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/2.16.840.1.113883.10.20.22.4.132 | Version: 2.1.0-draft1 | |||
| Active as of 2023-01-16 | Computable Name: HealthConcernAct | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.132:2015-08-01 | ||||
This template represents a health concern.
It is a wrapper for a single health concern which may be derived from a variety of sources within an EHR (such as Problem List, Family History, Social History, Social Worker Note, etc.).
A Health Concern Act is used to track non-optimal physical or psychological situations drawing the patient to the healthcare system. These may be from the perspective of the care team or from the perspective of the patient.
When the underlying condition is of concern (i.e., as long as the condition, whether active or resolved, is of ongoing concern and interest), the statusCode is active. Only when the underlying condition is no longer of concern is the statusCode set to completed. The effectiveTime reflects the time that the underlying condition was felt to be a concern; it may or may not correspond to the effectiveTime of the condition (e.g., even five years later, a prior heart attack may remain a concern).
Health concerns require intervention(s) to increase the likelihood of achieving the goals of care for the patient and they specify the condition oriented reasons for creating the plan.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Act
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Act | 1..1 | CDAR2.Act | Base for all types and resources | |
 classCode | 1..1 | code | Required Pattern: ACT | |
| 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: 2.16.840.1.113883.10.20.22.4.132 | |
  extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | ||
| code | 1..1 | string | Required Pattern: 75310-3 | |
 codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
| statusCode | 1..1 | CS | ||
| code | 1..1 | string | Binding: ProblemAct statusCode (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
 author | 0..* | AuthorParticipation | A health concern may be a patient or provider concern. If the author is set to the recordTarget (patient), this is a patient concern. If the author is set to a provider, this is a provider concern. If both patient and provider are set as authors, this is a concern of both the patient and the provider. | |
| Slices for entryRelationship | 0..* | Element | Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. Slice: Unordered, Open by profile:observation, profile:act, profile:organizer | |
 entryRelationship:problemObservation | 0..* | Element | ||
 typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | ProblemObservation | Base for all types and resources | |
| entryRelationship:allergy-IntoleranceObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | AllergyIntoleranceObservation | Base for all types and resources | |
| entryRelationship:entryReference | 0..* | Element | The following entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern REFERS TO Health Concern). For example, a patient has 2 health concerns identified in a CARE Plan: Failure to Thrive and Poor Feeding, while it could be that one may have caused the other, at the time of care planning and documentation it is not necessary, nor desirable to have to assert what caused what. The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| act | C | 1..1 | EntryReference | Base for all types and resources 1198-32860: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32860). |
| entryRelationship:entryReference | 0..* | Element | The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). For example, a patient has an Impaired Mobility Health Concern. There may then be the need to document several component health concerns, such as "Unable to Transfer Bed to Chair", "Unable to Rise from Commode", "Short of Breath Walking with Walker". The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. | |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| act | C | 1..1 | EntryReference | Base for all types and resources 1198-32745: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32745). |
| entryRelationship:assessmentScaleObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | AssessmentScaleObservation | Base for all types and resources | |
| entryRelationship:self-CareActivities(ADLandIADL) | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | SelfCareActivitiesADLandIADL | Base for all types and resources | |
| entryRelationship:mentalStatusObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | MentalStatusObservation | Base for all types and resources | |
| entryRelationship:smokingStatus-MeaningfulUse | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | SmokingStatusMeaningfulUse | Base for all types and resources | |
| entryRelationship:encounterDiagnosis | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| act | 1..1 | EncounterDiagnosis | Base for all types and resources | |
| entryRelationship:entryRelationship10 | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| organizer | 1..1 | FamilyHistoryOrganizer | Base for all types and resources | |
| entryRelationship:functionalStatusObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | FunctionalStatusObservation | Base for all types and resources | |
| entryRelationship:hospitalAdmissionDiagnosis | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| act | 1..1 | HospitalAdmissionDiagnosis | Base for all types and resources | |
| entryRelationship:nutritionAssessment | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | NutritionAssessment | Base for all types and resources | |
| entryRelationship:postprocedureDiagnosis | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| act | 1..1 | PostprocedureDiagnosis | Base for all types and resources | |
| entryRelationship:pregnancyObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | PregnancyObservation | Base for all types and resources | |
| entryRelationship:preoperativeDiagnosis | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| act | 1..1 | PreoperativeDiagnosis | Base for all types and resources | |
| entryRelationship:reactionObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | ReactionObservation | Base for all types and resources | |
| entryRelationship:resultObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | ResultObservation | Base for all types and resources | |
| entryRelationship:sensoryStatus | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | SensoryStatus | Base for all types and resources | |
| entryRelationship:socialHistoryObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | SocialHistoryObservation | Base for all types and resources | |
| entryRelationship:substanceorDeviceAllergy-IntoleranceObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | SubstanceOrDeviceAllergyIntoleranceObservation | Base for all types and resources | |
| entryRelationship:tobaccoUse | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | TobaccoUse | Base for all types and resources | |
| entryRelationship:vitalSignObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | VitalSignObservation | Base for all types and resources | |
| entryRelationship:longitudinalCareWoundObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | LongitudinalCareWoundObservation | Base for all types and resources | |
| entryRelationship:problemObservation | 0..* | Element | The following entryRelationship represents the relationship Health Concern HAS SUPPORT Observation. | |
| typeCode | 1..1 | code | Required Pattern: SPRT | |
| observation | 1..1 | ProblemObservation | Base for all types and resources | |
| entryRelationship:caregiverCharacteristics | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | CaregiverCharacteristics | Base for all types and resources | |
| entryRelationship:culturalandReligiousObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | CulturalandReligiousObservation | Base for all types and resources | |
| entryRelationship:characteristicsofHomeEnvironment | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | CharacteristicsofHomeEnvironment | Base for all types and resources | |
| entryRelationship:nutritionalStatusObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | NutritionalStatusObservation | Base for all types and resources | |
| entryRelationship:entryRelationship30 | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| organizer | 1..1 | ResultOrganizer | Base for all types and resources | |
| entryRelationship:priorityPreference | 0..* | Element | The following entryRelationship represents the priority that the patient or a provider puts on the health concern. | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:problemConcernAct | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| act | 1..1 | ProblemConcernAct | Base for all types and resources | |
| entryRelationship:entryReference | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| act | 1..1 | EntryReference | Base for all types and resources | |
 reference | 0..* | Element | Where it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| externalDocument | 1..1 | ExternalDocumentReference | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Act.statusCode.code | required | ProblemAct statusCode |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32745 | error | Act.entryRelationship:entryReference.act | The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32745). : | |
| 1198-32860 | error | Act.entryRelationship:entryReference.act | The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32860). : |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act | 1..1 | CDAR2.Act | Base for all types and resources | |
 classCode | 1..1 | code | Required Pattern: ACT | |
| 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: 2.16.840.1.113883.10.20.22.4.132 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: v3 Code System ActCode (extensible) | |
| code | 1..1 | string | Required Pattern: 75310-3 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| code | 1..1 | string | Binding: ProblemAct statusCode (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
| author | 0..* | AuthorParticipation | A health concern may be a patient or provider concern. If the author is set to the recordTarget (patient), this is a patient concern. If the author is set to a provider, this is a provider concern. If both patient and provider are set as authors, this is a concern of both the patient and the provider. | |
| Slices for entryRelationship | C | 0..* | Element | Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. Slice: Unordered, Open by profile:observation, profile:act, profile:organizer |
| entryRelationship:All Slices | Content/Rules for all slices | |||
 typeCode | 1..1 | code | ||
 contextConductionInd | 1..1 | boolean | ||
| entryRelationship:problemObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | ProblemObservation | Base for all types and resources | |
| entryRelationship:allergy-IntoleranceObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | AllergyIntoleranceObservation | Base for all types and resources | |
| entryRelationship:entryReference | C | 0..* | Element | The following entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern REFERS TO Health Concern). For example, a patient has 2 health concerns identified in a CARE Plan: Failure to Thrive and Poor Feeding, while it could be that one may have caused the other, at the time of care planning and documentation it is not necessary, nor desirable to have to assert what caused what. The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| act | C | 1..1 | EntryReference | Base for all types and resources 1198-32860: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32860). |
| entryRelationship:entryReference | C | 0..* | Element | The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). For example, a patient has an Impaired Mobility Health Concern. There may then be the need to document several component health concerns, such as "Unable to Transfer Bed to Chair", "Unable to Rise from Commode", "Short of Breath Walking with Walker". The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| contextConductionInd | 1..1 | boolean | ||
| act | C | 1..1 | EntryReference | Base for all types and resources 1198-32745: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32745). |
| entryRelationship:assessmentScaleObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | AssessmentScaleObservation | Base for all types and resources | |
| entryRelationship:self-CareActivities(ADLandIADL) | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | SelfCareActivitiesADLandIADL | Base for all types and resources | |
| entryRelationship:mentalStatusObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | MentalStatusObservation | Base for all types and resources | |
| entryRelationship:smokingStatus-MeaningfulUse | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | SmokingStatusMeaningfulUse | Base for all types and resources | |
| entryRelationship:encounterDiagnosis | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | EncounterDiagnosis | Base for all types and resources | |
| entryRelationship:entryRelationship10 | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| organizer | 1..1 | FamilyHistoryOrganizer | Base for all types and resources | |
| entryRelationship:functionalStatusObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | FunctionalStatusObservation | Base for all types and resources | |
| entryRelationship:hospitalAdmissionDiagnosis | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | HospitalAdmissionDiagnosis | Base for all types and resources | |
| entryRelationship:nutritionAssessment | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | NutritionAssessment | Base for all types and resources | |
| entryRelationship:postprocedureDiagnosis | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | PostprocedureDiagnosis | Base for all types and resources | |
| entryRelationship:pregnancyObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | PregnancyObservation | Base for all types and resources | |
| entryRelationship:preoperativeDiagnosis | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | PreoperativeDiagnosis | Base for all types and resources | |
| entryRelationship:reactionObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | ReactionObservation | Base for all types and resources | |
| entryRelationship:resultObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | ResultObservation | Base for all types and resources | |
| entryRelationship:sensoryStatus | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | SensoryStatus | Base for all types and resources | |
| entryRelationship:socialHistoryObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | SocialHistoryObservation | Base for all types and resources | |
| entryRelationship:substanceorDeviceAllergy-IntoleranceObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | SubstanceOrDeviceAllergyIntoleranceObservation | Base for all types and resources | |
| entryRelationship:tobaccoUse | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | TobaccoUse | Base for all types and resources | |
| entryRelationship:vitalSignObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | VitalSignObservation | Base for all types and resources | |
| entryRelationship:longitudinalCareWoundObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | LongitudinalCareWoundObservation | Base for all types and resources | |
| entryRelationship:problemObservation | C | 0..* | Element | The following entryRelationship represents the relationship Health Concern HAS SUPPORT Observation. |
| typeCode | 1..1 | code | Required Pattern: SPRT | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | ProblemObservation | Base for all types and resources | |
| entryRelationship:caregiverCharacteristics | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | CaregiverCharacteristics | Base for all types and resources | |
| entryRelationship:culturalandReligiousObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | CulturalandReligiousObservation | Base for all types and resources | |
| entryRelationship:characteristicsofHomeEnvironment | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | CharacteristicsofHomeEnvironment | Base for all types and resources | |
| entryRelationship:nutritionalStatusObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | NutritionalStatusObservation | Base for all types and resources | |
| entryRelationship:entryRelationship30 | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| organizer | 1..1 | ResultOrganizer | Base for all types and resources | |
| entryRelationship:priorityPreference | C | 0..* | Element | The following entryRelationship represents the priority that the patient or a provider puts on the health concern. |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:problemConcernAct | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | ProblemConcernAct | Base for all types and resources | |
| entryRelationship:entryReference | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | EntryReference | Base for all types and resources | |
 reference | 0..* | Element | Where it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| externalDocument | 1..1 | ExternalDocumentReference | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Act.code | extensible | ActCode |
| Act.statusCode | required | ActStatus |
| Act.statusCode.code | required | ProblemAct statusCode |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32745 | error | Act.entryRelationship:entryReference.act | The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32745). : | |
| 1198-32860 | error | Act.entryRelationship:entryReference.act | The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32860). : | |
| act-er-1 | error | Act.entryRelationship, Act.entryRelationship:problemObservation, Act.entryRelationship:allergy-IntoleranceObservation, Act.entryRelationship:entryReference, Act.entryRelationship:entryReference, Act.entryRelationship:assessmentScaleObservation, Act.entryRelationship:self-CareActivities(ADLandIADL), Act.entryRelationship:mentalStatusObservation, Act.entryRelationship:smokingStatus-MeaningfulUse, Act.entryRelationship:encounterDiagnosis, Act.entryRelationship:entryRelationship10, Act.entryRelationship:functionalStatusObservation, Act.entryRelationship:hospitalAdmissionDiagnosis, Act.entryRelationship:nutritionAssessment, Act.entryRelationship:postprocedureDiagnosis, Act.entryRelationship:pregnancyObservation, Act.entryRelationship:preoperativeDiagnosis, Act.entryRelationship:reactionObservation, Act.entryRelationship:resultObservation, Act.entryRelationship:sensoryStatus, Act.entryRelationship:socialHistoryObservation, Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation, Act.entryRelationship:tobaccoUse, Act.entryRelationship:vitalSignObservation, Act.entryRelationship:longitudinalCareWoundObservation, Act.entryRelationship:problemObservation, Act.entryRelationship:caregiverCharacteristics, Act.entryRelationship:culturalandReligiousObservation, Act.entryRelationship:characteristicsofHomeEnvironment, Act.entryRelationship:nutritionalStatusObservation, Act.entryRelationship:entryRelationship30, Act.entryRelationship:priorityPreference, Act.entryRelationship:problemConcernAct, Act.entryRelationship:entryReference | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act | 1..1 | CDAR2.Act | Base for all types and resources | |
| classCode | 1..1 | code | Required Pattern: ACT | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| 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: 2.16.840.1.113883.10.20.22.4.132 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: v3 Code System ActCode (extensible) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: 75310-3 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
| 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 | ||
| negationInd | 0..1 | boolean | ||
| text | 0..1 | ED | ||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Binding: ProblemAct 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 (extensible) | |
| languageCode | 0..1 | CS | Binding: HumanLanguage (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 | ||
| author | 0..* | AuthorParticipation | A health concern may be a patient or provider concern. If the author is set to the recordTarget (patient), this is a patient concern. If the author is set to a provider, this is a provider concern. If both patient and provider are set as authors, this is a concern of both the patient and the provider. | |
| 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 | Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. Slice: Unordered, Open by profile:observation, profile:act, profile:organizer |
| 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:problemObservation | 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 | ProblemObservation | Base for all types and resources | |
| entryRelationship:allergy-IntoleranceObservation | 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 | AllergyIntoleranceObservation | Base for all types and resources | |
| entryRelationship:entryReference | C | 0..* | Element | The following entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern REFERS TO Health Concern). For example, a patient has 2 health concerns identified in a CARE Plan: Failure to Thrive and Poor Feeding, while it could be that one may have caused the other, at the time of care planning and documentation it is not necessary, nor desirable to have to assert what caused what. The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. |
| 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 | ||
| act | C | 1..1 | EntryReference | Base for all types and resources 1198-32860: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32860). |
| entryRelationship:entryReference | C | 0..* | Element | The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). For example, a patient has an Impaired Mobility Health Concern. There may then be the need to document several component health concerns, such as "Unable to Transfer Bed to Chair", "Unable to Rise from Commode", "Short of Breath Walking with Walker". The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. |
| 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 | ||
| act | C | 1..1 | EntryReference | Base for all types and resources 1198-32745: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32745). |
| entryRelationship:assessmentScaleObservation | 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 | AssessmentScaleObservation | Base for all types and resources | |
| entryRelationship:self-CareActivities(ADLandIADL) | 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 | SelfCareActivitiesADLandIADL | Base for all types and resources | |
| entryRelationship:mentalStatusObservation | 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 | MentalStatusObservation | Base for all types and resources | |
| entryRelationship:smokingStatus-MeaningfulUse | 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 | SmokingStatusMeaningfulUse | Base for all types and resources | |
| entryRelationship:encounterDiagnosis | 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 | ||
| act | 1..1 | EncounterDiagnosis | Base for all types and resources | |
| entryRelationship:entryRelationship10 | 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 | ||
| organizer | 1..1 | FamilyHistoryOrganizer | Base for all types and resources | |
| entryRelationship:functionalStatusObservation | 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 | FunctionalStatusObservation | Base for all types and resources | |
| entryRelationship:hospitalAdmissionDiagnosis | 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 | ||
| act | 1..1 | HospitalAdmissionDiagnosis | Base for all types and resources | |
| entryRelationship:nutritionAssessment | 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 | NutritionAssessment | Base for all types and resources | |
| entryRelationship:postprocedureDiagnosis | 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 | ||
| act | 1..1 | PostprocedureDiagnosis | Base for all types and resources | |
| entryRelationship:pregnancyObservation | 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 | PregnancyObservation | Base for all types and resources | |
| entryRelationship:preoperativeDiagnosis | 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 | ||
| act | 1..1 | PreoperativeDiagnosis | Base for all types and resources | |
| entryRelationship:reactionObservation | 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 | ReactionObservation | Base for all types and resources | |
| entryRelationship:resultObservation | 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 | ResultObservation | Base for all types and resources | |
| entryRelationship:sensoryStatus | 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 | SensoryStatus | Base for all types and resources | |
| entryRelationship:socialHistoryObservation | 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 | SocialHistoryObservation | Base for all types and resources | |
| entryRelationship:substanceorDeviceAllergy-IntoleranceObservation | 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 | SubstanceOrDeviceAllergyIntoleranceObservation | Base for all types and resources | |
| entryRelationship:tobaccoUse | 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 | TobaccoUse | Base for all types and resources | |
| entryRelationship:vitalSignObservation | 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 | VitalSignObservation | Base for all types and resources | |
| entryRelationship:longitudinalCareWoundObservation | 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 | LongitudinalCareWoundObservation | Base for all types and resources | |
| entryRelationship:problemObservation | C | 0..* | Element | The following entryRelationship represents the relationship Health Concern HAS SUPPORT Observation. |
| 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: SPRT | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | ProblemObservation | Base for all types and resources | |
| entryRelationship:caregiverCharacteristics | 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 | CaregiverCharacteristics | Base for all types and resources | |
| entryRelationship:culturalandReligiousObservation | 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 | CulturalandReligiousObservation | Base for all types and resources | |
| entryRelationship:characteristicsofHomeEnvironment | 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 | CharacteristicsofHomeEnvironment | Base for all types and resources | |
| entryRelationship:nutritionalStatusObservation | 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 | NutritionalStatusObservation | Base for all types and resources | |
| entryRelationship:entryRelationship30 | 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 | ||
| organizer | 1..1 | ResultOrganizer | Base for all types and resources | |
| entryRelationship:priorityPreference | C | 0..* | Element | The following entryRelationship represents the priority that the patient or a provider puts on the health concern. |
| 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:problemConcernAct | 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 | ||
| act | 1..1 | ProblemConcernAct | Base for all types and resources | |
| entryRelationship:entryReference | 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 | ||
| act | 1..1 | EntryReference | Base for all types and resources | |
| reference | 0..* | Element | Where it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. | |
| 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 | |
| seperatableInd | 0..1 | BL | ||
| externalAct | 0..1 | ExternalAct | ||
| externalObservation | 0..1 | ExternalObservation | ||
| externalProcedure | 0..1 | ExternalProcedure | ||
| externalDocument | 1..1 | ExternalDocumentReference | Base for all types and resources | |
| precondition | 0..* | Precondition | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Act.templateId:primary.nullFlavor | required | NullFlavor |
| Act.code | extensible | ActCode |
| Act.code.nullFlavor | required | NullFlavor |
| Act.statusCode | required | ActStatus |
| Act.statusCode.nullFlavor | required | NullFlavor |
| Act.statusCode.code | required | ProblemAct statusCode |
| Act.priorityCode | extensible | ActPriority |
| Act.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Act.subject.typeCode | required | Fixed Value: SBJ |
| Act.subject.contextControlCode | required | Fixed Value: OP |
| Act.subject.awarenessCode | extensible | TargetAwareness |
| Act.informant.typeCode | required | Fixed Value: INF |
| Act.informant.contextControlCode | required | Fixed Value: OP |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32745 | error | Act.entryRelationship:entryReference.act | The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32745). : | |
| 1198-32860 | error | Act.entryRelationship:entryReference.act | The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32860). : | |
| act-er-1 | error | Act.entryRelationship, Act.entryRelationship:problemObservation, Act.entryRelationship:allergy-IntoleranceObservation, Act.entryRelationship:entryReference, Act.entryRelationship:entryReference, Act.entryRelationship:assessmentScaleObservation, Act.entryRelationship:self-CareActivities(ADLandIADL), Act.entryRelationship:mentalStatusObservation, Act.entryRelationship:smokingStatus-MeaningfulUse, Act.entryRelationship:encounterDiagnosis, Act.entryRelationship:entryRelationship10, Act.entryRelationship:functionalStatusObservation, Act.entryRelationship:hospitalAdmissionDiagnosis, Act.entryRelationship:nutritionAssessment, Act.entryRelationship:postprocedureDiagnosis, Act.entryRelationship:pregnancyObservation, Act.entryRelationship:preoperativeDiagnosis, Act.entryRelationship:reactionObservation, Act.entryRelationship:resultObservation, Act.entryRelationship:sensoryStatus, Act.entryRelationship:socialHistoryObservation, Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation, Act.entryRelationship:tobaccoUse, Act.entryRelationship:vitalSignObservation, Act.entryRelationship:longitudinalCareWoundObservation, Act.entryRelationship:problemObservation, Act.entryRelationship:caregiverCharacteristics, Act.entryRelationship:culturalandReligiousObservation, Act.entryRelationship:characteristicsofHomeEnvironment, Act.entryRelationship:nutritionalStatusObservation, Act.entryRelationship:entryRelationship30, Act.entryRelationship:priorityPreference, Act.entryRelationship:problemConcernAct, Act.entryRelationship:entryReference | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
| 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() |
This structure is derived from CDAR2.Act
Summary
Mandatory: 11 elements (68 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 CDAR2.Act
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act | 1..1 | CDAR2.Act | Base for all types and resources | |
| classCode | 1..1 | code | Required Pattern: ACT | |
| 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: 2.16.840.1.113883.10.20.22.4.132 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | ||
| code | 1..1 | string | Required Pattern: 75310-3 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
| statusCode | 1..1 | CS | ||
| code | 1..1 | string | Binding: ProblemAct statusCode (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
| author | 0..* | AuthorParticipation | A health concern may be a patient or provider concern. If the author is set to the recordTarget (patient), this is a patient concern. If the author is set to a provider, this is a provider concern. If both patient and provider are set as authors, this is a concern of both the patient and the provider. | |
| Slices for entryRelationship | 0..* | Element | Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. Slice: Unordered, Open by profile:observation, profile:act, profile:organizer | |
| entryRelationship:problemObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | ProblemObservation | Base for all types and resources | |
| entryRelationship:allergy-IntoleranceObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | AllergyIntoleranceObservation | Base for all types and resources | |
| entryRelationship:entryReference | 0..* | Element | The following entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern REFERS TO Health Concern). For example, a patient has 2 health concerns identified in a CARE Plan: Failure to Thrive and Poor Feeding, while it could be that one may have caused the other, at the time of care planning and documentation it is not necessary, nor desirable to have to assert what caused what. The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| act | C | 1..1 | EntryReference | Base for all types and resources 1198-32860: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32860). |
| entryRelationship:entryReference | 0..* | Element | The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). For example, a patient has an Impaired Mobility Health Concern. There may then be the need to document several component health concerns, such as "Unable to Transfer Bed to Chair", "Unable to Rise from Commode", "Short of Breath Walking with Walker". The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. | |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| act | C | 1..1 | EntryReference | Base for all types and resources 1198-32745: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32745). |
| entryRelationship:assessmentScaleObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | AssessmentScaleObservation | Base for all types and resources | |
| entryRelationship:self-CareActivities(ADLandIADL) | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | SelfCareActivitiesADLandIADL | Base for all types and resources | |
| entryRelationship:mentalStatusObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | MentalStatusObservation | Base for all types and resources | |
| entryRelationship:smokingStatus-MeaningfulUse | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | SmokingStatusMeaningfulUse | Base for all types and resources | |
| entryRelationship:encounterDiagnosis | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| act | 1..1 | EncounterDiagnosis | Base for all types and resources | |
| entryRelationship:entryRelationship10 | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| organizer | 1..1 | FamilyHistoryOrganizer | Base for all types and resources | |
| entryRelationship:functionalStatusObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | FunctionalStatusObservation | Base for all types and resources | |
| entryRelationship:hospitalAdmissionDiagnosis | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| act | 1..1 | HospitalAdmissionDiagnosis | Base for all types and resources | |
| entryRelationship:nutritionAssessment | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | NutritionAssessment | Base for all types and resources | |
| entryRelationship:postprocedureDiagnosis | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| act | 1..1 | PostprocedureDiagnosis | Base for all types and resources | |
| entryRelationship:pregnancyObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | PregnancyObservation | Base for all types and resources | |
| entryRelationship:preoperativeDiagnosis | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| act | 1..1 | PreoperativeDiagnosis | Base for all types and resources | |
| entryRelationship:reactionObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | ReactionObservation | Base for all types and resources | |
| entryRelationship:resultObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | ResultObservation | Base for all types and resources | |
| entryRelationship:sensoryStatus | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | SensoryStatus | Base for all types and resources | |
| entryRelationship:socialHistoryObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | SocialHistoryObservation | Base for all types and resources | |
| entryRelationship:substanceorDeviceAllergy-IntoleranceObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | SubstanceOrDeviceAllergyIntoleranceObservation | Base for all types and resources | |
| entryRelationship:tobaccoUse | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | TobaccoUse | Base for all types and resources | |
| entryRelationship:vitalSignObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | VitalSignObservation | Base for all types and resources | |
| entryRelationship:longitudinalCareWoundObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | LongitudinalCareWoundObservation | Base for all types and resources | |
| entryRelationship:problemObservation | 0..* | Element | The following entryRelationship represents the relationship Health Concern HAS SUPPORT Observation. | |
| typeCode | 1..1 | code | Required Pattern: SPRT | |
| observation | 1..1 | ProblemObservation | Base for all types and resources | |
| entryRelationship:caregiverCharacteristics | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | CaregiverCharacteristics | Base for all types and resources | |
| entryRelationship:culturalandReligiousObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | CulturalandReligiousObservation | Base for all types and resources | |
| entryRelationship:characteristicsofHomeEnvironment | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | CharacteristicsofHomeEnvironment | Base for all types and resources | |
| entryRelationship:nutritionalStatusObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | NutritionalStatusObservation | Base for all types and resources | |
| entryRelationship:entryRelationship30 | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| organizer | 1..1 | ResultOrganizer | Base for all types and resources | |
| entryRelationship:priorityPreference | 0..* | Element | The following entryRelationship represents the priority that the patient or a provider puts on the health concern. | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:problemConcernAct | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| act | 1..1 | ProblemConcernAct | Base for all types and resources | |
| entryRelationship:entryReference | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| act | 1..1 | EntryReference | Base for all types and resources | |
| reference | 0..* | Element | Where it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| externalDocument | 1..1 | ExternalDocumentReference | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Act.statusCode.code | required | ProblemAct statusCode |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32745 | error | Act.entryRelationship:entryReference.act | The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32745). : | |
| 1198-32860 | error | Act.entryRelationship:entryReference.act | The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32860). : |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act | 1..1 | CDAR2.Act | Base for all types and resources | |
| classCode | 1..1 | code | Required Pattern: ACT | |
| 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: 2.16.840.1.113883.10.20.22.4.132 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: v3 Code System ActCode (extensible) | |
| code | 1..1 | string | Required Pattern: 75310-3 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| code | 1..1 | string | Binding: ProblemAct statusCode (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
| author | 0..* | AuthorParticipation | A health concern may be a patient or provider concern. If the author is set to the recordTarget (patient), this is a patient concern. If the author is set to a provider, this is a provider concern. If both patient and provider are set as authors, this is a concern of both the patient and the provider. | |
| Slices for entryRelationship | C | 0..* | Element | Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. Slice: Unordered, Open by profile:observation, profile:act, profile:organizer |
| entryRelationship:All Slices | Content/Rules for all slices | |||
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| entryRelationship:problemObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | ProblemObservation | Base for all types and resources | |
| entryRelationship:allergy-IntoleranceObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | AllergyIntoleranceObservation | Base for all types and resources | |
| entryRelationship:entryReference | C | 0..* | Element | The following entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern REFERS TO Health Concern). For example, a patient has 2 health concerns identified in a CARE Plan: Failure to Thrive and Poor Feeding, while it could be that one may have caused the other, at the time of care planning and documentation it is not necessary, nor desirable to have to assert what caused what. The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| act | C | 1..1 | EntryReference | Base for all types and resources 1198-32860: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32860). |
| entryRelationship:entryReference | C | 0..* | Element | The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). For example, a patient has an Impaired Mobility Health Concern. There may then be the need to document several component health concerns, such as "Unable to Transfer Bed to Chair", "Unable to Rise from Commode", "Short of Breath Walking with Walker". The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| contextConductionInd | 1..1 | boolean | ||
| act | C | 1..1 | EntryReference | Base for all types and resources 1198-32745: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32745). |
| entryRelationship:assessmentScaleObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | AssessmentScaleObservation | Base for all types and resources | |
| entryRelationship:self-CareActivities(ADLandIADL) | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | SelfCareActivitiesADLandIADL | Base for all types and resources | |
| entryRelationship:mentalStatusObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | MentalStatusObservation | Base for all types and resources | |
| entryRelationship:smokingStatus-MeaningfulUse | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | SmokingStatusMeaningfulUse | Base for all types and resources | |
| entryRelationship:encounterDiagnosis | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | EncounterDiagnosis | Base for all types and resources | |
| entryRelationship:entryRelationship10 | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| organizer | 1..1 | FamilyHistoryOrganizer | Base for all types and resources | |
| entryRelationship:functionalStatusObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | FunctionalStatusObservation | Base for all types and resources | |
| entryRelationship:hospitalAdmissionDiagnosis | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | HospitalAdmissionDiagnosis | Base for all types and resources | |
| entryRelationship:nutritionAssessment | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | NutritionAssessment | Base for all types and resources | |
| entryRelationship:postprocedureDiagnosis | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | PostprocedureDiagnosis | Base for all types and resources | |
| entryRelationship:pregnancyObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | PregnancyObservation | Base for all types and resources | |
| entryRelationship:preoperativeDiagnosis | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | PreoperativeDiagnosis | Base for all types and resources | |
| entryRelationship:reactionObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | ReactionObservation | Base for all types and resources | |
| entryRelationship:resultObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | ResultObservation | Base for all types and resources | |
| entryRelationship:sensoryStatus | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | SensoryStatus | Base for all types and resources | |
| entryRelationship:socialHistoryObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | SocialHistoryObservation | Base for all types and resources | |
| entryRelationship:substanceorDeviceAllergy-IntoleranceObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | SubstanceOrDeviceAllergyIntoleranceObservation | Base for all types and resources | |
| entryRelationship:tobaccoUse | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | TobaccoUse | Base for all types and resources | |
| entryRelationship:vitalSignObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | VitalSignObservation | Base for all types and resources | |
| entryRelationship:longitudinalCareWoundObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | LongitudinalCareWoundObservation | Base for all types and resources | |
| entryRelationship:problemObservation | C | 0..* | Element | The following entryRelationship represents the relationship Health Concern HAS SUPPORT Observation. |
| typeCode | 1..1 | code | Required Pattern: SPRT | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | ProblemObservation | Base for all types and resources | |
| entryRelationship:caregiverCharacteristics | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | CaregiverCharacteristics | Base for all types and resources | |
| entryRelationship:culturalandReligiousObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | CulturalandReligiousObservation | Base for all types and resources | |
| entryRelationship:characteristicsofHomeEnvironment | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | CharacteristicsofHomeEnvironment | Base for all types and resources | |
| entryRelationship:nutritionalStatusObservation | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | NutritionalStatusObservation | Base for all types and resources | |
| entryRelationship:entryRelationship30 | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| organizer | 1..1 | ResultOrganizer | Base for all types and resources | |
| entryRelationship:priorityPreference | C | 0..* | Element | The following entryRelationship represents the priority that the patient or a provider puts on the health concern. |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:problemConcernAct | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | ProblemConcernAct | Base for all types and resources | |
| entryRelationship:entryReference | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | EntryReference | Base for all types and resources | |
| reference | 0..* | Element | Where it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| externalDocument | 1..1 | ExternalDocumentReference | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Act.code | extensible | ActCode |
| Act.statusCode | required | ActStatus |
| Act.statusCode.code | required | ProblemAct statusCode |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32745 | error | Act.entryRelationship:entryReference.act | The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32745). : | |
| 1198-32860 | error | Act.entryRelationship:entryReference.act | The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32860). : | |
| act-er-1 | error | Act.entryRelationship, Act.entryRelationship:problemObservation, Act.entryRelationship:allergy-IntoleranceObservation, Act.entryRelationship:entryReference, Act.entryRelationship:entryReference, Act.entryRelationship:assessmentScaleObservation, Act.entryRelationship:self-CareActivities(ADLandIADL), Act.entryRelationship:mentalStatusObservation, Act.entryRelationship:smokingStatus-MeaningfulUse, Act.entryRelationship:encounterDiagnosis, Act.entryRelationship:entryRelationship10, Act.entryRelationship:functionalStatusObservation, Act.entryRelationship:hospitalAdmissionDiagnosis, Act.entryRelationship:nutritionAssessment, Act.entryRelationship:postprocedureDiagnosis, Act.entryRelationship:pregnancyObservation, Act.entryRelationship:preoperativeDiagnosis, Act.entryRelationship:reactionObservation, Act.entryRelationship:resultObservation, Act.entryRelationship:sensoryStatus, Act.entryRelationship:socialHistoryObservation, Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation, Act.entryRelationship:tobaccoUse, Act.entryRelationship:vitalSignObservation, Act.entryRelationship:longitudinalCareWoundObservation, Act.entryRelationship:problemObservation, Act.entryRelationship:caregiverCharacteristics, Act.entryRelationship:culturalandReligiousObservation, Act.entryRelationship:characteristicsofHomeEnvironment, Act.entryRelationship:nutritionalStatusObservation, Act.entryRelationship:entryRelationship30, Act.entryRelationship:priorityPreference, Act.entryRelationship:problemConcernAct, Act.entryRelationship:entryReference | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act | 1..1 | CDAR2.Act | Base for all types and resources | |
| classCode | 1..1 | code | Required Pattern: ACT | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| 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: 2.16.840.1.113883.10.20.22.4.132 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: v3 Code System ActCode (extensible) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: 75310-3 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
| 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 | ||
| negationInd | 0..1 | boolean | ||
| text | 0..1 | ED | ||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Binding: ProblemAct 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 (extensible) | |
| languageCode | 0..1 | CS | Binding: HumanLanguage (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 | ||
| author | 0..* | AuthorParticipation | A health concern may be a patient or provider concern. If the author is set to the recordTarget (patient), this is a patient concern. If the author is set to a provider, this is a provider concern. If both patient and provider are set as authors, this is a concern of both the patient and the provider. | |
| 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 | Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. Slice: Unordered, Open by profile:observation, profile:act, profile:organizer |
| 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:problemObservation | 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 | ProblemObservation | Base for all types and resources | |
| entryRelationship:allergy-IntoleranceObservation | 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 | AllergyIntoleranceObservation | Base for all types and resources | |
| entryRelationship:entryReference | C | 0..* | Element | The following entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern REFERS TO Health Concern). For example, a patient has 2 health concerns identified in a CARE Plan: Failure to Thrive and Poor Feeding, while it could be that one may have caused the other, at the time of care planning and documentation it is not necessary, nor desirable to have to assert what caused what. The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. |
| 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 | ||
| act | C | 1..1 | EntryReference | Base for all types and resources 1198-32860: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32860). |
| entryRelationship:entryReference | C | 0..* | Element | The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). For example, a patient has an Impaired Mobility Health Concern. There may then be the need to document several component health concerns, such as "Unable to Transfer Bed to Chair", "Unable to Rise from Commode", "Short of Breath Walking with Walker". The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required. |
| 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 | ||
| act | C | 1..1 | EntryReference | Base for all types and resources 1198-32745: The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32745). |
| entryRelationship:assessmentScaleObservation | 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 | AssessmentScaleObservation | Base for all types and resources | |
| entryRelationship:self-CareActivities(ADLandIADL) | 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 | SelfCareActivitiesADLandIADL | Base for all types and resources | |
| entryRelationship:mentalStatusObservation | 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 | MentalStatusObservation | Base for all types and resources | |
| entryRelationship:smokingStatus-MeaningfulUse | 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 | SmokingStatusMeaningfulUse | Base for all types and resources | |
| entryRelationship:encounterDiagnosis | 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 | ||
| act | 1..1 | EncounterDiagnosis | Base for all types and resources | |
| entryRelationship:entryRelationship10 | 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 | ||
| organizer | 1..1 | FamilyHistoryOrganizer | Base for all types and resources | |
| entryRelationship:functionalStatusObservation | 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 | FunctionalStatusObservation | Base for all types and resources | |
| entryRelationship:hospitalAdmissionDiagnosis | 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 | ||
| act | 1..1 | HospitalAdmissionDiagnosis | Base for all types and resources | |
| entryRelationship:nutritionAssessment | 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 | NutritionAssessment | Base for all types and resources | |
| entryRelationship:postprocedureDiagnosis | 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 | ||
| act | 1..1 | PostprocedureDiagnosis | Base for all types and resources | |
| entryRelationship:pregnancyObservation | 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 | PregnancyObservation | Base for all types and resources | |
| entryRelationship:preoperativeDiagnosis | 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 | ||
| act | 1..1 | PreoperativeDiagnosis | Base for all types and resources | |
| entryRelationship:reactionObservation | 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 | ReactionObservation | Base for all types and resources | |
| entryRelationship:resultObservation | 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 | ResultObservation | Base for all types and resources | |
| entryRelationship:sensoryStatus | 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 | SensoryStatus | Base for all types and resources | |
| entryRelationship:socialHistoryObservation | 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 | SocialHistoryObservation | Base for all types and resources | |
| entryRelationship:substanceorDeviceAllergy-IntoleranceObservation | 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 | SubstanceOrDeviceAllergyIntoleranceObservation | Base for all types and resources | |
| entryRelationship:tobaccoUse | 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 | TobaccoUse | Base for all types and resources | |
| entryRelationship:vitalSignObservation | 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 | VitalSignObservation | Base for all types and resources | |
| entryRelationship:longitudinalCareWoundObservation | 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 | LongitudinalCareWoundObservation | Base for all types and resources | |
| entryRelationship:problemObservation | C | 0..* | Element | The following entryRelationship represents the relationship Health Concern HAS SUPPORT Observation. |
| 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: SPRT | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | ProblemObservation | Base for all types and resources | |
| entryRelationship:caregiverCharacteristics | 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 | CaregiverCharacteristics | Base for all types and resources | |
| entryRelationship:culturalandReligiousObservation | 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 | CulturalandReligiousObservation | Base for all types and resources | |
| entryRelationship:characteristicsofHomeEnvironment | 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 | CharacteristicsofHomeEnvironment | Base for all types and resources | |
| entryRelationship:nutritionalStatusObservation | 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 | NutritionalStatusObservation | Base for all types and resources | |
| entryRelationship:entryRelationship30 | 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 | ||
| organizer | 1..1 | ResultOrganizer | Base for all types and resources | |
| entryRelationship:priorityPreference | C | 0..* | Element | The following entryRelationship represents the priority that the patient or a provider puts on the health concern. |
| 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:problemConcernAct | 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 | ||
| act | 1..1 | ProblemConcernAct | Base for all types and resources | |
| entryRelationship:entryReference | 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 | ||
| act | 1..1 | EntryReference | Base for all types and resources | |
| reference | 0..* | Element | Where it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. | |
| 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 | |
| seperatableInd | 0..1 | BL | ||
| externalAct | 0..1 | ExternalAct | ||
| externalObservation | 0..1 | ExternalObservation | ||
| externalProcedure | 0..1 | ExternalProcedure | ||
| externalDocument | 1..1 | ExternalDocumentReference | Base for all types and resources | |
| precondition | 0..* | Precondition | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Act.templateId:primary.nullFlavor | required | NullFlavor |
| Act.code | extensible | ActCode |
| Act.code.nullFlavor | required | NullFlavor |
| Act.statusCode | required | ActStatus |
| Act.statusCode.nullFlavor | required | NullFlavor |
| Act.statusCode.code | required | ProblemAct statusCode |
| Act.priorityCode | extensible | ActPriority |
| Act.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Act.subject.typeCode | required | Fixed Value: SBJ |
| Act.subject.contextControlCode | required | Fixed Value: OP |
| Act.subject.awarenessCode | extensible | TargetAwareness |
| Act.informant.typeCode | required | Fixed Value: INF |
| Act.informant.contextControlCode | required | Fixed Value: OP |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32745 | error | Act.entryRelationship:entryReference.act | The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32745). : | |
| 1198-32860 | error | Act.entryRelationship:entryReference.act | The Entry Reference template **SHALL** contain an id that references a Health Concern Act (CONF:1198-32860). : | |
| act-er-1 | error | Act.entryRelationship, Act.entryRelationship:problemObservation, Act.entryRelationship:allergy-IntoleranceObservation, Act.entryRelationship:entryReference, Act.entryRelationship:entryReference, Act.entryRelationship:assessmentScaleObservation, Act.entryRelationship:self-CareActivities(ADLandIADL), Act.entryRelationship:mentalStatusObservation, Act.entryRelationship:smokingStatus-MeaningfulUse, Act.entryRelationship:encounterDiagnosis, Act.entryRelationship:entryRelationship10, Act.entryRelationship:functionalStatusObservation, Act.entryRelationship:hospitalAdmissionDiagnosis, Act.entryRelationship:nutritionAssessment, Act.entryRelationship:postprocedureDiagnosis, Act.entryRelationship:pregnancyObservation, Act.entryRelationship:preoperativeDiagnosis, Act.entryRelationship:reactionObservation, Act.entryRelationship:resultObservation, Act.entryRelationship:sensoryStatus, Act.entryRelationship:socialHistoryObservation, Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation, Act.entryRelationship:tobaccoUse, Act.entryRelationship:vitalSignObservation, Act.entryRelationship:longitudinalCareWoundObservation, Act.entryRelationship:problemObservation, Act.entryRelationship:caregiverCharacteristics, Act.entryRelationship:culturalandReligiousObservation, Act.entryRelationship:characteristicsofHomeEnvironment, Act.entryRelationship:nutritionalStatusObservation, Act.entryRelationship:entryRelationship30, Act.entryRelationship:priorityPreference, Act.entryRelationship:problemConcernAct, Act.entryRelationship:entryReference | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
| 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() |
This structure is derived from CDAR2.Act
Summary
Mandatory: 11 elements (68 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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