Specialty Eyecare CDA Implementation Guide, published by Dogwood Health Consulting. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/cda-eyecare/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/cda/us/eyecare/StructureDefinition/AidToVisionObservation | Version: 0.1.0 | |||
Draft as of 2024-02-07 | Computable Name: AidToVisionObservation |
A constraint on ResultObservation that is used to indicate the type of vision aids used in a Visual Acuity measurement.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ResultObservation
Path | Conformance | ValueSet | URI |
Observation.value:coded.code | required | AidToVisionCodeshttp://hl7.org/cda/us/eyecare/ValueSet/AidToVisionCodes from this IG |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 1..1 | ResultObservation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, value, value, interpretationCode, methodCode, targetSiteCode, author, referenceRange Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:result-obs | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
@extension | 1..1 | st | Required Pattern: 2023-05-01 | |
@classCode | 1..1 | cs | Binding: ActClassObservation (2.0.0) (required) Fixed Value: OBS | |
@moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
id | 1..* | II | ||
code | C | 1..1 | CD | (USCDI) Tests Binding: ObservationType (example) |
@code | 0..1 | cs | Required Pattern: 257192006 | |
@codeSystem | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.96 | |
@displayName | 0..1 | st | Required Pattern: Aid to vision | |
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
@code | 1..1 | cs | Binding: Result Status (required) | |
effectiveTime | 1..1 | IVL_TS | Represents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
Slices for value | 1..1 | (USCDI) Values/Results - Value can be any type, but certain types have additional rules. Slice: Unordered, Open by type:$this | ||
value | ANY | |||
value | BL | |||
value | ED | |||
value | ST | |||
value | CD | |||
value | CV | |||
value | CE | |||
value | CO | |||
value | SC | |||
value | II | |||
value | TEL | |||
value | AD | |||
value | EN | |||
value | INT | |||
value | REAL | |||
value | PQ | |||
value | MO | |||
value | TS | |||
value | IVL_PQ | |||
value | IVL_TS | |||
value | PIVL_TS | |||
value | EIVL_TS | |||
value | SXPR_TS | |||
value | RTO_PQ_PQ | |||
value:coded | C | 1..1 | CD | |
@code | 0..1 | cs | Binding: Aid to Vision Codes (required) | |
translation | 0..1 | CD | Can be used to represent the original results as output by the lab | |
methodCode | 0..1 | CE | Binding: ObservationMethod (example) | |
targetSiteCode | 0..1 | CD | ||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Observation.classCode | required | Fixed Value: OBShttp://terminology.hl7.org/ValueSet/v3-ActClassObservation|2.0.0 | |
Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
Observation.statusCode.code | required | Result Status http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39 | |
Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
Observation.value:coded.code | required | AidToVisionCodeshttp://hl7.org/cda/us/eyecare/ValueSet/AidToVisionCodes from this IG | |
Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod |
Id | Grade | Path(s) | Details | Requirements |
4537-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). : codeSystem = '2.16.840.1.113883.6.1' | |
4537-32610 | warning | Observation.value:coded | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). : codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.1' | |
shall-code-or-nullflavor | error | Observation.code | SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. : (code | nullFlavor).count() = 1 | |
should-author | warning | Observation | SHOULD contain author : author.exists() | |
should-interpretationCode | warning | Observation | SHOULD contain interpretationCode : interpretationCode.exists() | |
should-referenceRange | warning | Observation | SHOULD contain referenceRange : referenceRange.exists() | |
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 1..1 | ResultObservation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, value, value, interpretationCode, methodCode, targetSiteCode, author, referenceRange Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@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:result-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: 2.16.840.1.113883.10.20.22.4.2 | |
@extension | 1..1 | st | Required Pattern: 2023-05-01 | |
@classCode | 1..1 | cs | Binding: ActClassObservation (2.0.0) (required) Fixed Value: OBS | |
@moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
@negationInd | 0..1 | bl | ||
id | 1..* | II | ||
code | C | 1..1 | CD | (USCDI) Tests Binding: ObservationType (example) |
(Choice of one) | 1..1 | |||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 0..1 | cs | Required Pattern: 257192006 | |
@codeSystem | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.96 | |
@codeSystemName | 0..1 | st | ||
@codeSystemVersion | 0..1 | st | ||
@displayName | 0..1 | st | Required Pattern: Aid to vision | |
@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: CompressionAlgorithm (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: Binary Data Encoding Value Set (required) | |
xmlText | 0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |
reference | C | 0..1 | TEL | |
thumbnail | 0..1 | ED | ||
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 1..1 | cs | Binding: Result Status (required) | |
@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 | Represents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
priorityCode | 0..1 | CE | Binding: ActPriority (example) | |
repeatNumber | 0..1 | IVL_INT | ||
languageCode | 0..1 | CS | Binding: AllLanguages (required) | |
Slices for value | 1..1 | (USCDI) Values/Results - Value can be any type, but certain types have additional rules. Slice: Unordered, Open by type:$this | ||
value | ANY | |||
value | BL | |||
value | ED | |||
value | ST | |||
value | CD | |||
value | CV | |||
value | CE | |||
value | CO | |||
value | SC | |||
value | II | |||
value | TEL | |||
value | AD | |||
value | EN | |||
value | INT | |||
value | REAL | |||
value | PQ | |||
value | MO | |||
value | TS | |||
value | IVL_PQ | |||
value | IVL_TS | |||
value | PIVL_TS | |||
value | EIVL_TS | |||
value | SXPR_TS | |||
value | RTO_PQ_PQ | |||
value:coded | C | 1..1 | CD | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 0..1 | cs | Binding: Aid to Vision Codes (required) | |
@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..1 | CD | Can be used to represent the original results as output by the lab | |
interpretationCode | 0..* | CE | (USCDI) Result Interpretation Binding: ObservationInterpretation (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 | Base for all types and resources | |
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 | (USCDI) Result Reference Range | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@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: ActRelationshipType (2.0.0) (required) Fixed Value: REFV | |
observationRange | 1..1 | ObservationRange | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@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 | ||
@classCode | 1..1 | cs | Binding: ActClassObservation (required) | |
@moodCode | 0..1 | cs | Binding: ActMoodPredicate (required) Fixed Value: EVN.CRT | |
text | 0..1 | ED | ||
value | 1..1 | |||
value | BL | |||
value | ED | |||
value | ST | |||
value | CD | |||
value | CV | |||
value | CE | |||
value | CO | |||
value | SC | |||
value | II | |||
value | TEL | |||
value | AD | |||
value | EN | |||
value | INT | |||
value | REAL | |||
value | PQ | |||
value | MO | |||
value | TS | |||
value | IVL_PQ | |||
value | IVL_TS | |||
value | PIVL_TS | |||
value | EIVL_TS | |||
value | SXPR_TS | |||
interpretationCode | 0..1 | CE | Binding: ObservationInterpretation (required) | |
sdtcPrecondition1 | 0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: precondition1 (urn:hl7-org:sdtc) | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@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: ActRelationshipType (required) Fixed Value: PRCN | |
conjunctionCode | 1..1 | CS | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc Binding: RelationshipConjunction (2.0.0) (required) | |
criterion1 | 1..1 | Criterion | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
sdtcInFulfillmentOf1 | 0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.templateId:result-obs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.classCode | required | Fixed Value: OBShttp://terminology.hl7.org/ValueSet/v3-ActClassObservation|2.0.0 | |
Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
Observation.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
Observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
Observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
Observation.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.statusCode.code | required | Result Status http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39 | |
Observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Observation.value:physical-quantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
Observation.value:coded.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.value:coded.code | required | AidToVisionCodeshttp://hl7.org/cda/us/eyecare/ValueSet/AidToVisionCodes from this IG | |
Observation.interpretationCode | required | ObservationInterpretationhttp://terminology.hl7.org/ValueSet/v3-ObservationInterpretation | |
Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
Observation.referenceRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.referenceRange.typeCode | required | Fixed Value: REFVhttp://terminology.hl7.org/ValueSet/v3-ActRelationshipType|2.0.0 | |
Observation.referenceRange.observationRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.referenceRange.observationRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.referenceRange.observationRange.classCode | required | ActClassObservationhttp://terminology.hl7.org/ValueSet/v3-ActClassObservation | |
Observation.referenceRange.observationRange.moodCode | required | Fixed Value: EVN.CRThttp://terminology.hl7.org/ValueSet/v3-ActMoodPredicate | |
Observation.referenceRange.observationRange.interpretationCode | required | ObservationInterpretationhttp://terminology.hl7.org/ValueSet/v3-ObservationInterpretation | |
Observation.referenceRange.observationRange.sdtcPrecondition1.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.referenceRange.observationRange.sdtcPrecondition1.typeCode | required | Fixed Value: PRCNhttp://terminology.hl7.org/ValueSet/v3-ActRelationshipType | |
Observation.referenceRange.observationRange.sdtcPrecondition1.conjunctionCode | required | RelationshipConjunctionhttp://terminology.hl7.org/ValueSet/v3-RelationshipConjunction|2.0.0 |
Id | Grade | Path(s) | Details | Requirements |
4537-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). : codeSystem = '2.16.840.1.113883.6.1' | |
4537-32610 | warning | Observation.value:coded | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). : codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.1' | |
shall-code-or-nullflavor | error | Observation.code | SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. : (code | nullFlavor).count() = 1 | |
should-author | warning | Observation | SHOULD contain author : author.exists() | |
should-interpretationCode | warning | Observation | SHOULD contain interpretationCode : interpretationCode.exists() | |
should-referenceRange | warning | Observation | SHOULD contain referenceRange : referenceRange.exists() | |
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 ResultObservation
Differential View
This structure is derived from ResultObservation
Path | Conformance | ValueSet | URI |
Observation.value:coded.code | required | AidToVisionCodeshttp://hl7.org/cda/us/eyecare/ValueSet/AidToVisionCodes from this IG |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 1..1 | ResultObservation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, value, value, interpretationCode, methodCode, targetSiteCode, author, referenceRange Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:result-obs | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
@extension | 1..1 | st | Required Pattern: 2023-05-01 | |
@classCode | 1..1 | cs | Binding: ActClassObservation (2.0.0) (required) Fixed Value: OBS | |
@moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
id | 1..* | II | ||
code | C | 1..1 | CD | (USCDI) Tests Binding: ObservationType (example) |
@code | 0..1 | cs | Required Pattern: 257192006 | |
@codeSystem | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.96 | |
@displayName | 0..1 | st | Required Pattern: Aid to vision | |
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
@code | 1..1 | cs | Binding: Result Status (required) | |
effectiveTime | 1..1 | IVL_TS | Represents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
Slices for value | 1..1 | (USCDI) Values/Results - Value can be any type, but certain types have additional rules. Slice: Unordered, Open by type:$this | ||
value | ANY | |||
value | BL | |||
value | ED | |||
value | ST | |||
value | CD | |||
value | CV | |||
value | CE | |||
value | CO | |||
value | SC | |||
value | II | |||
value | TEL | |||
value | AD | |||
value | EN | |||
value | INT | |||
value | REAL | |||
value | PQ | |||
value | MO | |||
value | TS | |||
value | IVL_PQ | |||
value | IVL_TS | |||
value | PIVL_TS | |||
value | EIVL_TS | |||
value | SXPR_TS | |||
value | RTO_PQ_PQ | |||
value:coded | C | 1..1 | CD | |
@code | 0..1 | cs | Binding: Aid to Vision Codes (required) | |
translation | 0..1 | CD | Can be used to represent the original results as output by the lab | |
methodCode | 0..1 | CE | Binding: ObservationMethod (example) | |
targetSiteCode | 0..1 | CD | ||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Observation.classCode | required | Fixed Value: OBShttp://terminology.hl7.org/ValueSet/v3-ActClassObservation|2.0.0 | |
Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
Observation.statusCode.code | required | Result Status http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39 | |
Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
Observation.value:coded.code | required | AidToVisionCodeshttp://hl7.org/cda/us/eyecare/ValueSet/AidToVisionCodes from this IG | |
Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod |
Id | Grade | Path(s) | Details | Requirements |
4537-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). : codeSystem = '2.16.840.1.113883.6.1' | |
4537-32610 | warning | Observation.value:coded | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). : codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.1' | |
shall-code-or-nullflavor | error | Observation.code | SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. : (code | nullFlavor).count() = 1 | |
should-author | warning | Observation | SHOULD contain author : author.exists() | |
should-interpretationCode | warning | Observation | SHOULD contain interpretationCode : interpretationCode.exists() | |
should-referenceRange | warning | Observation | SHOULD contain referenceRange : referenceRange.exists() | |
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 1..1 | ResultObservation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, value, value, interpretationCode, methodCode, targetSiteCode, author, referenceRange Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@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:result-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: 2.16.840.1.113883.10.20.22.4.2 | |
@extension | 1..1 | st | Required Pattern: 2023-05-01 | |
@classCode | 1..1 | cs | Binding: ActClassObservation (2.0.0) (required) Fixed Value: OBS | |
@moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
@negationInd | 0..1 | bl | ||
id | 1..* | II | ||
code | C | 1..1 | CD | (USCDI) Tests Binding: ObservationType (example) |
(Choice of one) | 1..1 | |||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 0..1 | cs | Required Pattern: 257192006 | |
@codeSystem | 0..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.96 | |
@codeSystemName | 0..1 | st | ||
@codeSystemVersion | 0..1 | st | ||
@displayName | 0..1 | st | Required Pattern: Aid to vision | |
@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: CompressionAlgorithm (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: Binary Data Encoding Value Set (required) | |
xmlText | 0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |
reference | C | 0..1 | TEL | |
thumbnail | 0..1 | ED | ||
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 1..1 | cs | Binding: Result Status (required) | |
@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 | Represents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
priorityCode | 0..1 | CE | Binding: ActPriority (example) | |
repeatNumber | 0..1 | IVL_INT | ||
languageCode | 0..1 | CS | Binding: AllLanguages (required) | |
Slices for value | 1..1 | (USCDI) Values/Results - Value can be any type, but certain types have additional rules. Slice: Unordered, Open by type:$this | ||
value | ANY | |||
value | BL | |||
value | ED | |||
value | ST | |||
value | CD | |||
value | CV | |||
value | CE | |||
value | CO | |||
value | SC | |||
value | II | |||
value | TEL | |||
value | AD | |||
value | EN | |||
value | INT | |||
value | REAL | |||
value | PQ | |||
value | MO | |||
value | TS | |||
value | IVL_PQ | |||
value | IVL_TS | |||
value | PIVL_TS | |||
value | EIVL_TS | |||
value | SXPR_TS | |||
value | RTO_PQ_PQ | |||
value:coded | C | 1..1 | CD | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
@code | 0..1 | cs | Binding: Aid to Vision Codes (required) | |
@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..1 | CD | Can be used to represent the original results as output by the lab | |
interpretationCode | 0..* | CE | (USCDI) Result Interpretation Binding: ObservationInterpretation (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 | Base for all types and resources | |
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 | (USCDI) Result Reference Range | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@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: ActRelationshipType (2.0.0) (required) Fixed Value: REFV | |
observationRange | 1..1 | ObservationRange | ||
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@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 | ||
@classCode | 1..1 | cs | Binding: ActClassObservation (required) | |
@moodCode | 0..1 | cs | Binding: ActMoodPredicate (required) Fixed Value: EVN.CRT | |
text | 0..1 | ED | ||
value | 1..1 | |||
value | BL | |||
value | ED | |||
value | ST | |||
value | CD | |||
value | CV | |||
value | CE | |||
value | CO | |||
value | SC | |||
value | II | |||
value | TEL | |||
value | AD | |||
value | EN | |||
value | INT | |||
value | REAL | |||
value | PQ | |||
value | MO | |||
value | TS | |||
value | IVL_PQ | |||
value | IVL_TS | |||
value | PIVL_TS | |||
value | EIVL_TS | |||
value | SXPR_TS | |||
interpretationCode | 0..1 | CE | Binding: ObservationInterpretation (required) | |
sdtcPrecondition1 | 0..* | InfrastructureRoot | XML Namespace: urn:hl7-org:sdtc XML: precondition1 (urn:hl7-org:sdtc) | |
@nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
@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: ActRelationshipType (required) Fixed Value: PRCN | |
conjunctionCode | 1..1 | CS | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc Binding: RelationshipConjunction (2.0.0) (required) | |
criterion1 | 1..1 | Criterion | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
sdtcInFulfillmentOf1 | 0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.templateId:result-obs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.classCode | required | Fixed Value: OBShttp://terminology.hl7.org/ValueSet/v3-ActClassObservation|2.0.0 | |
Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
Observation.code | example | ObservationTypehttp://terminology.hl7.org/ValueSet/v3-ObservationType | |
Observation.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
Observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
Observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
Observation.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.statusCode.code | required | Result Status http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39 | |
Observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Observation.value:physical-quantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
Observation.value:coded.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.value:coded.code | required | AidToVisionCodeshttp://hl7.org/cda/us/eyecare/ValueSet/AidToVisionCodes from this IG | |
Observation.interpretationCode | required | ObservationInterpretationhttp://terminology.hl7.org/ValueSet/v3-ObservationInterpretation | |
Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
Observation.referenceRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.referenceRange.typeCode | required | Fixed Value: REFVhttp://terminology.hl7.org/ValueSet/v3-ActRelationshipType|2.0.0 | |
Observation.referenceRange.observationRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.referenceRange.observationRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.referenceRange.observationRange.classCode | required | ActClassObservationhttp://terminology.hl7.org/ValueSet/v3-ActClassObservation | |
Observation.referenceRange.observationRange.moodCode | required | Fixed Value: EVN.CRThttp://terminology.hl7.org/ValueSet/v3-ActMoodPredicate | |
Observation.referenceRange.observationRange.interpretationCode | required | ObservationInterpretationhttp://terminology.hl7.org/ValueSet/v3-ObservationInterpretation | |
Observation.referenceRange.observationRange.sdtcPrecondition1.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Observation.referenceRange.observationRange.sdtcPrecondition1.typeCode | required | Fixed Value: PRCNhttp://terminology.hl7.org/ValueSet/v3-ActRelationshipType | |
Observation.referenceRange.observationRange.sdtcPrecondition1.conjunctionCode | required | RelationshipConjunctionhttp://terminology.hl7.org/ValueSet/v3-RelationshipConjunction|2.0.0 |
Id | Grade | Path(s) | Details | Requirements |
4537-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:4537-19212). : codeSystem = '2.16.840.1.113883.6.1' | |
4537-32610 | warning | Observation.value:coded | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT or LOINC (CONF:4537-32610). : codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.1' | |
shall-code-or-nullflavor | error | Observation.code | SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. : (code | nullFlavor).count() = 1 | |
should-author | warning | Observation | SHOULD contain author : author.exists() | |
should-interpretationCode | warning | Observation | SHOULD contain interpretationCode : interpretationCode.exists() | |
should-referenceRange | warning | Observation | SHOULD contain referenceRange : referenceRange.exists() | |
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 ResultObservation