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

Paramedicine Summary Of Care CDA, published by IHE Patient Care Coordination Technical Committee. This guide is not an authorized publication; it is the continuous build for version 0.0.1-current built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IHE/PCC.PCSc/ and changes regularly. See the Directory of published versions

## Logical Model: Problem Entry

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

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

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

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

TBD for more

Usages:

- Derived from this Logical Model Profile: IHE Allergies and Intolerances Entry and IHE Probelm Reaction Entry
- Use this Logical Model Profile: IHE Concern Entry

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.

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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation | C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value, should-author
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
Slices for templateId | S | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:problem-obs |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.1.28
@extension |  | 0..1 | st |
templateId:problem-entry |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.4.5
@extension |  | 0..1 | st |
@classCode |  | 1..1 | cs | Binding: CDAActClassObservation (required)
@moodCode |  | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN
@negationInd | S | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
id | S | 1..* | II |
sdtcCategory |  | 0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc)
code | S | 1..1 | CD | Binding: ObservationType (example)
derivationExpr |  | 0..1 | ST |
text | S | 1..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@compression |  | 0..1 | cs | Binding: CDACompressionAlgorithm (required)
@integrityCheck |  | 0..1 | bin |
@integrityCheckAlgorithm |  | 0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required)
@language |  | 0..1 | cs |
@mediaType |  | 0..1 | cs | Binding: MediaType (example)
@representation |  | 0..1 | cs | Binding: CDABinaryDataEncoding (required)
xmlText |  | 0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
reference | C | 0..1 | TEL | Constraints: value-starts-octothorpe
thumbnail |  | 0..1 | ED |
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@code |  | 1..1 | cs | Fixed Value: completed
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
effectiveTime | S | 0..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@value |  | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
@operator |  | 0..1 | cs | Binding: CDASetOperator (required)
low | S | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
center |  | 0..1 | TS |
width |  | 0..1 | PQ |
high | S | 0..1 | IVXB_TS |
priorityCode |  | 0..1 | CE | Binding: ActPriority (example)
repeatNumber |  | 0..1 | IVL_INT |
languageCode |  | 0..1 | CS | Binding: AllLanguages (required)
value | S | 1..* | CD |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@code |  | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951).
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
qualifier |  | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo - Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML.
translation |  | 0..* | CD |
interpretationCode |  | 0..* | CE | Binding: CDAObservationInterpretation (required)
methodCode |  | 0..* | CE | Binding: ObservationMethod (example)
targetSiteCode |  | 0..* | CD |
subject |  | 0..1 | Subject |
specimen |  | 0..* | Specimen |
performer |  | 0..* | Performer2 |
author |  | 0..* | Author |
informant |  | 0..* | Informant |
participant |  | 0..* | Participant2 |
Slices for entryRelationship | S | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, profile:act
entryRelationship:severity-entry | S | 0..1 | EntryRelationship |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ
@inversionInd |  | 1..1 | bl | Fixed Value: true
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 0..1 | Act |
encounter |  | 0..1 | Encounter |
observation |  | 1..1 | IHE_PCC_Severity_Entry |
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
entryRelationship:problem-status | S | 0..1 | EntryRelationship |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR
@inversionInd |  | 0..1 | bl | Fixed Value: false
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 0..1 | Act |
encounter |  | 0..1 | Encounter |
observation |  | 1..1 | IHE_Problem_Status_Observation |
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
entryRelationship:health-status | S | 0..1 | EntryRelationship |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR
@inversionInd |  | 0..1 | bl | Fixed Value: false
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 0..1 | Act |
encounter |  | 0..1 | Encounter |
observation | S | 1..1 | IHE_Health_Status_Observation |
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
reference |  | 0..* | Reference |
precondition |  | 0..* | Precondition |
sdtcPrecondition2 |  | 0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc)
referenceRange |  | 0..* | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: REFV
observationRange |  | 1..1 | ObservationRange |
sdtcInFulfillmentOf1 |  | 0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Observation.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.templateId:problem-obs.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.templateId:problem-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.classCode | Base | required | CDAActClassObservation | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.moodCode | Base | required | x_ActMoodDocumentObservation | 📍2.0.0 | THO v5.2
Observation.code | Base | example | ObservationType | 📦3.0.0 | THO v6.5
Observation.text.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.text.compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.text.integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2
Observation.text.mediaType | Base | example | MediaType | 📦3.0.0 | THO v6.5
Observation.text.representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5
Observation.statusCode.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.effectiveTime.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.effectiveTime.​operator | Base | required | CDASetOperator | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5
Observation.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std.
Observation.value.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.interpretationCode | Base | required | CDAObservationInterpretation | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.methodCode | Base | example | ObservationMethod | 📦3.0.0 | THO v6.5
Observation.entryRelationship:severity-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:severity-entry.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:severity-entry.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5
Observation.entryRelationship:problem-status.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:problem-status.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:problem-status.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5
Observation.entryRelationship:health-status.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:health-status.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:health-status.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5
Observation.referenceRange.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.referenceRange.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.referenceRange.​typeCode | Base | required | CDAActRelationshipType | 📦2.0.1-sd | Clinical Document Architecture v2.0

#### Constraints

Id | Grade | Path(s) | Description | Expression
II-1 | error | Observation.typeId, Observation.entryRelationship:severity-entry.typeId, Observation.entryRelationship:problem-status.typeId, Observation.entryRelationship:health-status.typeId, Observation.referenceRange.typeId | An II instance must have either a root or an nullFlavor. | `root.exists() or nullFlavor.exists()`
should-author | warning | Observation | SHOULD contain author | `author.exists()`
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value | `text.reference.value.exists()`
value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | `value.exists() implies value.startsWith('#')`

This structure is derived from Observation

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation | C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value, should-author
Slices for templateId | S | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:problem-obs |  | 1..1 | II |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.1.28
templateId:problem-entry |  | 1..1 | II |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.4.5
@moodCode |  | 1..1 | cs | Fixed Value: EVN
@negationInd | S | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
id | S | 1..* | II |
code | S | 1..1 | CD |
text | S | 1..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry
reference | C | 0..1 | TEL | Constraints: value-starts-octothorpe
statusCode |  | 1..1 | CS |
@code |  | 1..1 | cs | Fixed Value: completed
effectiveTime | S | 0..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
low | S | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
high | S | 0..1 | IVXB_TS |
value | S | 1..* | CD |
@code |  | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951).
qualifier |  | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo - Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML.
Slices for entryRelationship | S | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, profile:act
entryRelationship:severity-entry | S | 0..1 | EntryRelationship |
@typeCode |  | 1..1 | cs | Fixed Value: SUBJ
@inversionInd |  | 1..1 | bl | Fixed Value: true
observation |  | 1..1 | IHE_PCC_Severity_Entry |
entryRelationship:problem-status | S | 0..1 | EntryRelationship |
@typeCode |  | 1..1 | cs | Fixed Value: REFR
@inversionInd |  | 0..1 | bl | Fixed Value: false
observation |  | 1..1 | IHE_Problem_Status_Observation |
entryRelationship:health-status | S | 0..1 | EntryRelationship |
@typeCode |  | 1..1 | cs | Fixed Value: REFR
@inversionInd |  | 0..1 | bl | Fixed Value: false
observation | S | 1..1 | IHE_Health_Status_Observation |
Documentation for this format

#### Constraints

Id | Grade | Path(s) | Description | Expression
should-author | warning | Observation | SHOULD contain author | `author.exists()`
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value | `text.reference.value.exists()`
value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | `value.exists() implies value.startsWith('#')`

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation | C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value, should-author
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
Slices for templateId | S | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:problem-obs |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.1.28
@extension |  | 0..1 | st |
templateId:problem-entry |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.4.5
@extension |  | 0..1 | st |
@classCode |  | 1..1 | cs | Binding: CDAActClassObservation (required)
@moodCode |  | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN
@negationInd | S | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
id | S | 1..* | II |
sdtcCategory |  | 0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc)
code | S | 1..1 | CD | Binding: ObservationType (example)
derivationExpr |  | 0..1 | ST |
text | S | 1..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@compression |  | 0..1 | cs | Binding: CDACompressionAlgorithm (required)
@integrityCheck |  | 0..1 | bin |
@integrityCheckAlgorithm |  | 0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required)
@language |  | 0..1 | cs |
@mediaType |  | 0..1 | cs | Binding: MediaType (example)
@representation |  | 0..1 | cs | Binding: CDABinaryDataEncoding (required)
xmlText |  | 0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
reference | C | 0..1 | TEL | Constraints: value-starts-octothorpe
thumbnail |  | 0..1 | ED |
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@code |  | 1..1 | cs | Fixed Value: completed
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
effectiveTime | S | 0..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@value |  | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
@operator |  | 0..1 | cs | Binding: CDASetOperator (required)
low | S | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
center |  | 0..1 | TS |
width |  | 0..1 | PQ |
high | S | 0..1 | IVXB_TS |
priorityCode |  | 0..1 | CE | Binding: ActPriority (example)
repeatNumber |  | 0..1 | IVL_INT |
languageCode |  | 0..1 | CS | Binding: AllLanguages (required)
value | S | 1..* | CD |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@code |  | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951).
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
qualifier |  | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo - Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML.
translation |  | 0..* | CD |
interpretationCode |  | 0..* | CE | Binding: CDAObservationInterpretation (required)
methodCode |  | 0..* | CE | Binding: ObservationMethod (example)
targetSiteCode |  | 0..* | CD |
subject |  | 0..1 | Subject |
specimen |  | 0..* | Specimen |
performer |  | 0..* | Performer2 |
author |  | 0..* | Author |
informant |  | 0..* | Informant |
participant |  | 0..* | Participant2 |
Slices for entryRelationship | S | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, profile:act
entryRelationship:severity-entry | S | 0..1 | EntryRelationship |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ
@inversionInd |  | 1..1 | bl | Fixed Value: true
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 0..1 | Act |
encounter |  | 0..1 | Encounter |
observation |  | 1..1 | IHE_PCC_Severity_Entry |
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
entryRelationship:problem-status | S | 0..1 | EntryRelationship |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR
@inversionInd |  | 0..1 | bl | Fixed Value: false
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 0..1 | Act |
encounter |  | 0..1 | Encounter |
observation |  | 1..1 | IHE_Problem_Status_Observation |
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
entryRelationship:health-status | S | 0..1 | EntryRelationship |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR
@inversionInd |  | 0..1 | bl | Fixed Value: false
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 0..1 | Act |
encounter |  | 0..1 | Encounter |
observation | S | 1..1 | IHE_Health_Status_Observation |
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
reference |  | 0..* | Reference |
precondition |  | 0..* | Precondition |
sdtcPrecondition2 |  | 0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc)
referenceRange |  | 0..* | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: REFV
observationRange |  | 1..1 | ObservationRange |
sdtcInFulfillmentOf1 |  | 0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Observation.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.templateId:problem-obs.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.templateId:problem-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.classCode | Base | required | CDAActClassObservation | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.moodCode | Base | required | x_ActMoodDocumentObservation | 📍2.0.0 | THO v5.2
Observation.code | Base | example | ObservationType | 📦3.0.0 | THO v6.5
Observation.text.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.text.compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.text.integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2
Observation.text.mediaType | Base | example | MediaType | 📦3.0.0 | THO v6.5
Observation.text.representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5
Observation.statusCode.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.effectiveTime.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.effectiveTime.​operator | Base | required | CDASetOperator | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5
Observation.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std.
Observation.value.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.interpretationCode | Base | required | CDAObservationInterpretation | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.methodCode | Base | example | ObservationMethod | 📦3.0.0 | THO v6.5
Observation.entryRelationship:severity-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:severity-entry.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:severity-entry.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5
Observation.entryRelationship:problem-status.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:problem-status.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:problem-status.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5
Observation.entryRelationship:health-status.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:health-status.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:health-status.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5
Observation.referenceRange.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.referenceRange.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.referenceRange.​typeCode | Base | required | CDAActRelationshipType | 📦2.0.1-sd | Clinical Document Architecture v2.0

#### Constraints

Id | Grade | Path(s) | Description | Expression
II-1 | error | Observation.typeId, Observation.entryRelationship:severity-entry.typeId, Observation.entryRelationship:problem-status.typeId, Observation.entryRelationship:health-status.typeId, Observation.referenceRange.typeId | An II instance must have either a root or an nullFlavor. | `root.exists() or nullFlavor.exists()`
should-author | warning | Observation | SHOULD contain author | `author.exists()`
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value | `text.reference.value.exists()`
value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | `value.exists() implies value.startsWith('#')`

This structure is derived from Observation

Summary

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

Structures

This structure refers to these other structures:

- Severity Entry (https://profiles.ihe.net/PCC/PSCc/StructureDefinition/IHE.PCC.Severity.Entry)
- Problem Status Observation (https://profiles.ihe.net/PCC/PSCc/StructureDefinition/IHE.Problem.Status.Observation)
- Health Status (https://profiles.ihe.net/PCC/PSCc/StructureDefinition/IHE.Health.Status.Observation)

Slices

This structure defines the following Slices:

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

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation | C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value, should-author
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
Slices for templateId | S | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:problem-obs |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.1.28
@extension |  | 0..1 | st |
templateId:problem-entry |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.4.5
@extension |  | 0..1 | st |
@classCode |  | 1..1 | cs | Binding: CDAActClassObservation (required)
@moodCode |  | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN
@negationInd | S | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
id | S | 1..* | II |
sdtcCategory |  | 0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc)
code | S | 1..1 | CD | Binding: ObservationType (example)
derivationExpr |  | 0..1 | ST |
text | S | 1..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@compression |  | 0..1 | cs | Binding: CDACompressionAlgorithm (required)
@integrityCheck |  | 0..1 | bin |
@integrityCheckAlgorithm |  | 0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required)
@language |  | 0..1 | cs |
@mediaType |  | 0..1 | cs | Binding: MediaType (example)
@representation |  | 0..1 | cs | Binding: CDABinaryDataEncoding (required)
xmlText |  | 0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
reference | C | 0..1 | TEL | Constraints: value-starts-octothorpe
thumbnail |  | 0..1 | ED |
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@code |  | 1..1 | cs | Fixed Value: completed
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
effectiveTime | S | 0..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@value |  | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
@operator |  | 0..1 | cs | Binding: CDASetOperator (required)
low | S | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
center |  | 0..1 | TS |
width |  | 0..1 | PQ |
high | S | 0..1 | IVXB_TS |
priorityCode |  | 0..1 | CE | Binding: ActPriority (example)
repeatNumber |  | 0..1 | IVL_INT |
languageCode |  | 0..1 | CS | Binding: AllLanguages (required)
value | S | 1..* | CD |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@code |  | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951).
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
qualifier |  | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo - Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML.
translation |  | 0..* | CD |
interpretationCode |  | 0..* | CE | Binding: CDAObservationInterpretation (required)
methodCode |  | 0..* | CE | Binding: ObservationMethod (example)
targetSiteCode |  | 0..* | CD |
subject |  | 0..1 | Subject |
specimen |  | 0..* | Specimen |
performer |  | 0..* | Performer2 |
author |  | 0..* | Author |
informant |  | 0..* | Informant |
participant |  | 0..* | Participant2 |
Slices for entryRelationship | S | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, profile:act
entryRelationship:severity-entry | S | 0..1 | EntryRelationship |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ
@inversionInd |  | 1..1 | bl | Fixed Value: true
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 0..1 | Act |
encounter |  | 0..1 | Encounter |
observation |  | 1..1 | IHE_PCC_Severity_Entry |
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
entryRelationship:problem-status | S | 0..1 | EntryRelationship |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR
@inversionInd |  | 0..1 | bl | Fixed Value: false
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 0..1 | Act |
encounter |  | 0..1 | Encounter |
observation |  | 1..1 | IHE_Problem_Status_Observation |
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
entryRelationship:health-status | S | 0..1 | EntryRelationship |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR
@inversionInd |  | 0..1 | bl | Fixed Value: false
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 0..1 | Act |
encounter |  | 0..1 | Encounter |
observation | S | 1..1 | IHE_Health_Status_Observation |
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
reference |  | 0..* | Reference |
precondition |  | 0..* | Precondition |
sdtcPrecondition2 |  | 0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc)
referenceRange |  | 0..* | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: REFV
observationRange |  | 1..1 | ObservationRange |
sdtcInFulfillmentOf1 |  | 0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Observation.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.templateId:problem-obs.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.templateId:problem-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.classCode | Base | required | CDAActClassObservation | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.moodCode | Base | required | x_ActMoodDocumentObservation | 📍2.0.0 | THO v5.2
Observation.code | Base | example | ObservationType | 📦3.0.0 | THO v6.5
Observation.text.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.text.compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.text.integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2
Observation.text.mediaType | Base | example | MediaType | 📦3.0.0 | THO v6.5
Observation.text.representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5
Observation.statusCode.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.effectiveTime.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.effectiveTime.​operator | Base | required | CDASetOperator | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5
Observation.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std.
Observation.value.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.interpretationCode | Base | required | CDAObservationInterpretation | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.methodCode | Base | example | ObservationMethod | 📦3.0.0 | THO v6.5
Observation.entryRelationship:severity-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:severity-entry.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:severity-entry.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5
Observation.entryRelationship:problem-status.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:problem-status.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:problem-status.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5
Observation.entryRelationship:health-status.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:health-status.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:health-status.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5
Observation.referenceRange.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.referenceRange.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.referenceRange.​typeCode | Base | required | CDAActRelationshipType | 📦2.0.1-sd | Clinical Document Architecture v2.0

#### Constraints

Id | Grade | Path(s) | Description | Expression
II-1 | error | Observation.typeId, Observation.entryRelationship:severity-entry.typeId, Observation.entryRelationship:problem-status.typeId, Observation.entryRelationship:health-status.typeId, Observation.referenceRange.typeId | An II instance must have either a root or an nullFlavor. | `root.exists() or nullFlavor.exists()`
should-author | warning | Observation | SHOULD contain author | `author.exists()`
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value | `text.reference.value.exists()`
value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | `value.exists() implies value.startsWith('#')`

Differential View

This structure is derived from Observation

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation | C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value, should-author
Slices for templateId | S | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:problem-obs |  | 1..1 | II |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.1.28
templateId:problem-entry |  | 1..1 | II |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.4.5
@moodCode |  | 1..1 | cs | Fixed Value: EVN
@negationInd | S | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
id | S | 1..* | II |
code | S | 1..1 | CD |
text | S | 1..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry
reference | C | 0..1 | TEL | Constraints: value-starts-octothorpe
statusCode |  | 1..1 | CS |
@code |  | 1..1 | cs | Fixed Value: completed
effectiveTime | S | 0..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
low | S | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
high | S | 0..1 | IVXB_TS |
value | S | 1..* | CD |
@code |  | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951).
qualifier |  | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo - Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML.
Slices for entryRelationship | S | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, profile:act
entryRelationship:severity-entry | S | 0..1 | EntryRelationship |
@typeCode |  | 1..1 | cs | Fixed Value: SUBJ
@inversionInd |  | 1..1 | bl | Fixed Value: true
observation |  | 1..1 | IHE_PCC_Severity_Entry |
entryRelationship:problem-status | S | 0..1 | EntryRelationship |
@typeCode |  | 1..1 | cs | Fixed Value: REFR
@inversionInd |  | 0..1 | bl | Fixed Value: false
observation |  | 1..1 | IHE_Problem_Status_Observation |
entryRelationship:health-status | S | 0..1 | EntryRelationship |
@typeCode |  | 1..1 | cs | Fixed Value: REFR
@inversionInd |  | 0..1 | bl | Fixed Value: false
observation | S | 1..1 | IHE_Health_Status_Observation |
Documentation for this format

#### Constraints

Id | Grade | Path(s) | Description | Expression
should-author | warning | Observation | SHOULD contain author | `author.exists()`
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value | `text.reference.value.exists()`
value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | `value.exists() implies value.startsWith('#')`

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation | C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value, should-author
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
Slices for templateId | S | 2..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:problem-obs |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.1.28
@extension |  | 0..1 | st |
templateId:problem-entry |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.4.5
@extension |  | 0..1 | st |
@classCode |  | 1..1 | cs | Binding: CDAActClassObservation (required)
@moodCode |  | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN
@negationInd | S | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions.
id | S | 1..* | II |
sdtcCategory |  | 0..* | CD | XML Namespace: urn:hl7-org:sdtc XML: category (urn:hl7-org:sdtc)
code | S | 1..1 | CD | Binding: ObservationType (example)
derivationExpr |  | 0..1 | ST |
text | S | 1..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@compression |  | 0..1 | cs | Binding: CDACompressionAlgorithm (required)
@integrityCheck |  | 0..1 | bin |
@integrityCheckAlgorithm |  | 0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required)
@language |  | 0..1 | cs |
@mediaType |  | 0..1 | cs | Binding: MediaType (example)
@representation |  | 0..1 | cs | Binding: CDABinaryDataEncoding (required)
xmlText |  | 0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
reference | C | 0..1 | TEL | Constraints: value-starts-octothorpe
thumbnail |  | 0..1 | ED |
statusCode |  | 1..1 | CS | Binding: ActStatus (required)
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@code |  | 1..1 | cs | Fixed Value: completed
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
effectiveTime | S | 0..1 | IVL_TS | If the problem is known to be resolved, but the date of resolution is not known, then the high element **SHALL** be present, and the nullFlavor attribute **SHALL** be set to 'UNK'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved.
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@value |  | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
@operator |  | 0..1 | cs | Binding: CDASetOperator (required)
low | S | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
center |  | 0..1 | TS |
width |  | 0..1 | PQ |
high | S | 0..1 | IVXB_TS |
priorityCode |  | 0..1 | CE | Binding: ActPriority (example)
repeatNumber |  | 0..1 | IVL_INT |
languageCode |  | 0..1 | CS | Binding: AllLanguages (required)
value | S | 1..* | CD |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@code |  | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951).
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
qualifier |  | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo - Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML.
translation |  | 0..* | CD |
interpretationCode |  | 0..* | CE | Binding: CDAObservationInterpretation (required)
methodCode |  | 0..* | CE | Binding: ObservationMethod (example)
targetSiteCode |  | 0..* | CD |
subject |  | 0..1 | Subject |
specimen |  | 0..* | Specimen |
performer |  | 0..* | Performer2 |
author |  | 0..* | Author |
informant |  | 0..* | Informant |
participant |  | 0..* | Participant2 |
Slices for entryRelationship | S | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation, profile:act
entryRelationship:severity-entry | S | 0..1 | EntryRelationship |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ
@inversionInd |  | 1..1 | bl | Fixed Value: true
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 0..1 | Act |
encounter |  | 0..1 | Encounter |
observation |  | 1..1 | IHE_PCC_Severity_Entry |
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
entryRelationship:problem-status | S | 0..1 | EntryRelationship |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR
@inversionInd |  | 0..1 | bl | Fixed Value: false
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 0..1 | Act |
encounter |  | 0..1 | Encounter |
observation |  | 1..1 | IHE_Problem_Status_Observation |
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
entryRelationship:health-status | S | 0..1 | EntryRelationship |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR
@inversionInd |  | 0..1 | bl | Fixed Value: false
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 0..1 | Act |
encounter |  | 0..1 | Encounter |
observation | S | 1..1 | IHE_Health_Status_Observation |
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
reference |  | 0..* | Reference |
precondition |  | 0..* | Precondition |
sdtcPrecondition2 |  | 0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc)
referenceRange |  | 0..* | InfrastructureRoot |
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
realmCode |  | 0..* | CS |
typeId | C | 0..1 | II | Constraints: II-1
@nullFlavor |  | 0..1 | cs | Binding: CDANullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3
@extension |  | 1..1 | st |
templateId |  | 0..* | II |
@typeCode |  | 0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: REFV
observationRange |  | 1..1 | ObservationRange |
sdtcInFulfillmentOf1 |  | 0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Observation.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.templateId:problem-obs.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.templateId:problem-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.classCode | Base | required | CDAActClassObservation | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.moodCode | Base | required | x_ActMoodDocumentObservation | 📍2.0.0 | THO v5.2
Observation.code | Base | example | ObservationType | 📦3.0.0 | THO v6.5
Observation.text.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.text.compression | Base | required | CDACompressionAlgorithm | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.text.integrityCheckAlgorithm | Base | required | IntegrityCheckAlgorithm | 📍2.0.0 | THO v5.2
Observation.text.mediaType | Base | example | MediaType | 📦3.0.0 | THO v6.5
Observation.text.representation | Base | required | CDABinaryDataEncoding | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.statusCode | Base | required | ActStatus | 📦3.0.0 | THO v6.5
Observation.statusCode.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.effectiveTime.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.effectiveTime.​operator | Base | required | CDASetOperator | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.priorityCode | Base | example | ActPriority | 📦3.0.0 | THO v6.5
Observation.languageCode | Base | required | All Languages | 📦5.0.0 | FHIR Std.
Observation.value.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.interpretationCode | Base | required | CDAObservationInterpretation | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.methodCode | Base | example | ObservationMethod | 📦3.0.0 | THO v6.5
Observation.entryRelationship:severity-entry.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:severity-entry.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:severity-entry.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5
Observation.entryRelationship:problem-status.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:problem-status.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:problem-status.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5
Observation.entryRelationship:health-status.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:health-status.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.entryRelationship:health-status.​typeCode | Base | required | x_ActRelationshipEntryRelationship | 📦3.0.0 | THO v6.5
Observation.referenceRange.​nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.referenceRange.​typeId.nullFlavor | Base | required | CDANullFlavor | 📦2.0.1-sd | Clinical Document Architecture v2.0
Observation.referenceRange.​typeCode | Base | required | CDAActRelationshipType | 📦2.0.1-sd | Clinical Document Architecture v2.0

#### Constraints

Id | Grade | Path(s) | Description | Expression
II-1 | error | Observation.typeId, Observation.entryRelationship:severity-entry.typeId, Observation.entryRelationship:problem-status.typeId, Observation.entryRelationship:health-status.typeId, Observation.referenceRange.typeId | An II instance must have either a root or an nullFlavor. | `root.exists() or nullFlavor.exists()`
should-author | warning | Observation | SHOULD contain author | `author.exists()`
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value | `text.reference.value.exists()`
value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | `value.exists() implies value.startsWith('#')`

This structure is derived from Observation

Summary

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

Structures

This structure refers to these other structures:

- Severity Entry (https://profiles.ihe.net/PCC/PSCc/StructureDefinition/IHE.PCC.Severity.Entry)
- Problem Status Observation (https://profiles.ihe.net/PCC/PSCc/StructureDefinition/IHE.Problem.Status.Observation)
- Health Status (https://profiles.ihe.net/PCC/PSCc/StructureDefinition/IHE.Health.Status.Observation)

Slices

This structure defines the following Slices:

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

Other representations of profile: CSV, Excel