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

Resource Profile: Sensory Status

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.127 Version: 2.1.0-draft1
Active as of 2023-01-16 Computable Name: SensoryStatus
Other Identifiers: id: urn:oid:2.16.840.1.113883.10.20.22.4.127

This template represents a patient’s sensory or speech ability. It may contain an assessment scale observations related to the sensory or speech ability.

Usage:

Formal Views of Profile Content

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

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationBase for all types and resources
... classCode 1..1codeRequired Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.127
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: completed
... effectiveTime 1..1IVL_TS
.... low 1..1TSThe effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
.... high 0..1TSThe effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved.
... value 1..1CDBinding: Mental and Functional Status Response (preferred)
... author 0..*AuthorParticipationBase for all types and resources
... Slices for entryRelationship 0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:assessmentScaleObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... observation 1..1AssessmentScaleObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.codepreferredSensory Status Problem Type
Observation.valuepreferredMental and Functional Status Response
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationBase for all types and resources
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.127
... statusCode 1..1CSBinding: ActStatus (required)
.... code 1..1stringRequired Pattern: completed
... effectiveTime 1..1IVL_TS
.... low 1..1TSThe effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
.... high 0..1TSThe effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved.
... value 1..1CDBinding: Mental and Functional Status Response (preferred)
... author 0..*AuthorParticipationBase for all types and resources
... Slices for entryRelationship C0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
.... entryRelationship:assessmentScaleObservation C0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... contextConductionInd 1..1boolean
..... observation 1..1AssessmentScaleObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredPattern: OBS
Observation.codepreferredSensory Status Problem Type
Observation.statusCoderequiredActStatus
Observation.valuepreferredMental and Functional Status Response

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
obs-er-1errorObservation.entryRelationship, Observation.entryRelationship:assessmentScaleObservationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationBase for all types and resources
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... negationInd 0..1boolean
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 0..*IISlice: Unordered, Open by value:root
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.127
..... extension 0..1string
... id 0..*II
... code 1..1CDBinding: Sensory Status Problem Type (preferred)
... derivationExpr 0..1ED
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: completed
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 1..1IVL_TS
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... value 0..1dateTime
.... inclusive 0..1boolean
.... operator 0..1code
.... low 1..1TSThe effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
.... high 0..1TSThe effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved.
.... width 0..1PQ
.... center 0..1TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 1..1CDBinding: Mental and Functional Status Response (preferred)
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..*CEBinding: ObservationMethod (extensible)
... targetSiteCode 0..*CD
... subject 0..1Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*AuthorParticipationBase for all types and resources
... informant 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... Slices for entryRelationship C0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1code
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entryRelationship:assessmentScaleObservation C0..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1AssessmentScaleObservationBase for all types and resources
... reference 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition
... referenceRange 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredPattern: OBS
Observation.templateId:primary.nullFlavorrequiredNullFlavor
Observation.codepreferredSensory Status Problem Type
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.effectiveTime.nullFlavorrequiredNullFlavor
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Observation.valuepreferredMental and Functional Status Response
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeextensibleObservationMethod
Observation.subject.typeCoderequiredFixed Value: SBJ
Observation.subject.contextControlCoderequiredFixed Value: OP
Observation.subject.awarenessCodeextensibleTargetAwareness
Observation.informant.typeCoderequiredFixed Value: INF
Observation.informant.contextControlCoderequiredFixed Value: OP
Observation.referenceRange.typeCoderequiredFixed Value: REFV

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
obs-er-1errorObservation.entryRelationship, Observation.entryRelationship:assessmentScaleObservationOnly 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 CDAR2.Observation

Summary

Mandatory: 10 elements (2 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Observation.templateId is sliced based on the value of value:root
  • The element Observation.entryRelationship is sliced based on the value of profile:observation

Differential View

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationBase for all types and resources
... classCode 1..1codeRequired Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.127
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: completed
... effectiveTime 1..1IVL_TS
.... low 1..1TSThe effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
.... high 0..1TSThe effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved.
... value 1..1CDBinding: Mental and Functional Status Response (preferred)
... author 0..*AuthorParticipationBase for all types and resources
... Slices for entryRelationship 0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:assessmentScaleObservation 0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... observation 1..1AssessmentScaleObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.codepreferredSensory Status Problem Type
Observation.valuepreferredMental and Functional Status Response

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationBase for all types and resources
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.127
... statusCode 1..1CSBinding: ActStatus (required)
.... code 1..1stringRequired Pattern: completed
... effectiveTime 1..1IVL_TS
.... low 1..1TSThe effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
.... high 0..1TSThe effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved.
... value 1..1CDBinding: Mental and Functional Status Response (preferred)
... author 0..*AuthorParticipationBase for all types and resources
... Slices for entryRelationship C0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
.... entryRelationship:assessmentScaleObservation C0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... contextConductionInd 1..1boolean
..... observation 1..1AssessmentScaleObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredPattern: OBS
Observation.codepreferredSensory Status Problem Type
Observation.statusCoderequiredActStatus
Observation.valuepreferredMental and Functional Status Response

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
obs-er-1errorObservation.entryRelationship, Observation.entryRelationship:assessmentScaleObservationOnly 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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationBase for all types and resources
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... negationInd 0..1boolean
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 0..*IISlice: Unordered, Open by value:root
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.127
..... extension 0..1string
... id 0..*II
... code 1..1CDBinding: Sensory Status Problem Type (preferred)
... derivationExpr 0..1ED
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: completed
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 1..1IVL_TS
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... value 0..1dateTime
.... inclusive 0..1boolean
.... operator 0..1code
.... low 1..1TSThe effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
.... high 0..1TSThe effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved.
.... width 0..1PQ
.... center 0..1TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 1..1CDBinding: Mental and Functional Status Response (preferred)
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..*CEBinding: ObservationMethod (extensible)
... targetSiteCode 0..*CD
... subject 0..1Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*AuthorParticipationBase for all types and resources
... informant 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... Slices for entryRelationship C0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1code
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entryRelationship:assessmentScaleObservation C0..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1AssessmentScaleObservationBase for all types and resources
... reference 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition
... referenceRange 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredPattern: OBS
Observation.templateId:primary.nullFlavorrequiredNullFlavor
Observation.codepreferredSensory Status Problem Type
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.effectiveTime.nullFlavorrequiredNullFlavor
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Observation.valuepreferredMental and Functional Status Response
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeextensibleObservationMethod
Observation.subject.typeCoderequiredFixed Value: SBJ
Observation.subject.contextControlCoderequiredFixed Value: OP
Observation.subject.awarenessCodeextensibleTargetAwareness
Observation.informant.typeCoderequiredFixed Value: INF
Observation.informant.contextControlCoderequiredFixed Value: OP
Observation.referenceRange.typeCoderequiredFixed Value: REFV

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
obs-er-1errorObservation.entryRelationship, Observation.entryRelationship:assessmentScaleObservationOnly 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 CDAR2.Observation

Summary

Mandatory: 10 elements (2 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Observation.templateId is sliced based on the value of value:root
  • The element Observation.entryRelationship is sliced based on the value of profile:observation

 

​Other representations of profile: CSV, Excel, Schematron