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

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

Logical Model: Vital Sign Observation

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/VitalSignObservation Version: 4.0.0
Draft as of 2025-10-02 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) %

Usages:

You can also check for usages in the FHIR IG Statistics

Changes since version 3.0.0:

  • New Content

    • Formal Views of Template Content

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

    This structure is derived from Observation

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Observation C 1..1 Observation XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, should-code, should-author, should-percent, should-cm, should-kg, should-cel, should-bp, should-rates, should-bmi, should-bsa
    ... 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
    ... 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 Constraints: value-starts-octothorpe
    ... 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

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    Observation.code.code Base preferred Vital Sign Result Type . 📦20240322 VSAC v0.23
    Observation.value.unit Base required UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    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('#')
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Observation C 1..1 Observation XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, should-code, should-author, should-percent, should-cm, should-kg, should-cel, should-bp, should-rates, should-bmi, should-bsa
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
    .... templateId: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 Constraints: value-starts-octothorpe
    .... thumbnail 0..1 ED
    ... statusCode 1..1 CS Binding: ActStatus (required)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Fixed Value: completed
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    XML: valueSetVersion (urn:hl7-org:sdtc)
    ... effectiveTime 1..1 IVL_TS
    ... priorityCode 0..1 CE Binding: ActPriority (example)
    ... repeatNumber 0..1 IVL_INT
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... 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
    ... 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 Constraints: II-1
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ..... @extension 1..1 st
    .... templateId 0..* II
    .... @typeCode 0..1 cs Binding: CDAActRelationshipType (required)
    Fixed Value: REFV
    .... observationRange 1..1 ObservationRange
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Observation.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.templateId:vital-sign-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.classCode Base required CDAActClassObservation 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.moodCode Base required x_ActMoodDocumentObservation 📍2.0.0 THO v5.2
    Observation.code Base example ObservationType 📦3.0.0 THO v6.5
    Observation.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.code.code Base preferred Vital Sign Result Type . 📦20240322 VSAC v0.23
    Observation.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Observation.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Observation.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Observation.statusCode.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Observation.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Observation.value.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.value.unit Base required UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    Observation.interpretationCode Base required CDAObservationInterpretation 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.methodCode Base example ObservationMethod 📦3.0.0 THO v6.5
    Observation.referenceRange.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.referenceRange.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.referenceRange.​typeCode Base required CDAActRelationshipType 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    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('#')
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Observation C 1..1 Observation XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, should-code, should-author, should-percent, should-cm, should-kg, should-cel, should-bp, should-rates, should-bmi, should-bsa
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
    .... templateId: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 Constraints: value-starts-octothorpe
    .... thumbnail 0..1 ED
    ... statusCode 1..1 CS Binding: ActStatus (required)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Fixed Value: completed
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    XML: valueSetVersion (urn:hl7-org:sdtc)
    ... effectiveTime 1..1 IVL_TS
    ... priorityCode 0..1 CE Binding: ActPriority (example)
    ... repeatNumber 0..1 IVL_INT
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... 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
    ... 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 Constraints: II-1
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ..... @extension 1..1 st
    .... templateId 0..* II
    .... @typeCode 0..1 cs Binding: CDAActRelationshipType (required)
    Fixed Value: REFV
    .... observationRange 1..1 ObservationRange
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Observation.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.templateId:vital-sign-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.classCode Base required CDAActClassObservation 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.moodCode Base required x_ActMoodDocumentObservation 📍2.0.0 THO v5.2
    Observation.code Base example ObservationType 📦3.0.0 THO v6.5
    Observation.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.code.code Base preferred Vital Sign Result Type . 📦20240322 VSAC v0.23
    Observation.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Observation.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Observation.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Observation.statusCode.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Observation.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Observation.value.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.value.unit Base required UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    Observation.interpretationCode Base required CDAObservationInterpretation 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.methodCode Base example ObservationMethod 📦3.0.0 THO v6.5
    Observation.referenceRange.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.referenceRange.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.referenceRange.​typeCode Base required CDAActRelationshipType 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    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:

    • The element 2 is sliced based on the values of Observation.templateId

    Differential View

    This structure is derived from Observation

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Observation C 1..1 Observation XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, should-code, should-author, should-percent, should-cm, should-kg, should-cel, should-bp, should-rates, should-bmi, should-bsa
    ... 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
    ... 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 Constraints: value-starts-octothorpe
    ... 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

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    Observation.code.code Base preferred Vital Sign Result Type . 📦20240322 VSAC v0.23
    Observation.value.unit Base required UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    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

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Observation C 1..1 Observation XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, should-code, should-author, should-percent, should-cm, should-kg, should-cel, should-bp, should-rates, should-bmi, should-bsa
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
    .... templateId: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 Constraints: value-starts-octothorpe
    .... thumbnail 0..1 ED
    ... statusCode 1..1 CS Binding: ActStatus (required)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Fixed Value: completed
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    XML: valueSetVersion (urn:hl7-org:sdtc)
    ... effectiveTime 1..1 IVL_TS
    ... priorityCode 0..1 CE Binding: ActPriority (example)
    ... repeatNumber 0..1 IVL_INT
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... 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
    ... 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 Constraints: II-1
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ..... @extension 1..1 st
    .... templateId 0..* II
    .... @typeCode 0..1 cs Binding: CDAActRelationshipType (required)
    Fixed Value: REFV
    .... observationRange 1..1 ObservationRange
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Observation.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.templateId:vital-sign-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.classCode Base required CDAActClassObservation 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.moodCode Base required x_ActMoodDocumentObservation 📍2.0.0 THO v5.2
    Observation.code Base example ObservationType 📦3.0.0 THO v6.5
    Observation.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.code.code Base preferred Vital Sign Result Type . 📦20240322 VSAC v0.23
    Observation.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Observation.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Observation.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Observation.statusCode.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Observation.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Observation.value.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.value.unit Base required UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    Observation.interpretationCode Base required CDAObservationInterpretation 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.methodCode Base example ObservationMethod 📦3.0.0 THO v6.5
    Observation.referenceRange.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.referenceRange.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.referenceRange.​typeCode Base required CDAActRelationshipType 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    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

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Observation C 1..1 Observation XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, should-code, should-author, should-percent, should-cm, should-kg, should-cel, should-bp, should-rates, should-bmi, should-bsa
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
    .... templateId: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 Constraints: value-starts-octothorpe
    .... thumbnail 0..1 ED
    ... statusCode 1..1 CS Binding: ActStatus (required)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Fixed Value: completed
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    XML: valueSetVersion (urn:hl7-org:sdtc)
    ... effectiveTime 1..1 IVL_TS
    ... priorityCode 0..1 CE Binding: ActPriority (example)
    ... repeatNumber 0..1 IVL_INT
    ... languageCode 0..1 CS Binding: AllLanguages (required)
    ... 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
    ... 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 Constraints: II-1
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ..... @extension 1..1 st
    .... templateId 0..* II
    .... @typeCode 0..1 cs Binding: CDAActRelationshipType (required)
    Fixed Value: REFV
    .... observationRange 1..1 ObservationRange
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Observation.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.templateId:vital-sign-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.classCode Base required CDAActClassObservation 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.moodCode Base required x_ActMoodDocumentObservation 📍2.0.0 THO v5.2
    Observation.code Base example ObservationType 📦3.0.0 THO v6.5
    Observation.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.code.code Base preferred Vital Sign Result Type . 📦20240322 VSAC v0.23
    Observation.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Observation.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Observation.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Observation.statusCode.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Observation.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Observation.value.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.value.unit Base required UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    Observation.interpretationCode Base required CDAObservationInterpretation 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.methodCode Base example ObservationMethod 📦3.0.0 THO v6.5
    Observation.referenceRange.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.referenceRange.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Observation.referenceRange.​typeCode Base required CDAActRelationshipType 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    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:

    • The element 2 is sliced based on the values of Observation.templateId

     

    Other representations of profile: CSV, Excel