Specialty Eyecare CDA Implementation Guide
0.1.0 - ci-build

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

Logical Model: DiagnosticAssessmentEyeTestObservation - Detailed Descriptions

Draft as of 2024-02-07

Definitions for the DiagnosticAssessmentEyeTestObservation logical model.

Guidance on how to interpret the contents of this table can be found here

0. Observation
Logical ContainerClinicalDocument (CDA Class)
ValidationInstances of this type are validated by templateId
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
2. Observation.code
4. Observation.code.code
BindingThe codes SHALL be taken from Diagnostic Assessment Eye Test Value Set
(required to http://hl7.org/cda/us/eyecare/ValueSet/DiagnosticAssessmentEyeTestCodes
6. Observation.value:physical-quantity
Slice Namephysical-quantity
Control1..?
8. Observation.value:coded
Slice Namecoded
Control0..0
10. Observation.methodCode
Must Supporttrue
12. Observation.methodCode.code
BindingThe codes SHALL be taken from Dry Eye Questionnaire Value Set
(required to http://hl7.org/cda/us/eyecare/ValueSet/DryEyeQuestionnaireCodes
14. Observation.targetSiteCode
Control1..?
Must Supporttrue
16. Observation.targetSiteCode.code
BindingThe codes SHALL be taken from Eyecare Target Site Codes
(required to http://hl7.org/cda/us/eyecare/ValueSet/EyecareTargetSiteCodes

Guidance on how to interpret the contents of this table can be found here

0. Observation
Definition

Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type.


Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Control10..1*
Is Modifierfalse
Logical ContainerClinicalDocument (CDA Class)
ValidationInstances of this type are validated by templateId
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
Invariantsshould-text-ref-value: SHOULD contain text/reference/@value (text.reference.value.exists())
should-interpretationCode: SHOULD contain interpretationCode (interpretationCode.exists())
should-author: SHOULD contain author (author.exists())
should-referenceRange: SHOULD contain referenceRange (referenceRange.exists())
2. Observation.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
SlicingThis element introduces a set of slices on Observation.templateId. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ root
  • value @ extension
4. Observation.templateId:result-obs
Slice Nameresult-obs
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
6. Observation.templateId:result-obs.root
Definition

A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.

Control1..1
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelRoot
Pattern Value2.16.840.1.113883.10.20.22.4.2
8. Observation.templateId:result-obs.extension
Definition

A character string as a unique identifier within the scope of the identifier root.

Control1..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExtension
Pattern Value2023-05-01
10. Observation.classCode
Comments

SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:4537-7130).

Control1..1
BindingThe codes SHALL be taken from ActClassObservation (2.0.0)
(required to http://terminology.hl7.org/ValueSet/v3-ActClassObservation|2.0.0
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueOBS
12. Observation.moodCode
Comments

SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:4537-7131).

Control1..1
BindingThe codes SHALL be taken from XActMoodDocumentObservation (2.0.0)
(required to http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueEVN
14. Observation.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

ShortLogical id of this artifact
Comments

SHALL contain at least one [1..*] id (CONF:4537-7137).


Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case.

Control10..*1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/IIid
Is Modifierfalse
16. Observation.code
Definition

Describes what was observed. Sometimes this is called the observation "name".

Short(USCDI) TestsType of observation (code / type)
Comments

SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4537-7133).


All code-value and, if present, component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.

Control1..1
This element is affected by the following invariants: obs-7
BindingFor example codes, see ObservationTypehttp://hl7.org/fhir/ValueSet/observation-codes
(example to http://terminology.hl7.org/ValueSet/v3-ObservationType
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CDCodeableConcept
Is Modifierfalse
XML FormatThe type of this property is determined using the xsi:typeattribute.
Requirements

Knowing what kind of observation is being made is essential to understanding the observation.

Alternate NamesName
Invariantsshall-code-or-nullflavor: SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. ((code | nullFlavor).count() = 1)
4537-19212: 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')
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. Observation.code.code
Definition

The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

Comments

Either code or nullFlavor MUST be present

Control0..1
BindingThe codes SHALL be taken from Diagnostic Assessment Eye Test Value Set
(required to http://hl7.org/cda/us/eyecare/ValueSet/DiagnosticAssessmentEyeTestCodes
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode
20. Observation.statusCode
Comments

SHALL contain exactly one [1..1] statusCode (CONF:4537-7134).

Control1..1
BindingThe codes SHALL be taken from ActStatus
(required to http://terminology.hl7.org/ValueSet/v3-ActStatus
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
22. Observation.statusCode.code
Definition

The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

Comments

This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Result Status urn:oid:2.16.840.1.113883.11.20.9.39 STATIC (CONF:4537-14849).

Control1..1
BindingThe codes SHALL be taken from Result Status
(required to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode
24. Observation.statusCode.codeSystem
Definition

Specifies the code system that defines the code.

Control0..0
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System
26. Observation.statusCode.codeSystemName
Definition

The common name of the coding system.

Control0..0
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System Name
28. Observation.statusCode.codeSystemVersion
Definition

If applicable, a version descriptor defined specifically for the given code system.

Control0..0
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System Version
30. Observation.statusCode.displayName
Definition

A name or title for the code, under which the sending system shows the code value to its users.

Control0..0
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelDisplay Name
32. Observation.statusCode.originalText
Definition

The text or phrase used as the basis for the coding.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
LabelOriginal Text
34. Observation.statusCode.qualifier
Definition

Specifies additional codes that increase the specificity of the the primary code.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CR
LabelQualifier
36. Observation.statusCode.translation
Definition

A set of other concept descriptors that translate this concept descriptor into other code systems.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
XML FormatThe type of this property is determined using the xsi:typeattribute.
LabelTranslation
38. Observation.effectiveTime
ShortRepresents 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).
Comments

SHALL contain exactly one [1..1] effectiveTime (CONF:4537-7140).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/IVL-TS
40. Observation.value
Short(USCDI) Values/Results - Value can be any type, but certain types have additional rules.
Control1..1
TypeChoice of: http://hl7.org/cda/stds/core/StructureDefinition/ANY, http://hl7.org/cda/stds/core/StructureDefinition/BL, http://hl7.org/cda/stds/core/StructureDefinition/ED, http://hl7.org/cda/stds/core/StructureDefinition/ST, http://hl7.org/cda/stds/core/StructureDefinition/CD, http://hl7.org/cda/stds/core/StructureDefinition/CV, http://hl7.org/cda/stds/core/StructureDefinition/CE, http://hl7.org/cda/stds/core/StructureDefinition/CO, http://hl7.org/cda/stds/core/StructureDefinition/SC, http://hl7.org/cda/stds/core/StructureDefinition/II, http://hl7.org/cda/stds/core/StructureDefinition/TEL, http://hl7.org/cda/stds/core/StructureDefinition/AD, http://hl7.org/cda/stds/core/StructureDefinition/EN, http://hl7.org/cda/stds/core/StructureDefinition/INT, http://hl7.org/cda/stds/core/StructureDefinition/REAL, http://hl7.org/cda/stds/core/StructureDefinition/PQ, http://hl7.org/cda/stds/core/StructureDefinition/MO, http://hl7.org/cda/stds/core/StructureDefinition/TS, http://hl7.org/cda/stds/core/StructureDefinition/IVL-PQ, http://hl7.org/cda/stds/core/StructureDefinition/IVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/PIVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/EIVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/SXPR-TS, http://hl7.org/cda/stds/core/StructureDefinition/RTO-PQ-PQ
XML FormatThe type of this property is determined using the xsi:typeattribute.
SlicingThis element introduces a set of slices on Observation.value. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • type @ $this
42. Observation.value:physical-quantity
Slice Namephysical-quantity
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/PQ
XML FormatThe type of this property is determined using the xsi:typeattribute.
44. Observation.value:physical-quantity.unit
Definition

The unit of measure specified in the Unified Code for Units of Measure (UCUM) [].

Short(USCDI) Result Unit of Measure
Control1..1
BindingThe codes SHOULD be taken from UnitsOfMeasureCaseSensitive
(preferred to http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelUnit of Measure
Default Value1
46. Observation.value:physical-quantity.translation
Definition

An alternative representation of the same physical quantity expressed in a different unit, of a different unit code system and possibly with a different value.

ShortCan be used to represent the original results as output by the lab
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/PQR
LabelTranslation
48. Observation.value:coded
Slice Namecoded
Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
XML FormatThe type of this property is determined using the xsi:typeattribute.
Invariants4537-32610: 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')
51. Observation.methodCode
Comments

MAY contain zero or one [0..1] methodCode (CONF:4537-7148).

Control0..1
BindingFor example codes, see ObservationMethod
(example to http://terminology.hl7.org/ValueSet/v3-ObservationMethod
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
Must Supporttrue
53. Observation.methodCode.code
Definition

The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

Control0..1
BindingThe codes SHALL be taken from Dry Eye Questionnaire Value Set
(required to http://hl7.org/cda/us/eyecare/ValueSet/DryEyeQuestionnaireCodes
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode
55. Observation.methodCode.qualifier
Definition

Specifies additional codes that increase the specificity of the the primary code.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CR
LabelQualifier
57. Observation.targetSiteCode
Definition

Drawn from concept domain ActSite

Comments

MAY contain zero or one [0..1] targetSiteCode (CONF:4537-7153).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
Must Supporttrue
59. Observation.targetSiteCode.code
Definition

The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

Control0..1
BindingThe codes SHALL be taken from Eyecare Target Site Codes
(required to http://hl7.org/cda/us/eyecare/ValueSet/EyecareTargetSiteCodes
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode

Guidance on how to interpret the contents of this table can be found here

0. Observation
Definition

Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type.

ShortBase for all types and resources
Control1..1
Is Modifierfalse
Logical ContainerClinicalDocument (CDA Class)
ValidationInstances of this type are validated by templateId
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
Invariantsshould-text-ref-value: SHOULD contain text/reference/@value (text.reference.value.exists())
should-interpretationCode: SHOULD contain interpretationCode (interpretationCode.exists())
should-author: SHOULD contain author (author.exists())
should-referenceRange: SHOULD contain referenceRange (referenceRange.exists())
2. Observation.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from CDANullFlavor
(required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
4. Observation.realmCode
Definition

When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
6. Observation.typeId
Definition

When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
8. Observation.typeId.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from CDANullFlavor
(required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
10. Observation.typeId.assigningAuthorityName
Definition

A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelAssigning Authority Name
12. Observation.typeId.displayable
Definition

Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

Control0..1
Typeboolean(bl: Boolean)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelDisplayable
14. Observation.typeId.root
Definition

Identifies the type as an HL7 Registered model

Control1..1
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelRoot
Fixed Value2.16.840.1.113883.1.3
16. Observation.typeId.extension
Definition

A character string as a unique identifier within the scope of the identifier root.

Control1..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExtension
18. Observation.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
SlicingThis element introduces a set of slices on Observation.templateId. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ root
  • value @ extension
20. Observation.templateId:result-obs
Slice Nameresult-obs
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
22. Observation.templateId:result-obs.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from CDANullFlavor
(required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
24. Observation.templateId:result-obs.assigningAuthorityName
Definition

A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelAssigning Authority Name
26. Observation.templateId:result-obs.displayable
Definition

Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

Control0..1
Typeboolean(bl: Boolean)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelDisplayable
28. Observation.templateId:result-obs.root
Definition

A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.

Control1..1
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelRoot
Pattern Value2.16.840.1.113883.10.20.22.4.2
30. Observation.templateId:result-obs.extension
Definition

A character string as a unique identifier within the scope of the identifier root.

Control1..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExtension
Pattern Value2023-05-01
32. Observation.classCode
Comments

SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:4537-7130).

Control1..1
BindingThe codes SHALL be taken from ActClassObservation (2.0.0)
(required to http://terminology.hl7.org/ValueSet/v3-ActClassObservation|2.0.0
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueOBS
34. Observation.moodCode
Comments

SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:4537-7131).

Control1..1
BindingThe codes SHALL be taken from XActMoodDocumentObservation (2.0.0)
(required to http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueEVN
36. Observation.negationInd
Control0..1
Typeboolean(bl: Boolean)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
38. Observation.id
Comments

SHALL contain at least one [1..*] id (CONF:4537-7137).

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
40. Observation.code
Short(USCDI) Tests
Comments

SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4537-7133).

Control1..1
BindingFor example codes, see ObservationType
(example to http://terminology.hl7.org/ValueSet/v3-ObservationType
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
XML FormatThe type of this property is determined using the xsi:typeattribute.
Invariantsshall-code-or-nullflavor: SHALL contain either a @code attribute or a @nullFlavor attribute, but not both. ((code | nullFlavor).count() = 1)
4537-19212: 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')
42. Observation.code.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Comments

Either code or nullFlavor MUST be present

Control0..1
BindingThe codes SHALL be taken from CDANullFlavor
(required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
44. Observation.code.code
Definition

The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

Comments

Either code or nullFlavor MUST be present

Control0..1
BindingThe codes SHALL be taken from Diagnostic Assessment Eye Test Value Set
(required to http://hl7.org/cda/us/eyecare/ValueSet/DiagnosticAssessmentEyeTestCodes
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode
46. Observation.code.codeSystem
Definition

Specifies the code system that defines the code.

Control0..1
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System
48. Observation.code.codeSystemName
Definition

The common name of the coding system.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System Name
50. Observation.code.codeSystemVersion
Definition

If applicable, a version descriptor defined specifically for the given code system.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System Version
52. Observation.code.displayName
Definition

A name or title for the code, under which the sending system shows the code value to its users.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelDisplay Name
54. Observation.code.sdtcValueSet
Definition

The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.

Control0..1
Typestring(oid: ISO Object Identifier)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSet.
56. Observation.code.sdtcValueSetVersion
Definition

The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSetVersion.
58. Observation.code.originalText
Definition

The text or phrase used as the basis for the coding.

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
LabelOriginal Text
60. Observation.code.qualifier
Definition

Specifies additional codes that increase the specificity of the the primary code.

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CR
LabelQualifier
62. Observation.code.translation
Definition

A set of other concept descriptors that translate this concept descriptor into other code systems.

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
XML FormatThe type of this property is determined using the xsi:typeattribute.
LabelTranslation
64. Observation.derivationExpr
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ST
66. Observation.text
ShortSHOULD reference the portion of section narrative text corresponding to this entry
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
XML FormatThe type of this property is determined using the xsi:typeattribute.
68. Observation.text.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from CDANullFlavor
(required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
70. Observation.text.compression
Definition

Indicates whether the raw byte data is compressed, and what compression algorithm was used.

Control0..1
BindingThe codes SHALL be taken from CompressionAlgorithm
(required to http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCompression
72. Observation.text.integrityCheck
Definition

The integrity check is a short binary value representing a cryptographically strong checksum that is calculated over the binary data. The purpose of this property, when communicated with a reference is for anyone to validate later whether the reference still resolved to the same data that the reference resolved to when the encapsulated data value with reference was created.

Control0..1
Typebase64Binary(bin: Binary Data)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelIntegrity Check
74. Observation.text.integrityCheckAlgorithm
Definition

Specifies the algorithm used to compute the integrityCheck value. The cryptographically strong checksum algorithm Secure Hash Algorithm-1 (SHA-1) is currently the industry standard. It has superseded the MD5 algorithm only a couple of years ago, when certain flaws in the security of MD5 were discovered. Currently the SHA-1 hash algorithm is the default choice for the integrity check algorithm. Note that SHA-256 is also entering widespread usage.

Control0..1
BindingThe codes SHALL be taken from IntegrityCheckAlgorithm (2.0.0)
(required to http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelIntegrity Check Algorithm
76. Observation.text.language
Definition

For character based information the language property specifies the human language of the text.

Control0..1
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelLanguage
78. Observation.text.mediaType
Definition

Identifies the type of the encapsulated data and identifies a method to interpret or render the data.

Control0..1
BindingFor example codes, see MediaType
(example to http://terminology.hl7.org/ValueSet/v3-MediaType
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelMedia Type
80. Observation.text.representation
Control0..1
BindingThe codes SHALL be taken from Binary Data Encoding Value Set
(required to http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
82. Observation.text.xmlText
Definition

Data that is primarily intended for human interpretation or for further machine processing is outside the scope of HL7. This includes unformatted or formatted written language, multimedia data, or structured information as defined by a different standard (e.g., XML-signatures.)

ShortAllows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
Comments

This element is represented in XML as textual content. The actual name "xmlText" will not appear in a CDA instance.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as unadorned text.
84. Observation.text.reference
Definition

A telecommunication address (TEL), such as a URL for HTTP or FTP, which will resolve to precisely the same binary data that could as well have been provided as inline data.

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/TEL
LabelReference
Invariantsvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative (value.exists() implies value.startsWith('#'))
86. Observation.text.thumbnail
Definition

An abbreviated rendition of the full data. A thumbnail requires significantly fewer resources than the full data, while still maintaining some distinctive similarity with the full data. A thumbnail is typically used with by-reference encapsulated data. It allows a user to select data more efficiently before actually downloading through the reference.

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
LabelThumbnail
88. Observation.statusCode
Comments

SHALL contain exactly one [1..1] statusCode (CONF:4537-7134).

Control1..1
BindingThe codes SHALL be taken from ActStatus
(required to http://terminology.hl7.org/ValueSet/v3-ActStatus
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
90. Observation.statusCode.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from CDANullFlavor
(required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
92. Observation.statusCode.code
Definition

The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

Comments

This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Result Status urn:oid:2.16.840.1.113883.11.20.9.39 STATIC (CONF:4537-14849).

Control1..1
BindingThe codes SHALL be taken from Result Status
(required to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.39
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode
94. Observation.statusCode.codeSystem
Definition

Specifies the code system that defines the code.

Control0..0
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System
96. Observation.statusCode.codeSystemName
Definition

The common name of the coding system.

Control0..0
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System Name
98. Observation.statusCode.codeSystemVersion
Definition

If applicable, a version descriptor defined specifically for the given code system.

Control0..0
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System Version
100. Observation.statusCode.displayName
Definition

A name or title for the code, under which the sending system shows the code value to its users.

Control0..0
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelDisplay Name
102. Observation.statusCode.sdtcValueSet
Definition

The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.

Control0..1
Typestring(oid: ISO Object Identifier)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSet.
104. Observation.statusCode.sdtcValueSetVersion
Definition

The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSetVersion.
106. Observation.statusCode.originalText
Definition

The text or phrase used as the basis for the coding.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
LabelOriginal Text
108. Observation.statusCode.qualifier
Definition

Specifies additional codes that increase the specificity of the the primary code.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CR
LabelQualifier
110. Observation.statusCode.translation
Definition

A set of other concept descriptors that translate this concept descriptor into other code systems.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
XML FormatThe type of this property is determined using the xsi:typeattribute.
LabelTranslation
112. Observation.effectiveTime
ShortRepresents 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).
Comments

SHALL contain exactly one [1..1] effectiveTime (CONF:4537-7140).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/IVL-TS
114. Observation.priorityCode
Control0..1
BindingFor example codes, see ActPriority
(example to http://terminology.hl7.org/ValueSet/v3-ActPriority
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
116. Observation.repeatNumber
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/IVL-INT
118. Observation.languageCode
Control0..1
BindingThe codes SHALL be taken from AllLanguages
(required to http://hl7.org/fhir/ValueSet/all-languages
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
120. Observation.value
Short(USCDI) Values/Results - Value can be any type, but certain types have additional rules.
Control1..1
TypeChoice of: http://hl7.org/cda/stds/core/StructureDefinition/ANY, http://hl7.org/cda/stds/core/StructureDefinition/BL, http://hl7.org/cda/stds/core/StructureDefinition/ED, http://hl7.org/cda/stds/core/StructureDefinition/ST, http://hl7.org/cda/stds/core/StructureDefinition/CD, http://hl7.org/cda/stds/core/StructureDefinition/CV, http://hl7.org/cda/stds/core/StructureDefinition/CE, http://hl7.org/cda/stds/core/StructureDefinition/CO, http://hl7.org/cda/stds/core/StructureDefinition/SC, http://hl7.org/cda/stds/core/StructureDefinition/II, http://hl7.org/cda/stds/core/StructureDefinition/TEL, http://hl7.org/cda/stds/core/StructureDefinition/AD, http://hl7.org/cda/stds/core/StructureDefinition/EN, http://hl7.org/cda/stds/core/StructureDefinition/INT, http://hl7.org/cda/stds/core/StructureDefinition/REAL, http://hl7.org/cda/stds/core/StructureDefinition/PQ, http://hl7.org/cda/stds/core/StructureDefinition/MO, http://hl7.org/cda/stds/core/StructureDefinition/TS, http://hl7.org/cda/stds/core/StructureDefinition/IVL-PQ, http://hl7.org/cda/stds/core/StructureDefinition/IVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/PIVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/EIVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/SXPR-TS, http://hl7.org/cda/stds/core/StructureDefinition/RTO-PQ-PQ
XML FormatThe type of this property is determined using the xsi:typeattribute.
SlicingThis element introduces a set of slices on Observation.value. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • type @ $this
122. Observation.value:physical-quantity
Slice Namephysical-quantity
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/PQ
XML FormatThe type of this property is determined using the xsi:typeattribute.
124. Observation.value:physical-quantity.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from CDANullFlavor
(required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
126. Observation.value:physical-quantity.unit
Definition

The unit of measure specified in the Unified Code for Units of Measure (UCUM) [].

Short(USCDI) Result Unit of Measure
Control1..1
BindingThe codes SHOULD be taken from UnitsOfMeasureCaseSensitive
(preferred to http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelUnit of Measure
Default Value1
128. Observation.value:physical-quantity.value
Definition

The magnitude of the quantity measured in terms of the unit.

Control0..1
Typedecimal(real: Real Number)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelMaginitude Value
130. Observation.value:physical-quantity.translation
Definition

An alternative representation of the same physical quantity expressed in a different unit, of a different unit code system and possibly with a different value.

ShortCan be used to represent the original results as output by the lab
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/PQR
LabelTranslation
132. Observation.value:coded
Slice Namecoded
Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
XML FormatThe type of this property is determined using the xsi:typeattribute.
Invariants4537-32610: 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')
145. Observation.interpretationCode
Short(USCDI) Result Interpretation
Comments

SHOULD contain zero or more [0..*] interpretationCode, which SHALL be selected from ValueSet Observation Interpretation (HL7) urn:oid:2.16.840.1.113883.1.11.78 DYNAMIC (CONF:4537-7147).

Control0..*
BindingThe codes SHALL be taken from ObservationInterpretation
(required to http://terminology.hl7.org/ValueSet/v3-ObservationInterpretation
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
147. Observation.methodCode
Comments

MAY contain zero or one [0..1] methodCode (CONF:4537-7148).

Control0..1
BindingFor example codes, see ObservationMethod
(example to http://terminology.hl7.org/ValueSet/v3-ObservationMethod
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
Must Supporttrue
149. Observation.methodCode.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from CDANullFlavor
(required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
151. Observation.methodCode.code
Definition

The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

Control0..1
BindingThe codes SHALL be taken from Dry Eye Questionnaire Value Set
(required to http://hl7.org/cda/us/eyecare/ValueSet/DryEyeQuestionnaireCodes
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode
153. Observation.methodCode.codeSystem
Definition

Specifies the code system that defines the code.

Control0..1
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System
155. Observation.methodCode.codeSystemName
Definition

The common name of the coding system.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System Name
157. Observation.methodCode.codeSystemVersion
Definition

If applicable, a version descriptor defined specifically for the given code system.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System Version
159. Observation.methodCode.displayName
Definition

A name or title for the code, under which the sending system shows the code value to its users.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelDisplay Name
161. Observation.methodCode.sdtcValueSet
Definition

The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.

Control0..1
Typestring(oid: ISO Object Identifier)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSet.
163. Observation.methodCode.sdtcValueSetVersion
Definition

The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSetVersion.
165. Observation.methodCode.originalText
Definition

The text or phrase used as the basis for the coding.

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
LabelOriginal Text
167. Observation.methodCode.qualifier
Definition

Specifies additional codes that increase the specificity of the the primary code.

Control0..0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CR
LabelQualifier
169. Observation.methodCode.translation
Definition

A set of other concept descriptors that translate this concept descriptor into other code systems.

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
XML FormatThe type of this property is determined using the xsi:typeattribute.
LabelTranslation
171. Observation.targetSiteCode
Definition

Drawn from concept domain ActSite

Comments

MAY contain zero or one [0..1] targetSiteCode (CONF:4537-7153).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
Must Supporttrue
173. Observation.targetSiteCode.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from CDANullFlavor
(required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
175. Observation.targetSiteCode.code
Definition

The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

Control0..1
BindingThe codes SHALL be taken from Eyecare Target Site Codes
(required to http://hl7.org/cda/us/eyecare/ValueSet/EyecareTargetSiteCodes
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode
177. Observation.targetSiteCode.codeSystem
Definition

Specifies the code system that defines the code.

Control0..1
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System
179. Observation.targetSiteCode.codeSystemName
Definition

The common name of the coding system.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System Name
181. Observation.targetSiteCode.codeSystemVersion
Definition

If applicable, a version descriptor defined specifically for the given code system.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelCode System Version
183. Observation.targetSiteCode.displayName
Definition

A name or title for the code, under which the sending system shows the code value to its users.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelDisplay Name
185. Observation.targetSiteCode.sdtcValueSet
Definition

The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.

Control0..1
Typestring(oid: ISO Object Identifier)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSet.
187. Observation.targetSiteCode.sdtcValueSetVersion
Definition

The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSetVersion.
189. Observation.targetSiteCode.originalText
Definition

The text or phrase used as the basis for the coding.

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
LabelOriginal Text
191. Observation.targetSiteCode.qualifier
Definition

Specifies additional codes that increase the specificity of the the primary code.

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CR
LabelQualifier
193. Observation.targetSiteCode.translation
Definition

A set of other concept descriptors that translate this concept descriptor into other code systems.

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
XML FormatThe type of this property is determined using the xsi:typeattribute.
LabelTranslation
195. Observation.subject
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Subject
197. Observation.specimen
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Specimen
199. Observation.performer
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Performer2
201. Observation.author
Definition

Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type.

ShortBase for all types and resources
Comments

SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:4537-7149).

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Author(Author Participation)
Is Modifierfalse
203. Observation.informant
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Informant
205. Observation.participant
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Participant2
207. Observation.entryRelationship
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/EntryRelationship
209. Observation.reference
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Reference
211. Observation.precondition
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Precondition
213. Observation.sdtcPrecondition2
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Precondition2
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual nameprecondition2.
215. Observation.referenceRange
Definition

Relates an Observation to the ObservationRange class, where the expected range of values for a particular observation can be specified.

Short(USCDI) Result Reference Range
Comments

SHOULD contain zero or more [0..*] referenceRange (CONF:4537-7150).

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
217. Observation.referenceRange.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from CDANullFlavor
(required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
219. Observation.referenceRange.realmCode
Definition

When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
221. Observation.referenceRange.typeId
Definition

When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
223. Observation.referenceRange.typeId.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from CDANullFlavor
(required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
225. Observation.referenceRange.typeId.assigningAuthorityName
Definition

A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelAssigning Authority Name
227. Observation.referenceRange.typeId.displayable
Definition

Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

Control0..1
Typeboolean(bl: Boolean)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelDisplayable
229. Observation.referenceRange.typeId.root
Definition

Identifies the type as an HL7 Registered model

Control1..1
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelRoot
Fixed Value2.16.840.1.113883.1.3
231. Observation.referenceRange.typeId.extension
Definition

A character string as a unique identifier within the scope of the identifier root.

Control1..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExtension
233. Observation.referenceRange.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
235. Observation.referenceRange.typeCode
Control0..1
BindingThe codes SHALL be taken from ActRelationshipType (2.0.0)
(required to http://terminology.hl7.org/ValueSet/v3-ActRelationshipType|2.0.0
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueREFV
237. Observation.referenceRange.observationRange
Comments

The referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:4537-7151).

Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ObservationRange
239. Observation.referenceRange.observationRange.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from CDANullFlavor
(required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
241. Observation.referenceRange.observationRange.realmCode
Definition

When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
243. Observation.referenceRange.observationRange.typeId
Definition

When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
245. Observation.referenceRange.observationRange.typeId.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from CDANullFlavor
(required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
247. Observation.referenceRange.observationRange.typeId.assigningAuthorityName
Definition

A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelAssigning Authority Name
249. Observation.referenceRange.observationRange.typeId.displayable
Definition

Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

Control0..1
Typeboolean(bl: Boolean)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelDisplayable
251. Observation.referenceRange.observationRange.typeId.root
Definition

Identifies the type as an HL7 Registered model

Control1..1
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelRoot
Fixed Value2.16.840.1.113883.1.3
253. Observation.referenceRange.observationRange.typeId.extension
Definition

A character string as a unique identifier within the scope of the identifier root.

Control1..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExtension
255. Observation.referenceRange.observationRange.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
257. Observation.referenceRange.observationRange.classCode
Control1..1
BindingThe codes SHALL be taken from ActClassObservation
(required to http://terminology.hl7.org/ValueSet/v3-ActClassObservation
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Default ValueOBS
259. Observation.referenceRange.observationRange.moodCode
Control0..1
BindingThe codes SHALL be taken from ActMoodPredicate
(required to http://terminology.hl7.org/ValueSet/v3-ActMoodPredicate
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValueEVN.CRT
261. Observation.referenceRange.observationRange.code
Comments

This observationRange SHALL NOT contain [0..0] code (CONF:4537-7152).

Control0..0
BindingFor example codes, see v3 Code System ActCode
(example to http://terminology.hl7.org/ValueSet/v3-ActCode
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
263. Observation.referenceRange.observationRange.text
Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
265. Observation.referenceRange.observationRange.value
Comments

This observationRange SHALL contain exactly one [1..1] value (CONF:4537-32175).

Control1..1
TypeChoice of: http://hl7.org/cda/stds/core/StructureDefinition/BL, http://hl7.org/cda/stds/core/StructureDefinition/ED, http://hl7.org/cda/stds/core/StructureDefinition/ST, http://hl7.org/cda/stds/core/StructureDefinition/CD, http://hl7.org/cda/stds/core/StructureDefinition/CV, http://hl7.org/cda/stds/core/StructureDefinition/CE, http://hl7.org/cda/stds/core/StructureDefinition/CO, http://hl7.org/cda/stds/core/StructureDefinition/SC, http://hl7.org/cda/stds/core/StructureDefinition/II, http://hl7.org/cda/stds/core/StructureDefinition/TEL, http://hl7.org/cda/stds/core/StructureDefinition/AD, http://hl7.org/cda/stds/core/StructureDefinition/EN, http://hl7.org/cda/stds/core/StructureDefinition/INT, http://hl7.org/cda/stds/core/StructureDefinition/REAL, http://hl7.org/cda/stds/core/StructureDefinition/PQ, http://hl7.org/cda/stds/core/StructureDefinition/MO, http://hl7.org/cda/stds/core/StructureDefinition/TS, http://hl7.org/cda/stds/core/StructureDefinition/IVL-PQ, http://hl7.org/cda/stds/core/StructureDefinition/IVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/PIVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/EIVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/SXPR-TS
XML FormatThe type of this property is determined using the xsi:typeattribute.
267. Observation.referenceRange.observationRange.interpretationCode
Control0..1
BindingThe codes SHALL be taken from ObservationInterpretation
(required to http://terminology.hl7.org/ValueSet/v3-ObservationInterpretation
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
269. Observation.referenceRange.observationRange.sdtcPrecondition1
Definition

The sdtc:precondition1 extension allows for the association of a criterion with a reference range (ObservationRange), which allows the expression in a lab report that a reference range is conditional on some criterion such as patient sex or age (or a combination of criterion).

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual nameprecondition1.
271. Observation.referenceRange.observationRange.sdtcPrecondition1.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from CDANullFlavor
(required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
273. Observation.referenceRange.observationRange.sdtcPrecondition1.realmCode
Definition

When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
275. Observation.referenceRange.observationRange.sdtcPrecondition1.typeId
Definition

When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
277. Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from CDANullFlavor
(required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
279. Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.assigningAuthorityName
Definition

A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelAssigning Authority Name
281. Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.displayable
Definition

Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

Control0..1
Typeboolean(bl: Boolean)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelDisplayable
283. Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.root
Definition

Identifies the type as an HL7 Registered model

Control1..1
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelRoot
Fixed Value2.16.840.1.113883.1.3
285. Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.extension
Definition

A character string as a unique identifier within the scope of the identifier root.

Control1..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExtension
287. Observation.referenceRange.observationRange.sdtcPrecondition1.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
289. Observation.referenceRange.observationRange.sdtcPrecondition1.typeCode
Control0..1
BindingThe codes SHALL be taken from ActRelationshipType
(required to http://terminology.hl7.org/ValueSet/v3-ActRelationshipType
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
Fixed ValuePRCN
291. Observation.referenceRange.observationRange.sdtcPrecondition1.conjunctionCode
Definition

A code specifying the logical conjunction of the criteria among all the condition-links of Acts (e.g., and, or, exclusive-or). All AND criteria must be true. If OR and AND criteria occur together, one criterion out of the OR-group must be true and all AND criteria must be true also. If XOR criteria occur together with OR and AND criteria, exactly one of the XOR criteria must be true, and at least one of the OR criteria and all AND criteria must be true. In other words, the sets of AND, OR, and XOR criteria are in turn combined by a logical AND operator (all AND criteria and at least one OR criterion and exactly one XOR criterion).

Control1..1
BindingThe codes SHALL be taken from RelationshipConjunction (2.0.0)
(required to http://terminology.hl7.org/ValueSet/v3-RelationshipConjunction|2.0.0
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.
293. Observation.referenceRange.observationRange.sdtcPrecondition1.criterion1
Control1..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/Criterion
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.
295. Observation.sdtcInFulfillmentOf1
Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/InFulfillmentOf1
XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual nameinFulfillmentOf1.