Consolidated CDA Release 2.1 StructureDefinition Prototype Publication
2.1.0-draft1 - CI Build
United States of America
Consolidated CDA Release 2.1 StructureDefinition Prototype Publication
2.1.0-draft1 - CI Build
United States of America
This page is part of the CCDA: Consolidated CDA Release (v2.1.0-draft1: CCDA 2.1 Draft) based on FHIR v5.0.0. . For a full list of available versions, see the Directory of published versions 
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.114 | Version: 2.1.0-draft1 | |||
| Active as of 2023-01-16 | Computable Name: LongitudinalCareWoundObservation | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.114:2015-08-01 | ||||
This template represents acquired or surgical wounds and is not intended to encompass all wound types. The template applies to wounds such as pressure ulcers, surgical incisions, and deep tissue injury wounds. Information in this template may include information about the wound measurements characteristics.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ProblemObservation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Observation | 1..1 | ProblemObservation | Base for all types and resources | |
  classCode | 1..1 | code | Required Pattern: OBS | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
  Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:secondary | 1..1 | II | ||
  root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.114 | |
  extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| code | 1..1 | CD | ||
| code | 1..1 | string | Required Pattern: ASSERTION | |
 codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.5.4 | |
| value | 1..1 | CD | Binding: Wound Type (preferred) | |
| Slices for targetSiteCode | 0..* | CD | Slice: Unordered, Open by | |
| targetSiteCode:targetSiteCode1 | 0..1 | CD | Binding: Body Site Value Set (preferred) | |
 qualifier | 0..* | CR | If targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality. | |
| name | 1..1 | CV | ||
| code | 1..1 | string | Required Pattern: 272741003 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
 value | 1..1 | CD | ||
| code | 1..1 | string | Binding: TargetSite Qualifiers (preferred) | |
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | Element | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage. Slice: Unordered, Open by profile:observation | |
 entryRelationship:woundMeasurementObservation | 0..* | Element | ||
 typeCode | 1..1 | Required Pattern: COMP | ||
| observation | 1..1 | WoundMeasurementObservation | ||
| entryRelationship:woundCharacteristic | 0..* | Element | ||
| typeCode | 1..1 | Required Pattern: COMP | ||
| observation | 1..1 | WoundCharacteristic | ||
| entryRelationship:numberofPressureUlcersObservation | 0..* | Element | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers. | |
| typeCode | 1..1 | Required Pattern: COMP | ||
| observation | 1..1 | NumberofPressureUlcersObservation | ||
| entryRelationship:highestPressureUlcerStage | 0..1 | Element | ||
| typeCode | 1..1 | Required Pattern: COMP | ||
| observation | 1..1 | HighestPressureUlcerStage | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.value | preferred | Wound Type |
| Observation.targetSiteCode:targetSiteCode1 | preferred | Body Site Value Set |
| Observation.targetSiteCode:targetSiteCode1.qualifier.value.code | preferred | TargetSite Qualifiers |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 1..1 | ProblemObservation | Base for all types and resources | |
 classCode | 1..1 | code | Binding: ActClassObservation (required) Required Pattern: OBS | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.4 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| templateId:secondary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.114 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred) |
| code | 1..1 | string | Required Pattern: ASSERTION | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.5.4 | |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| code | 1..1 | string | Required Pattern: completed | |
| effectiveTime | 1..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 | 1..1 | TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |
| value | 1..1 | CD | Binding: Wound Type (preferred) | |
| Slices for translation | 0..* | CD | Slice: Unordered, Open by | |
 translation:alt | 0..* | CD | ||
| Slices for targetSiteCode | 0..* | CD | Slice: Unordered, Open by | |
| targetSiteCode:targetSiteCode1 | 0..1 | CD | Binding: Body Site Value Set (preferred) | |
| qualifier | 0..* | CR | If targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality. | |
| name | 1..1 | CV | ||
| code | 1..1 | string | Required Pattern: 272741003 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
| value | 1..1 | CD | ||
| code | 1..1 | string | Binding: TargetSite Qualifiers (preferred) | |
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | C | 0..* | Element | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage. Slice: Unordered, Open by profile:observation |
| entryRelationship:age | C | 0..1 | Element | |
| typeCode | 1..1 | code | Required Pattern: SUBJ | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | AgeObservation | Base for all types and resources | |
| entryRelationship:prognosis | C | 0..1 | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | PrognosisObservation | Base for all types and resources | |
| entryRelationship:priority | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:status | C | 0..1 | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | ProblemStatus | Base for all types and resources | |
 entryRelationship:woundMeasurementObservation | C | 0..* | Element | |
| entryRelationship:woundCharacteristic | C | 0..* | Element | |
| entryRelationship:numberofPressureUlcersObservation | C | 0..* | Element | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers. |
| entryRelationship:highestPressureUlcerStage | C | 0..1 | Element | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Pattern: OBS |
| Observation.code | preferred | Problem Type (SNOMEDCT) |
| Observation.statusCode | required | ActStatus |
| Observation.value | preferred | Wound Type |
| Observation.targetSiteCode:targetSiteCode1 | preferred | Body Site Value Set |
| Observation.targetSiteCode:targetSiteCode1.qualifier.value.code | preferred | TargetSite Qualifiers |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32950 | error | Observation.code | If code is selected from ValueSet Problem Type (SNOMEDCT) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950) (CONF:1198-32950). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| obs-er-1 | error | Observation.entryRelationship, Observation.entryRelationship:age, Observation.entryRelationship:prognosis, Observation.entryRelationship:priority, Observation.entryRelationship:status, Observation.entryRelationship:woundMeasurementObservation, Observation.entryRelationship:woundCharacteristic, Observation.entryRelationship:numberofPressureUlcersObservation, Observation.entryRelationship:highestPressureUlcerStage | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 1..1 | ProblemObservation | Base for all types and resources | |
| classCode | 1..1 | code | Binding: ActClassObservation (required) Required Pattern: OBS | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| negationInd | 0..1 | boolean | 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. | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.4 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| templateId:secondary | 1..1 | II | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.114 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred) |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: ASSERTION | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.5.4 | |
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| qualifier | 0..* | CR | ||
| translation | 0..* | CD | ||
| derivationExpr | 0..1 | ED | ||
| text | 0..1 | ED | ||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: completed | |
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| effectiveTime | 1..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 | code | Binding: NullFlavor (required) | |
| value | 0..1 | dateTime | ||
| inclusive | 0..1 | boolean | ||
| operator | 0..1 | code | ||
| low | 1..1 | TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |
| high | 0..1 | TS | The effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved. | |
| width | 0..1 | PQ | ||
| center | 0..1 | TS | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| value | 1..1 | CD | Binding: Wound Type (preferred) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 0..1 | string | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | 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.
For example, SNOMED CT allows constructing concepts as a combination of multiple codes. SNOMED CT defines a concept "pneumonia (disorder)" (233604007) an attribute "finding site" (363698007) and another concept "left lower lobe of lung (body structure)" (41224006). SNOMED CT allows one to combine these codes in a code phrase, as shown in the sample XML. | |
| Slices for translation | 0..* | CD | Slice: Unordered, Open by | |
| translation:alt | 0..* | CD | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 0..1 | string | ||
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| qualifier | 0..* | CR | ||
| translation | 0..* | CD | ||
| interpretationCode | 0..* | CE | Binding: ObservationInterpretation (required) | |
| methodCode | 0..* | CE | Binding: ObservationMethod (extensible) | |
| Slices for targetSiteCode | 0..* | CD | Slice: Unordered, Open by | |
| targetSiteCode:targetSiteCode1 | 0..1 | CD | Binding: Body Site Value Set (preferred) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 0..1 | string | ||
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
 qualifier | 0..* | CR | If targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality. | |
 nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| inverted | 0..1 | boolean | ||
| name | 1..1 | CV | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: 272741003 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| value | 1..1 | CD | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Binding: TargetSite Qualifiers (preferred) | |
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| qualifier | 0..* | CR | ||
| translation | 0..* | CD | ||
| translation | 0..* | CD | ||
 subject | 0..1 | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| awarenessCode | 0..1 | CE | Binding: TargetAwareness (extensible) | |
| relatedSubject | 1..1 | RelatedSubject | ||
| specimen | 0..* | Specimen | ||
| performer | 0..* | Performer2 | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| informant | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 0..1 | RelatedEntity | ||
| participant | 0..* | Participant2 | ||
| Slices for entryRelationship | C | 0..* | Element | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage. Slice: Unordered, Open by profile:observation |
| entryRelationship:age | C | 0..1 | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: SUBJ | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | AgeObservation | Base for all types and resources | |
| entryRelationship:prognosis | C | 0..1 | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | PrognosisObservation | Base for all types and resources | |
| entryRelationship:priority | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:status | C | 0..1 | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | ProblemStatus | Base for all types and resources | |
| entryRelationship:woundMeasurementObservation | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| entryRelationship:woundCharacteristic | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| entryRelationship:numberofPressureUlcersObservation | C | 0..* | Element | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers. |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| entryRelationship:highestPressureUlcerStage | C | 0..1 | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| seperatableInd | 0..1 | BL | ||
| externalAct | 0..1 | ExternalAct | ||
| externalObservation | 0..1 | ExternalObservation | ||
| externalProcedure | 0..1 | ExternalProcedure | ||
| externalDocument | 0..1 | ExternalDocument | ||
| precondition | 0..* | Precondition | ||
| referenceRange | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ActRelationshipPertains (required) Fixed Value: REFV | |
| observationRange | 1..1 | ObservationRange | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Pattern: OBS |
| Observation.templateId:primary.nullFlavor | required | NullFlavor |
| Observation.templateId:secondary.nullFlavor | required | NullFlavor |
| Observation.code | preferred | Problem Type (SNOMEDCT) |
| Observation.code.nullFlavor | required | NullFlavor |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.nullFlavor | required | NullFlavor |
| Observation.effectiveTime.nullFlavor | required | NullFlavor |
| Observation.priorityCode | extensible | ActPriority |
| Observation.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Observation.value | preferred | Wound Type |
| Observation.value.nullFlavor | required | NullFlavor |
| Observation.value.translation:alt.nullFlavor | required | NullFlavor |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | extensible | ObservationMethod |
| Observation.targetSiteCode:targetSiteCode1 | preferred | Body Site Value Set |
| Observation.targetSiteCode:targetSiteCode1.nullFlavor | required | NullFlavor |
| Observation.targetSiteCode:targetSiteCode1.qualifier.nullFlavor | required | NullFlavor |
| Observation.targetSiteCode:targetSiteCode1.qualifier.name.nullFlavor | required | NullFlavor |
| Observation.targetSiteCode:targetSiteCode1.qualifier.value.nullFlavor | required | NullFlavor |
| Observation.targetSiteCode:targetSiteCode1.qualifier.value.code | preferred | TargetSite Qualifiers |
| Observation.subject.typeCode | required | Fixed Value: SBJ |
| Observation.subject.contextControlCode | required | Fixed Value: OP |
| Observation.subject.awarenessCode | extensible | TargetAwareness |
| Observation.informant.typeCode | required | Fixed Value: INF |
| Observation.informant.contextControlCode | required | Fixed Value: OP |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32950 | error | Observation.code | If code is selected from ValueSet Problem Type (SNOMEDCT) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950) (CONF:1198-32950). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-er-1 | error | Observation.entryRelationship, Observation.entryRelationship:age, Observation.entryRelationship:prognosis, Observation.entryRelationship:priority, Observation.entryRelationship:status, Observation.entryRelationship:woundMeasurementObservation, Observation.entryRelationship:woundCharacteristic, Observation.entryRelationship:numberofPressureUlcersObservation, Observation.entryRelationship:highestPressureUlcerStage | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
This structure is derived from ProblemObservation
Summary
Mandatory: 9 elements (13 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from ProblemObservation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 1..1 | ProblemObservation | Base for all types and resources | |
| classCode | 1..1 | code | Required Pattern: OBS | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:secondary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.114 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| code | 1..1 | CD | ||
| code | 1..1 | string | Required Pattern: ASSERTION | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.5.4 | |
| value | 1..1 | CD | Binding: Wound Type (preferred) | |
| Slices for targetSiteCode | 0..* | CD | Slice: Unordered, Open by | |
| targetSiteCode:targetSiteCode1 | 0..1 | CD | Binding: Body Site Value Set (preferred) | |
| qualifier | 0..* | CR | If targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality. | |
| name | 1..1 | CV | ||
| code | 1..1 | string | Required Pattern: 272741003 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
| value | 1..1 | CD | ||
| code | 1..1 | string | Binding: TargetSite Qualifiers (preferred) | |
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | Element | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage. Slice: Unordered, Open by profile:observation | |
| entryRelationship:woundMeasurementObservation | 0..* | Element | ||
| typeCode | 1..1 | Required Pattern: COMP | ||
| observation | 1..1 | WoundMeasurementObservation | ||
| entryRelationship:woundCharacteristic | 0..* | Element | ||
| typeCode | 1..1 | Required Pattern: COMP | ||
| observation | 1..1 | WoundCharacteristic | ||
| entryRelationship:numberofPressureUlcersObservation | 0..* | Element | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers. | |
| typeCode | 1..1 | Required Pattern: COMP | ||
| observation | 1..1 | NumberofPressureUlcersObservation | ||
| entryRelationship:highestPressureUlcerStage | 0..1 | Element | ||
| typeCode | 1..1 | Required Pattern: COMP | ||
| observation | 1..1 | HighestPressureUlcerStage | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.value | preferred | Wound Type |
| Observation.targetSiteCode:targetSiteCode1 | preferred | Body Site Value Set |
| Observation.targetSiteCode:targetSiteCode1.qualifier.value.code | preferred | TargetSite Qualifiers |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 1..1 | ProblemObservation | Base for all types and resources | |
| classCode | 1..1 | code | Binding: ActClassObservation (required) Required Pattern: OBS | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.4 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| templateId:secondary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.114 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred) |
| code | 1..1 | string | Required Pattern: ASSERTION | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.5.4 | |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| code | 1..1 | string | Required Pattern: completed | |
| effectiveTime | 1..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 | 1..1 | TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |
| value | 1..1 | CD | Binding: Wound Type (preferred) | |
| Slices for translation | 0..* | CD | Slice: Unordered, Open by | |
| translation:alt | 0..* | CD | ||
| Slices for targetSiteCode | 0..* | CD | Slice: Unordered, Open by | |
| targetSiteCode:targetSiteCode1 | 0..1 | CD | Binding: Body Site Value Set (preferred) | |
| qualifier | 0..* | CR | If targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality. | |
| name | 1..1 | CV | ||
| code | 1..1 | string | Required Pattern: 272741003 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
| value | 1..1 | CD | ||
| code | 1..1 | string | Binding: TargetSite Qualifiers (preferred) | |
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | C | 0..* | Element | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage. Slice: Unordered, Open by profile:observation |
| entryRelationship:age | C | 0..1 | Element | |
| typeCode | 1..1 | code | Required Pattern: SUBJ | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | AgeObservation | Base for all types and resources | |
| entryRelationship:prognosis | C | 0..1 | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | PrognosisObservation | Base for all types and resources | |
| entryRelationship:priority | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:status | C | 0..1 | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | ProblemStatus | Base for all types and resources | |
| entryRelationship:woundMeasurementObservation | C | 0..* | Element | |
| entryRelationship:woundCharacteristic | C | 0..* | Element | |
| entryRelationship:numberofPressureUlcersObservation | C | 0..* | Element | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers. |
| entryRelationship:highestPressureUlcerStage | C | 0..1 | Element | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Pattern: OBS |
| Observation.code | preferred | Problem Type (SNOMEDCT) |
| Observation.statusCode | required | ActStatus |
| Observation.value | preferred | Wound Type |
| Observation.targetSiteCode:targetSiteCode1 | preferred | Body Site Value Set |
| Observation.targetSiteCode:targetSiteCode1.qualifier.value.code | preferred | TargetSite Qualifiers |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32950 | error | Observation.code | If code is selected from ValueSet Problem Type (SNOMEDCT) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950) (CONF:1198-32950). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| obs-er-1 | error | Observation.entryRelationship, Observation.entryRelationship:age, Observation.entryRelationship:prognosis, Observation.entryRelationship:priority, Observation.entryRelationship:status, Observation.entryRelationship:woundMeasurementObservation, Observation.entryRelationship:woundCharacteristic, Observation.entryRelationship:numberofPressureUlcersObservation, Observation.entryRelationship:highestPressureUlcerStage | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 1..1 | ProblemObservation | Base for all types and resources | |
| classCode | 1..1 | code | Binding: ActClassObservation (required) Required Pattern: OBS | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| negationInd | 0..1 | boolean | 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. | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.4 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| templateId:secondary | 1..1 | II | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.114 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred) |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: ASSERTION | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.5.4 | |
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| qualifier | 0..* | CR | ||
| translation | 0..* | CD | ||
| derivationExpr | 0..1 | ED | ||
| text | 0..1 | ED | ||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: completed | |
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| effectiveTime | 1..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 | code | Binding: NullFlavor (required) | |
| value | 0..1 | dateTime | ||
| inclusive | 0..1 | boolean | ||
| operator | 0..1 | code | ||
| low | 1..1 | TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |
| high | 0..1 | TS | The effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved. | |
| width | 0..1 | PQ | ||
| center | 0..1 | TS | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| value | 1..1 | CD | Binding: Wound Type (preferred) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 0..1 | string | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | 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.
For example, SNOMED CT allows constructing concepts as a combination of multiple codes. SNOMED CT defines a concept "pneumonia (disorder)" (233604007) an attribute "finding site" (363698007) and another concept "left lower lobe of lung (body structure)" (41224006). SNOMED CT allows one to combine these codes in a code phrase, as shown in the sample XML. | |
| Slices for translation | 0..* | CD | Slice: Unordered, Open by | |
| translation:alt | 0..* | CD | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 0..1 | string | ||
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| qualifier | 0..* | CR | ||
| translation | 0..* | CD | ||
| interpretationCode | 0..* | CE | Binding: ObservationInterpretation (required) | |
| methodCode | 0..* | CE | Binding: ObservationMethod (extensible) | |
| Slices for targetSiteCode | 0..* | CD | Slice: Unordered, Open by | |
| targetSiteCode:targetSiteCode1 | 0..1 | CD | Binding: Body Site Value Set (preferred) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 0..1 | string | ||
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| qualifier | 0..* | CR | If targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality. | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| inverted | 0..1 | boolean | ||
| name | 1..1 | CV | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: 272741003 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| value | 1..1 | CD | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Binding: TargetSite Qualifiers (preferred) | |
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| qualifier | 0..* | CR | ||
| translation | 0..* | CD | ||
| translation | 0..* | CD | ||
| subject | 0..1 | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| awarenessCode | 0..1 | CE | Binding: TargetAwareness (extensible) | |
| relatedSubject | 1..1 | RelatedSubject | ||
| specimen | 0..* | Specimen | ||
| performer | 0..* | Performer2 | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| informant | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 0..1 | RelatedEntity | ||
| participant | 0..* | Participant2 | ||
| Slices for entryRelationship | C | 0..* | Element | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage. Slice: Unordered, Open by profile:observation |
| entryRelationship:age | C | 0..1 | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: SUBJ | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | AgeObservation | Base for all types and resources | |
| entryRelationship:prognosis | C | 0..1 | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | PrognosisObservation | Base for all types and resources | |
| entryRelationship:priority | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:status | C | 0..1 | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | ProblemStatus | Base for all types and resources | |
| entryRelationship:woundMeasurementObservation | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| entryRelationship:woundCharacteristic | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| entryRelationship:numberofPressureUlcersObservation | C | 0..* | Element | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers. |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| entryRelationship:highestPressureUlcerStage | C | 0..1 | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| seperatableInd | 0..1 | BL | ||
| externalAct | 0..1 | ExternalAct | ||
| externalObservation | 0..1 | ExternalObservation | ||
| externalProcedure | 0..1 | ExternalProcedure | ||
| externalDocument | 0..1 | ExternalDocument | ||
| precondition | 0..* | Precondition | ||
| referenceRange | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ActRelationshipPertains (required) Fixed Value: REFV | |
| observationRange | 1..1 | ObservationRange | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Pattern: OBS |
| Observation.templateId:primary.nullFlavor | required | NullFlavor |
| Observation.templateId:secondary.nullFlavor | required | NullFlavor |
| Observation.code | preferred | Problem Type (SNOMEDCT) |
| Observation.code.nullFlavor | required | NullFlavor |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.nullFlavor | required | NullFlavor |
| Observation.effectiveTime.nullFlavor | required | NullFlavor |
| Observation.priorityCode | extensible | ActPriority |
| Observation.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Observation.value | preferred | Wound Type |
| Observation.value.nullFlavor | required | NullFlavor |
| Observation.value.translation:alt.nullFlavor | required | NullFlavor |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | extensible | ObservationMethod |
| Observation.targetSiteCode:targetSiteCode1 | preferred | Body Site Value Set |
| Observation.targetSiteCode:targetSiteCode1.nullFlavor | required | NullFlavor |
| Observation.targetSiteCode:targetSiteCode1.qualifier.nullFlavor | required | NullFlavor |
| Observation.targetSiteCode:targetSiteCode1.qualifier.name.nullFlavor | required | NullFlavor |
| Observation.targetSiteCode:targetSiteCode1.qualifier.value.nullFlavor | required | NullFlavor |
| Observation.targetSiteCode:targetSiteCode1.qualifier.value.code | preferred | TargetSite Qualifiers |
| Observation.subject.typeCode | required | Fixed Value: SBJ |
| Observation.subject.contextControlCode | required | Fixed Value: OP |
| Observation.subject.awarenessCode | extensible | TargetAwareness |
| Observation.informant.typeCode | required | Fixed Value: INF |
| Observation.informant.contextControlCode | required | Fixed Value: OP |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32950 | error | Observation.code | If code is selected from ValueSet Problem Type (SNOMEDCT) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950) (CONF:1198-32950). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-er-1 | error | Observation.entryRelationship, Observation.entryRelationship:age, Observation.entryRelationship:prognosis, Observation.entryRelationship:priority, Observation.entryRelationship:status, Observation.entryRelationship:woundMeasurementObservation, Observation.entryRelationship:woundCharacteristic, Observation.entryRelationship:numberofPressureUlcersObservation, Observation.entryRelationship:highestPressureUlcerStage | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
This structure is derived from ProblemObservation
Summary
Mandatory: 9 elements (13 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#2.1.0-draft1 based on FHIR 5.0.0-snapshot3. Generated 2023-01-16
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