Paramedicine Summary Of Care CDA
0.0.1-current - ci-build International flag

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

Logical Model: Problem Entry

Official URL: https://profiles.ihe.net/PCC/PSCc/StructureDefinition/IHE.PCC.Problem.Entry Version: 0.0.1-current
Draft as of 2025-11-04 Computable Name: IHE_PCC_Problem_Entry

This section makes use of the linking, severity, clinical status and comment content specifications defined elsewhere in the technical framework. In HL7 RIM parlance, observations about a problem, complaint, symptom, finding, diagnosis, or functional limitation of a patient is the event (moodCode='EVN') of observing () that problem. The of the observation comes from a controlled vocabulary representing such things. The contained within the describes the method of determination from yet another controlled vocabulary. An example appears below in the figure below

The basic pattern for reporting a problem uses the CDA element, setting the classCode='OBS' to represent that this is an observation of a problem, and the moodCode='EVN', to represent that this is an observation that has in fact taken place. The negationInd attribute, if true, specifies that the problem indicated was observed to not have occurred (which is subtly but importantly different from having not been observed).

The value of negationInd should not normally be set to true. Instead, to record that there is 'no prior history of chicken pox', one would use a coded value indicated exactly that. However, it is not always possible to record problems in this manner, especially if using a controlled vocabulary that does not supply pre-coordinated negations, or which do not allow the negation to be recorded with post-coordinated coded terminology.

TBD for more

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 1..1 Observation 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 2..* 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
... @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 The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
... 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
.... @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 0..* Participant2
... 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
... 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)

doco Documentation for this format

Terminology Bindings

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.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.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.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.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

Constraints

Id Grade Path(s) Description Expression
II-1 error Observation.typeId, Observation.entryRelationship:severity-entry.typeId, Observation.entryRelationship:problem-status.typeId, Observation.entryRelationship:health-status.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 Observation

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 1..1 Observation 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
... Slices for templateId S 2..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:problem-obs 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.1.28
.... templateId:problem-entry 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.4.5
... @moodCode 1..1 cs Fixed Value: EVN
... @negationInd S 0..1 bl The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
... id S 1..* II
... code S 1..1 CD
... text S 1..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... reference C 0..1 TEL Constraints: value-starts-octothorpe
... statusCode 1..1 CS
.... @code 1..1 cs Fixed Value: completed
... 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.
.... low S 1..1 IVXB_TS The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
.... high S 0..1 IVXB_TS
... value S 1..* CD
.... @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).
.... 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.
... Slices for entryRelationship S 0..* EntryRelationship Slice: Unordered, Open by profile:observation, profile:act
.... entryRelationship:severity-entry S 0..1 EntryRelationship
..... @typeCode 1..1 cs Fixed Value: SUBJ
..... @inversionInd 1..1 bl Fixed Value: true
..... observation 1..1 IHE_PCC_Severity_Entry
.... entryRelationship:problem-status S 0..1 EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... @inversionInd 0..1 bl Fixed Value: false
..... observation 1..1 IHE_Problem_Status_Observation
.... entryRelationship:health-status S 0..1 EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... @inversionInd 0..1 bl Fixed Value: false
..... observation S 1..1 IHE_Health_Status_Observation

doco Documentation for this format

Constraints

Id Grade Path(s) Description Expression
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('#')
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 1..1 Observation 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 2..* 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
... @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 The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
... 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
.... @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 0..* Participant2
... 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
... 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)

doco Documentation for this format

Terminology Bindings

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.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.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.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.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

Constraints

Id Grade Path(s) Description Expression
II-1 error Observation.typeId, Observation.entryRelationship:severity-entry.typeId, Observation.entryRelationship:problem-status.typeId, Observation.entryRelationship:health-status.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 Observation

Summary

Mandatory: 9 elements(5 nested mandatory elements)
Must-Support: 14 elements
Fixed: 8 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of Observation.templateId
  • The element 2 is sliced based on the values of Observation.entryRelationship

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 1..1 Observation 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 2..* 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
... @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 The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
... 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
.... @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 0..* Participant2
... 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
... 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)

doco Documentation for this format

Terminology Bindings

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.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.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.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.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

Constraints

Id Grade Path(s) Description Expression
II-1 error Observation.typeId, Observation.entryRelationship:severity-entry.typeId, Observation.entryRelationship:problem-status.typeId, Observation.entryRelationship:health-status.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 Observation

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 1..1 Observation 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
... Slices for templateId S 2..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:problem-obs 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.1.28
.... templateId:problem-entry 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.4.5
... @moodCode 1..1 cs Fixed Value: EVN
... @negationInd S 0..1 bl The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
... id S 1..* II
... code S 1..1 CD
... text S 1..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... reference C 0..1 TEL Constraints: value-starts-octothorpe
... statusCode 1..1 CS
.... @code 1..1 cs Fixed Value: completed
... 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.
.... low S 1..1 IVXB_TS The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
.... high S 0..1 IVXB_TS
... value S 1..* CD
.... @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).
.... 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.
... Slices for entryRelationship S 0..* EntryRelationship Slice: Unordered, Open by profile:observation, profile:act
.... entryRelationship:severity-entry S 0..1 EntryRelationship
..... @typeCode 1..1 cs Fixed Value: SUBJ
..... @inversionInd 1..1 bl Fixed Value: true
..... observation 1..1 IHE_PCC_Severity_Entry
.... entryRelationship:problem-status S 0..1 EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... @inversionInd 0..1 bl Fixed Value: false
..... observation 1..1 IHE_Problem_Status_Observation
.... entryRelationship:health-status S 0..1 EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... @inversionInd 0..1 bl Fixed Value: false
..... observation S 1..1 IHE_Health_Status_Observation

doco Documentation for this format

Constraints

Id Grade Path(s) Description Expression
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('#')

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 1..1 Observation 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 2..* 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
... @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 The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
... 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
.... @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 0..* Participant2
... 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
... 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)

doco Documentation for this format

Terminology Bindings

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.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.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.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.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

Constraints

Id Grade Path(s) Description Expression
II-1 error Observation.typeId, Observation.entryRelationship:severity-entry.typeId, Observation.entryRelationship:problem-status.typeId, Observation.entryRelationship:health-status.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 Observation

Summary

Mandatory: 9 elements(5 nested mandatory elements)
Must-Support: 14 elements
Fixed: 8 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of Observation.templateId
  • The element 2 is sliced based on the values of Observation.entryRelationship

 

Other representations of profile: CSV, Excel