Paramedicine Summary Of Care CDA
0.0.1-current - ci-build
Paramedicine Summary Of Care CDA
0.0.1-current - ci-build
Paramedicine Summary Of Care CDA, published by IHE Patient Care Coordination Technical Committee. This guide is not an authorized publication; it is the continuous build for version 0.0.1-current built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IHE/PCC.PCSc/ and changes regularly. See the Directory of published versions
| Official URL: https://profiles.ihe.net/PCC/PSCc/StructureDefinition/IHE.Allergies.And.Intolerances.Entry | Version: 0.0.1-current | |||
| Draft as of 2025-11-04 | Computable Name: IHE_Allergies_And_Intolerances_Entry | |||
Allergies and intolerances are special kinds of problems, and so are also recorded in the CDA
TBD Still needs to be finished building Troubleshooting for comment needs to be done
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  Observation |
C | 1..1 | IHE_PCC_Problem_Entry | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value, should-author |
  @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
 realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
 @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 |
S | 3..* | II | Slice: Unordered, Open by value:root, value:extension |
  templateId:problem-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: 2.16.840.1.113883.10.20.1.28 | |
 @extension |
0..1 | st | ||
| templateId:problem-entry |
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: 1.3.6.1.4.1.19376.1.5.3.1.4.5 | |
| @extension |
0..1 | st | ||
 templateId:ihe-prob-concern-entry |
S | 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: 1.3.6.1.4.1.19376.1.5.3.1.4.6 | |
| @extension |
0..1 | st | ||
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) | |
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
| @negationInd |
S | 0..1 | bl | Use negationInd="true" to indicate that the allergy was not observed. |
| id |
S | 1..* | II | |
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |
| code |
S | 1..1 | CD | Binding: ObservationType (example) |
| derivationExpr |
0..1 | ST | ||
| text |
S | 1..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: CDACompressionAlgorithm (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: CDABinaryDataEncoding (required) | |
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |
| reference |
C | 0..1 | TEL | Constraints: value-starts-octothorpe |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| @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 |
S | 0..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator |
0..1 | cs | Binding: CDASetOperator (required) | |
| low |
S | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. |
| center |
0..1 | TS | ||
| width |
0..1 | PQ | ||
| high |
S | 0..1 | IVXB_TS | |
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| value |
S | 1..* | CD | Binding: ObservationIntoleranceType (preferred) |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951). | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @codeSystemName |
0..1 | st | ||
| @codeSystemVersion |
0..1 | st | ||
| @displayName |
0..1 | st | ||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText |
0..1 | ED | ||
| qualifier |
0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined.
In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo -
Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML. | |
| translation |
0..* | CD | ||
| interpretationCode |
0..* | CE | Binding: CDAObservationInterpretation (required) | |
| methodCode |
0..* | CE | Binding: ObservationMethod (example) | |
| targetSiteCode |
0..* | CD | ||
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | Author | ||
| informant |
0..* | Informant | ||
| participant |
S | 0..* | Participant2 | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: CDAParticipationType (required) Required Pattern: CSM | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| sdtcFunctionCode |
0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: functionCode (urn:hl7-org:sdtc) | |
| time |
0..1 | IVL_TS | ||
| awarenessCode |
0..1 | CE | ||
| participantRole |
1..1 | ParticipantRole | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
0..1 | cs | Binding: CDARoleClassRoot (required) Required Pattern: MANU | |
| id |
0..* | II | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: CDARoleCode (example) | |
| addr |
0..* | AD | ||
| telecom |
0..* | TEL | ||
| playingDevice |
0..1 | Device | ||
| playingEntity |
0..1 | PlayingEntity | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
0..1 | cs | Binding: EntityClassRoot (required) Required Pattern: MMAT | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| code |
0..1 | CE | Binding: CDAEntityCode (example) | |
| quantity |
0..* | PQ | ||
| name |
0..* | PN | ||
| sdtcBirthTime |
0..1 | TS | XML Namespace: urn:hl7-org:sdtc XML: birthTime (urn:hl7-org:sdtc) | |
| desc |
0..1 | ED | ||
| scopingEntity |
0..1 | Entity | ||
| Slices for entryRelationship |
S | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, profile:act |
| entryRelationship:severity-entry |
S | 0..1 | EntryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
 @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
1..1 | IHE_PCC_Severity_Entry | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| entryRelationship:problem-status |
S | 0..1 | EntryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd |
0..1 | bl | Fixed Value: false | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
1..1 | IHE_Problem_Status_Observation | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| entryRelationship:health-status |
S | 0..1 | EntryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd |
0..1 | bl | Fixed Value: false | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
S | 1..1 | IHE_Health_Status_Observation | |
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| entryRelationship:reactions |
S | 0..* | EntryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: MFST | |
| @inversionInd |
0..1 | bl | Fixed Value: false | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
1..1 | IHE_Problem_Reaction_Entry | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| referenceRange |
0..* | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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: CDAActRelationshipType (required) Fixed Value: REFV | |
| observationRange |
1..1 | ObservationRange | ||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Observation.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.templateId:problem-obs.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.templateId:problem-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.templateId:ihe-prob-concern-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.classCode | Base | required | CDAActClassObservation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.moodCode | Base | required | x_ActMoodDocumentObservation | 📍2.0.0 | THO v5.2 |
| Observation.code | Base | example | ObservationType | 📦3.0.0 | THO v6.5 |
| Observation.text.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.text.compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.text.integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2 |
| Observation.text.mediaType | Base | example | MediaType | 📦3.0.0 | THO v6.5 |
| Observation.text.representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5 |
| Observation.statusCode.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.effectiveTime.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.effectiveTime.​operator | Base | required | CDASetOperator | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5 |
| Observation.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std. |
| Observation.value | Base | preferred | ObservationIntoleranceType | 📦3.0.0 | THO v6.5 |
| Observation.value.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.interpretationCode | Base | required | CDAObservationInterpretation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.methodCode | Base | example | ObservationMethod | 📦3.0.0 | THO v6.5 |
| Observation.participant.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​typeCode | Base | required | CDAParticipationType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​contextControlCode | Base | required | CDAContextControl | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.classCode | Base | required | CDARoleClassRoot | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.code | Base | example | CDARoleCode | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.playingEntity.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.playingEntity.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.playingEntity.​classCode | Base | required | EntityClassRoot | 📦3.0.0 | THO v6.5 |
| Observation.participant.​participantRole.playingEntity.​determinerCode | Base | required | EntityDeterminer | 📦3.0.0 | THO v6.5 |
| Observation.participant.​participantRole.playingEntity.​code | Base | example | CDAEntityCode | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:severity-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:severity-entry.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:severity-entry.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.entryRelationship:problem-status.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:problem-status.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:problem-status.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.entryRelationship:health-status.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:health-status.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:health-status.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.entryRelationship:reactions.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:reactions.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:reactions.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​typeCode | Base | required | CDAActRelationshipType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Id | Grade | Path(s) | Description | Expression |
| II-1 | error | Observation.typeId, Observation.participant.typeId, Observation.participant.participantRole.typeId, Observation.participant.participantRole.playingEntity.typeId, Observation.entryRelationship:severity-entry.typeId, Observation.entryRelationship:problem-status.typeId, Observation.entryRelationship:health-status.typeId, Observation.entryRelationship:reactions.typeId, Observation.referenceRange.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
| should-author | warning | Observation | SHOULD contain author |
author.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 IHE_PCC_Problem_Entry
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Observation |
IHE_PCC_Problem_Entry | XML Namespace: urn:hl7-org:v3 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||
| templateId |
3..* | II | ||
| Slices for templateId |
Content/Rules for all slices | |||
| templateId:ihe-prob-concern-entry |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.4.6 | |
| @negationInd |
0..1 | bl | Use negationInd="true" to indicate that the allergy was not observed. | |
| value |
1..* | CD | Binding: ObservationIntoleranceType (preferred) | |
| participant |
S | 0..* | Participant2 | |
| @typeCode |
1..1 | cs | Required Pattern: CSM | |
| participantRole |
||||
| @classCode |
0..1 | cs | Required Pattern: MANU | |
| playingEntity |
||||
| @classCode |
0..1 | cs | Required Pattern: MMAT | |
| Slices for entryRelationship |
Content/Rules for all slices | |||
| entryRelationship:reactions |
0..* | EntryRelationship | ||
| @typeCode |
1..1 | cs | Fixed Value: MFST | |
| @inversionInd |
0..1 | bl | Fixed Value: false | |
| observation |
1..1 | IHE_Problem_Reaction_Entry | ||
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Observation.value | Base | preferred | ObservationIntoleranceType | 📦3.0.0 | THO v6.5 |
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Observation |
C | 1..1 | IHE_PCC_Problem_Entry | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value, should-author |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
S | 3..* | II | Slice: Unordered, Open by value:root, value:extension |
| templateId:problem-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: 2.16.840.1.113883.10.20.1.28 | |
| @extension |
0..1 | st | ||
| templateId:problem-entry |
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: 1.3.6.1.4.1.19376.1.5.3.1.4.5 | |
| @extension |
0..1 | st | ||
| templateId:ihe-prob-concern-entry |
S | 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: 1.3.6.1.4.1.19376.1.5.3.1.4.6 | |
| @extension |
0..1 | st | ||
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) | |
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
| @negationInd |
S | 0..1 | bl | Use negationInd="true" to indicate that the allergy was not observed. |
| id |
S | 1..* | II | |
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |
| code |
S | 1..1 | CD | Binding: ObservationType (example) |
| derivationExpr |
0..1 | ST | ||
| text |
S | 1..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: CDACompressionAlgorithm (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: CDABinaryDataEncoding (required) | |
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |
| reference |
C | 0..1 | TEL | Constraints: value-starts-octothorpe |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| @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 |
S | 0..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator |
0..1 | cs | Binding: CDASetOperator (required) | |
| low |
S | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. |
| center |
0..1 | TS | ||
| width |
0..1 | PQ | ||
| high |
S | 0..1 | IVXB_TS | |
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| value |
S | 1..* | CD | Binding: ObservationIntoleranceType (preferred) |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951). | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @codeSystemName |
0..1 | st | ||
| @codeSystemVersion |
0..1 | st | ||
| @displayName |
0..1 | st | ||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText |
0..1 | ED | ||
| qualifier |
0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined.
In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo -
Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML. | |
| translation |
0..* | CD | ||
| interpretationCode |
0..* | CE | Binding: CDAObservationInterpretation (required) | |
| methodCode |
0..* | CE | Binding: ObservationMethod (example) | |
| targetSiteCode |
0..* | CD | ||
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | Author | ||
| informant |
0..* | Informant | ||
| participant |
S | 0..* | Participant2 | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: CDAParticipationType (required) Required Pattern: CSM | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| sdtcFunctionCode |
0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: functionCode (urn:hl7-org:sdtc) | |
| time |
0..1 | IVL_TS | ||
| awarenessCode |
0..1 | CE | ||
| participantRole |
1..1 | ParticipantRole | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
0..1 | cs | Binding: CDARoleClassRoot (required) Required Pattern: MANU | |
| id |
0..* | II | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: CDARoleCode (example) | |
| addr |
0..* | AD | ||
| telecom |
0..* | TEL | ||
| playingDevice |
0..1 | Device | ||
| playingEntity |
0..1 | PlayingEntity | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
0..1 | cs | Binding: EntityClassRoot (required) Required Pattern: MMAT | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| code |
0..1 | CE | Binding: CDAEntityCode (example) | |
| quantity |
0..* | PQ | ||
| name |
0..* | PN | ||
| sdtcBirthTime |
0..1 | TS | XML Namespace: urn:hl7-org:sdtc XML: birthTime (urn:hl7-org:sdtc) | |
| desc |
0..1 | ED | ||
| scopingEntity |
0..1 | Entity | ||
| Slices for entryRelationship |
S | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, profile:act |
| entryRelationship:severity-entry |
S | 0..1 | EntryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
1..1 | IHE_PCC_Severity_Entry | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| entryRelationship:problem-status |
S | 0..1 | EntryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd |
0..1 | bl | Fixed Value: false | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
1..1 | IHE_Problem_Status_Observation | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| entryRelationship:health-status |
S | 0..1 | EntryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd |
0..1 | bl | Fixed Value: false | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
S | 1..1 | IHE_Health_Status_Observation | |
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| entryRelationship:reactions |
S | 0..* | EntryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: MFST | |
| @inversionInd |
0..1 | bl | Fixed Value: false | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
1..1 | IHE_Problem_Reaction_Entry | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| referenceRange |
0..* | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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: CDAActRelationshipType (required) Fixed Value: REFV | |
| observationRange |
1..1 | ObservationRange | ||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Observation.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.templateId:problem-obs.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.templateId:problem-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.templateId:ihe-prob-concern-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.classCode | Base | required | CDAActClassObservation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.moodCode | Base | required | x_ActMoodDocumentObservation | 📍2.0.0 | THO v5.2 |
| Observation.code | Base | example | ObservationType | 📦3.0.0 | THO v6.5 |
| Observation.text.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.text.compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.text.integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2 |
| Observation.text.mediaType | Base | example | MediaType | 📦3.0.0 | THO v6.5 |
| Observation.text.representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5 |
| Observation.statusCode.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.effectiveTime.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.effectiveTime.​operator | Base | required | CDASetOperator | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5 |
| Observation.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std. |
| Observation.value | Base | preferred | ObservationIntoleranceType | 📦3.0.0 | THO v6.5 |
| Observation.value.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.interpretationCode | Base | required | CDAObservationInterpretation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.methodCode | Base | example | ObservationMethod | 📦3.0.0 | THO v6.5 |
| Observation.participant.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​typeCode | Base | required | CDAParticipationType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​contextControlCode | Base | required | CDAContextControl | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.classCode | Base | required | CDARoleClassRoot | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.code | Base | example | CDARoleCode | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.playingEntity.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.playingEntity.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.playingEntity.​classCode | Base | required | EntityClassRoot | 📦3.0.0 | THO v6.5 |
| Observation.participant.​participantRole.playingEntity.​determinerCode | Base | required | EntityDeterminer | 📦3.0.0 | THO v6.5 |
| Observation.participant.​participantRole.playingEntity.​code | Base | example | CDAEntityCode | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:severity-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:severity-entry.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:severity-entry.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.entryRelationship:problem-status.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:problem-status.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:problem-status.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.entryRelationship:health-status.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:health-status.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:health-status.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.entryRelationship:reactions.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:reactions.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:reactions.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​typeCode | Base | required | CDAActRelationshipType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Id | Grade | Path(s) | Description | Expression |
| II-1 | error | Observation.typeId, Observation.participant.typeId, Observation.participant.participantRole.typeId, Observation.participant.participantRole.playingEntity.typeId, Observation.entryRelationship:severity-entry.typeId, Observation.entryRelationship:problem-status.typeId, Observation.entryRelationship:health-status.typeId, Observation.entryRelationship:reactions.typeId, Observation.referenceRange.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
| should-author | warning | Observation | SHOULD contain author |
author.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 IHE_PCC_Problem_Entry
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Observation |
C | 1..1 | IHE_PCC_Problem_Entry | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value, should-author |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
S | 3..* | II | Slice: Unordered, Open by value:root, value:extension |
| templateId:problem-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: 2.16.840.1.113883.10.20.1.28 | |
| @extension |
0..1 | st | ||
| templateId:problem-entry |
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: 1.3.6.1.4.1.19376.1.5.3.1.4.5 | |
| @extension |
0..1 | st | ||
| templateId:ihe-prob-concern-entry |
S | 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: 1.3.6.1.4.1.19376.1.5.3.1.4.6 | |
| @extension |
0..1 | st | ||
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) | |
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
| @negationInd |
S | 0..1 | bl | Use negationInd="true" to indicate that the allergy was not observed. |
| id |
S | 1..* | II | |
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |
| code |
S | 1..1 | CD | Binding: ObservationType (example) |
| derivationExpr |
0..1 | ST | ||
| text |
S | 1..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: CDACompressionAlgorithm (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: CDABinaryDataEncoding (required) | |
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |
| reference |
C | 0..1 | TEL | Constraints: value-starts-octothorpe |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| @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 |
S | 0..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator |
0..1 | cs | Binding: CDASetOperator (required) | |
| low |
S | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. |
| center |
0..1 | TS | ||
| width |
0..1 | PQ | ||
| high |
S | 0..1 | IVXB_TS | |
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| value |
S | 1..* | CD | Binding: ObservationIntoleranceType (preferred) |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951). | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @codeSystemName |
0..1 | st | ||
| @codeSystemVersion |
0..1 | st | ||
| @displayName |
0..1 | st | ||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText |
0..1 | ED | ||
| qualifier |
0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined.
In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo -
Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML. | |
| translation |
0..* | CD | ||
| interpretationCode |
0..* | CE | Binding: CDAObservationInterpretation (required) | |
| methodCode |
0..* | CE | Binding: ObservationMethod (example) | |
| targetSiteCode |
0..* | CD | ||
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | Author | ||
| informant |
0..* | Informant | ||
| participant |
S | 0..* | Participant2 | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: CDAParticipationType (required) Required Pattern: CSM | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| sdtcFunctionCode |
0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: functionCode (urn:hl7-org:sdtc) | |
| time |
0..1 | IVL_TS | ||
| awarenessCode |
0..1 | CE | ||
| participantRole |
1..1 | ParticipantRole | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
0..1 | cs | Binding: CDARoleClassRoot (required) Required Pattern: MANU | |
| id |
0..* | II | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: CDARoleCode (example) | |
| addr |
0..* | AD | ||
| telecom |
0..* | TEL | ||
| playingDevice |
0..1 | Device | ||
| playingEntity |
0..1 | PlayingEntity | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
0..1 | cs | Binding: EntityClassRoot (required) Required Pattern: MMAT | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| code |
0..1 | CE | Binding: CDAEntityCode (example) | |
| quantity |
0..* | PQ | ||
| name |
0..* | PN | ||
| sdtcBirthTime |
0..1 | TS | XML Namespace: urn:hl7-org:sdtc XML: birthTime (urn:hl7-org:sdtc) | |
| desc |
0..1 | ED | ||
| scopingEntity |
0..1 | Entity | ||
| Slices for entryRelationship |
S | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, profile:act |
| entryRelationship:severity-entry |
S | 0..1 | EntryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
1..1 | IHE_PCC_Severity_Entry | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| entryRelationship:problem-status |
S | 0..1 | EntryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd |
0..1 | bl | Fixed Value: false | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
1..1 | IHE_Problem_Status_Observation | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| entryRelationship:health-status |
S | 0..1 | EntryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd |
0..1 | bl | Fixed Value: false | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
S | 1..1 | IHE_Health_Status_Observation | |
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| entryRelationship:reactions |
S | 0..* | EntryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: MFST | |
| @inversionInd |
0..1 | bl | Fixed Value: false | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
1..1 | IHE_Problem_Reaction_Entry | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| referenceRange |
0..* | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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: CDAActRelationshipType (required) Fixed Value: REFV | |
| observationRange |
1..1 | ObservationRange | ||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Observation.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.templateId:problem-obs.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.templateId:problem-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.templateId:ihe-prob-concern-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.classCode | Base | required | CDAActClassObservation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.moodCode | Base | required | x_ActMoodDocumentObservation | 📍2.0.0 | THO v5.2 |
| Observation.code | Base | example | ObservationType | 📦3.0.0 | THO v6.5 |
| Observation.text.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.text.compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.text.integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2 |
| Observation.text.mediaType | Base | example | MediaType | 📦3.0.0 | THO v6.5 |
| Observation.text.representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5 |
| Observation.statusCode.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.effectiveTime.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.effectiveTime.​operator | Base | required | CDASetOperator | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5 |
| Observation.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std. |
| Observation.value | Base | preferred | ObservationIntoleranceType | 📦3.0.0 | THO v6.5 |
| Observation.value.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.interpretationCode | Base | required | CDAObservationInterpretation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.methodCode | Base | example | ObservationMethod | 📦3.0.0 | THO v6.5 |
| Observation.participant.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​typeCode | Base | required | CDAParticipationType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​contextControlCode | Base | required | CDAContextControl | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.classCode | Base | required | CDARoleClassRoot | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.code | Base | example | CDARoleCode | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.playingEntity.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.playingEntity.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.playingEntity.​classCode | Base | required | EntityClassRoot | 📦3.0.0 | THO v6.5 |
| Observation.participant.​participantRole.playingEntity.​determinerCode | Base | required | EntityDeterminer | 📦3.0.0 | THO v6.5 |
| Observation.participant.​participantRole.playingEntity.​code | Base | example | CDAEntityCode | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:severity-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:severity-entry.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:severity-entry.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.entryRelationship:problem-status.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:problem-status.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:problem-status.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.entryRelationship:health-status.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:health-status.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:health-status.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.entryRelationship:reactions.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:reactions.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:reactions.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​typeCode | Base | required | CDAActRelationshipType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Id | Grade | Path(s) | Description | Expression |
| II-1 | error | Observation.typeId, Observation.participant.typeId, Observation.participant.participantRole.typeId, Observation.participant.participantRole.playingEntity.typeId, Observation.entryRelationship:severity-entry.typeId, Observation.entryRelationship:problem-status.typeId, Observation.entryRelationship:health-status.typeId, Observation.entryRelationship:reactions.typeId, Observation.referenceRange.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
| should-author | warning | Observation | SHOULD contain author |
author.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('#')
|
Differential View
This structure is derived from IHE_PCC_Problem_Entry
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Observation |
IHE_PCC_Problem_Entry | XML Namespace: urn:hl7-org:v3 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||
| templateId |
3..* | II | ||
| Slices for templateId |
Content/Rules for all slices | |||
| templateId:ihe-prob-concern-entry |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.4.6 | |
| @negationInd |
0..1 | bl | Use negationInd="true" to indicate that the allergy was not observed. | |
| value |
1..* | CD | Binding: ObservationIntoleranceType (preferred) | |
| participant |
S | 0..* | Participant2 | |
| @typeCode |
1..1 | cs | Required Pattern: CSM | |
| participantRole |
||||
| @classCode |
0..1 | cs | Required Pattern: MANU | |
| playingEntity |
||||
| @classCode |
0..1 | cs | Required Pattern: MMAT | |
| Slices for entryRelationship |
Content/Rules for all slices | |||
| entryRelationship:reactions |
0..* | EntryRelationship | ||
| @typeCode |
1..1 | cs | Fixed Value: MFST | |
| @inversionInd |
0..1 | bl | Fixed Value: false | |
| observation |
1..1 | IHE_Problem_Reaction_Entry | ||
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Observation.value | Base | preferred | ObservationIntoleranceType | 📦3.0.0 | THO v6.5 |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Observation |
C | 1..1 | IHE_PCC_Problem_Entry | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value, should-author |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
S | 3..* | II | Slice: Unordered, Open by value:root, value:extension |
| templateId:problem-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: 2.16.840.1.113883.10.20.1.28 | |
| @extension |
0..1 | st | ||
| templateId:problem-entry |
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: 1.3.6.1.4.1.19376.1.5.3.1.4.5 | |
| @extension |
0..1 | st | ||
| templateId:ihe-prob-concern-entry |
S | 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: 1.3.6.1.4.1.19376.1.5.3.1.4.6 | |
| @extension |
0..1 | st | ||
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) | |
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
| @negationInd |
S | 0..1 | bl | Use negationInd="true" to indicate that the allergy was not observed. |
| id |
S | 1..* | II | |
| sdtcCategory |
0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc) | |
| code |
S | 1..1 | CD | Binding: ObservationType (example) |
| derivationExpr |
0..1 | ST | ||
| text |
S | 1..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: CDACompressionAlgorithm (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: CDABinaryDataEncoding (required) | |
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |
| reference |
C | 0..1 | TEL | Constraints: value-starts-octothorpe |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| @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 |
S | 0..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator |
0..1 | cs | Binding: CDASetOperator (required) | |
| low |
S | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. |
| center |
0..1 | TS | ||
| width |
0..1 | PQ | ||
| high |
S | 0..1 | IVXB_TS | |
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | ||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| value |
S | 1..* | CD | Binding: ObservationIntoleranceType (preferred) |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951). | |
| @codeSystem |
0..1 | oid, uuid, ruid | ||
| @codeSystemName |
0..1 | st | ||
| @codeSystemVersion |
0..1 | st | ||
| @displayName |
0..1 | st | ||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText |
0..1 | ED | ||
| qualifier |
0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined.
In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo -
Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML. | |
| translation |
0..* | CD | ||
| interpretationCode |
0..* | CE | Binding: CDAObservationInterpretation (required) | |
| methodCode |
0..* | CE | Binding: ObservationMethod (example) | |
| targetSiteCode |
0..* | CD | ||
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | Author | ||
| informant |
0..* | Informant | ||
| participant |
S | 0..* | Participant2 | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: CDAParticipationType (required) Required Pattern: CSM | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| sdtcFunctionCode |
0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: functionCode (urn:hl7-org:sdtc) | |
| time |
0..1 | IVL_TS | ||
| awarenessCode |
0..1 | CE | ||
| participantRole |
1..1 | ParticipantRole | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
0..1 | cs | Binding: CDARoleClassRoot (required) Required Pattern: MANU | |
| id |
0..* | II | ||
| sdtcIdentifiedBy |
0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc) | |
| code |
0..1 | CE | Binding: CDARoleCode (example) | |
| addr |
0..* | AD | ||
| telecom |
0..* | TEL | ||
| playingDevice |
0..1 | Device | ||
| playingEntity |
0..1 | PlayingEntity | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
0..1 | cs | Binding: EntityClassRoot (required) Required Pattern: MMAT | |
| @determinerCode |
0..1 | cs | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| code |
0..1 | CE | Binding: CDAEntityCode (example) | |
| quantity |
0..* | PQ | ||
| name |
0..* | PN | ||
| sdtcBirthTime |
0..1 | TS | XML Namespace: urn:hl7-org:sdtc XML: birthTime (urn:hl7-org:sdtc) | |
| desc |
0..1 | ED | ||
| scopingEntity |
0..1 | Entity | ||
| Slices for entryRelationship |
S | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, profile:act |
| entryRelationship:severity-entry |
S | 0..1 | EntryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @inversionInd |
1..1 | bl | Fixed Value: true | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
1..1 | IHE_PCC_Severity_Entry | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| entryRelationship:problem-status |
S | 0..1 | EntryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd |
0..1 | bl | Fixed Value: false | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
1..1 | IHE_Problem_Status_Observation | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| entryRelationship:health-status |
S | 0..1 | EntryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd |
0..1 | bl | Fixed Value: false | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
S | 1..1 | IHE_Health_Status_Observation | |
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| entryRelationship:reactions |
S | 0..* | EntryRelationship | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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 |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: MFST | |
| @inversionInd |
0..1 | bl | Fixed Value: false | |
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
0..1 | Act | ||
| encounter |
0..1 | Encounter | ||
| observation |
1..1 | IHE_Problem_Reaction_Entry | ||
| observationMedia |
0..1 | ObservationMedia | ||
| organizer |
0..1 | Organizer | ||
| procedure |
0..1 | Procedure | ||
| regionOfInterest |
0..1 | RegionOfInterest | ||
| substanceAdministration |
0..1 | SubstanceAdministration | ||
| supply |
0..1 | Supply | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| referenceRange |
0..* | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | Constraints: II-1 |
| @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: CDAActRelationshipType (required) Fixed Value: REFV | |
| observationRange |
1..1 | ObservationRange | ||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Observation.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.templateId:problem-obs.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.templateId:problem-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.templateId:ihe-prob-concern-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.classCode | Base | required | CDAActClassObservation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.moodCode | Base | required | x_ActMoodDocumentObservation | 📍2.0.0 | THO v5.2 |
| Observation.code | Base | example | ObservationType | 📦3.0.0 | THO v6.5 |
| Observation.text.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.text.compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.text.integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2 |
| Observation.text.mediaType | Base | example | MediaType | 📦3.0.0 | THO v6.5 |
| Observation.text.representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5 |
| Observation.statusCode.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.effectiveTime.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.effectiveTime.​operator | Base | required | CDASetOperator | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5 |
| Observation.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std. |
| Observation.value | Base | preferred | ObservationIntoleranceType | 📦3.0.0 | THO v6.5 |
| Observation.value.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.interpretationCode | Base | required | CDAObservationInterpretation | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.methodCode | Base | example | ObservationMethod | 📦3.0.0 | THO v6.5 |
| Observation.participant.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​typeCode | Base | required | CDAParticipationType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​contextControlCode | Base | required | CDAContextControl | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.typeId.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.classCode | Base | required | CDARoleClassRoot | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.code | Base | example | CDARoleCode | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.playingEntity.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.playingEntity.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.participant.​participantRole.playingEntity.​classCode | Base | required | EntityClassRoot | 📦3.0.0 | THO v6.5 |
| Observation.participant.​participantRole.playingEntity.​determinerCode | Base | required | EntityDeterminer | 📦3.0.0 | THO v6.5 |
| Observation.participant.​participantRole.playingEntity.​code | Base | example | CDAEntityCode | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:severity-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:severity-entry.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:severity-entry.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.entryRelationship:problem-status.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:problem-status.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:problem-status.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.entryRelationship:health-status.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:health-status.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:health-status.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.entryRelationship:reactions.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:reactions.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.entryRelationship:reactions.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5 |
| Observation.referenceRange.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Observation.referenceRange.​typeCode | Base | required | CDAActRelationshipType | 📦2.0.1-sd | Clinical Document Architecture v2.0 |
| Id | Grade | Path(s) | Description | Expression |
| II-1 | error | Observation.typeId, Observation.participant.typeId, Observation.participant.participantRole.typeId, Observation.participant.participantRole.playingEntity.typeId, Observation.entryRelationship:severity-entry.typeId, Observation.entryRelationship:problem-status.typeId, Observation.entryRelationship:health-status.typeId, Observation.entryRelationship:reactions.typeId, Observation.referenceRange.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
| should-author | warning | Observation | SHOULD contain author |
author.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 IHE_PCC_Problem_Entry
IG © 2023+ IHE Patient Care Coordination Technical Committee. Package ihe.pcc.pscc#0.0.1-current based on FHIR 5.0.0. Generated 2025-11-04
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