This is the set of resources that conform to either of the profiles Problem Observation (http://hl7.org/cda/us/ccda/StructureDefinition/ProblemObservation) and Problem Observation (http://hl7.org/cda/us/ccda/StructureDefinition/ProblemObservation). E.g. what you have to deal with if you get resources conforming to one of them
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 1..1 | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author | |
nullFlavor | 0..1 | ?? | Binding: ?? (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
nullFlavor | 0..1 | ?? | Binding: ?? (required) | |
assigningAuthorityName | 0..1 | ?? | ||
displayable | 0..1 | ?? | ||
root | 1..1 | ??, ??, ?? | ||
extension | 1..1 | ?? | ||
templateId | 1..* | II | ||
classCode | 1..1 | ?? | Binding: ?? (required) | |
moodCode | 1..1 | ?? | Binding: ?? (required) | |
negationInd | 0..1 | ?? | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |
code | 1..1 | CD | Binding: ?? (preferred) | |
derivationExpr | 0..1 | ST | ||
text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
nullFlavor | 0..1 | ?? | Binding: ?? (required) | |
compression | 0..1 | ?? | Binding: ?? (required) | |
integrityCheck | 0..1 | ?? | ||
integrityCheckAlgorithm | 0..1 | ?? | Binding: ?? (required) | |
language | 0..1 | ?? | ||
mediaType | 0..1 | ?? | Binding: ?? (example) | |
representation | 0..1 | ?? | Binding: ?? (required) | |
xmlText | 0..1 | ?? | 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: ?? (required) | |
nullFlavor | 0..1 | ?? | Binding: ?? (required) | |
code | 1..1 | ?? | ||
sdtcValueSet | 0..1 | ?? | ||
sdtcValueSetVersion | 0..1 | ?? | ||
effectiveTime | 1..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. | |
nullFlavor | 0..1 | ?? | Binding: ?? (required) | |
value | 0..1 | ?? | ||
operator | 0..1 | ?? | Binding: ?? (required) | |
low | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |
center | 0..1 | TS | ||
width | 0..1 | PQ | ||
high | 0..1 | IVXB_TS | (USCDI) Date of Resolution - The effectiveTime/high (a.k.a. resolution date) asserts when the condition became biologically resolved. | |
priorityCode | 0..1 | CE | Binding: ?? (example) | |
repeatNumber | 0..1 | IVL_INT | ||
languageCode | 0..1 | CS | Binding: ?? (required) | |
value | 1..1 | CD | (USCDI) SDOH Problems/Health Concerns Binding: ?? (preferred) | |
nullFlavor | 0..1 | ?? | Binding: ?? (required) | |
code | 0..1 | ?? | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951). Binding Description (No ValueSet): (example): See additional binding | |
codeSystem | 0..1 | ??, ??, ?? | ||
codeSystemName | 0..1 | ?? | ||
codeSystemVersion | 0..1 | ?? | ||
displayName | 0..1 | ?? | ||
sdtcValueSet | 0..1 | ?? | ||
sdtcValueSetVersion | 0..1 | ?? | ||
originalText | 0..1 | ED | ||
qualifier | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined.
In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo -
Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML. | |
translation | 0..* | CD | ||
interpretationCode | 0..* | CE | Binding: ?? (required) | |
methodCode | 0..* | CE | Binding: ?? (example) | |
targetSiteCode | 0..* | CD | ||
subject | 0..1 | Subject | ||
specimen | 0..* | Specimen | ||
performer | 0..* | Performer2 | ||
author | 0..* | ?? | Base for all types and resources | |
informant | 0..* | Informant | ||
participant | 0..* | Participant2 | ||
entryRelationship | 0..* | EntryRelationship | ||
reference | 0..* | Reference | ||
precondition | 0..* | Precondition | ||
sdtcPrecondition2 | 0..* | Precondition2 | ||
referenceRange | 0..* | InfrastructureRoot | ||
nullFlavor | 0..1 | ?? | Binding: ?? (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
nullFlavor | 0..1 | ?? | Binding: ?? (required) | |
assigningAuthorityName | 0..1 | ?? | ||
displayable | 0..1 | ?? | ||
root | 1..1 | ??, ??, ?? | ||
extension | 1..1 | ?? | ||
templateId | 0..* | II | ||
typeCode | 0..1 | ?? | Binding: ?? (required) | |
observationRange | 1..1 | ObservationRange | ||
sdtcInFulfillmentOf1 | 0..* | InFulfillmentOf1 | ||
Documentation for this format |