Consolidated CDA Release 2.2
2.2 - CI Build

Consolidated CDA Release 2.2, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.2). This version is based on the current content of https://github.com/HL7/cda-ccda-2.2/ and changes regularly. See the Directory of published versions

Resource Profile: Assessment Scale Observation

Defining URL:http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.69
Version:2.2
Name:AssessmentScaleObservation
Title:Assessment Scale Observation
Status:Active as of 11/24/21, 5:43 PM
Definition:

An assessment scale is a collection of observations that together yield a summary evaluation of a particular condition. Examples include the Braden Scale (assesses pressure ulcer risk), APACHE Score (estimates mortality in critically ill patients), Mini-Mental Status Exam (assesses cognitive function), APGAR Score (assesses the health of a newborn), and Glasgow Coma Scale (assesses coma and impaired consciousness).

Publisher:Health Level Seven
Source Resource:XML / JSON / Turtle

The official URL for this profile is:

http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.69

Formal Views of Profile Content

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

This structure is derived from CDAR2.Observation

Summary

Mandatory: 10 elements (3 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Observation.templateId is sliced based on the value of value:root
  • The element Observation.entryRelationship is sliced based on the value of profile:observation

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeRequired Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.69
... code I1..1CD81-14440: **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440).
... derivationExpr 0..1EDSuch derivation expression can contain a text calculation of how the components total up to the summed score
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: completed
... effectiveTime 1..1IVL_TSRepresents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards)
... value 1..1BL, ED, ED, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ
... interpretationCode 0..*CE
.... translation 0..*CD
... author 0..*Author
... Slices for entryRelationship 0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:supporting 0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... observation 1..1AssessmentScaleSupportingObservation
... referenceRange 0..*ElementThe referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain)
.... observationRange 1..1ObservationRange
..... text 0..1EDThe text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain)
...... reference 0..1TEL
....... value I0..1uri81-16804: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:81-16804).

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... negationInd 0..1boolean
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 0..*IISlice: Unordered, Open by value:root
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.69
..... extension 0..1string
... id 1..*II
... code I1..1CDBinding: ObservationType (extensible)
81-14440: **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440).
... derivationExpr 0..1EDSuch derivation expression can contain a text calculation of how the components total up to the summed score
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: completed
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 1..1IVL_TSRepresents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards)
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 1..1
.... valueBL
.... valueED
.... valueED
.... valueCD
.... valueCV
.... valueCE
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 0..1string
.... codeSystem 0..1string
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... methodCode 0..*CEBinding: ObservationMethod (extensible)
... targetSiteCode 0..*CD
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... Slices for entryRelationship I0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entryRelationship:supporting I0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1AssessmentScaleSupportingObservation
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition
... referenceRange 0..*ElementThe referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain)
.... typeCode 1..1codeBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange
..... classCode 1..1codeBinding: ActClassObservation (required)
..... moodCode 1..1codeBinding: ActMoodPredicate (required)
Fixed Value: EVN.CRT
..... templateId 0..*II
..... code 0..1CDBinding: v3 Code System ActCode (extensible)
..... text 0..1EDThe text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain)
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... charset 0..1code
...... compression 0..1codeBinding: CompressionAlgorithm (required)
...... integrityCheck 0..1base64Binary
...... integrityCheckAlgorithm 0..1codeBinding: IntegrityCheckAlgorithm (required)
...... language 0..1code
...... mediaType 0..1code
...... representation 0..1code
...... data[x] 0..1
....... dataStringstring
....... dataBase64Binarybase64Binary
...... reference 0..1TEL
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... value I0..1uri81-16804: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:81-16804).
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... use 0..*codeBinding: AddressUse (required)
...... thumbnail 0..1ED
..... value 0..1
...... valueBL
...... valueED
...... valueED
...... valueCD
...... valueCV
...... valueCE
...... valueSC
...... valueII
...... valueTEL
...... valueAD
...... valueEN
...... valueINT
...... valueREAL
...... valuePQ
...... valueMO
...... valueTS
...... valueIVL_PQ
...... valueIVL_TS
...... valuePIVL_TS
...... valueEIVL_TS
...... valueSXPR_TS
..... interpretationCode 0..1CEBinding: ObservationInterpretation (required)

doco Documentation for this format

This structure is derived from CDAR2.Observation

Summary

Mandatory: 10 elements (3 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Observation.templateId is sliced based on the value of value:root
  • The element Observation.entryRelationship is sliced based on the value of profile:observation

Differential View

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeRequired Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.69
... code I1..1CD81-14440: **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440).
... derivationExpr 0..1EDSuch derivation expression can contain a text calculation of how the components total up to the summed score
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: completed
... effectiveTime 1..1IVL_TSRepresents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards)
... value 1..1BL, ED, ED, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ
... interpretationCode 0..*CE
.... translation 0..*CD
... author 0..*Author
... Slices for entryRelationship 0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:supporting 0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... observation 1..1AssessmentScaleSupportingObservation
... referenceRange 0..*ElementThe referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain)
.... observationRange 1..1ObservationRange
..... text 0..1EDThe text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain)
...... reference 0..1TEL
....... value I0..1uri81-16804: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:81-16804).

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.Observation
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... negationInd 0..1boolean
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 0..*IISlice: Unordered, Open by value:root
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.69
..... extension 0..1string
... id 1..*II
... code I1..1CDBinding: ObservationType (extensible)
81-14440: **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440).
... derivationExpr 0..1EDSuch derivation expression can contain a text calculation of how the components total up to the summed score
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: completed
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 1..1IVL_TSRepresents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards)
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 1..1
.... valueBL
.... valueED
.... valueED
.... valueCD
.... valueCV
.... valueCE
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 0..1string
.... codeSystem 0..1string
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... methodCode 0..*CEBinding: ObservationMethod (extensible)
... targetSiteCode 0..*CD
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... Slices for entryRelationship I0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entryRelationship:supporting I0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1AssessmentScaleSupportingObservation
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition
... referenceRange 0..*ElementThe referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain)
.... typeCode 1..1codeBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange
..... classCode 1..1codeBinding: ActClassObservation (required)
..... moodCode 1..1codeBinding: ActMoodPredicate (required)
Fixed Value: EVN.CRT
..... templateId 0..*II
..... code 0..1CDBinding: v3 Code System ActCode (extensible)
..... text 0..1EDThe text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain)
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... charset 0..1code
...... compression 0..1codeBinding: CompressionAlgorithm (required)
...... integrityCheck 0..1base64Binary
...... integrityCheckAlgorithm 0..1codeBinding: IntegrityCheckAlgorithm (required)
...... language 0..1code
...... mediaType 0..1code
...... representation 0..1code
...... data[x] 0..1
....... dataStringstring
....... dataBase64Binarybase64Binary
...... reference 0..1TEL
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... value I0..1uri81-16804: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:81-16804).
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... use 0..*codeBinding: AddressUse (required)
...... thumbnail 0..1ED
..... value 0..1
...... valueBL
...... valueED
...... valueED
...... valueCD
...... valueCV
...... valueCE
...... valueSC
...... valueII
...... valueTEL
...... valueAD
...... valueEN
...... valueINT
...... valueREAL
...... valuePQ
...... valueMO
...... valueTS
...... valueIVL_PQ
...... valueIVL_TS
...... valuePIVL_TS
...... valueEIVL_TS
...... valueSXPR_TS
..... interpretationCode 0..1CEBinding: ObservationInterpretation (required)

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredPattern: OBS
Observation.templateId:primary.nullFlavorrequiredNullFlavor
Observation.codeextensibleObservationType
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage
Observation.interpretationCoderequiredObservationInterpretation
Observation.interpretationCode.nullFlavorrequiredNullFlavor
Observation.methodCodeextensibleObservationMethod
Observation.subject.typeCoderequiredFixed Value: SBJ
Observation.subject.contextControlCoderequiredFixed Value: OP
Observation.subject.awarenessCodeextensibleTargetAwareness
Observation.informant.typeCoderequiredFixed Value: INF
Observation.informant.contextControlCoderequiredFixed Value: OP
Observation.referenceRange.typeCoderequiredFixed Value: REFV
Observation.referenceRange.observationRange.classCoderequiredActClassObservation
Observation.referenceRange.observationRange.moodCoderequiredFixed Value: EVN.CRT
Observation.referenceRange.observationRange.codeextensibleActCode
Observation.referenceRange.observationRange.text.nullFlavorrequiredNullFlavor
Observation.referenceRange.observationRange.text.compressionrequiredCompressionAlgorithm
Observation.referenceRange.observationRange.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
Observation.referenceRange.observationRange.text.reference.nullFlavorrequiredNullFlavor
Observation.referenceRange.observationRange.text.reference.userequiredAddressUse
Observation.referenceRange.observationRange.interpretationCoderequiredObservationInterpretation

Constraints

IdPathDetailsRequirements
81-14440Observation.code**SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440).
:
obs-er-1Observation.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
obs-er-1Observation.entryRelationship:supportingOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
81-16804Observation.referenceRange.observationRange.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:81-16804).
: