Clinical Document Architecture V2.0.1
2.1.0 - CI Build

Clinical Document Architecture V2.0.1, published by Health Level 7. This is not an authorized publication; it is the continuous build for version 2.1.0). This version is based on the current content of https://github.com/HL7/cda-core-2.0/ and changes regularly. See the Directory of published versions

Logical Model: Observation (CDA Class)

Defining URL:http://hl7.org/fhir/cda/StructureDefinition/Observation
Version:2.1.0
Name:CDAR2.Observation
Title:Observation (CDA Class)
Status:Active as of 2020-11-19T18:06:12+00:00
Definition:

A derivative of the RIM Observation class, used for representing coded and other observations. Observation.negationInd, when set to "true", is a positive assertion that the Observation as a whole is negated. Some properties such as Observation.id, Observation.moodCode, and the participations are not negated. These properties always have the same meaning: i.e., the author remains the author of the negative Observation. An observation statement with negationInd is still a statement about the specific fact described by the Observation. For instance, a negated "finding of wheezing on July 1" means that the author positively denies that there was wheezing on July 1, and that he takes the same responsibility for such statement and the same requirement to have evidence for such statement than if he had not used negation.

Publisher:Health Level 7
Source Resource:XML / JSON / Turtle

The official URL for this profile is:

http://hl7.org/fhir/cda/StructureDefinition/Observation

Formal Views of Profile Content

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

This structure is derived from Base

Summary

Mandatory: 0 element (22 nested mandatory elements)
Fixed Value: 9 elements

This structure is derived from Base

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1
... classCode 1..1codeBinding: ActClassObservation (required)
... moodCode 1..1code
... negationInd 0..1boolean
... code 1..1CDBinding: ObservationType (extensible)
... derivationExpr 0..1ED
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 0..*
.... 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)
... 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..*Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: SPC
.... specimenRole 1..1SpecimenRole
... performer 0..*Element
.... typeCode 1..1codeBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... templateId 0..*II
.... time 0..1IVL_TS
.... modeCode 0..1CEBinding: ParticipationMode (extensible)
.... assignedEntity 1..1AssignedEntity
... 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..*Element
.... typeCode 1..1codeBinding: ParticipationType (required)
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... time 0..1IVL_TS
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... participantRole 1..1ParticipantRole
... entryRelationship I0..*Elementobs-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... 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
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Element
.... typeCode 1..1codeBinding: ActRelationshipConditional (required)
Fixed Value: PRCN
.... criterion 1..1Criterion
... referenceRange 0..*Element
.... typeCode 1..1codeBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1
... classCode 1..1codeBinding: ActClassObservation (required)
... moodCode 1..1code
... negationInd 0..1boolean
... code 1..1CDBinding: ObservationType (extensible)
... derivationExpr 0..1ED
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 0..*
.... 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)
... 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..*Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: SPC
.... specimenRole 1..1SpecimenRole
... performer 0..*Element
.... typeCode 1..1codeBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... templateId 0..*II
.... time 0..1IVL_TS
.... modeCode 0..1CEBinding: ParticipationMode (extensible)
.... assignedEntity 1..1AssignedEntity
... 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..*Element
.... typeCode 1..1codeBinding: ParticipationType (required)
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... time 0..1IVL_TS
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... participantRole 1..1ParticipantRole
... entryRelationship I0..*Elementobs-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... 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
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Element
.... typeCode 1..1codeBinding: ActRelationshipConditional (required)
Fixed Value: PRCN
.... criterion 1..1Criterion
... referenceRange 0..*Element
.... typeCode 1..1codeBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

This structure is derived from Base

Summary

Mandatory: 0 element (22 nested mandatory elements)
Fixed Value: 9 elements

Differential View

This structure is derived from Base

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1
... classCode 1..1codeBinding: ActClassObservation (required)
... moodCode 1..1code
... negationInd 0..1boolean
... code 1..1CDBinding: ObservationType (extensible)
... derivationExpr 0..1ED
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 0..*
.... 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)
... 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..*Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: SPC
.... specimenRole 1..1SpecimenRole
... performer 0..*Element
.... typeCode 1..1codeBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... templateId 0..*II
.... time 0..1IVL_TS
.... modeCode 0..1CEBinding: ParticipationMode (extensible)
.... assignedEntity 1..1AssignedEntity
... 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..*Element
.... typeCode 1..1codeBinding: ParticipationType (required)
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... time 0..1IVL_TS
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... participantRole 1..1ParticipantRole
... entryRelationship I0..*Elementobs-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... 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
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Element
.... typeCode 1..1codeBinding: ActRelationshipConditional (required)
Fixed Value: PRCN
.... criterion 1..1Criterion
... referenceRange 0..*Element
.... typeCode 1..1codeBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1
... classCode 1..1codeBinding: ActClassObservation (required)
... moodCode 1..1code
... negationInd 0..1boolean
... code 1..1CDBinding: ObservationType (extensible)
... derivationExpr 0..1ED
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 0..*
.... 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)
... 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..*Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: SPC
.... specimenRole 1..1SpecimenRole
... performer 0..*Element
.... typeCode 1..1codeBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... templateId 0..*II
.... time 0..1IVL_TS
.... modeCode 0..1CEBinding: ParticipationMode (extensible)
.... assignedEntity 1..1AssignedEntity
... 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..*Element
.... typeCode 1..1codeBinding: ParticipationType (required)
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... time 0..1IVL_TS
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... participantRole 1..1ParticipantRole
... entryRelationship I0..*Elementobs-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... 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
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Element
.... typeCode 1..1codeBinding: ActRelationshipConditional (required)
Fixed Value: PRCN
.... criterion 1..1Criterion
... referenceRange 0..*Element
.... typeCode 1..1codeBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

 

Other representations of profile: Schematron

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredActClassObservation
Observation.codeextensibleObservationType
Observation.statusCoderequiredActStatus
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeextensibleObservationMethod
Observation.subject.typeCoderequiredFixed Value: SBJ
Observation.subject.contextControlCoderequiredFixed Value: OP
Observation.subject.awarenessCodeextensibleTargetAwareness
Observation.specimen.typeCoderequiredFixed Value: SPC
Observation.performer.typeCoderequiredFixed Value: PRF
Observation.performer.modeCodeextensibleParticipationMode
Observation.informant.typeCoderequiredFixed Value: INF
Observation.informant.contextControlCoderequiredFixed Value: OP
Observation.participant.typeCoderequiredParticipationType
Observation.participant.contextControlCoderequiredFixed Value: OP
Observation.participant.awarenessCodeextensibleTargetAwareness
Observation.precondition.typeCoderequiredFixed Value: PRCN
Observation.referenceRange.typeCoderequiredFixed Value: REFV

Constraints

IdPathDetailsRequirements
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