Consolidated CDA (C-CDA)
4.0.0 - STU4 United States of America flag

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 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: Social History Observation

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/SocialHistoryObservation Version: 4.0.0
Draft as of 2025-10-02 Computable Name: SocialHistoryObservation
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.38:2022-06-01

This template represents a patient's job (occupation and industry), lifestyle, and environmental health risk factors. Demographic data (e.g., marital status, race, ethnicity, religious affiliation) are captured in the header. Though tobacco use and exposure may be represented with a Social History Observation, it is recommended to use the Current Smoking Status template or the Tobacco Use template instead, to represent smoking or tobacco habits. There are supplemental templates and guidance for observations of Occupational Data for Health, nutrition and pregnancy that could be captured in the Social History Observation, and implementers may want to consider using those more specific templates in the Social History section.

Templates Used

Although open templates may contain any valid CDA content, the following templates are specifically called out by this template:

Optional EntryRelationships: AssessmentScaleObservation, EntryReference

Usages:

You can also check for usages in the FHIR IG Statistics

Changes since version 3.0.0:

  • New Content

    • Formal Views of Template Content

    Description of Template, Differentials, Snapshots and how the different presentations work.

    This structure is derived from Observation

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Observation C 1..1 Observation XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, should-sdtcCategory, category-social-history, should-value, 4515-8555, should-sh-author
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
    .... templateId:social-history-obs 1..1 II
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.38
    ..... @extension 1..1 st Required Pattern: 2022-06-01
    ... @classCode 1..1 cs Fixed Value: OBS
    ... @moodCode 1..1 cs Fixed Value: EVN
    ... Slices for sdtcCategory 0..* CD Category is optional, but if present it SHALL contain a category with code=social-history.
    Slice: Unordered, Open by value:code, value:codeSystem
    .... sdtcCategory:social-history 0..1 CD Social History
    ..... @code 1..1 cs Required Pattern: social-history
    ..... @codeSystem 1..1 oid, uuid, ruid Required Pattern: http://terminology.hl7.org/CodeSystem/observation-category
    ... code C 1..1 CD Binding: Social History Type . (preferred)
    Constraints: 4515-32956
    ... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
    .... reference C 0..1 TEL Constraints: value-starts-octothorpe
    ... statusCode 1..1 CS
    .... @code 1..1 cs Fixed Value: completed
    ... effectiveTime 1..1 IVL_TS
    ... Slices for value 0..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: Alcohol Use, Substance Use, SDOH Problems/Health Concerns
    Slice: Unordered, Open by type:$this
    .... value:physical-quantity 0..1 PQ
    ..... @unit 1..1 cs Binding: UnitsOfMeasureCaseSensitive (preferred)
    .... value:coded 0..1 CD Binding Description: (example): See additional binding
    Additional BindingsPurposeDocumentation
    Social Determinants of Health Conditions . Preferred
    Social Determinant of Health Observations
    ... author 0..* AuthorParticipation
    ... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
    .... entryRelationship:supportingObs 0..* EntryRelationship When 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.
    ..... @typeCode 1..1 cs Fixed Value: SPRT
    ..... observation 1..1 AssessmentScaleObservation
    .... entryRelationship:entryReference 0..* EntryRelationship When 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.
    ..... @typeCode 1..1 cs Fixed Value: SPRT
    ..... act 1..1 EntryReference

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    Observation.code Base preferred Social History Type . 📦20250423 VSAC v0.23
    Observation.value:physical-quantity.​unit Base preferred UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    Observation.value:coded Base example ? Unknown

    Constraints

    Id Grade Path(s) Description Expression
    4515-8555 error Observation 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.
    4515-32956 warning Observation.code 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()
    category-social-history error Observation If category is present, then there shall be a category with code 'social-history'. sdtcCategory.empty() or sdtcCategory.exists(code = 'social-history' and codeSystem = 'http://terminology.hl7.org/CodeSystem/observation-category')
    should-sdtcCategory warning Observation SHOULD contain sdtcCategory sdtcCategory.exists()
    should-sh-author warning Observation SHOULD contain author author.exists()
    should-text-ref-value warning Observation SHOULD contain text/reference/@value text.reference.value.exists()
    should-value warning Observation SHOULD contain value 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('#')
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Observation C 1..1 Observation XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, should-sdtcCategory, category-social-history, should-value, 4515-8555, should-sh-author
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @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:social-history-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: 2.16.840.1.113883.10.20.22.4.38
    ..... @extension 1..1 st Required Pattern: 2022-06-01
    ... @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
    ... Slices for sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
    Category is optional, but if present it SHALL contain a category with code=social-history.
    Slice: Unordered, Open by value:code, value:codeSystem
    XML: category (urn:hl7-org:sdtc)
    .... sdtcCategory:social-history 0..1 CD XML Namespace: urn:hl7-org:sdtc
    Social History
    XML: category (urn:hl7-org:sdtc)
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @code 1..1 cs Required Pattern: social-history
    ..... @codeSystem 1..1 oid, uuid, ruid Required Pattern: http://terminology.hl7.org/CodeSystem/observation-category
    ..... @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
    ... code C 1..1 CD Binding: Social History Type . (preferred)
    Constraints: 4515-32956
    ... 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 Constraints: value-starts-octothorpe
    .... 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
    ... priorityCode 0..1 CE Binding: ActPriority (example)
    ... repeatNumber 0..1 IVL_INT
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... Slices for value 0..1 𝗨𝗦𝗖𝗗𝗜: Alcohol Use, Substance Use, SDOH Problems/Health Concerns
    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 Binding: UnitsOfMeasureCaseSensitive (preferred)
    ..... @value 0..1 real
    ..... translation 0..* PQR
    .... value:coded 0..1 CD Binding Description: (example): See additional binding
    Additional BindingsPurposeDocumentation
    Social Determinants of Health Conditions . Preferred
    Social Determinant of Health Observations

    ... 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..* AuthorParticipation
    ... informant 0..* Informant
    ... participant 0..* Participant2
    ... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
    .... entryRelationship:supportingObs 0..* EntryRelationship When 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.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: SPRT
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 AssessmentScaleObservation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:entryReference 0..* EntryRelationship When 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.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: SPRT
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 1..1 EntryReference
    ..... encounter 0..1 Encounter
    ..... observation 0..1 Observation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    ... 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 C 0..1 II Constraints: II-1
    ..... @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)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Observation.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.templateId:social-history-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.classCode Base required CDAActClassObservation 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.moodCode Base required x_ActMoodDocumentObservation 📍2.0.0 THO v5.2
    Observation.sdtcCategory:social-history.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.code Base preferred Social History Type . 📦20250423 VSAC v0.23
    Observation.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Observation.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Observation.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Observation.statusCode.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Observation.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Observation.value:physical-quantity.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.value:physical-quantity.​unit Base preferred UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    Observation.value:coded Base example ? Unknown
    Observation.interpretationCode Base required CDAObservationInterpretation 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.methodCode Base example ObservationMethod 📦3.0.0 THO v6.5
    Observation.entryRelationship:supportingObs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.entryRelationship:supportingObs.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.entryRelationship:supportingObs.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Observation.entryRelationship:entryReference.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.entryRelationship:entryReference.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.entryRelationship:entryReference.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Observation.referenceRange.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.referenceRange.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.referenceRange.​typeCode Base required CDAActRelationshipType 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    4515-8555 error Observation 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.
    4515-32956 warning Observation.code 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()
    II-1 error Observation.typeId, Observation.entryRelationship:supportingObs.typeId, Observation.entryRelationship:entryReference.typeId, Observation.referenceRange.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    category-social-history error Observation If category is present, then there shall be a category with code 'social-history'. sdtcCategory.empty() or sdtcCategory.exists(code = 'social-history' and codeSystem = 'http://terminology.hl7.org/CodeSystem/observation-category')
    should-sdtcCategory warning Observation SHOULD contain sdtcCategory sdtcCategory.exists()
    should-sh-author warning Observation SHOULD contain author author.exists()
    should-text-ref-value warning Observation SHOULD contain text/reference/@value text.reference.value.exists()
    should-value warning Observation SHOULD contain value 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('#')
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Observation C 1..1 Observation XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, should-sdtcCategory, category-social-history, should-value, 4515-8555, should-sh-author
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @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:social-history-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: 2.16.840.1.113883.10.20.22.4.38
    ..... @extension 1..1 st Required Pattern: 2022-06-01
    ... @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
    ... Slices for sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
    Category is optional, but if present it SHALL contain a category with code=social-history.
    Slice: Unordered, Open by value:code, value:codeSystem
    XML: category (urn:hl7-org:sdtc)
    .... sdtcCategory:social-history 0..1 CD XML Namespace: urn:hl7-org:sdtc
    Social History
    XML: category (urn:hl7-org:sdtc)
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @code 1..1 cs Required Pattern: social-history
    ..... @codeSystem 1..1 oid, uuid, ruid Required Pattern: http://terminology.hl7.org/CodeSystem/observation-category
    ..... @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
    ... code C 1..1 CD Binding: Social History Type . (preferred)
    Constraints: 4515-32956
    ... 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 Constraints: value-starts-octothorpe
    .... 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
    ... priorityCode 0..1 CE Binding: ActPriority (example)
    ... repeatNumber 0..1 IVL_INT
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... Slices for value 0..1 𝗨𝗦𝗖𝗗𝗜: Alcohol Use, Substance Use, SDOH Problems/Health Concerns
    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 Binding: UnitsOfMeasureCaseSensitive (preferred)
    ..... @value 0..1 real
    ..... translation 0..* PQR
    .... value:coded 0..1 CD Binding Description: (example): See additional binding
    Additional BindingsPurposeDocumentation
    Social Determinants of Health Conditions . Preferred
    Social Determinant of Health Observations

    ... 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..* AuthorParticipation
    ... informant 0..* Informant
    ... participant 0..* Participant2
    ... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
    .... entryRelationship:supportingObs 0..* EntryRelationship When 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.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: SPRT
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 AssessmentScaleObservation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:entryReference 0..* EntryRelationship When 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.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: SPRT
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 1..1 EntryReference
    ..... encounter 0..1 Encounter
    ..... observation 0..1 Observation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    ... 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 C 0..1 II Constraints: II-1
    ..... @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)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Observation.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.templateId:social-history-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.classCode Base required CDAActClassObservation 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.moodCode Base required x_ActMoodDocumentObservation 📍2.0.0 THO v5.2
    Observation.sdtcCategory:social-history.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.code Base preferred Social History Type . 📦20250423 VSAC v0.23
    Observation.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Observation.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Observation.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Observation.statusCode.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Observation.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Observation.value:physical-quantity.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.value:physical-quantity.​unit Base preferred UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    Observation.value:coded Base example ? Unknown
    Observation.interpretationCode Base required CDAObservationInterpretation 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.methodCode Base example ObservationMethod 📦3.0.0 THO v6.5
    Observation.entryRelationship:supportingObs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.entryRelationship:supportingObs.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.entryRelationship:supportingObs.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Observation.entryRelationship:entryReference.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.entryRelationship:entryReference.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.entryRelationship:entryReference.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Observation.referenceRange.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.referenceRange.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.referenceRange.​typeCode Base required CDAActRelationshipType 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    4515-8555 error Observation 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.
    4515-32956 warning Observation.code 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()
    II-1 error Observation.typeId, Observation.entryRelationship:supportingObs.typeId, Observation.entryRelationship:entryReference.typeId, Observation.referenceRange.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    category-social-history error Observation If category is present, then there shall be a category with code 'social-history'. sdtcCategory.empty() or sdtcCategory.exists(code = 'social-history' and codeSystem = 'http://terminology.hl7.org/CodeSystem/observation-category')
    should-sdtcCategory warning Observation SHOULD contain sdtcCategory sdtcCategory.exists()
    should-sh-author warning Observation SHOULD contain author author.exists()
    should-text-ref-value warning Observation SHOULD contain text/reference/@value text.reference.value.exists()
    should-value warning Observation SHOULD contain value 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: 8 elements(5 nested mandatory elements)
    Fixed: 5 elements

    Structures

    This structure refers to these other structures:

    Slices

    This structure defines the following Slices:

    • The element 2 is sliced based on the values of Observation.templateId
    • The element 2 is sliced based on the values of Observation.sdtcCategory
    • The element 1 is sliced based on the value of Observation.value
    • The element 2 is sliced based on the values of Observation.entryRelationship

    Differential View

    This structure is derived from Observation

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Observation C 1..1 Observation XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, should-sdtcCategory, category-social-history, should-value, 4515-8555, should-sh-author
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
    .... templateId:social-history-obs 1..1 II
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.38
    ..... @extension 1..1 st Required Pattern: 2022-06-01
    ... @classCode 1..1 cs Fixed Value: OBS
    ... @moodCode 1..1 cs Fixed Value: EVN
    ... Slices for sdtcCategory 0..* CD Category is optional, but if present it SHALL contain a category with code=social-history.
    Slice: Unordered, Open by value:code, value:codeSystem
    .... sdtcCategory:social-history 0..1 CD Social History
    ..... @code 1..1 cs Required Pattern: social-history
    ..... @codeSystem 1..1 oid, uuid, ruid Required Pattern: http://terminology.hl7.org/CodeSystem/observation-category
    ... code C 1..1 CD Binding: Social History Type . (preferred)
    Constraints: 4515-32956
    ... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
    .... reference C 0..1 TEL Constraints: value-starts-octothorpe
    ... statusCode 1..1 CS
    .... @code 1..1 cs Fixed Value: completed
    ... effectiveTime 1..1 IVL_TS
    ... Slices for value 0..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: Alcohol Use, Substance Use, SDOH Problems/Health Concerns
    Slice: Unordered, Open by type:$this
    .... value:physical-quantity 0..1 PQ
    ..... @unit 1..1 cs Binding: UnitsOfMeasureCaseSensitive (preferred)
    .... value:coded 0..1 CD Binding Description: (example): See additional binding
    Additional BindingsPurposeDocumentation
    Social Determinants of Health Conditions . Preferred
    Social Determinant of Health Observations
    ... author 0..* AuthorParticipation
    ... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
    .... entryRelationship:supportingObs 0..* EntryRelationship When 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.
    ..... @typeCode 1..1 cs Fixed Value: SPRT
    ..... observation 1..1 AssessmentScaleObservation
    .... entryRelationship:entryReference 0..* EntryRelationship When 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.
    ..... @typeCode 1..1 cs Fixed Value: SPRT
    ..... act 1..1 EntryReference

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    Observation.code Base preferred Social History Type . 📦20250423 VSAC v0.23
    Observation.value:physical-quantity.​unit Base preferred UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    Observation.value:coded Base example ? Unknown

    Constraints

    Id Grade Path(s) Description Expression
    4515-8555 error Observation 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.
    4515-32956 warning Observation.code 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()
    category-social-history error Observation If category is present, then there shall be a category with code 'social-history'. sdtcCategory.empty() or sdtcCategory.exists(code = 'social-history' and codeSystem = 'http://terminology.hl7.org/CodeSystem/observation-category')
    should-sdtcCategory warning Observation SHOULD contain sdtcCategory sdtcCategory.exists()
    should-sh-author warning Observation SHOULD contain author author.exists()
    should-text-ref-value warning Observation SHOULD contain text/reference/@value text.reference.value.exists()
    should-value warning Observation SHOULD contain value 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

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Observation C 1..1 Observation XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, should-sdtcCategory, category-social-history, should-value, 4515-8555, should-sh-author
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @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:social-history-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: 2.16.840.1.113883.10.20.22.4.38
    ..... @extension 1..1 st Required Pattern: 2022-06-01
    ... @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
    ... Slices for sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
    Category is optional, but if present it SHALL contain a category with code=social-history.
    Slice: Unordered, Open by value:code, value:codeSystem
    XML: category (urn:hl7-org:sdtc)
    .... sdtcCategory:social-history 0..1 CD XML Namespace: urn:hl7-org:sdtc
    Social History
    XML: category (urn:hl7-org:sdtc)
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @code 1..1 cs Required Pattern: social-history
    ..... @codeSystem 1..1 oid, uuid, ruid Required Pattern: http://terminology.hl7.org/CodeSystem/observation-category
    ..... @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
    ... code C 1..1 CD Binding: Social History Type . (preferred)
    Constraints: 4515-32956
    ... 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 Constraints: value-starts-octothorpe
    .... 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
    ... priorityCode 0..1 CE Binding: ActPriority (example)
    ... repeatNumber 0..1 IVL_INT
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... Slices for value 0..1 𝗨𝗦𝗖𝗗𝗜: Alcohol Use, Substance Use, SDOH Problems/Health Concerns
    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 Binding: UnitsOfMeasureCaseSensitive (preferred)
    ..... @value 0..1 real
    ..... translation 0..* PQR
    .... value:coded 0..1 CD Binding Description: (example): See additional binding
    Additional BindingsPurposeDocumentation
    Social Determinants of Health Conditions . Preferred
    Social Determinant of Health Observations

    ... 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..* AuthorParticipation
    ... informant 0..* Informant
    ... participant 0..* Participant2
    ... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
    .... entryRelationship:supportingObs 0..* EntryRelationship When 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.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: SPRT
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 AssessmentScaleObservation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:entryReference 0..* EntryRelationship When 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.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: SPRT
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 1..1 EntryReference
    ..... encounter 0..1 Encounter
    ..... observation 0..1 Observation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    ... 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 C 0..1 II Constraints: II-1
    ..... @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)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Observation.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.templateId:social-history-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.classCode Base required CDAActClassObservation 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.moodCode Base required x_ActMoodDocumentObservation 📍2.0.0 THO v5.2
    Observation.sdtcCategory:social-history.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.code Base preferred Social History Type . 📦20250423 VSAC v0.23
    Observation.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Observation.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Observation.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Observation.statusCode.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Observation.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Observation.value:physical-quantity.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.value:physical-quantity.​unit Base preferred UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    Observation.value:coded Base example ? Unknown
    Observation.interpretationCode Base required CDAObservationInterpretation 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.methodCode Base example ObservationMethod 📦3.0.0 THO v6.5
    Observation.entryRelationship:supportingObs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.entryRelationship:supportingObs.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.entryRelationship:supportingObs.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Observation.entryRelationship:entryReference.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.entryRelationship:entryReference.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.entryRelationship:entryReference.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Observation.referenceRange.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.referenceRange.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.referenceRange.​typeCode Base required CDAActRelationshipType 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    4515-8555 error Observation 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.
    4515-32956 warning Observation.code 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()
    II-1 error Observation.typeId, Observation.entryRelationship:supportingObs.typeId, Observation.entryRelationship:entryReference.typeId, Observation.referenceRange.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    category-social-history error Observation If category is present, then there shall be a category with code 'social-history'. sdtcCategory.empty() or sdtcCategory.exists(code = 'social-history' and codeSystem = 'http://terminology.hl7.org/CodeSystem/observation-category')
    should-sdtcCategory warning Observation SHOULD contain sdtcCategory sdtcCategory.exists()
    should-sh-author warning Observation SHOULD contain author author.exists()
    should-text-ref-value warning Observation SHOULD contain text/reference/@value text.reference.value.exists()
    should-value warning Observation SHOULD contain value 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

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Observation C 1..1 Observation XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, should-sdtcCategory, category-social-history, should-value, 4515-8555, should-sh-author
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @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:social-history-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: 2.16.840.1.113883.10.20.22.4.38
    ..... @extension 1..1 st Required Pattern: 2022-06-01
    ... @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
    ... Slices for sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
    Category is optional, but if present it SHALL contain a category with code=social-history.
    Slice: Unordered, Open by value:code, value:codeSystem
    XML: category (urn:hl7-org:sdtc)
    .... sdtcCategory:social-history 0..1 CD XML Namespace: urn:hl7-org:sdtc
    Social History
    XML: category (urn:hl7-org:sdtc)
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @code 1..1 cs Required Pattern: social-history
    ..... @codeSystem 1..1 oid, uuid, ruid Required Pattern: http://terminology.hl7.org/CodeSystem/observation-category
    ..... @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
    ... code C 1..1 CD Binding: Social History Type . (preferred)
    Constraints: 4515-32956
    ... 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 Constraints: value-starts-octothorpe
    .... 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
    ... priorityCode 0..1 CE Binding: ActPriority (example)
    ... repeatNumber 0..1 IVL_INT
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... Slices for value 0..1 𝗨𝗦𝗖𝗗𝗜: Alcohol Use, Substance Use, SDOH Problems/Health Concerns
    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 Binding: UnitsOfMeasureCaseSensitive (preferred)
    ..... @value 0..1 real
    ..... translation 0..* PQR
    .... value:coded 0..1 CD Binding Description: (example): See additional binding
    Additional BindingsPurposeDocumentation
    Social Determinants of Health Conditions . Preferred
    Social Determinant of Health Observations

    ... 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..* AuthorParticipation
    ... informant 0..* Informant
    ... participant 0..* Participant2
    ... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
    .... entryRelationship:supportingObs 0..* EntryRelationship When 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.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: SPRT
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 AssessmentScaleObservation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:entryReference 0..* EntryRelationship When 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.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: SPRT
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 1..1 EntryReference
    ..... encounter 0..1 Encounter
    ..... observation 0..1 Observation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    ... 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 C 0..1 II Constraints: II-1
    ..... @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)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Observation.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.templateId:social-history-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.classCode Base required CDAActClassObservation 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.moodCode Base required x_ActMoodDocumentObservation 📍2.0.0 THO v5.2
    Observation.sdtcCategory:social-history.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.code Base preferred Social History Type . 📦20250423 VSAC v0.23
    Observation.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Observation.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Observation.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Observation.statusCode.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Observation.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Observation.value:physical-quantity.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.value:physical-quantity.​unit Base preferred UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    Observation.value:coded Base example ? Unknown
    Observation.interpretationCode Base required CDAObservationInterpretation 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.methodCode Base example ObservationMethod 📦3.0.0 THO v6.5
    Observation.entryRelationship:supportingObs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.entryRelationship:supportingObs.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.entryRelationship:supportingObs.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Observation.entryRelationship:entryReference.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.entryRelationship:entryReference.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.entryRelationship:entryReference.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Observation.referenceRange.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.referenceRange.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.referenceRange.​typeCode Base required CDAActRelationshipType 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    4515-8555 error Observation 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.
    4515-32956 warning Observation.code 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()
    II-1 error Observation.typeId, Observation.entryRelationship:supportingObs.typeId, Observation.entryRelationship:entryReference.typeId, Observation.referenceRange.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    category-social-history error Observation If category is present, then there shall be a category with code 'social-history'. sdtcCategory.empty() or sdtcCategory.exists(code = 'social-history' and codeSystem = 'http://terminology.hl7.org/CodeSystem/observation-category')
    should-sdtcCategory warning Observation SHOULD contain sdtcCategory sdtcCategory.exists()
    should-sh-author warning Observation SHOULD contain author author.exists()
    should-text-ref-value warning Observation SHOULD contain text/reference/@value text.reference.value.exists()
    should-value warning Observation SHOULD contain value 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: 8 elements(5 nested mandatory elements)
    Fixed: 5 elements

    Structures

    This structure refers to these other structures:

    Slices

    This structure defines the following Slices:

    • The element 2 is sliced based on the values of Observation.templateId
    • The element 2 is sliced based on the values of Observation.sdtcCategory
    • The element 1 is sliced based on the value of Observation.value
    • The element 2 is sliced based on the values of Observation.entryRelationship

     

    Other representations of profile: CSV, Excel