Consolidated CDA (C-CDA)
4.0.0-ballot - STU4
Consolidated CDA (C-CDA)
4.0.0-ballot - STU4
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
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/SmokingStatus | Version: 4.0.0-ballot | |||
| Draft as of 2024-11-21 | Computable Name: SmokingStatus | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.511:2024-05-01 | ||||
This template represents a patient's smoking status. It is a combination and replacement of the two previous templates Smoking Status - Meaningful Use and Tobacco Use, and it aligns with the US Core Smoking Status profile.
When the code represents a quantifiable observation (such as Cigarette pack-years - 401201003), the value may be a Physical Quantity. When the code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded.
Regarding effectiveTime: some values in the Tobacco Use value set represent temporal meanings (e.g. 266919005 - Never smoked tobacco) and should correspond to a single timestamp representing when the observation was true. Other codes, such as 59978006 - Cigar smoker, may be represented with a single timestamp or a time range indicating when the patient began smoking and when they stopped.
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, 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 coded-value: When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded |
  Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:tobacco-use |
1..1 | II | ||
  @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.511 | |
  @extension |
1..1 | st | Required Pattern: 2024-05-01 | |
 @classCode |
1..1 | cs | Fixed Value: OBS | |
| @moodCode |
1..1 | cs | Fixed Value: EVN | |
| id |
1..* | II | ||
| code |
1..1 | CD | Binding: Smoking Status Type  (required): Smoking status type | |
 @code |
1..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 | ||
| @code |
1..1 | cs | Fixed Value: completed | |
| effectiveTime |
1..1 | IVL_TS | ||
| @value |
0..1 | ts | Represents a timestamp indicating a "point in time" when the observation was true | |
| low |
0..1 | IVXB_TS | Represents the earliest time the observation was true. Should not be used for temporal codes (e.g. 266919005 - Never smoked tobacco) | |
| high |
0..1 | IVXB_TS | Represents the last known time the observation was true. If the observation is still true, set `@nullFlavor` to `UNK`. | |
 Slices for value |
1..1 | REAL shall only be used for Smoking Status where code = 401201003 or 782516008 Slice: Unordered, Closed by type:$this | ||
  value |
CD | |||
| value |
REAL | |||
| value:packYears |
0..1 | REAL | Only used for Smoking Status where code = 401201003 or 782516008 | |
| value:coded |
0..1 | CD | ||
| @code |
1..1 | cs | Binding: Smoking status comprehensive (required): Smoking status comprehensive | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Observation.code | required | SmokingStatusType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.6 | |
| Observation.value:coded.code | required | SmokingStatusComprehensive http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.3 |
| Id | Grade | Path(s) | Details | Requirements |
| coded-value | error | Observation | When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded : (code.code = '72166-2' or code.code = '11367-0') implies value.code.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, 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 coded-value: When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:tobacco-use |
1..1 | II | ||
 @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.511 | |
| @extension |
1..1 | st | Required Pattern: 2024-05-01 | |
| @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 |
1..1 | CD | Binding: Smoking Status Type (required): Smoking status type | |
| @code |
1..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 | Binding: ActStatus (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| effectiveTime |
1..1 | IVL_TS | ||
| @value |
0..1 | ts | Represents a timestamp indicating a "point in time" when the observation was true Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| low |
0..1 | IVXB_TS | Represents the earliest time the observation was true. Should not be used for temporal codes (e.g. 266919005 - Never smoked tobacco) | |
| high |
0..1 | IVXB_TS | Represents the last known time the observation was true. If the observation is still true, set `@nullFlavor` to `UNK`. | |
| Slices for value |
1..1 | REAL shall only be used for Smoking Status where code = 401201003 or 782516008 Slice: Unordered, Closed by type:$this | ||
| value |
CD | |||
| value |
REAL | |||
| value:packYears |
0..1 | REAL | Only used for Smoking Status where code = 401201003 or 782516008 | |
| value:coded |
0..1 | CD | ||
| @code |
1..1 | cs | Binding: Smoking status comprehensive (required): Smoking status comprehensive | |
| 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 | required | SmokingStatusType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.6 | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.value:coded.code | required | SmokingStatusComprehensive http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.3 |
| Id | Grade | Path(s) | Details | Requirements |
| coded-value | error | Observation | When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded : (code.code = '72166-2' or code.code = '11367-0') implies value.code.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, 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 coded-value: When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded |
| @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:tobacco-use |
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: 2.16.840.1.113883.10.20.22.4.511 | |
| @extension |
1..1 | st | Required Pattern: 2024-05-01 | |
| @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 | ||
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |
| code |
1..1 | CD | Binding: Smoking Status Type (required): Smoking status type | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..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 | 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 |
1..1 | IVL_TS | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | Represents a timestamp indicating a "point in time" when the observation was true Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator |
0..1 | cs | Binding: CDASetOperator (required) | |
| low |
0..1 | IVXB_TS | Represents the earliest time the observation was true. Should not be used for temporal codes (e.g. 266919005 - Never smoked tobacco) | |
| center |
0..1 | TS | ||
| width |
0..1 | PQ | ||
| high |
0..1 | IVXB_TS | Represents the last known time the observation was true. If the observation is still true, set `@nullFlavor` to `UNK`. | |
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| Slices for value |
1..1 | REAL shall only be used for Smoking Status where code = 401201003 or 782516008 Slice: Unordered, Closed by type:$this | ||
| value |
CD | |||
| value |
REAL | |||
| value:packYears |
0..1 | REAL | Only used for Smoking Status where code = 401201003 or 782516008 | |
| value:coded |
0..1 | CD | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Binding: Smoking status comprehensive (required): Smoking status comprehensive | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @codeSystemName |
0..1 | st | ||
| @codeSystemVersion |
0..1 | st | ||
| @displayName |
0..1 | st | ||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText |
0..1 | ED | ||
| qualifier |
0..* | CR | ||
| translation |
0..* | CD | ||
| interpretationCode |
0..* | CE | Binding: CDAObservationInterpretation (required) | |
| methodCode |
0..* | CE | Binding: ObservationMethod (example) | |
| targetSiteCode |
0..* | CD | ||
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | Author | ||
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| entryRelationship |
0..* | EntryRelationship | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| referenceRange |
0..* | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: REFV | |
| observationRange |
1..1 | ObservationRange | ||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.templateId:tobacco-use.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 | required | SmokingStatusType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.6 | |
| 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.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.effectiveTime.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.effectiveTime.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| 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:coded.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.value:coded.code | required | SmokingStatusComprehensive http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.3 | |
| 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 |
| Id | Grade | Path(s) | Details | Requirements |
| coded-value | error | Observation | When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded : (code.code = '72166-2' or code.code = '11367-0') implies value.code.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: 10 elements(1 nested mandatory element)
Fixed: 3 elements
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, 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 coded-value: When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:tobacco-use |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.511 | |
| @extension |
1..1 | st | Required Pattern: 2024-05-01 | |
| @classCode |
1..1 | cs | Fixed Value: OBS | |
| @moodCode |
1..1 | cs | Fixed Value: EVN | |
| id |
1..* | II | ||
| code |
1..1 | CD | Binding: Smoking Status Type (required): Smoking status type | |
| @code |
1..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 | ||
| @code |
1..1 | cs | Fixed Value: completed | |
| effectiveTime |
1..1 | IVL_TS | ||
| @value |
0..1 | ts | Represents a timestamp indicating a "point in time" when the observation was true | |
| low |
0..1 | IVXB_TS | Represents the earliest time the observation was true. Should not be used for temporal codes (e.g. 266919005 - Never smoked tobacco) | |
| high |
0..1 | IVXB_TS | Represents the last known time the observation was true. If the observation is still true, set `@nullFlavor` to `UNK`. | |
| Slices for value |
1..1 | REAL shall only be used for Smoking Status where code = 401201003 or 782516008 Slice: Unordered, Closed by type:$this | ||
| value |
CD | |||
| value |
REAL | |||
| value:packYears |
0..1 | REAL | Only used for Smoking Status where code = 401201003 or 782516008 | |
| value:coded |
0..1 | CD | ||
| @code |
1..1 | cs | Binding: Smoking status comprehensive (required): Smoking status comprehensive | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Observation.code | required | SmokingStatusType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.6 | |
| Observation.value:coded.code | required | SmokingStatusComprehensive http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.3 |
| Id | Grade | Path(s) | Details | Requirements |
| coded-value | error | Observation | When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded : (code.code = '72166-2' or code.code = '11367-0') implies value.code.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, 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 coded-value: When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:tobacco-use |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.511 | |
| @extension |
1..1 | st | Required Pattern: 2024-05-01 | |
| @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 |
1..1 | CD | Binding: Smoking Status Type (required): Smoking status type | |
| @code |
1..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 | Binding: ActStatus (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| effectiveTime |
1..1 | IVL_TS | ||
| @value |
0..1 | ts | Represents a timestamp indicating a "point in time" when the observation was true Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| low |
0..1 | IVXB_TS | Represents the earliest time the observation was true. Should not be used for temporal codes (e.g. 266919005 - Never smoked tobacco) | |
| high |
0..1 | IVXB_TS | Represents the last known time the observation was true. If the observation is still true, set `@nullFlavor` to `UNK`. | |
| Slices for value |
1..1 | REAL shall only be used for Smoking Status where code = 401201003 or 782516008 Slice: Unordered, Closed by type:$this | ||
| value |
CD | |||
| value |
REAL | |||
| value:packYears |
0..1 | REAL | Only used for Smoking Status where code = 401201003 or 782516008 | |
| value:coded |
0..1 | CD | ||
| @code |
1..1 | cs | Binding: Smoking status comprehensive (required): Smoking status comprehensive | |
| 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 | required | SmokingStatusType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.6 | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.value:coded.code | required | SmokingStatusComprehensive http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.3 |
| Id | Grade | Path(s) | Details | Requirements |
| coded-value | error | Observation | When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded : (code.code = '72166-2' or code.code = '11367-0') implies value.code.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, 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 coded-value: When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded |
| @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:tobacco-use |
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: 2.16.840.1.113883.10.20.22.4.511 | |
| @extension |
1..1 | st | Required Pattern: 2024-05-01 | |
| @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 | ||
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |
| code |
1..1 | CD | Binding: Smoking Status Type (required): Smoking status type | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..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 | 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 |
1..1 | IVL_TS | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | Represents a timestamp indicating a "point in time" when the observation was true Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator |
0..1 | cs | Binding: CDASetOperator (required) | |
| low |
0..1 | IVXB_TS | Represents the earliest time the observation was true. Should not be used for temporal codes (e.g. 266919005 - Never smoked tobacco) | |
| center |
0..1 | TS | ||
| width |
0..1 | PQ | ||
| high |
0..1 | IVXB_TS | Represents the last known time the observation was true. If the observation is still true, set `@nullFlavor` to `UNK`. | |
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| Slices for value |
1..1 | REAL shall only be used for Smoking Status where code = 401201003 or 782516008 Slice: Unordered, Closed by type:$this | ||
| value |
CD | |||
| value |
REAL | |||
| value:packYears |
0..1 | REAL | Only used for Smoking Status where code = 401201003 or 782516008 | |
| value:coded |
0..1 | CD | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Binding: Smoking status comprehensive (required): Smoking status comprehensive | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @codeSystemName |
0..1 | st | ||
| @codeSystemVersion |
0..1 | st | ||
| @displayName |
0..1 | st | ||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText |
0..1 | ED | ||
| qualifier |
0..* | CR | ||
| translation |
0..* | CD | ||
| interpretationCode |
0..* | CE | Binding: CDAObservationInterpretation (required) | |
| methodCode |
0..* | CE | Binding: ObservationMethod (example) | |
| targetSiteCode |
0..* | CD | ||
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | Author | ||
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| entryRelationship |
0..* | EntryRelationship | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| referenceRange |
0..* | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: REFV | |
| observationRange |
1..1 | ObservationRange | ||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.templateId:tobacco-use.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 | required | SmokingStatusType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.6 | |
| 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.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.effectiveTime.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.effectiveTime.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| 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:coded.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.value:coded.code | required | SmokingStatusComprehensive http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.3 | |
| 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 |
| Id | Grade | Path(s) | Details | Requirements |
| coded-value | error | Observation | When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded : (code.code = '72166-2' or code.code = '11367-0') implies value.code.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: 10 elements(1 nested mandatory element)
Fixed: 3 elements
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#4.0.0-ballot based on FHIR 5.0.0. Generated 2024-11-21
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