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 Status Observation

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

Any problem or allergy observation may reference a problem status observation. This structure is included in the target observation using the element defined in the CDA Schema. The clinical status observation records information about the current status of the problem or allergy, for example, whether it is active, in remission, resolved, et cetera. The example below shows the recording of clinical status of a condition or allergy, and is used as the context for the following sections.

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
... @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:status-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: 2.16.840.1.113883.10.20.1.57
..... @extension 0..1 st
.... templateId:problem-status-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: 2.16.840.1.113883.10.20.1.50
..... @extension 0..1 st
.... templateId:ihe-problem-status-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: 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
..... @extension 0..1 st
... @classCode 1..1 cs Binding: CDAActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1 cs Binding: XActMoodDocumentObservation (2.0.0) (required)
Fixed Value: EVN
... @negationInd 0..1 bl
... id 0..* II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code S 1..1 CD Diagnosis status
Binding: ObservationType (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 33999-4
.... @codeSystem 1..1 oid, uuid, ruid LOINC
Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st Required Pattern: Status
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... qualifier 0..* CR
.... translation 0..* CD
... derivationExpr 0..1 ST
... text 0..1 ED The <text> element is required and points to the text describing the problem being recorded; including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.
.... @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 SC 1..1 TEL Constraints: value-starts-octothorpe
.... thumbnail 0..1 ED
... statusCode S 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 0..1 IVL_TS
... priorityCode 0..1 CE Binding: ActPriority (example)
... repeatNumber 0..1 IVL_INT
... languageCode 0..1 CS Binding: AllLanguages (required)
... value 1..1 CD Binding: Problem Status Observation Value (required)
... 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
... entryRelationship 0..* EntryRelationship
... reference 0..* Reference
... precondition 0..* Precondition
... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... referenceRange 0..* InfrastructureRoot
.... @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:status-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
Observation.templateId:problem-status-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
Observation.templateId:ihe-problem-status-obs.​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.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
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.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
Observation.languageCode Base required All Languages 📦5.0.0 FHIR Std.
Observation.value Base required Problem Status Observation Value 📦0.0.1-current This IG
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.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.referenceRange.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.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
... Slices for templateId S 3..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:status-obs 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.1.57
.... templateId:problem-status-obs 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.1.50
.... templateId:ihe-problem-status-obs 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
... @classCode 1..1 cs Fixed Value: OBS
... @moodCode 1..1 cs Fixed Value: EVN
... code S 1..1 CD Diagnosis status
.... @code 1..1 cs Required Pattern: 33999-4
.... @codeSystem 1..1 oid, uuid, ruid LOINC
Required Pattern: 2.16.840.1.113883.6.1
.... @displayName 0..1 st Required Pattern: Status
... text 0..1 ED The <text> element is required and points to the text describing the problem being recorded; including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.
.... reference SC 1..1 TEL Constraints: value-starts-octothorpe
... statusCode S 1..1 CS
.... @code 1..1 cs Fixed Value: completed
... value 1..1 CD Binding: Problem Status Observation Value (required)

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Observation.value Base required Problem Status Observation Value 📦0.0.1-current This IG

Constraints

Id Grade Path(s) Description Expression
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
... @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:status-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: 2.16.840.1.113883.10.20.1.57
..... @extension 0..1 st
.... templateId:problem-status-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: 2.16.840.1.113883.10.20.1.50
..... @extension 0..1 st
.... templateId:ihe-problem-status-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: 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
..... @extension 0..1 st
... @classCode 1..1 cs Binding: CDAActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1 cs Binding: XActMoodDocumentObservation (2.0.0) (required)
Fixed Value: EVN
... @negationInd 0..1 bl
... id 0..* II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code S 1..1 CD Diagnosis status
Binding: ObservationType (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 33999-4
.... @codeSystem 1..1 oid, uuid, ruid LOINC
Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st Required Pattern: Status
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... qualifier 0..* CR
.... translation 0..* CD
... derivationExpr 0..1 ST
... text 0..1 ED The <text> element is required and points to the text describing the problem being recorded; including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.
.... @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 SC 1..1 TEL Constraints: value-starts-octothorpe
.... thumbnail 0..1 ED
... statusCode S 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 0..1 IVL_TS
... priorityCode 0..1 CE Binding: ActPriority (example)
... repeatNumber 0..1 IVL_INT
... languageCode 0..1 CS Binding: AllLanguages (required)
... value 1..1 CD Binding: Problem Status Observation Value (required)
... 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
... entryRelationship 0..* EntryRelationship
... reference 0..* Reference
... precondition 0..* Precondition
... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... referenceRange 0..* InfrastructureRoot
.... @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:status-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
Observation.templateId:problem-status-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
Observation.templateId:ihe-problem-status-obs.​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.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
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.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
Observation.languageCode Base required All Languages 📦5.0.0 FHIR Std.
Observation.value Base required Problem Status Observation Value 📦0.0.1-current This IG
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.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.referenceRange.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.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: 11 elements(1 nested mandatory element)
Must-Support: 4 elements
Fixed: 3 elements

Slices

This structure defines the following Slices:

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

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
... @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:status-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: 2.16.840.1.113883.10.20.1.57
..... @extension 0..1 st
.... templateId:problem-status-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: 2.16.840.1.113883.10.20.1.50
..... @extension 0..1 st
.... templateId:ihe-problem-status-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: 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
..... @extension 0..1 st
... @classCode 1..1 cs Binding: CDAActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1 cs Binding: XActMoodDocumentObservation (2.0.0) (required)
Fixed Value: EVN
... @negationInd 0..1 bl
... id 0..* II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code S 1..1 CD Diagnosis status
Binding: ObservationType (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 33999-4
.... @codeSystem 1..1 oid, uuid, ruid LOINC
Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st Required Pattern: Status
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... qualifier 0..* CR
.... translation 0..* CD
... derivationExpr 0..1 ST
... text 0..1 ED The <text> element is required and points to the text describing the problem being recorded; including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.
.... @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 SC 1..1 TEL Constraints: value-starts-octothorpe
.... thumbnail 0..1 ED
... statusCode S 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 0..1 IVL_TS
... priorityCode 0..1 CE Binding: ActPriority (example)
... repeatNumber 0..1 IVL_INT
... languageCode 0..1 CS Binding: AllLanguages (required)
... value 1..1 CD Binding: Problem Status Observation Value (required)
... 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
... entryRelationship 0..* EntryRelationship
... reference 0..* Reference
... precondition 0..* Precondition
... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... referenceRange 0..* InfrastructureRoot
.... @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:status-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
Observation.templateId:problem-status-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
Observation.templateId:ihe-problem-status-obs.​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.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
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.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
Observation.languageCode Base required All Languages 📦5.0.0 FHIR Std.
Observation.value Base required Problem Status Observation Value 📦0.0.1-current This IG
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.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.referenceRange.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.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
... Slices for templateId S 3..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:status-obs 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.1.57
.... templateId:problem-status-obs 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.1.50
.... templateId:ihe-problem-status-obs 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
... @classCode 1..1 cs Fixed Value: OBS
... @moodCode 1..1 cs Fixed Value: EVN
... code S 1..1 CD Diagnosis status
.... @code 1..1 cs Required Pattern: 33999-4
.... @codeSystem 1..1 oid, uuid, ruid LOINC
Required Pattern: 2.16.840.1.113883.6.1
.... @displayName 0..1 st Required Pattern: Status
... text 0..1 ED The <text> element is required and points to the text describing the problem being recorded; including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.
.... reference SC 1..1 TEL Constraints: value-starts-octothorpe
... statusCode S 1..1 CS
.... @code 1..1 cs Fixed Value: completed
... value 1..1 CD Binding: Problem Status Observation Value (required)

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Observation.value Base required Problem Status Observation Value 📦0.0.1-current This IG

Constraints

Id Grade Path(s) Description Expression
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
... @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:status-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: 2.16.840.1.113883.10.20.1.57
..... @extension 0..1 st
.... templateId:problem-status-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: 2.16.840.1.113883.10.20.1.50
..... @extension 0..1 st
.... templateId:ihe-problem-status-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: 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
..... @extension 0..1 st
... @classCode 1..1 cs Binding: CDAActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1 cs Binding: XActMoodDocumentObservation (2.0.0) (required)
Fixed Value: EVN
... @negationInd 0..1 bl
... id 0..* II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code S 1..1 CD Diagnosis status
Binding: ObservationType (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 33999-4
.... @codeSystem 1..1 oid, uuid, ruid LOINC
Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st Required Pattern: Status
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... qualifier 0..* CR
.... translation 0..* CD
... derivationExpr 0..1 ST
... text 0..1 ED The <text> element is required and points to the text describing the problem being recorded; including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.
.... @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 SC 1..1 TEL Constraints: value-starts-octothorpe
.... thumbnail 0..1 ED
... statusCode S 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 0..1 IVL_TS
... priorityCode 0..1 CE Binding: ActPriority (example)
... repeatNumber 0..1 IVL_INT
... languageCode 0..1 CS Binding: AllLanguages (required)
... value 1..1 CD Binding: Problem Status Observation Value (required)
... 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
... entryRelationship 0..* EntryRelationship
... reference 0..* Reference
... precondition 0..* Precondition
... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... referenceRange 0..* InfrastructureRoot
.... @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:status-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
Observation.templateId:problem-status-obs.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
Observation.templateId:ihe-problem-status-obs.​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.code.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
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.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
Observation.languageCode Base required All Languages 📦5.0.0 FHIR Std.
Observation.value Base required Problem Status Observation Value 📦0.0.1-current This IG
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.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.referenceRange.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.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: 11 elements(1 nested mandatory element)
Must-Support: 4 elements
Fixed: 3 elements

Slices

This structure defines the following Slices:

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

 

Other representations of profile: CSV, Excel