |
| value:coded |
C | 0..1 | CD | 4537-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). |
| translation |
0..1 | CD | Can be used to represent the original results as output by the lab | |
| interpretationCode |
0..* | CE | (USCDI) Result Interpretation Binding: CDAObservationInterpretation (required) | |
| methodCode |
0..1 | CE | Binding: ObservationMethod (example) | |
| targetSiteCode |
0..1 | CD | ||
| author |
0..* | AuthorParticipation | Base for all types and resources | |
| referenceRange |
0..* | InfrastructureRoot | (USCDI) Result Reference Range | |
| observationRange |
1..1 | ObservationRange | ||
| value |
1..1 | When the value is a quantity, then the unit SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive. | ||
| value |
BL | |||
| value |
ED | |||
| value |
ST | |||
| value |
CD | |||
| value |
CV | |||
| value |
CE | |||
| value |
CO | |||
| value |
SC | |||
| value |
II | |||
| value |
TEL | |||
| value |
AD | |||
| value |
EN | |||
| value |
INT | |||
| value |
REAL | |||
| value |
PQ | |||
| value |
MO | |||
| value |
TS | |||
| value |
IVL_PQ | |||
| value |
IVL_TS | |||
| value |
PIVL_TS | |||
| value |
EIVL_TS | |||
| value |
SXPR_TS | |||
| 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.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.statusCode.code | required | ResultStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39 | |
| Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod |
| Id | Grade | Path(s) | Details | Requirements |
| 4537-19212 | warning | Observation.code | 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' | |
| 4537-32610 | warning | Observation.value:coded | 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' | |
| shall-code-or-nullflavor | error | Observation.code | SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. : (code | nullFlavor).count() = 1 | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-interpretationCode | warning | Observation | SHOULD contain interpretationCode : interpretationCode.exists() | |
| should-referenceRange | warning | Observation | SHOULD contain referenceRange : referenceRange.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-interpretationCode: SHOULD contain interpretationCode should-author: SHOULD contain author should-referenceRange: SHOULD contain referenceRange |
| @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:result-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: 2.16.840.1.113883.10.20.22.4.2 | |
| @extension |
1..1 | st | Required Pattern: 2023-05-01 | |
| @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 |
1..* | II | ||
| code |
C | 1..1 | CD | (USCDI) Tests Binding: ObservationType (example) shall-code-or-nullflavor: SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. 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). |
| (Choice of one) |
1..1 | |||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
0..1 | cs | ||
| @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 | ||
| 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 | (USCDI) Result Status Binding: ActStatus (required) | |
| @code |
1..1 | cs | Binding: Result Status (required) | |
| @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 |
1..1 | IVL_TS | Represents 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). | |
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| Slices for value |
1..1 | (USCDI) Values/Results - Value can be any type, but certain types have additional rules. Slice: Unordered, Open by type:$this | ||
| value |
ANY | |||
| value |
BL | |||
| value |
ED | |||
| value |
ST | |||
| value |
CD | |||
| value |
CV | |||
| value |
CE | |||
| value |
CO | |||
| value |
SC | |||
| value |
II | |||
| value |
TEL | |||
| value |
AD | |||
| value |
EN | |||
| value |
INT | |||
| value |
REAL | |||
| value |
PQ | |||
| value |
MO | |||
| value |
TS | |||
| value |
IVL_PQ | |||
| value |
IVL_TS | |||
| value |
PIVL_TS | |||
| value |
EIVL_TS | |||
| value |
SXPR_TS | |||
| value |
RTO_PQ_PQ | |||
| value:physical-quantity |
0..1 | PQ | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @unit |
1..1 | cs | (USCDI) Result Unit of Measure Binding: UnitsOfMeasureCaseSensitive (preferred) | |
| @value |
0..1 | real | ||
| translation |
0..1 | PQR | Can be used to represent the original results as output by the lab | |
| value:coded |
C | 0..1 | CD | 4537-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
0..1 | cs | ||
| @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..1 | CD | Can be used to represent the original results as output by the lab | |
| interpretationCode |
0..* | CE | (USCDI) Result Interpretation Binding: CDAObservationInterpretation (required) | |
| methodCode |
0..1 | CE | Binding: ObservationMethod (example) | |
| targetSiteCode |
0..1 | CD | ||
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | AuthorParticipation | Base for all types and resources | |
| 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 | (USCDI) Result Reference Range | |
| @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 | ||
| @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: CDAActClassObservation (required) | |
| @moodCode |
0..1 | cs | Binding: ActMoodPredicate (required) Fixed Value: EVN.CRT | |
| code |
0..1 | CD | Binding: v3 Code System ActCode (example) | |
| text |
0..1 | ED | ||
| value |
1..1 | When the value is a quantity, then the unit SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive. | ||
| value |
BL | |||
| value |
ED | |||
| value |
ST | |||
| value |
CD | |||
| value |
CV | |||
| value |
CE | |||
| value |
CO | |||
| value |
SC | |||
| value |
II | |||
| value |
TEL | |||
| value |
AD | |||
| value |
EN | |||
| value |
INT | |||
| value |
REAL | |||
| value |
PQ | |||
| value |
MO | |||
| value |
TS | |||
| value |
IVL_PQ | |||
| value |
IVL_TS | |||
| value |
PIVL_TS | |||
| value |
EIVL_TS | |||
| value |
SXPR_TS | |||
| interpretationCode |
0..1 | CE | Binding: CDAObservationInterpretation (required) | |
| sdtcPrecondition1 |
0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: precondition1 (urn:hl7-org:sdtc) | |
| @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: PRCN | |
| conjunctionCode |
1..1 | CS | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc Binding: RelationshipConjunction (2.0.0) (required) | |
| criterion1 |
1..1 | Criterion | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| 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:result-obs.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.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.code | required | ResultStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39 | |
| 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:physical-quantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| Observation.value:coded.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| 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 | |
| Observation.referenceRange.observationRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.classCode | required | CDAActClassObservationhttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.referenceRange.observationRange.moodCode | required | Fixed Value: EVN.CRThttp://terminology.hl7.org/ValueSet/v3-ActMoodPredicate | |
| Observation.referenceRange.observationRange.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Observation.referenceRange.observationRange.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.typeCode | required | Fixed Value: PRCNhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType | |
| Observation.referenceRange.observationRange.sdtcPrecondition1.conjunctionCode | required | RelationshipConjunctionhttp://terminology.hl7.org/ValueSet/v3-RelationshipConjunction|2.0.0 |
| Id | Grade | Path(s) | Details | Requirements |
| 4537-19212 | warning | Observation.code | 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' | |
| 4537-32610 | warning | Observation.value:coded | 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' | |
| shall-code-or-nullflavor | error | Observation.code | SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. : (code | nullFlavor).count() = 1 | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-interpretationCode | warning | Observation | SHOULD contain interpretationCode : interpretationCode.exists() | |
| should-referenceRange | warning | Observation | SHOULD contain referenceRange : referenceRange.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: 9 elements(2 nested mandatory elements)
Fixed: 2 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
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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