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: IHE Probelm Reaction Entry

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

TBD…

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 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:allergy-int-reaction 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: 2.16.840.1.113883.10.20.1.54
..... @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.templateId:allergy-int-reaction.​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 IHE_PCC_Problem_Entry

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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:allergy-int-reaction 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.1.54

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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:allergy-int-reaction 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: 2.16.840.1.113883.10.20.1.54
..... @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.templateId:allergy-int-reaction.​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 IHE_PCC_Problem_Entry

Summary

Mandatory: 2 elements

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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:allergy-int-reaction 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: 2.16.840.1.113883.10.20.1.54
..... @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.templateId:allergy-int-reaction.​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 IHE_PCC_Problem_Entry

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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:allergy-int-reaction 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.1.54

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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:allergy-int-reaction 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: 2.16.840.1.113883.10.20.1.54
..... @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.templateId:allergy-int-reaction.​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 IHE_PCC_Problem_Entry

Summary

Mandatory: 2 elements

 

Other representations of profile: CSV, Excel