Consolidated CDA (C-CDA)
4.0.0-ballot - STU4 Ballot
Consolidated CDA (C-CDA)
4.0.0-ballot - STU4 Ballot
Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 4.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignObservation | Version: 4.0.0-ballot | |||
| Draft as of 2024-12-19 | Computable Name: VitalSignObservation | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.27:2014-06-09 | ||||
This template represents measurement of common vital signs. Vital signs are represented with additional vocabulary constraints for type of vital sign and unit of measure.
The following is a list of recommended units for common types of vital sign measurements:
| Name | Unit |
|---|---|
| PulseOx | % |
| Height/Head Circumf | cm |
| Weight | kg |
| Temp | Cel |
| BP | mm[Hg] |
| Pulse/Resp Rate | /min |
| BMI | kg/m2 |
| BSA | m2 |
| inhaled oxygen concentration | % |
| Occipital Front Head Circumference Percentile (Birth -36 months) | % |
Usage:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-code: SHOULD contain code should-author: SHOULD contain author should-percent: Percentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with % should-cm: Height & Head Circumference should be represented in cm should-kg: Weight should be represented in kg should-cel: Temperature should be represented in Celcius (Cel) should-bp: Blood pressure should be represented in mm[Hg] should-rates: Rates should be represented in /min should-bmi: BMI should be represented in kg/m2 should-bsa: BSA should be represented in m2 |
  Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:vital-sign-obs |
1..1 | II | ||
  @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.27 | |
  @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 |
0..1 | cs | Binding: Vital Sign Result Type  (preferred) | |
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| statusCode |
1..1 | CS | ||
| @code |
1..1 | cs | Fixed Value: completed | |
| effectiveTime |
1..1 | IVL_TS | ||
 value |
1..1 | PQ | ||
| @unit |
1..1 | cs | NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (required) | |
| interpretationCode |
0..1 | CE | ||
| methodCode |
0..1 | CE | ||
| targetSiteCode |
0..1 | CD | ||
| author |
0..* | AuthorParticipation | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Observation.code.code | preferred | VitalSignResultType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.62 | |
| Observation.value.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-bmi | warning | Observation | BMI should be represented in kg/m2 : (code.code = '39156-5') implies value.unit = 'kg/m2' | |
| should-bp | warning | Observation | Blood pressure should be represented in mm[Hg] : (code.code in ('8480-6' | '8462-4' | '8478-0' | '96608-5' | '96609-3')) implies value.unit = 'mm[Hg]' | |
| should-bsa | warning | Observation | BSA should be represented in m2 : (code.code = '3140-1') implies value.unit = 'm2' | |
| should-cel | warning | Observation | Temperature should be represented in Celcius (Cel) : (code.code = '8310-5') implies value.unit = 'Cel' | |
| should-cm | warning | Observation | Height & Head Circumference should be represented in cm : (code.code in ('8287-5' | '8302-2' | '8306-3' | '9843-4')) implies value.unit = 'cm' | |
| should-code | warning | Observation | SHOULD contain code : code.exists() | |
| should-kg | warning | Observation | Weight should be represented in kg : (code.code = '29463-7') implies value.unit = 'kg' | |
| should-percent | warning | Observation | Percentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with % : (code.code in ('2708-6' | '3150-0' | '59408-5' | '8289-1' | '59575-1' | '59576-9')) implies value.unit = '%' | |
| should-rates | warning | Observation | Rates should be represented in /min : (code.code in ('8867-4' | '9279-1')) implies value.unit = '/min' | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-code: SHOULD contain code should-author: SHOULD contain author should-percent: Percentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with % should-cm: Height & Head Circumference should be represented in cm should-kg: Weight should be represented in kg should-cel: Temperature should be represented in Celcius (Cel) should-bp: Blood pressure should be represented in mm[Hg] should-rates: Rates should be represented in /min should-bmi: BMI should be represented in kg/m2 should-bsa: BSA should be represented in m2 |
 @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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:vital-sign-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: 2.16.840.1.113883.10.20.22.4.27 | |
| @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 | |
| @negationInd |
0..1 | bl | ||
| id |
1..* | II | ||
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |
| code |
1..1 | CD | Binding: ObservationType (example) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
0..1 | cs | Binding: Vital Sign Result Type (preferred) | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @codeSystemName |
0..1 | st | ||
| @codeSystemVersion |
0..1 | st | ||
| @displayName |
0..1 | st | ||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText |
0..1 | ED | ||
| qualifier |
0..* | CR | ||
| translation |
0..* | CD | ||
| derivationExpr |
0..1 | ST | ||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @compression |
0..1 | cs | Binding: CDACompressionAlgorithm (required) | |
| @integrityCheck |
0..1 | bin | ||
| @integrityCheckAlgorithm |
0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |
| @language |
0..1 | cs | ||
| @mediaType |
0..1 | cs | Binding: MediaType (example) | |
| @representation |
0..1 | cs | Binding: CDABinaryDataEncoding (required) | |
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| effectiveTime |
1..1 | IVL_TS | ||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| value |
1..1 | PQ | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @unit |
1..1 | cs | NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (required) | |
| @value |
0..1 | real | ||
| translation |
0..* | PQR | ||
| interpretationCode |
0..1 | CE | Binding: CDAObservationInterpretation (required) | |
| methodCode |
0..1 | CE | Binding: ObservationMethod (example) | |
| targetSiteCode |
0..1 | CD | ||
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | AuthorParticipation | Base for all types and resources | |
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| entryRelationship |
0..* | EntryRelationship | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| referenceRange |
0..* | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: REFV | |
| observationRange |
1..1 | ObservationRange | ||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.templateId:vital-sign-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.code.code | preferred | VitalSignResultType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.62 | |
| 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.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Observation.value.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.value.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
| 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 |
| II-1 | error | Observation.typeId, Observation.referenceRange.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-bmi | warning | Observation | BMI should be represented in kg/m2 : (code.code = '39156-5') implies value.unit = 'kg/m2' | |
| should-bp | warning | Observation | Blood pressure should be represented in mm[Hg] : (code.code in ('8480-6' | '8462-4' | '8478-0' | '96608-5' | '96609-3')) implies value.unit = 'mm[Hg]' | |
| should-bsa | warning | Observation | BSA should be represented in m2 : (code.code = '3140-1') implies value.unit = 'm2' | |
| should-cel | warning | Observation | Temperature should be represented in Celcius (Cel) : (code.code = '8310-5') implies value.unit = 'Cel' | |
| should-cm | warning | Observation | Height & Head Circumference should be represented in cm : (code.code in ('8287-5' | '8302-2' | '8306-3' | '9843-4')) implies value.unit = 'cm' | |
| should-code | warning | Observation | SHOULD contain code : code.exists() | |
| should-kg | warning | Observation | Weight should be represented in kg : (code.code = '29463-7') implies value.unit = 'kg' | |
| should-percent | warning | Observation | Percentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with % : (code.code in ('2708-6' | '3150-0' | '59408-5' | '8289-1' | '59575-1' | '59576-9')) implies value.unit = '%' | |
| should-rates | warning | Observation | Rates should be represented in /min : (code.code in ('8867-4' | '9279-1')) implies value.unit = '/min' | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-code: SHOULD contain code should-author: SHOULD contain author should-percent: Percentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with % should-cm: Height & Head Circumference should be represented in cm should-kg: Weight should be represented in kg should-cel: Temperature should be represented in Celcius (Cel) should-bp: Blood pressure should be represented in mm[Hg] should-rates: Rates should be represented in /min should-bmi: BMI should be represented in kg/m2 should-bsa: BSA should be represented in m2 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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:vital-sign-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: 2.16.840.1.113883.10.20.22.4.27 | |
| @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 | |
| @negationInd |
0..1 | bl | ||
| id |
1..* | II | ||
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |
| code |
1..1 | CD | Binding: ObservationType (example) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
0..1 | cs | Binding: Vital Sign Result Type (preferred) | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @codeSystemName |
0..1 | st | ||
| @codeSystemVersion |
0..1 | st | ||
| @displayName |
0..1 | st | ||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText |
0..1 | ED | ||
| qualifier |
0..* | CR | ||
| translation |
0..* | CD | ||
| derivationExpr |
0..1 | ST | ||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @compression |
0..1 | cs | Binding: CDACompressionAlgorithm (required) | |
| @integrityCheck |
0..1 | bin | ||
| @integrityCheckAlgorithm |
0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |
| @language |
0..1 | cs | ||
| @mediaType |
0..1 | cs | Binding: MediaType (example) | |
| @representation |
0..1 | cs | Binding: CDABinaryDataEncoding (required) | |
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| effectiveTime |
1..1 | IVL_TS | ||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| value |
1..1 | PQ | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @unit |
1..1 | cs | NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (required) | |
| @value |
0..1 | real | ||
| translation |
0..* | PQR | ||
| interpretationCode |
0..1 | CE | Binding: CDAObservationInterpretation (required) | |
| methodCode |
0..1 | CE | Binding: ObservationMethod (example) | |
| targetSiteCode |
0..1 | CD | ||
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | AuthorParticipation | Base for all types and resources | |
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| entryRelationship |
0..* | EntryRelationship | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| referenceRange |
0..* | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: REFV | |
| observationRange |
1..1 | ObservationRange | ||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.templateId:vital-sign-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.code.code | preferred | VitalSignResultType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.62 | |
| 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.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Observation.value.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.value.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
| 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 |
| II-1 | error | Observation.typeId, Observation.referenceRange.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-bmi | warning | Observation | BMI should be represented in kg/m2 : (code.code = '39156-5') implies value.unit = 'kg/m2' | |
| should-bp | warning | Observation | Blood pressure should be represented in mm[Hg] : (code.code in ('8480-6' | '8462-4' | '8478-0' | '96608-5' | '96609-3')) implies value.unit = 'mm[Hg]' | |
| should-bsa | warning | Observation | BSA should be represented in m2 : (code.code = '3140-1') implies value.unit = 'm2' | |
| should-cel | warning | Observation | Temperature should be represented in Celcius (Cel) : (code.code = '8310-5') implies value.unit = 'Cel' | |
| should-cm | warning | Observation | Height & Head Circumference should be represented in cm : (code.code in ('8287-5' | '8302-2' | '8306-3' | '9843-4')) implies value.unit = 'cm' | |
| should-code | warning | Observation | SHOULD contain code : code.exists() | |
| should-kg | warning | Observation | Weight should be represented in kg : (code.code = '29463-7') implies value.unit = 'kg' | |
| should-percent | warning | Observation | Percentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with % : (code.code in ('2708-6' | '3150-0' | '59408-5' | '8289-1' | '59575-1' | '59576-9')) implies value.unit = '%' | |
| should-rates | warning | Observation | Rates should be represented in /min : (code.code in ('8867-4' | '9279-1')) implies value.unit = '/min' | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from Observation
Summary
Mandatory: 10 elements
Fixed: 3 elements
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, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-code: SHOULD contain code should-author: SHOULD contain author should-percent: Percentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with % should-cm: Height & Head Circumference should be represented in cm should-kg: Weight should be represented in kg should-cel: Temperature should be represented in Celcius (Cel) should-bp: Blood pressure should be represented in mm[Hg] should-rates: Rates should be represented in /min should-bmi: BMI should be represented in kg/m2 should-bsa: BSA should be represented in m2 |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:vital-sign-obs |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.27 | |
| @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 |
0..1 | cs | Binding: Vital Sign Result Type (preferred) | |
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| statusCode |
1..1 | CS | ||
| @code |
1..1 | cs | Fixed Value: completed | |
| effectiveTime |
1..1 | IVL_TS | ||
| value |
1..1 | PQ | ||
| @unit |
1..1 | cs | NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (required) | |
| interpretationCode |
0..1 | CE | ||
| methodCode |
0..1 | CE | ||
| targetSiteCode |
0..1 | CD | ||
| author |
0..* | AuthorParticipation | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Observation.code.code | preferred | VitalSignResultType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.62 | |
| Observation.value.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-bmi | warning | Observation | BMI should be represented in kg/m2 : (code.code = '39156-5') implies value.unit = 'kg/m2' | |
| should-bp | warning | Observation | Blood pressure should be represented in mm[Hg] : (code.code in ('8480-6' | '8462-4' | '8478-0' | '96608-5' | '96609-3')) implies value.unit = 'mm[Hg]' | |
| should-bsa | warning | Observation | BSA should be represented in m2 : (code.code = '3140-1') implies value.unit = 'm2' | |
| should-cel | warning | Observation | Temperature should be represented in Celcius (Cel) : (code.code = '8310-5') implies value.unit = 'Cel' | |
| should-cm | warning | Observation | Height & Head Circumference should be represented in cm : (code.code in ('8287-5' | '8302-2' | '8306-3' | '9843-4')) implies value.unit = 'cm' | |
| should-code | warning | Observation | SHOULD contain code : code.exists() | |
| should-kg | warning | Observation | Weight should be represented in kg : (code.code = '29463-7') implies value.unit = 'kg' | |
| should-percent | warning | Observation | Percentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with % : (code.code in ('2708-6' | '3150-0' | '59408-5' | '8289-1' | '59575-1' | '59576-9')) implies value.unit = '%' | |
| should-rates | warning | Observation | Rates should be represented in /min : (code.code in ('8867-4' | '9279-1')) implies value.unit = '/min' | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-code: SHOULD contain code should-author: SHOULD contain author should-percent: Percentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with % should-cm: Height & Head Circumference should be represented in cm should-kg: Weight should be represented in kg should-cel: Temperature should be represented in Celcius (Cel) should-bp: Blood pressure should be represented in mm[Hg] should-rates: Rates should be represented in /min should-bmi: BMI should be represented in kg/m2 should-bsa: BSA should be represented in m2 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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:vital-sign-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: 2.16.840.1.113883.10.20.22.4.27 | |
| @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 | |
| @negationInd |
0..1 | bl | ||
| id |
1..* | II | ||
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |
| code |
1..1 | CD | Binding: ObservationType (example) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
0..1 | cs | Binding: Vital Sign Result Type (preferred) | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @codeSystemName |
0..1 | st | ||
| @codeSystemVersion |
0..1 | st | ||
| @displayName |
0..1 | st | ||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText |
0..1 | ED | ||
| qualifier |
0..* | CR | ||
| translation |
0..* | CD | ||
| derivationExpr |
0..1 | ST | ||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @compression |
0..1 | cs | Binding: CDACompressionAlgorithm (required) | |
| @integrityCheck |
0..1 | bin | ||
| @integrityCheckAlgorithm |
0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |
| @language |
0..1 | cs | ||
| @mediaType |
0..1 | cs | Binding: MediaType (example) | |
| @representation |
0..1 | cs | Binding: CDABinaryDataEncoding (required) | |
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| effectiveTime |
1..1 | IVL_TS | ||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| value |
1..1 | PQ | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @unit |
1..1 | cs | NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (required) | |
| @value |
0..1 | real | ||
| translation |
0..* | PQR | ||
| interpretationCode |
0..1 | CE | Binding: CDAObservationInterpretation (required) | |
| methodCode |
0..1 | CE | Binding: ObservationMethod (example) | |
| targetSiteCode |
0..1 | CD | ||
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | AuthorParticipation | Base for all types and resources | |
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| entryRelationship |
0..* | EntryRelationship | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| referenceRange |
0..* | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: REFV | |
| observationRange |
1..1 | ObservationRange | ||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.templateId:vital-sign-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.code.code | preferred | VitalSignResultType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.62 | |
| 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.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Observation.value.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.value.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
| 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 |
| II-1 | error | Observation.typeId, Observation.referenceRange.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-bmi | warning | Observation | BMI should be represented in kg/m2 : (code.code = '39156-5') implies value.unit = 'kg/m2' | |
| should-bp | warning | Observation | Blood pressure should be represented in mm[Hg] : (code.code in ('8480-6' | '8462-4' | '8478-0' | '96608-5' | '96609-3')) implies value.unit = 'mm[Hg]' | |
| should-bsa | warning | Observation | BSA should be represented in m2 : (code.code = '3140-1') implies value.unit = 'm2' | |
| should-cel | warning | Observation | Temperature should be represented in Celcius (Cel) : (code.code = '8310-5') implies value.unit = 'Cel' | |
| should-cm | warning | Observation | Height & Head Circumference should be represented in cm : (code.code in ('8287-5' | '8302-2' | '8306-3' | '9843-4')) implies value.unit = 'cm' | |
| should-code | warning | Observation | SHOULD contain code : code.exists() | |
| should-kg | warning | Observation | Weight should be represented in kg : (code.code = '29463-7') implies value.unit = 'kg' | |
| should-percent | warning | Observation | Percentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with % : (code.code in ('2708-6' | '3150-0' | '59408-5' | '8289-1' | '59575-1' | '59576-9')) implies value.unit = '%' | |
| should-rates | warning | Observation | Rates should be represented in /min : (code.code in ('8867-4' | '9279-1')) implies value.unit = '/min' | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, sdtcCategory, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-code: SHOULD contain code should-author: SHOULD contain author should-percent: Percentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with % should-cm: Height & Head Circumference should be represented in cm should-kg: Weight should be represented in kg should-cel: Temperature should be represented in Celcius (Cel) should-bp: Blood pressure should be represented in mm[Hg] should-rates: Rates should be represented in /min should-bmi: BMI should be represented in kg/m2 should-bsa: BSA should be represented in m2 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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:vital-sign-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: 2.16.840.1.113883.10.20.22.4.27 | |
| @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 | |
| @negationInd |
0..1 | bl | ||
| id |
1..* | II | ||
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |
| code |
1..1 | CD | Binding: ObservationType (example) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
0..1 | cs | Binding: Vital Sign Result Type (preferred) | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @codeSystemName |
0..1 | st | ||
| @codeSystemVersion |
0..1 | st | ||
| @displayName |
0..1 | st | ||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText |
0..1 | ED | ||
| qualifier |
0..* | CR | ||
| translation |
0..* | CD | ||
| derivationExpr |
0..1 | ST | ||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @compression |
0..1 | cs | Binding: CDACompressionAlgorithm (required) | |
| @integrityCheck |
0..1 | bin | ||
| @integrityCheckAlgorithm |
0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |
| @language |
0..1 | cs | ||
| @mediaType |
0..1 | cs | Binding: MediaType (example) | |
| @representation |
0..1 | cs | Binding: CDABinaryDataEncoding (required) | |
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| effectiveTime |
1..1 | IVL_TS | ||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| value |
1..1 | PQ | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @unit |
1..1 | cs | NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (required) | |
| @value |
0..1 | real | ||
| translation |
0..* | PQR | ||
| interpretationCode |
0..1 | CE | Binding: CDAObservationInterpretation (required) | |
| methodCode |
0..1 | CE | Binding: ObservationMethod (example) | |
| targetSiteCode |
0..1 | CD | ||
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | AuthorParticipation | Base for all types and resources | |
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| entryRelationship |
0..* | EntryRelationship | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| referenceRange |
0..* | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: REFV | |
| observationRange |
1..1 | ObservationRange | ||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.templateId:vital-sign-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.code.code | preferred | VitalSignResultType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.62 | |
| 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.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Observation.value.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.value.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
| 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 |
| II-1 | error | Observation.typeId, Observation.referenceRange.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-bmi | warning | Observation | BMI should be represented in kg/m2 : (code.code = '39156-5') implies value.unit = 'kg/m2' | |
| should-bp | warning | Observation | Blood pressure should be represented in mm[Hg] : (code.code in ('8480-6' | '8462-4' | '8478-0' | '96608-5' | '96609-3')) implies value.unit = 'mm[Hg]' | |
| should-bsa | warning | Observation | BSA should be represented in m2 : (code.code = '3140-1') implies value.unit = 'm2' | |
| should-cel | warning | Observation | Temperature should be represented in Celcius (Cel) : (code.code = '8310-5') implies value.unit = 'Cel' | |
| should-cm | warning | Observation | Height & Head Circumference should be represented in cm : (code.code in ('8287-5' | '8302-2' | '8306-3' | '9843-4')) implies value.unit = 'cm' | |
| should-code | warning | Observation | SHOULD contain code : code.exists() | |
| should-kg | warning | Observation | Weight should be represented in kg : (code.code = '29463-7') implies value.unit = 'kg' | |
| should-percent | warning | Observation | Percentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with % : (code.code in ('2708-6' | '3150-0' | '59408-5' | '8289-1' | '59575-1' | '59576-9')) implies value.unit = '%' | |
| should-rates | warning | Observation | Rates should be represented in /min : (code.code in ('8867-4' | '9279-1')) implies value.unit = '/min' | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from Observation
Summary
Mandatory: 10 elements
Fixed: 3 elements
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#4.0.0-ballot based on FHIR 5.0.0. Generated 2024-12-19
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