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/2.16.840.1.113883.10.20.22.4.13 | Version: 2.1.0-draft1 | |||
| Active as of 2023-01-16 | Computable Name: ProcedureActivityObservation | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.13:2014-06-09 | ||||
The common notion of procedure is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g., splenectomy).
This template represents procedures that result in new information about the patient that cannot be classified as a procedure according to the HL7 RIM. Examples of these procedures are diagnostic imaging procedures, EEGs, and EKGs.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Observation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Observation | 1..1 | CDAR2.Observation | 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:primary | 1..1 | II | ||
  root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.13 | |
  extension | 1..1 | string | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | 1098-19202: This @code **SHOULD** be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19202). |
 originalText | 0..1 | ED | ||
| reference | 0..1 | TEL | ||
 value | C | 0..1 | uri | 1098-19201: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-19201). |
| statusCode | 1..1 | CS | ||
| code | 1..1 | string | Binding: ProcedureAct statusCode (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (required) | |
| value | 1..1 | BL, ED, ED, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | ||
| nullFlavor | 0..1 | If nothing is appropriate for value, use an appropriate nullFlavor. | ||
| methodCode | C | 0..1 | CE | 1098-8249: MethodCode **SHALL NOT** conflict with the method inherent in Observation / code (CONF:1098-8249). |
| targetSiteCode | 0..* | CD | Binding: Body Site Value Set (required) | |
| performer | 0..* | Performer2 | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | ||
| addr | 1..* | AD | ||
| telecom | 1..* | TEL | ||
| representedOrganization | 0..1 | Organization | ||
| id | 0..* | II | ||
| name | 0..* | ON | ||
| telecom | 1..1 | TEL | ||
| addr | 1..1 | AD | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:typeCode, value:participantRole | |
| participant:location | 0..* | Participant2 | ||
| typeCode | 1..1 | code | Required Pattern: LOC | |
| participantRole | 1..1 | ServiceDeliveryLocation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | Element | Slice: Unordered, Open by profile:encounter, profile:act, profile:observation, profile:substanceAdministration | |
 entryRelationship:encounter | 0..* | Element | ||
 typeCode | 1..1 | code | Required Pattern: COMP | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
 encounter | 1..1 | Encounter | ||
| classCode | 1..1 | code | Required Pattern: ENC | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| id | C | 1..1 | II | 1098-16847: Set encounter/id to the id of an encounter in another section to signify they are the same encounter (CONF:1098-16847). |
| entryRelationship:instruction | 0..1 | Element | ||
| typeCode | 1..1 | code | Required Pattern: SUBJ | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:indication | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: RSON | |
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:medication | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: COMP | |
| substanceAdministration | 1..1 | MedicationActivity | Base for all types and resources | |
| entryRelationship:reaction | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: COMP | |
| observation | 1..1 | ReactionObservation | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.statusCode.code | required | ProcedureAct statusCode |
| Observation.priorityCode | required | ActPriority |
| Observation.targetSiteCode | required | Body Site Value Set |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-8249 | error | Observation.methodCode | MethodCode **SHALL NOT** conflict with the method inherent in Observation / code (CONF:1098-8249). : | |
| 1098-16847 | warning | Observation.entryRelationship:encounter.encounter.id | Set encounter/id to the id of an encounter in another section to signify they are the same encounter (CONF:1098-16847). : | |
| 1098-19201 | error | Observation.code.originalText.reference.value | This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-19201). : | |
| 1098-19202 | warning | Observation.code | This @code **SHOULD** be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19202). : |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 1..1 | CDAR2.Observation | 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: 2.16.840.1.113883.10.20.22.4.13 | |
| extension | 1..1 | string | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: ObservationType (extensible) 1098-19202: This @code **SHOULD** be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19202). |
| originalText | 0..1 | ED | ||
| reference | 0..1 | TEL | ||
| value | C | 0..1 | uri | 1098-19201: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-19201). |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| code | 1..1 | string | Binding: ProcedureAct statusCode (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (required) | |
 value | 1..1 | |||
 value | BL | |||
| value | ED | |||
| value | ED | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| value | RTO_PQ_PQ | |||
| methodCode | C | 0..1 | CE | Binding: ObservationMethod (extensible) 1098-8249: MethodCode **SHALL NOT** conflict with the method inherent in Observation / code (CONF:1098-8249). |
| targetSiteCode | 0..* | CD | Binding: Body Site Value Set (required) | |
| performer | 0..* | Performer2 | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id | 1..* | II | ||
| addr | 1..* | AD | ||
| telecom | 1..* | TEL | ||
| representedOrganization | 0..1 | Organization | ||
| classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| id | 0..* | II | ||
| name | 0..* | ON | ||
| telecom | 1..1 | TEL | ||
| addr | 1..1 | AD | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:typeCode, value:participantRole | |
| participant:location | 0..* | Participant2 | ||
| typeCode | 1..1 | code | Binding: ParticipationType (required) Required Pattern: LOC | |
| participantRole | 1..1 | ServiceDeliveryLocation | Base for all types and resources | |
| Slices for entryRelationship | C | 0..* | Element | Slice: Unordered, Open by profile:encounter, profile:act, profile:observation, profile:substanceAdministration |
| entryRelationship:All Slices | Content/Rules for all slices | |||
 typeCode | 1..1 | code | ||
 contextConductionInd | 1..1 | boolean | ||
| entryRelationship:encounter | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| contextConductionInd | 1..1 | boolean | ||
| encounter | 1..1 | Encounter | ||
| entryRelationship:instruction | C | 0..1 | Element | |
| typeCode | 1..1 | code | Required Pattern: SUBJ | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:indication | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: RSON | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:medication | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| contextConductionInd | 1..1 | boolean | ||
| substanceAdministration | C | 1..1 | MedicationActivity | Base for all types and resources |
| entryRelationship:reaction | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | ReactionObservation | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Pattern: OBS |
| Observation.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.code | required | ProcedureAct statusCode |
| Observation.priorityCode | required | ActPriority |
| Observation.methodCode | extensible | ObservationMethod |
| Observation.targetSiteCode | required | Body Site Value Set |
| Observation.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| Observation.performer.assignedEntity.representedOrganization.classCode | required | Fixed Value: ORG |
| Observation.performer.assignedEntity.representedOrganization.determinerCode | required | Fixed Value: INSTANCE |
| Observation.participant:location.typeCode | required | Pattern: LOC |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-8249 | error | Observation.methodCode | MethodCode **SHALL NOT** conflict with the method inherent in Observation / code (CONF:1098-8249). : | |
| 1098-19201 | error | Observation.code.originalText.reference.value | This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-19201). : | |
| 1098-19202 | warning | Observation.code | This @code **SHOULD** be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19202). : | |
| 1098-30800 | warning | Observation.entryRelationship:medication.substanceAdministration | Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800). : | |
| 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:encounter, Observation.entryRelationship:instruction, Observation.entryRelationship:indication, Observation.entryRelationship:medication, Observation.entryRelationship:reaction | 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 | CDAR2.Observation | 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 | ||
| 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: 2.16.840.1.113883.10.20.22.4.13 | |
| extension | 1..1 | string | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: ObservationType (extensible) 1098-19202: This @code **SHOULD** be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19202). |
| 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 | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| charset | 0..1 | code | ||
| compression | 0..1 | code | Binding: CompressionAlgorithm (required) | |
| integrityCheck | 0..1 | base64Binary | ||
| integrityCheckAlgorithm | 0..1 | code | Binding: IntegrityCheckAlgorithm (required) | |
| language | 0..1 | code | ||
| mediaType | 0..1 | code | ||
| representation | 0..1 | code | ||
| data[x] | 0..1 | |||
| dataString | string | |||
| dataBase64Binary | base64Binary | |||
| reference | 0..1 | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | C | 0..1 | uri | 1098-19201: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-19201). |
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..* | code | Binding: AddressUse (required) | |
| thumbnail | 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 | Binding: ProcedureAct statusCode (required) | |
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| effectiveTime | 0..1 | IVL_TS | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (required) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| value | 1..1 | |||
| value:All Types | Content/Rules for all Types | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| value | BL | |||
| value | ED | |||
| value | ED | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| value | RTO_PQ_PQ | |||
| interpretationCode | 0..* | CE | Binding: ObservationInterpretation (required) | |
| methodCode | C | 0..1 | CE | Binding: ObservationMethod (extensible) 1098-8249: MethodCode **SHALL NOT** conflict with the method inherent in Observation / code (CONF:1098-8249). |
| targetSiteCode | 0..* | CD | Binding: Body Site Value Set (required) | |
| 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 | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | cs | Binding: ParticipationPhysicalPerformer (required) Fixed Value: PRF | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| functionCode | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc | |
| time | 0..1 | IVL_TS | ||
| modeCode | 0..1 | CE | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
| addr | 1..* | AD | ||
| telecom | 1..* | TEL | ||
| assignedPerson | 0..1 | Person | ||
| representedOrganization | 0..1 | Organization | ||
| classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| name | 0..* | ON | ||
| telecom | 1..1 | TEL | ||
| addr | 1..1 | AD | ||
| standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible) | |
| asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
| 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 | ||
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:typeCode, value:participantRole | |
| participant:location | 0..* | Participant2 | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 1..1 | code | Binding: ParticipationType (required) Required Pattern: LOC | |
| contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| sdtcFunctionCode | 0..1 | CE | XML: functionCode (urn:hl7-org:sdtc) | |
| time | 0..1 | IVL_TS | ||
| awarenessCode | 0..1 | CE | ||
| participantRole | 1..1 | ServiceDeliveryLocation | Base for all types and resources | |
| Slices for entryRelationship | C | 0..* | Element | Slice: Unordered, Open by profile:encounter, profile:act, profile:observation, profile:substanceAdministration |
| entryRelationship:All Slices | Content/Rules for all slices | |||
| 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 | ||
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| (Choice of one) | 1..1 | |||
| observation | 0..1 | Observation | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| observationMedia | 0..1 | ObservationMedia | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| procedure | 0..1 | Procedure | ||
| encounter | 0..1 | Encounter | ||
| organizer | 0..1 | Organizer | ||
| act | 0..1 | Act | ||
| entryRelationship:encounter | 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: COMP | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| encounter | 1..1 | Encounter | ||
| entryRelationship:instruction | 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 | ||
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:indication | 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: RSON | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:medication | 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: COMP | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| substanceAdministration | C | 1..1 | MedicationActivity | Base for all types and resources |
| entryRelationship:reaction | 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: COMP | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | ReactionObservation | Base for all types and resources | |
| 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.code | extensible | ObservationType |
| Observation.code.nullFlavor | required | NullFlavor |
| Observation.code.originalText.nullFlavor | required | NullFlavor |
| Observation.code.originalText.compression | required | CompressionAlgorithm |
| Observation.code.originalText.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
| Observation.code.originalText.reference.nullFlavor | required | NullFlavor |
| Observation.code.originalText.reference.use | required | AddressUse |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.nullFlavor | required | NullFlavor |
| Observation.statusCode.code | required | ProcedureAct statusCode |
| Observation.priorityCode | required | ActPriority |
| Observation.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | extensible | ObservationMethod |
| Observation.targetSiteCode | required | Body Site Value Set |
| Observation.subject.typeCode | required | Fixed Value: SBJ |
| Observation.subject.contextControlCode | required | Fixed Value: OP |
| Observation.subject.awarenessCode | extensible | TargetAwareness |
| Observation.performer.nullFlavor | required | NullFlavor |
| Observation.performer.typeCode | required | Fixed Value: PRF |
| Observation.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| Observation.performer.assignedEntity.code | extensible | RoleCode |
| Observation.performer.assignedEntity.representedOrganization.classCode | required | Fixed Value: ORG |
| Observation.performer.assignedEntity.representedOrganization.determinerCode | required | Fixed Value: INSTANCE |
| Observation.performer.assignedEntity.representedOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS |
| Observation.informant.typeCode | required | Fixed Value: INF |
| Observation.informant.contextControlCode | required | Fixed Value: OP |
| Observation.participant:location.nullFlavor | required | NullFlavor |
| Observation.participant:location.typeCode | required | Pattern: LOC |
| Observation.participant:location.contextControlCode | required | Fixed Value: OP |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-8249 | error | Observation.methodCode | MethodCode **SHALL NOT** conflict with the method inherent in Observation / code (CONF:1098-8249). : | |
| 1098-19201 | error | Observation.code.originalText.reference.value | This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-19201). : | |
| 1098-19202 | warning | Observation.code | This @code **SHOULD** be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19202). : | |
| 1098-30800 | warning | Observation.entryRelationship:medication.substanceAdministration | Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800). : | |
| 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:encounter, Observation.entryRelationship:instruction, Observation.entryRelationship:indication, Observation.entryRelationship:medication, Observation.entryRelationship:reaction | 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 CDAR2.Observation
Differential View
This structure is derived from CDAR2.Observation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 1..1 | CDAR2.Observation | 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:primary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.13 | |
| extension | 1..1 | string | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | 1098-19202: This @code **SHOULD** be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19202). |
| originalText | 0..1 | ED | ||
| reference | 0..1 | TEL | ||
| value | C | 0..1 | uri | 1098-19201: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-19201). |
| statusCode | 1..1 | CS | ||
| code | 1..1 | string | Binding: ProcedureAct statusCode (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (required) | |
| value | 1..1 | BL, ED, ED, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | ||
| nullFlavor | 0..1 | If nothing is appropriate for value, use an appropriate nullFlavor. | ||
| methodCode | C | 0..1 | CE | 1098-8249: MethodCode **SHALL NOT** conflict with the method inherent in Observation / code (CONF:1098-8249). |
| targetSiteCode | 0..* | CD | Binding: Body Site Value Set (required) | |
| performer | 0..* | Performer2 | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | ||
| addr | 1..* | AD | ||
| telecom | 1..* | TEL | ||
| representedOrganization | 0..1 | Organization | ||
| id | 0..* | II | ||
| name | 0..* | ON | ||
| telecom | 1..1 | TEL | ||
| addr | 1..1 | AD | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:typeCode, value:participantRole | |
| participant:location | 0..* | Participant2 | ||
| typeCode | 1..1 | code | Required Pattern: LOC | |
| participantRole | 1..1 | ServiceDeliveryLocation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | Element | Slice: Unordered, Open by profile:encounter, profile:act, profile:observation, profile:substanceAdministration | |
| entryRelationship:encounter | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: COMP | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| encounter | 1..1 | Encounter | ||
| classCode | 1..1 | code | Required Pattern: ENC | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| id | C | 1..1 | II | 1098-16847: Set encounter/id to the id of an encounter in another section to signify they are the same encounter (CONF:1098-16847). |
| entryRelationship:instruction | 0..1 | Element | ||
| typeCode | 1..1 | code | Required Pattern: SUBJ | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:indication | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: RSON | |
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:medication | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: COMP | |
| substanceAdministration | 1..1 | MedicationActivity | Base for all types and resources | |
| entryRelationship:reaction | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: COMP | |
| observation | 1..1 | ReactionObservation | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.statusCode.code | required | ProcedureAct statusCode |
| Observation.priorityCode | required | ActPriority |
| Observation.targetSiteCode | required | Body Site Value Set |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-8249 | error | Observation.methodCode | MethodCode **SHALL NOT** conflict with the method inherent in Observation / code (CONF:1098-8249). : | |
| 1098-16847 | warning | Observation.entryRelationship:encounter.encounter.id | Set encounter/id to the id of an encounter in another section to signify they are the same encounter (CONF:1098-16847). : | |
| 1098-19201 | error | Observation.code.originalText.reference.value | This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-19201). : | |
| 1098-19202 | warning | Observation.code | This @code **SHOULD** be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19202). : |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 1..1 | CDAR2.Observation | 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: 2.16.840.1.113883.10.20.22.4.13 | |
| extension | 1..1 | string | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: ObservationType (extensible) 1098-19202: This @code **SHOULD** be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19202). |
| originalText | 0..1 | ED | ||
| reference | 0..1 | TEL | ||
| value | C | 0..1 | uri | 1098-19201: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-19201). |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| code | 1..1 | string | Binding: ProcedureAct statusCode (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (required) | |
| value | 1..1 | |||
| value | BL | |||
| value | ED | |||
| value | ED | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| value | RTO_PQ_PQ | |||
| methodCode | C | 0..1 | CE | Binding: ObservationMethod (extensible) 1098-8249: MethodCode **SHALL NOT** conflict with the method inherent in Observation / code (CONF:1098-8249). |
| targetSiteCode | 0..* | CD | Binding: Body Site Value Set (required) | |
| performer | 0..* | Performer2 | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| id | 1..* | II | ||
| addr | 1..* | AD | ||
| telecom | 1..* | TEL | ||
| representedOrganization | 0..1 | Organization | ||
| classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| id | 0..* | II | ||
| name | 0..* | ON | ||
| telecom | 1..1 | TEL | ||
| addr | 1..1 | AD | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:typeCode, value:participantRole | |
| participant:location | 0..* | Participant2 | ||
| typeCode | 1..1 | code | Binding: ParticipationType (required) Required Pattern: LOC | |
| participantRole | 1..1 | ServiceDeliveryLocation | Base for all types and resources | |
| Slices for entryRelationship | C | 0..* | Element | Slice: Unordered, Open by profile:encounter, profile:act, profile:observation, profile:substanceAdministration |
| entryRelationship:All Slices | Content/Rules for all slices | |||
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| entryRelationship:encounter | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| contextConductionInd | 1..1 | boolean | ||
| encounter | 1..1 | Encounter | ||
| entryRelationship:instruction | C | 0..1 | Element | |
| typeCode | 1..1 | code | Required Pattern: SUBJ | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:indication | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: RSON | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:medication | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| contextConductionInd | 1..1 | boolean | ||
| substanceAdministration | C | 1..1 | MedicationActivity | Base for all types and resources |
| entryRelationship:reaction | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | ReactionObservation | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Pattern: OBS |
| Observation.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.code | required | ProcedureAct statusCode |
| Observation.priorityCode | required | ActPriority |
| Observation.methodCode | extensible | ObservationMethod |
| Observation.targetSiteCode | required | Body Site Value Set |
| Observation.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| Observation.performer.assignedEntity.representedOrganization.classCode | required | Fixed Value: ORG |
| Observation.performer.assignedEntity.representedOrganization.determinerCode | required | Fixed Value: INSTANCE |
| Observation.participant:location.typeCode | required | Pattern: LOC |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-8249 | error | Observation.methodCode | MethodCode **SHALL NOT** conflict with the method inherent in Observation / code (CONF:1098-8249). : | |
| 1098-19201 | error | Observation.code.originalText.reference.value | This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-19201). : | |
| 1098-19202 | warning | Observation.code | This @code **SHOULD** be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19202). : | |
| 1098-30800 | warning | Observation.entryRelationship:medication.substanceAdministration | Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800). : | |
| 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:encounter, Observation.entryRelationship:instruction, Observation.entryRelationship:indication, Observation.entryRelationship:medication, Observation.entryRelationship:reaction | 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 | CDAR2.Observation | 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 | ||
| 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: 2.16.840.1.113883.10.20.22.4.13 | |
| extension | 1..1 | string | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: ObservationType (extensible) 1098-19202: This @code **SHOULD** be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19202). |
| 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 | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| charset | 0..1 | code | ||
| compression | 0..1 | code | Binding: CompressionAlgorithm (required) | |
| integrityCheck | 0..1 | base64Binary | ||
| integrityCheckAlgorithm | 0..1 | code | Binding: IntegrityCheckAlgorithm (required) | |
| language | 0..1 | code | ||
| mediaType | 0..1 | code | ||
| representation | 0..1 | code | ||
| data[x] | 0..1 | |||
| dataString | string | |||
| dataBase64Binary | base64Binary | |||
| reference | 0..1 | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | C | 0..1 | uri | 1098-19201: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-19201). |
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..* | code | Binding: AddressUse (required) | |
| thumbnail | 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 | Binding: ProcedureAct statusCode (required) | |
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| effectiveTime | 0..1 | IVL_TS | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (required) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| value | 1..1 | |||
| value:All Types | Content/Rules for all Types | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| value | BL | |||
| value | ED | |||
| value | ED | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| value | RTO_PQ_PQ | |||
| interpretationCode | 0..* | CE | Binding: ObservationInterpretation (required) | |
| methodCode | C | 0..1 | CE | Binding: ObservationMethod (extensible) 1098-8249: MethodCode **SHALL NOT** conflict with the method inherent in Observation / code (CONF:1098-8249). |
| targetSiteCode | 0..* | CD | Binding: Body Site Value Set (required) | |
| 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 | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 0..1 | cs | Binding: ParticipationPhysicalPerformer (required) Fixed Value: PRF | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| functionCode | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc | |
| time | 0..1 | IVL_TS | ||
| modeCode | 0..1 | CE | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| classCode | 1..1 | code | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED | |
| templateId | 0..* | II | ||
| id | 1..* | II | ||
| sdtcIdentifiedBy | 0..* | IdentifiedBy | XML: identifiedBy (urn:hl7-org:sdtc) | |
| code | 0..1 | CE | Binding: v3 Code System RoleCode (extensible) | |
| addr | 1..* | AD | ||
| telecom | 1..* | TEL | ||
| assignedPerson | 0..1 | Person | ||
| representedOrganization | 0..1 | Organization | ||
| classCode | 1..1 | code | Binding: EntityClassOrganization (required) Fixed Value: ORG | |
| determinerCode | 1..1 | code | Binding: EntityDeterminer (required) Fixed Value: INSTANCE | |
| templateId | 0..* | II | ||
| id | 0..* | II | ||
| name | 0..* | ON | ||
| telecom | 1..1 | TEL | ||
| addr | 1..1 | AD | ||
| standardIndustryClassCode | 0..1 | CE | Binding: OrganizationIndustryClassNAICS (extensible) | |
| asOrganizationPartOf | 0..1 | OrganizationPartOf | ||
| 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 | ||
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:typeCode, value:participantRole | |
| participant:location | 0..* | Participant2 | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| typeCode | 1..1 | code | Binding: ParticipationType (required) Required Pattern: LOC | |
| contextControlCode | 0..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| sdtcFunctionCode | 0..1 | CE | XML: functionCode (urn:hl7-org:sdtc) | |
| time | 0..1 | IVL_TS | ||
| awarenessCode | 0..1 | CE | ||
| participantRole | 1..1 | ServiceDeliveryLocation | Base for all types and resources | |
| Slices for entryRelationship | C | 0..* | Element | Slice: Unordered, Open by profile:encounter, profile:act, profile:observation, profile:substanceAdministration |
| entryRelationship:All Slices | Content/Rules for all slices | |||
| 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 | ||
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| (Choice of one) | 1..1 | |||
| observation | 0..1 | Observation | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| observationMedia | 0..1 | ObservationMedia | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| procedure | 0..1 | Procedure | ||
| encounter | 0..1 | Encounter | ||
| organizer | 0..1 | Organizer | ||
| act | 0..1 | Act | ||
| entryRelationship:encounter | 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: COMP | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| encounter | 1..1 | Encounter | ||
| entryRelationship:instruction | 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 | ||
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:indication | 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: RSON | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:medication | 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: COMP | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| substanceAdministration | C | 1..1 | MedicationActivity | Base for all types and resources |
| entryRelationship:reaction | 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: COMP | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | ReactionObservation | Base for all types and resources | |
| 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.code | extensible | ObservationType |
| Observation.code.nullFlavor | required | NullFlavor |
| Observation.code.originalText.nullFlavor | required | NullFlavor |
| Observation.code.originalText.compression | required | CompressionAlgorithm |
| Observation.code.originalText.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
| Observation.code.originalText.reference.nullFlavor | required | NullFlavor |
| Observation.code.originalText.reference.use | required | AddressUse |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.nullFlavor | required | NullFlavor |
| Observation.statusCode.code | required | ProcedureAct statusCode |
| Observation.priorityCode | required | ActPriority |
| Observation.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | extensible | ObservationMethod |
| Observation.targetSiteCode | required | Body Site Value Set |
| Observation.subject.typeCode | required | Fixed Value: SBJ |
| Observation.subject.contextControlCode | required | Fixed Value: OP |
| Observation.subject.awarenessCode | extensible | TargetAwareness |
| Observation.performer.nullFlavor | required | NullFlavor |
| Observation.performer.typeCode | required | Fixed Value: PRF |
| Observation.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| Observation.performer.assignedEntity.code | extensible | RoleCode |
| Observation.performer.assignedEntity.representedOrganization.classCode | required | Fixed Value: ORG |
| Observation.performer.assignedEntity.representedOrganization.determinerCode | required | Fixed Value: INSTANCE |
| Observation.performer.assignedEntity.representedOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS |
| Observation.informant.typeCode | required | Fixed Value: INF |
| Observation.informant.contextControlCode | required | Fixed Value: OP |
| Observation.participant:location.nullFlavor | required | NullFlavor |
| Observation.participant:location.typeCode | required | Pattern: LOC |
| Observation.participant:location.contextControlCode | required | Fixed Value: OP |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-8249 | error | Observation.methodCode | MethodCode **SHALL NOT** conflict with the method inherent in Observation / code (CONF:1098-8249). : | |
| 1098-19201 | error | Observation.code.originalText.reference.value | This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-19201). : | |
| 1098-19202 | warning | Observation.code | This @code **SHOULD** be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19202). : | |
| 1098-30800 | warning | Observation.entryRelationship:medication.substanceAdministration | Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800). : | |
| 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:encounter, Observation.entryRelationship:instruction, Observation.entryRelationship:indication, Observation.entryRelationship:medication, Observation.entryRelationship:reaction | 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 CDAR2.Observation
Cannot invoke "org.hl7.fhir.r5.model.ElementDefinition.getPath()" because "match" is null
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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