Consolidated CDA (C-CDA)
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Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 4.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions

Logical Model: SocialHistoryObservation - Detailed Descriptions

Draft as of 2024-12-19

Definitions for the SocialHistoryObservation logical model.

Guidance on how to interpret the contents of this table can be found here

0. Observation
Logical ContainerClinicalDocument (CDA Class)
ValidationInstance of this type are validated by templateId
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
Invariantsshould-text-ref-value: SHOULD contain text/reference/@value (text.reference.value.exists())
should-value: SHOULD contain value (value.exists())
4515-8555: If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. ()
should-sh-author: SHOULD contain author (author.exists())
2. Observation.templateId
Control1..?
SlicingThis element introduces a set of slices on Observation.templateId. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ root
  • value @ extension
  • 4. Observation.templateId:social-history-obs
    Slice Namesocial-history-obs
    Control1..1
    6. Observation.templateId:social-history-obs.root
    Control1..?
    Pattern Value2.16.840.1.113883.10.20.22.4.38
    8. Observation.templateId:social-history-obs.extension
    Control1..?
    Pattern Value2022-06-01
    10. Observation.classCode
    Comments

    SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:4515-8548).

    Fixed ValueOBS
    12. Observation.moodCode
    Comments

    SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:4515-8549).

    Fixed ValueEVN
    14. Observation.id
    Comments

    SHALL contain at least one [1..*] id (CONF:4515-8551).

    Control1..?
    16. Observation.code
    Comments

    SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Social History Type urn:oid:2.16.840.1.113883.3.88.12.80.60 DYNAMIC (CONF:4515-8558).

    BindingThe codes SHOULD be taken from Social History Type .
    (preferred to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.60)
    Invariants4515-32956: If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). (codeSystem = '2.16.840.1.113883.6.1' or translation.where(codeSystem = '2.16.840.1.113883.6.1').exists())
    18. Observation.text
    ShortSHOULD reference the portion of section narrative text corresponding to this entry
    20. Observation.text.reference
    Invariantsvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative (value.exists() implies value.startsWith('#'))
    22. Observation.statusCode
    Comments

    SHALL contain exactly one [1..1] statusCode (CONF:4515-8553).

    Control1..?
    24. Observation.statusCode.code
    Comments

    This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: HL7ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:4515-19117).

    Control1..?
    Fixed Valuecompleted
    26. Observation.effectiveTime
    Comments

    SHALL contain exactly one [1..1] effectiveTime (CONF:4515-31868).

    Control1..?
    28. Observation.value
    Short𝗨𝗦𝗖𝗗𝗜: Alcohol Use, Substance Use, SDOH Problems/Health Concerns
    Comments

    SHOULD contain zero or one [0..1] value (CONF:4515-8559).

    Control0..1
    SlicingThis element introduces a set of slices on Observation.value. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • type @ $this
    • 30. Observation.value:physical-quantity
      Slice Namephysical-quantity
      Control0..1
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/PQ
      32. Observation.value:physical-quantity.unit
      Control1..?
      BindingThe codes SHOULD be taken from UnitsOfMeasureCaseSensitive
      (preferred to http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive)
      34. Observation.value:coded
      Slice Namecoded
      Control0..1
      Binding

      See additional binding

      Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
      36. Observation.author
      Comments

      SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:4515-31869).

      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Author(Author Participation)
      38. Observation.entryRelationship
      Comments

      MAY contain zero or more [0..*] entryRelationship (CONF:4515-32969) such that it

      SlicingThis element introduces a set of slices on Observation.entryRelationship. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • profile @ act
      • profile @ observation
      • 40. Observation.entryRelationship:supportingObs
        Slice NamesupportingObs
        ShortWhen an Assessment Scale Observation is contained in a Social History Observation instance that is a Social Determinant of Health Social History Observation, that Assessment Scale Observation MAY contain Assessment Scale Supporting Observations that contain LOINC question and answer pairs from SDOH screening instruments.
        Comments

        MAY contain zero or more [0..*] entryRelationship (CONF:4515-32958) such that it

        Control0..*
        42. Observation.entryRelationship:supportingObs.typeCode
        Comments

        SHALL contain exactly one [1..1] @typeCode="SPRT" Has support (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:4515-32960).

        Fixed ValueSPRT
        44. Observation.entryRelationship:supportingObs.observation
        Comments

        SHALL contain exactly one [1..1] Assessment Scale Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.69) (CONF:4515-32959).

        Control1..?
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Assessment Scale Observation)
        46. Observation.entryRelationship:entryReference
        Slice NameentryReference
        ShortWhen an Entry Reference is contained in a Social History Template instance that is a Social Determinant of Health Social History, that Entry Reference **MAY** reference an Assessment Scale Observation elsewhere in the document that represent LOINC question and answer pairs from SDOH screening instruments.
        Control0..*
        48. Observation.entryRelationship:entryReference.typeCode
        Comments

        SHALL contain exactly one [1..1] @typeCode="SPRT" Has support (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:4515-32971).

        Fixed ValueSPRT
        50. Observation.entryRelationship:entryReference.act
        Comments

        SHALL contain exactly one [1..1] Entry Reference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.122) (CONF:4515-32970).

        Control1..?
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Act(Entry Reference)