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

• Content
• Detailed Descriptions
• Mappings
• XML
• JSON

Logical Model: VisualAcuityTestUnitObservation

An observation that conveys the units of the Visual Acuity test since we can not use a PQ since the acuity result is not a number.

Usage:

• Use this Logical Model: VisualAcuityObservation

Formal Views of Profile Content

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

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from ResultObservation

Name	Flags	Card.	Type	Description & Constraints
Observation			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 Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class)
code
@code		0..1	cs	Required Pattern: 246514001
@codeSystem		0..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.6.96
@displayName		0..1	st	Required Pattern: units
value:physical-quantity		0..0
value:coded		1..1	CD
@codeSystem		0..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.6.8
Documentation for this format

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: 246514001
@codeSystem		0..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.6.96
@displayName		0..1	st	Required Pattern: units
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
@codeSystem		0..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.6.8
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

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Observation.classCode	required	Fixed Value: OBS http://terminology.hl7.org/ValueSet/v3-ActClassObservation|2.0.0
Observation.moodCode	required	Fixed Value: EVN http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Observation.code	example	ObservationType http://terminology.hl7.org/ValueSet/v3-ObservationType
Observation.statusCode	required	ActStatus http://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 from https://vsac.nlm.nih.gov
Observation.value:physical-quantity.unit	preferred	UnitsOfMeasureCaseSensitive (a valid code from UCUM) http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive
Observation.methodCode	example	ObservationMethod http://terminology.hl7.org/ValueSet/v3-ObservationMethod

Constraints

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: 246514001
@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: units
@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
@codeSystem		0..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.6.8
@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

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Observation.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.templateId:result-obs.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.classCode	required	Fixed Value: OBS http://terminology.hl7.org/ValueSet/v3-ActClassObservation|2.0.0
Observation.moodCode	required	Fixed Value: EVN http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Observation.code	example	ObservationType http://terminology.hl7.org/ValueSet/v3-ObservationType
Observation.code.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.text.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.text.compression	required	CDACompressionAlgorithm http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Observation.text.integrityCheckAlgorithm	required	IntegrityCheckAlgorithm http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Observation.text.mediaType	example	MediaType http://terminology.hl7.org/ValueSet/v3-MediaType
Observation.text.representation	required	BinaryDataEncoding http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Observation.statusCode	required	ActStatus http://terminology.hl7.org/ValueSet/v3-ActStatus
Observation.statusCode.nullFlavor	required	CDANullFlavor http://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 from https://vsac.nlm.nih.gov
Observation.priorityCode	example	ActPriority http://terminology.hl7.org/ValueSet/v3-ActPriority
Observation.languageCode	required	AllLanguages http://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard
Observation.value:physical-quantity.nullFlavor	required	CDANullFlavor http://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	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.interpretationCode	required	ObservationInterpretation http://terminology.hl7.org/ValueSet/v3-ObservationInterpretation
Observation.methodCode	example	ObservationMethod http://terminology.hl7.org/ValueSet/v3-ObservationMethod
Observation.referenceRange.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.typeCode	required	Fixed Value: REFV http://terminology.hl7.org/ValueSet/v3-ActRelationshipType|2.0.0
Observation.referenceRange.observationRange.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.classCode	required	ActClassObservation http://terminology.hl7.org/ValueSet/v3-ActClassObservation
Observation.referenceRange.observationRange.moodCode	required	Fixed Value: EVN.CRT http://terminology.hl7.org/ValueSet/v3-ActMoodPredicate
Observation.referenceRange.observationRange.interpretationCode	required	ObservationInterpretation http://terminology.hl7.org/ValueSet/v3-ObservationInterpretation
Observation.referenceRange.observationRange.sdtcPrecondition1.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.sdtcPrecondition1.typeCode	required	Fixed Value: PRCN http://terminology.hl7.org/ValueSet/v3-ActRelationshipType
Observation.referenceRange.observationRange.sdtcPrecondition1.conjunctionCode	required	RelationshipConjunction http://terminology.hl7.org/ValueSet/v3-RelationshipConjunction|2.0.0

Constraints

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

Summary

Mandatory: 1 element
Prohibited: 1 element

Differential View

This structure is derived from ResultObservation

Name	Flags	Card.	Type	Description & Constraints
Observation			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 Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class)
code
@code		0..1	cs	Required Pattern: 246514001
@codeSystem		0..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.6.96
@displayName		0..1	st	Required Pattern: units
value:physical-quantity		0..0
value:coded		1..1	CD
@codeSystem		0..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.6.8
Documentation for this format

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: 246514001
@codeSystem		0..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.6.96
@displayName		0..1	st	Required Pattern: units
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
@codeSystem		0..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.6.8
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

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Observation.classCode	required	Fixed Value: OBS http://terminology.hl7.org/ValueSet/v3-ActClassObservation|2.0.0
Observation.moodCode	required	Fixed Value: EVN http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Observation.code	example	ObservationType http://terminology.hl7.org/ValueSet/v3-ObservationType
Observation.statusCode	required	ActStatus http://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 from https://vsac.nlm.nih.gov
Observation.value:physical-quantity.unit	preferred	UnitsOfMeasureCaseSensitive (a valid code from UCUM) http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive
Observation.methodCode	example	ObservationMethod http://terminology.hl7.org/ValueSet/v3-ObservationMethod

Constraints

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: 246514001
@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: units
@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
@codeSystem		0..1	oid, uuid, ruid	Required Pattern: 2.16.840.1.113883.6.8
@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

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Observation.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.templateId:result-obs.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.classCode	required	Fixed Value: OBS http://terminology.hl7.org/ValueSet/v3-ActClassObservation|2.0.0
Observation.moodCode	required	Fixed Value: EVN http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Observation.code	example	ObservationType http://terminology.hl7.org/ValueSet/v3-ObservationType
Observation.code.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.text.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.text.compression	required	CDACompressionAlgorithm http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Observation.text.integrityCheckAlgorithm	required	IntegrityCheckAlgorithm http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Observation.text.mediaType	example	MediaType http://terminology.hl7.org/ValueSet/v3-MediaType
Observation.text.representation	required	BinaryDataEncoding http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Observation.statusCode	required	ActStatus http://terminology.hl7.org/ValueSet/v3-ActStatus
Observation.statusCode.nullFlavor	required	CDANullFlavor http://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 from https://vsac.nlm.nih.gov
Observation.priorityCode	example	ActPriority http://terminology.hl7.org/ValueSet/v3-ActPriority
Observation.languageCode	required	AllLanguages http://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard
Observation.value:physical-quantity.nullFlavor	required	CDANullFlavor http://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	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.interpretationCode	required	ObservationInterpretation http://terminology.hl7.org/ValueSet/v3-ObservationInterpretation
Observation.methodCode	example	ObservationMethod http://terminology.hl7.org/ValueSet/v3-ObservationMethod
Observation.referenceRange.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.typeCode	required	Fixed Value: REFV http://terminology.hl7.org/ValueSet/v3-ActRelationshipType|2.0.0
Observation.referenceRange.observationRange.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.classCode	required	ActClassObservation http://terminology.hl7.org/ValueSet/v3-ActClassObservation
Observation.referenceRange.observationRange.moodCode	required	Fixed Value: EVN.CRT http://terminology.hl7.org/ValueSet/v3-ActMoodPredicate
Observation.referenceRange.observationRange.interpretationCode	required	ObservationInterpretation http://terminology.hl7.org/ValueSet/v3-ObservationInterpretation
Observation.referenceRange.observationRange.sdtcPrecondition1.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.sdtcPrecondition1.typeCode	required	Fixed Value: PRCN http://terminology.hl7.org/ValueSet/v3-ActRelationshipType
Observation.referenceRange.observationRange.sdtcPrecondition1.conjunctionCode	required	RelationshipConjunction http://terminology.hl7.org/ValueSet/v3-RelationshipConjunction|2.0.0

Constraints

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

Summary

Mandatory: 1 element
Prohibited: 1 element

Other representations of profile: CSV, Excel