Clinical Document Architecture V2.1
2.1.0 - CI Build

Clinical Document Architecture V2.1, 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

StructureDefinition: CDAR2.Observation

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.

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

Summary

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

This structure is derived from

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1
... classCode 1..1codeBinding: V3 Value SetActClassObservation (required)
... moodCode 1..1code
... negationInd 0..1boolean
... code 1..1CDBinding: V3 Value SetObservationType (extensible)
... derivationExpr 0..1ED
... text 0..1ED
... statusCode 0..1CSBinding: v3 Code System ActStatus (required)
... effectiveTime 0..1IVL-TS
... priorityCode 0..1CEBinding: v3 Code System ActPriority (extensible)
... repeatNumber 0..1IVL-INT
... languageCode 0..1CSBinding: V3 Value SetHumanLanguage (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: v3 Code System ObservationInterpretation (required)
... methodCode 0..*CEBinding: v3 Code System ObservationMethod (extensible)
... targetSiteCode 0..*CD
... subject 0..1Element
.... typeCode 1..1codeBinding: V3 Value SetParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: v3 Code System ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: v3 Code System TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Element
.... typeCode 1..1codeBinding: V3 Value SetParticipationTargetDirect (required)
Fixed Value: SPC
.... specimenRole 1..1SpecimenRole
... performer 0..*Element
.... typeCode 1..1codeBinding: V3 Value SetParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... templateId 0..*II
.... time 0..1IVL-TS
.... modeCode 0..1CEBinding: v3 Code System ParticipationMode (extensible)
.... assignedEntity 1..1AssignedEntity
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: V3 Value SetParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: v3 Code System ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Element
.... typeCode 1..1codeBinding: v3 Code System ParticipationType (required)
.... contextControlCode 1..1codeBinding: v3 Code System ContextControl (required)
Fixed Value: OP
.... time 0..1IVL-TS
.... awarenessCode 0..1CEBinding: v3 Code System TargetAwareness (extensible)
.... participantRole 1..1ParticipantRole
... entryRelationship 0..*Element
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... 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: V3 Value SetActRelationshipConditional (required)
Fixed Value: PRCN
.... criterion 1..1Criterion
... referenceRange 0..*Element
.... typeCode 1..1codeBinding: V3 Value SetActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1
... classCode 1..1codeBinding: V3 Value SetActClassObservation (required)
... moodCode 1..1code
... negationInd 0..1boolean
... code 1..1CDBinding: V3 Value SetObservationType (extensible)
... derivationExpr 0..1ED
... text 0..1ED
... statusCode 0..1CSBinding: v3 Code System ActStatus (required)
... effectiveTime 0..1IVL-TS
... priorityCode 0..1CEBinding: v3 Code System ActPriority (extensible)
... repeatNumber 0..1IVL-INT
... languageCode 0..1CSBinding: V3 Value SetHumanLanguage (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: v3 Code System ObservationInterpretation (required)
... methodCode 0..*CEBinding: v3 Code System ObservationMethod (extensible)
... targetSiteCode 0..*CD
... subject 0..1Element
.... typeCode 1..1codeBinding: V3 Value SetParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: v3 Code System ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: v3 Code System TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Element
.... typeCode 1..1codeBinding: V3 Value SetParticipationTargetDirect (required)
Fixed Value: SPC
.... specimenRole 1..1SpecimenRole
... performer 0..*Element
.... typeCode 1..1codeBinding: V3 Value SetParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... templateId 0..*II
.... time 0..1IVL-TS
.... modeCode 0..1CEBinding: v3 Code System ParticipationMode (extensible)
.... assignedEntity 1..1AssignedEntity
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: V3 Value SetParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: v3 Code System ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Element
.... typeCode 1..1codeBinding: v3 Code System ParticipationType (required)
.... contextControlCode 1..1codeBinding: v3 Code System ContextControl (required)
Fixed Value: OP
.... time 0..1IVL-TS
.... awarenessCode 0..1CEBinding: v3 Code System TargetAwareness (extensible)
.... participantRole 1..1ParticipantRole
... entryRelationship 0..*Element
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... 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: V3 Value SetActRelationshipConditional (required)
Fixed Value: PRCN
.... criterion 1..1Criterion
... referenceRange 0..*Element
.... typeCode 1..1codeBinding: V3 Value SetActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

This structure is derived from

Summary

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

Differential View

This structure is derived from

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1
... classCode 1..1codeBinding: V3 Value SetActClassObservation (required)
... moodCode 1..1code
... negationInd 0..1boolean
... code 1..1CDBinding: V3 Value SetObservationType (extensible)
... derivationExpr 0..1ED
... text 0..1ED
... statusCode 0..1CSBinding: v3 Code System ActStatus (required)
... effectiveTime 0..1IVL-TS
... priorityCode 0..1CEBinding: v3 Code System ActPriority (extensible)
... repeatNumber 0..1IVL-INT
... languageCode 0..1CSBinding: V3 Value SetHumanLanguage (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: v3 Code System ObservationInterpretation (required)
... methodCode 0..*CEBinding: v3 Code System ObservationMethod (extensible)
... targetSiteCode 0..*CD
... subject 0..1Element
.... typeCode 1..1codeBinding: V3 Value SetParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: v3 Code System ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: v3 Code System TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Element
.... typeCode 1..1codeBinding: V3 Value SetParticipationTargetDirect (required)
Fixed Value: SPC
.... specimenRole 1..1SpecimenRole
... performer 0..*Element
.... typeCode 1..1codeBinding: V3 Value SetParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... templateId 0..*II
.... time 0..1IVL-TS
.... modeCode 0..1CEBinding: v3 Code System ParticipationMode (extensible)
.... assignedEntity 1..1AssignedEntity
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: V3 Value SetParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: v3 Code System ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Element
.... typeCode 1..1codeBinding: v3 Code System ParticipationType (required)
.... contextControlCode 1..1codeBinding: v3 Code System ContextControl (required)
Fixed Value: OP
.... time 0..1IVL-TS
.... awarenessCode 0..1CEBinding: v3 Code System TargetAwareness (extensible)
.... participantRole 1..1ParticipantRole
... entryRelationship 0..*Element
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... 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: V3 Value SetActRelationshipConditional (required)
Fixed Value: PRCN
.... criterion 1..1Criterion
... referenceRange 0..*Element
.... typeCode 1..1codeBinding: V3 Value SetActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1
... classCode 1..1codeBinding: V3 Value SetActClassObservation (required)
... moodCode 1..1code
... negationInd 0..1boolean
... code 1..1CDBinding: V3 Value SetObservationType (extensible)
... derivationExpr 0..1ED
... text 0..1ED
... statusCode 0..1CSBinding: v3 Code System ActStatus (required)
... effectiveTime 0..1IVL-TS
... priorityCode 0..1CEBinding: v3 Code System ActPriority (extensible)
... repeatNumber 0..1IVL-INT
... languageCode 0..1CSBinding: V3 Value SetHumanLanguage (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: v3 Code System ObservationInterpretation (required)
... methodCode 0..*CEBinding: v3 Code System ObservationMethod (extensible)
... targetSiteCode 0..*CD
... subject 0..1Element
.... typeCode 1..1codeBinding: V3 Value SetParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: v3 Code System ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: v3 Code System TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Element
.... typeCode 1..1codeBinding: V3 Value SetParticipationTargetDirect (required)
Fixed Value: SPC
.... specimenRole 1..1SpecimenRole
... performer 0..*Element
.... typeCode 1..1codeBinding: V3 Value SetParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... templateId 0..*II
.... time 0..1IVL-TS
.... modeCode 0..1CEBinding: v3 Code System ParticipationMode (extensible)
.... assignedEntity 1..1AssignedEntity
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: V3 Value SetParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: v3 Code System ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Element
.... typeCode 1..1codeBinding: v3 Code System ParticipationType (required)
.... contextControlCode 1..1codeBinding: v3 Code System ContextControl (required)
Fixed Value: OP
.... time 0..1IVL-TS
.... awarenessCode 0..1CEBinding: v3 Code System TargetAwareness (extensible)
.... participantRole 1..1ParticipantRole
... entryRelationship 0..*Element
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... 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: V3 Value SetActRelationshipConditional (required)
Fixed Value: PRCN
.... criterion 1..1Criterion
... referenceRange 0..*Element
.... typeCode 1..1codeBinding: V3 Value SetActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

 

Other representations of profile: Schematron

Terminology Bindings

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredv3.ActClassObservation
Observation.codeextensiblev3.ObservationType
Observation.statusCoderequiredv3.ActStatus
Observation.priorityCodeextensiblev3.ActPriority
Observation.languageCoderequiredv3.HumanLanguage
Observation.interpretationCoderequiredv3.ObservationInterpretation
Observation.methodCodeextensiblev3.ObservationMethod
Observation.subject.typeCoderequiredFixed Value: SBJ
Observation.subject.contextControlCoderequiredFixed Value: OP
Observation.subject.awarenessCodeextensiblev3.TargetAwareness
Observation.specimen.typeCoderequiredFixed Value: SPC
Observation.performer.typeCoderequiredFixed Value: PRF
Observation.performer.modeCodeextensiblev3.ParticipationMode
Observation.informant.typeCoderequiredFixed Value: INF
Observation.informant.contextControlCoderequiredFixed Value: OP
Observation.participant.typeCoderequiredv3.ParticipationType
Observation.participant.contextControlCoderequiredFixed Value: OP
Observation.participant.awarenessCodeextensiblev3.TargetAwareness
Observation.precondition.typeCoderequiredFixed Value: PRCN
Observation.referenceRange.typeCoderequiredFixed Value: REFV

Constraints

Constraints

IdPathDetailsRequirements