Consolidated CDA (C-CDA)
3.0.0 - STU
Consolidated CDA (C-CDA)
3.0.0 - STU
Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 3.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/SubstanceOrDeviceAllergyIntoleranceObservation | Version: 3.0.0 | |||
| Draft as of 2024-05-07 | Computable Name: SubstanceOrDeviceAllergyIntoleranceObservation | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.24.3.90:2014-06-09 | ||||
This template reflects a discrete observation about a patient’s allergy or intolerance to a substance or device. Because it is a discrete observation, it will have a statusCode of “completed”. The effectiveTime, also referred to as the ‘clinically relevant time’ is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of penicillin allergy that developed five years ago, the effectiveTime is five years ago.
The effectiveTime of the Substance or Device Allergy - Intolerance Observation is the definitive indication of whether or not the underlying allergy/intolerance is resolved. If known to be resolved, then an effectiveTime/high would be present. If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of “UNK”.
Usage:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author should-not-severity: Allergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level. |
  Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:substance-device-allergy-intolerance-obs |
1..1 | II | ||
  @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.24.3.90 | |
  @extension |
1..1 | st | Required Pattern: 2014-06-09 | |
 @classCode |
1..1 | cs | Fixed Value: OBS | |
| @moodCode |
1..1 | cs | Fixed Value: EVN | |
| id |
1..* | II | ||
| code |
1..1 | CD | ||
| @code |
1..1 | cs | Required Pattern: ASSERTION | |
 @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.5.4 | |
| 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 | The effectiveTime/low (a.k.a. "onset date") asserts when the allergy/intolerance became clinically active. The effectiveTime/high (a.k.a. "resolution date") asserts when the allergy/intolerance became clinically resolved. If the allergy/intolerance is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'. | |
| low |
1..1 | IVXB_TS | ||
| high |
0..1 | IVXB_TS | ||
 value |
1..1 | CD | ||
| @nullFlavor |
0..0 | |||
| @code |
1..1 | cs | Binding: Allergy and Intolerance Type  (required) | |
| author |
0..* | AuthorParticipation | Base for all types and resources | |
| Slices for participant |
0..* | Participant2 | Slice: Unordered, Open by value:typeCode | |
| participant:consumable |
0..* | Participant2 | participant | |
| @typeCode |
1..1 | cs | Fixed Value: CSM | |
 participantRole |
1..1 | ParticipantRole | ||
| @classCode |
1..1 | cs | Fixed Value: MANU | |
 playingEntity |
1..1 | PlayingEntity | ||
| @classCode |
1..1 | cs | Fixed Value: MMAT | |
| code |
1..1 | CE | Binding: Substance Reactant for Intolerance (preferred) | |
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |
 entryRelationship:status |
0..1 | EntryRelationship | entryRelationship | |
 @typeCode |
1..1 | cs | Fixed Value: SUBJ | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| observation |
1..1 | AllergyStatusObservation | Base for all types and resources | |
| entryRelationship:reaction |
0..* | EntryRelationship | entryRelationship | |
| @typeCode |
1..1 | cs | Fixed Value: MFST | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| observation |
1..1 | ReactionObservation | Base for all types and resources | |
| entryRelationship:severity |
0..1 | EntryRelationship | entryRelationship | |
| @typeCode |
1..1 | cs | Fixed Value: SUBJ | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| observation |
1..1 | SeverityObservation | Base for all types and resources | |
| entryRelationship:criticality |
0..1 | EntryRelationship | entryRelationship | |
| @typeCode |
1..1 | cs | Fixed Value: SUBJ | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| observation |
1..1 | CriticalityObservation | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Observation.value.code | required | AllergyAndIntoleranceType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.6.2 | |
| Observation.participant:consumable.participantRole.playingEntity.code | preferred | SubstanceReactantForIntolerance http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1010.1 |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-not-severity | warning | Observation | Allergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level. : entryRelationship.observation.where(code.code = 'SEV' and code.codeSystem = '2.16.840.1.113883.5.4').empty() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author should-not-severity: Allergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level. |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:substance-device-allergy-intolerance-obs |
1..1 | II | ||
 @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.24.3.90 | |
| @extension |
1..1 | st | Required Pattern: 2014-06-09 | |
| @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: ObservationType (example) | |
| @code |
1..1 | cs | Required Pattern: ASSERTION | |
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.5.4 | |
| 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 | The effectiveTime/low (a.k.a. "onset date") asserts when the allergy/intolerance became clinically active. The effectiveTime/high (a.k.a. "resolution date") asserts when the allergy/intolerance became clinically resolved. If the allergy/intolerance is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'. | |
| low |
1..1 | IVXB_TS | ||
| high |
0..1 | IVXB_TS | ||
| value |
1..1 | CD | ||
| @code |
1..1 | cs | Binding: Allergy and Intolerance Type (required) | |
| author |
0..* | AuthorParticipation | Base for all types and resources | |
| Slices for participant |
0..* | Participant2 | Slice: Unordered, Open by value:typeCode | |
| participant:consumable |
0..* | Participant2 | participant | |
| @typeCode |
1..1 | cs | Binding: CDAParticipationType (required) Fixed Value: CSM | |
| participantRole |
1..1 | ParticipantRole | ||
| @classCode |
1..1 | cs | Binding: CDARoleClassRoot (required) Fixed Value: MANU | |
| playingEntity |
1..1 | PlayingEntity | ||
| @classCode |
1..1 | cs | Binding: EntityClassRoot (required) Fixed Value: MMAT | |
| code |
1..1 | CE | Binding: Substance Reactant for Intolerance (preferred) | |
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |
| entryRelationship:status |
0..1 | EntryRelationship | entryRelationship | |
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| observation |
C | 1..1 | AllergyStatusObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| entryRelationship:reaction |
0..* | EntryRelationship | entryRelationship | |
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: MFST | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| observation |
C | 1..1 | ReactionObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime |
| entryRelationship:severity |
0..1 | EntryRelationship | entryRelationship | |
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| observation |
C | 1..1 | SeverityObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| entryRelationship:criticality |
0..1 | EntryRelationship | entryRelationship | |
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| observation |
C | 1..1 | CriticalityObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.value.code | required | AllergyAndIntoleranceType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.6.2 | |
| Observation.participant:consumable.typeCode | required | Fixed Value: CSMhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| Observation.participant:consumable.participantRole.classCode | required | Fixed Value: MANUhttp://hl7.org/cda/stds/core/ValueSet/CDARoleClassRoot | |
| Observation.participant:consumable.participantRole.playingEntity.classCode | required | Fixed Value: MMAThttp://terminology.hl7.org/ValueSet/v3-EntityClassRoot | |
| Observation.participant:consumable.participantRole.playingEntity.code | preferred | SubstanceReactantForIntolerance http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1010.1 | |
| Observation.entryRelationship:status.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.entryRelationship:reaction.typeCode | required | Fixed Value: MFSThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.entryRelationship:severity.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.entryRelationship:criticality.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Observation.entryRelationship:reaction.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-not-severity | warning | Observation | Allergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level. : entryRelationship.observation.where(code.code = 'SEV' and code.codeSystem = '2.16.840.1.113883.5.4').empty() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Observation.entryRelationship:status.observation, Observation.entryRelationship:reaction.observation, Observation.entryRelationship:severity.observation, Observation.entryRelationship:criticality.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('#') |
| 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:substance-device-allergy-intolerance-obs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
| Observation.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.statusCode.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.code | required | AllergyAndIntoleranceType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.6.2 | |
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
| Observation.participant:consumable.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.participant:consumable.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.participant:consumable.typeCode | required | Fixed Value: CSMhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| Observation.participant:consumable.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| Observation.participant:consumable.participantRole.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.participant:consumable.participantRole.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.participant:consumable.participantRole.classCode | required | Fixed Value: MANUhttp://hl7.org/cda/stds/core/ValueSet/CDARoleClassRoot | |
| Observation.participant:consumable.participantRole.code | example | CDARoleCodehttp://hl7.org/cda/stds/core/ValueSet/CDARoleCode | |
| Observation.participant:consumable.participantRole.playingEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.participant:consumable.participantRole.playingEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.participant:consumable.participantRole.playingEntity.classCode | required | Fixed Value: MMAThttp://terminology.hl7.org/ValueSet/v3-EntityClassRoot | |
| Observation.participant:consumable.participantRole.playingEntity.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| Observation.participant:consumable.participantRole.playingEntity.code | preferred | SubstanceReactantForIntolerance http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1010.1 | |
| Observation.entryRelationship:status.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:status.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:status.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.entryRelationship:reaction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:reaction.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:reaction.typeCode | required | Fixed Value: MFSThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.entryRelationship:severity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:severity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:severity.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.entryRelationship:criticality.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:criticality.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:criticality.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| 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 |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Observation.entryRelationship:reaction.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-not-severity | warning | Observation | Allergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level. : entryRelationship.observation.where(code.code = 'SEV' and code.codeSystem = '2.16.840.1.113883.5.4').empty() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Observation.entryRelationship:status.observation, Observation.entryRelationship:reaction.observation, Observation.entryRelationship:severity.observation, Observation.entryRelationship:criticality.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: 13 elements(12 nested mandatory elements)
Fixed: 14 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Observation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author should-not-severity: Allergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level. |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:substance-device-allergy-intolerance-obs |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.24.3.90 | |
| @extension |
1..1 | st | Required Pattern: 2014-06-09 | |
| @classCode |
1..1 | cs | Fixed Value: OBS | |
| @moodCode |
1..1 | cs | Fixed Value: EVN | |
| id |
1..* | II | ||
| code |
1..1 | CD | ||
| @code |
1..1 | cs | Required Pattern: ASSERTION | |
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.5.4 | |
| 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 | The effectiveTime/low (a.k.a. "onset date") asserts when the allergy/intolerance became clinically active. The effectiveTime/high (a.k.a. "resolution date") asserts when the allergy/intolerance became clinically resolved. If the allergy/intolerance is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'. | |
| low |
1..1 | IVXB_TS | ||
| high |
0..1 | IVXB_TS | ||
| value |
1..1 | CD | ||
| @nullFlavor |
0..0 | |||
| @code |
1..1 | cs | Binding: Allergy and Intolerance Type (required) | |
| author |
0..* | AuthorParticipation | Base for all types and resources | |
| Slices for participant |
0..* | Participant2 | Slice: Unordered, Open by value:typeCode | |
| participant:consumable |
0..* | Participant2 | participant | |
| @typeCode |
1..1 | cs | Fixed Value: CSM | |
| participantRole |
1..1 | ParticipantRole | ||
| @classCode |
1..1 | cs | Fixed Value: MANU | |
| playingEntity |
1..1 | PlayingEntity | ||
| @classCode |
1..1 | cs | Fixed Value: MMAT | |
| code |
1..1 | CE | Binding: Substance Reactant for Intolerance (preferred) | |
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |
| entryRelationship:status |
0..1 | EntryRelationship | entryRelationship | |
| @typeCode |
1..1 | cs | Fixed Value: SUBJ | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| observation |
1..1 | AllergyStatusObservation | Base for all types and resources | |
| entryRelationship:reaction |
0..* | EntryRelationship | entryRelationship | |
| @typeCode |
1..1 | cs | Fixed Value: MFST | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| observation |
1..1 | ReactionObservation | Base for all types and resources | |
| entryRelationship:severity |
0..1 | EntryRelationship | entryRelationship | |
| @typeCode |
1..1 | cs | Fixed Value: SUBJ | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| observation |
1..1 | SeverityObservation | Base for all types and resources | |
| entryRelationship:criticality |
0..1 | EntryRelationship | entryRelationship | |
| @typeCode |
1..1 | cs | Fixed Value: SUBJ | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| observation |
1..1 | CriticalityObservation | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Observation.value.code | required | AllergyAndIntoleranceType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.6.2 | |
| Observation.participant:consumable.participantRole.playingEntity.code | preferred | SubstanceReactantForIntolerance http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1010.1 |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-not-severity | warning | Observation | Allergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level. : entryRelationship.observation.where(code.code = 'SEV' and code.codeSystem = '2.16.840.1.113883.5.4').empty() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author should-not-severity: Allergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level. |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:substance-device-allergy-intolerance-obs |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.24.3.90 | |
| @extension |
1..1 | st | Required Pattern: 2014-06-09 | |
| @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: ObservationType (example) | |
| @code |
1..1 | cs | Required Pattern: ASSERTION | |
| @codeSystem |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.5.4 | |
| 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 | The effectiveTime/low (a.k.a. "onset date") asserts when the allergy/intolerance became clinically active. The effectiveTime/high (a.k.a. "resolution date") asserts when the allergy/intolerance became clinically resolved. If the allergy/intolerance is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'. | |
| low |
1..1 | IVXB_TS | ||
| high |
0..1 | IVXB_TS | ||
| value |
1..1 | CD | ||
| @code |
1..1 | cs | Binding: Allergy and Intolerance Type (required) | |
| author |
0..* | AuthorParticipation | Base for all types and resources | |
| Slices for participant |
0..* | Participant2 | Slice: Unordered, Open by value:typeCode | |
| participant:consumable |
0..* | Participant2 | participant | |
| @typeCode |
1..1 | cs | Binding: CDAParticipationType (required) Fixed Value: CSM | |
| participantRole |
1..1 | ParticipantRole | ||
| @classCode |
1..1 | cs | Binding: CDARoleClassRoot (required) Fixed Value: MANU | |
| playingEntity |
1..1 | PlayingEntity | ||
| @classCode |
1..1 | cs | Binding: EntityClassRoot (required) Fixed Value: MMAT | |
| code |
1..1 | CE | Binding: Substance Reactant for Intolerance (preferred) | |
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |
| entryRelationship:status |
0..1 | EntryRelationship | entryRelationship | |
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| observation |
C | 1..1 | AllergyStatusObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| entryRelationship:reaction |
0..* | EntryRelationship | entryRelationship | |
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: MFST | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| observation |
C | 1..1 | ReactionObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime |
| entryRelationship:severity |
0..1 | EntryRelationship | entryRelationship | |
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| observation |
C | 1..1 | SeverityObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| entryRelationship:criticality |
0..1 | EntryRelationship | entryRelationship | |
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| observation |
C | 1..1 | CriticalityObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.value.code | required | AllergyAndIntoleranceType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.6.2 | |
| Observation.participant:consumable.typeCode | required | Fixed Value: CSMhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| Observation.participant:consumable.participantRole.classCode | required | Fixed Value: MANUhttp://hl7.org/cda/stds/core/ValueSet/CDARoleClassRoot | |
| Observation.participant:consumable.participantRole.playingEntity.classCode | required | Fixed Value: MMAThttp://terminology.hl7.org/ValueSet/v3-EntityClassRoot | |
| Observation.participant:consumable.participantRole.playingEntity.code | preferred | SubstanceReactantForIntolerance http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1010.1 | |
| Observation.entryRelationship:status.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.entryRelationship:reaction.typeCode | required | Fixed Value: MFSThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.entryRelationship:severity.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.entryRelationship:criticality.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Observation.entryRelationship:reaction.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-not-severity | warning | Observation | Allergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level. : entryRelationship.observation.where(code.code = 'SEV' and code.codeSystem = '2.16.840.1.113883.5.4').empty() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Observation.entryRelationship:status.observation, Observation.entryRelationship:reaction.observation, Observation.entryRelationship:severity.observation, Observation.entryRelationship:criticality.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
| 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:substance-device-allergy-intolerance-obs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
| Observation.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.statusCode.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.code | required | AllergyAndIntoleranceType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.6.2 | |
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
| Observation.participant:consumable.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.participant:consumable.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.participant:consumable.typeCode | required | Fixed Value: CSMhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| Observation.participant:consumable.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| Observation.participant:consumable.participantRole.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.participant:consumable.participantRole.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.participant:consumable.participantRole.classCode | required | Fixed Value: MANUhttp://hl7.org/cda/stds/core/ValueSet/CDARoleClassRoot | |
| Observation.participant:consumable.participantRole.code | example | CDARoleCodehttp://hl7.org/cda/stds/core/ValueSet/CDARoleCode | |
| Observation.participant:consumable.participantRole.playingEntity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.participant:consumable.participantRole.playingEntity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.participant:consumable.participantRole.playingEntity.classCode | required | Fixed Value: MMAThttp://terminology.hl7.org/ValueSet/v3-EntityClassRoot | |
| Observation.participant:consumable.participantRole.playingEntity.determinerCode | required | Fixed Value: INSTANCEhttp://terminology.hl7.org/ValueSet/v3-EntityDeterminer | |
| Observation.participant:consumable.participantRole.playingEntity.code | preferred | SubstanceReactantForIntolerance http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1010.1 | |
| Observation.entryRelationship:status.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:status.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:status.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.entryRelationship:reaction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:reaction.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:reaction.typeCode | required | Fixed Value: MFSThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.entryRelationship:severity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:severity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:severity.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.entryRelationship:criticality.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:criticality.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:criticality.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| 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 |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Observation.entryRelationship:reaction.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-not-severity | warning | Observation | Allergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level. : entryRelationship.observation.where(code.code = 'SEV' and code.codeSystem = '2.16.840.1.113883.5.4').empty() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Observation.entryRelationship:status.observation, Observation.entryRelationship:reaction.observation, Observation.entryRelationship:severity.observation, Observation.entryRelationship:criticality.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: 13 elements(12 nested mandatory elements)
Fixed: 14 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#3.0.0 based on FHIR 5.0.0. Generated 2024-05-07
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