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/2.16.840.1.113883.10.20.22.4.136 | Version: 2.1.0-draft1 | |||
| Active as of 2023-01-16 | Computable Name: RiskConcernAct | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.136:2015-08-01 | ||||
This template represents a risk concern.
It is a wrapper for a single risk 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 Risk Concern Act represents a health concern that is a risk. A risk is a clinical or socioeconomic condition that the patient does not currently have, but the probability of developing that condition rises to the level of concern such that an intervention and/or monitoring is needed.
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: 2.16.840.1.113883.10.20.22.4.136 | |
  extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | ||
| code | 1..1 | string | Required Pattern: 281694009 | |
 codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
| statusCode | 1..1 | CS | ||
| code | 1..1 | string | Binding: ProblemAct statusCode (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
 author | 0..* | AuthorParticipation | Base for all types and resources | |
| 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 RELATES TO Health Concern). 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 | 1..1 | EntryReference | Base for all types and resources | |
| 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). The Enry 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 | 1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:assessmentScaleObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | AssessmentScaleObservation | 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: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:entryRelationship11 | 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:resultOrganizer | 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 puts on the health concern. | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:priorityPreference | 0..* | Element | The following entryRelationship represents the priority that the 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 | ||
| 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 |
| 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: 2.16.840.1.113883.10.20.22.4.136 | |
| 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: 281694009 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| code | 1..1 | string | Binding: ProblemAct statusCode (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| 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 RELATES TO Health Concern). 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 | 1..1 | EntryReference | Base for all types and resources | |
| 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). The Enry 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 | 1..1 | EntryReference | Base for all types and resources | |
| 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: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: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:entryRelationship11 | 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:resultOrganizer | 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 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:priorityPreference | C | 0..* | Element | The following entryRelationship represents the priority that the 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 | ||
| 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 |
| act-er-1 | error | Act.entryRelationship, Act.entryRelationship:problemObservation, Act.entryRelationship:allergy-IntoleranceObservation, Act.entryRelationship:entryReference, Act.entryRelationship:entryReference, Act.entryRelationship:assessmentScaleObservation, Act.entryRelationship:mentalStatusObservation, Act.entryRelationship:self-CareActivities(ADLandIADL), Act.entryRelationship:mentalStatusObservation, Act.entryRelationship:smokingStatus-MeaningfulUse, Act.entryRelationship:encounterDiagnosis, Act.entryRelationship:entryRelationship11, 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:resultOrganizer, Act.entryRelationship:priorityPreference, 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: 2.16.840.1.113883.10.20.22.4.136 | |
| 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: 281694009 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| 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 | Base for all types and resources | |
| informant | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 0..1 | RelatedEntity | ||
| participant | 0..* | Participant2 | ||
| Slices for entryRelationship | C | 0..* | Element | 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 RELATES TO Health Concern). 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 | 1..1 | EntryReference | Base for all types and resources | |
| 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). The Enry 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 | 1..1 | EntryReference | Base for all types and resources | |
| 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: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: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:entryRelationship11 | 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:resultOrganizer | 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 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:priorityPreference | C | 0..* | Element | The following entryRelationship represents the priority that the 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 | ||
| 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 |
| act-er-1 | error | Act.entryRelationship, Act.entryRelationship:problemObservation, Act.entryRelationship:allergy-IntoleranceObservation, Act.entryRelationship:entryReference, Act.entryRelationship:entryReference, Act.entryRelationship:assessmentScaleObservation, Act.entryRelationship:mentalStatusObservation, Act.entryRelationship:self-CareActivities(ADLandIADL), Act.entryRelationship:mentalStatusObservation, Act.entryRelationship:smokingStatus-MeaningfulUse, Act.entryRelationship:encounterDiagnosis, Act.entryRelationship:entryRelationship11, 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:resultOrganizer, Act.entryRelationship:priorityPreference, 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 (72 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: 2.16.840.1.113883.10.20.22.4.136 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | ||
| code | 1..1 | string | Required Pattern: 281694009 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
| statusCode | 1..1 | CS | ||
| code | 1..1 | string | Binding: ProblemAct statusCode (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| 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 RELATES TO Health Concern). 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 | 1..1 | EntryReference | Base for all types and resources | |
| 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). The Enry 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 | 1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:assessmentScaleObservation | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | AssessmentScaleObservation | 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: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:entryRelationship11 | 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:resultOrganizer | 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 puts on the health concern. | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:priorityPreference | 0..* | Element | The following entryRelationship represents the priority that the 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 | ||
| 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 |
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: 2.16.840.1.113883.10.20.22.4.136 | |
| 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: 281694009 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| code | 1..1 | string | Binding: ProblemAct statusCode (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| 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 RELATES TO Health Concern). 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 | 1..1 | EntryReference | Base for all types and resources | |
| 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). The Enry 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 | 1..1 | EntryReference | Base for all types and resources | |
| 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: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: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:entryRelationship11 | 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:resultOrganizer | 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 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:priorityPreference | C | 0..* | Element | The following entryRelationship represents the priority that the 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 | ||
| 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 |
| act-er-1 | error | Act.entryRelationship, Act.entryRelationship:problemObservation, Act.entryRelationship:allergy-IntoleranceObservation, Act.entryRelationship:entryReference, Act.entryRelationship:entryReference, Act.entryRelationship:assessmentScaleObservation, Act.entryRelationship:mentalStatusObservation, Act.entryRelationship:self-CareActivities(ADLandIADL), Act.entryRelationship:mentalStatusObservation, Act.entryRelationship:smokingStatus-MeaningfulUse, Act.entryRelationship:encounterDiagnosis, Act.entryRelationship:entryRelationship11, 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:resultOrganizer, Act.entryRelationship:priorityPreference, 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: 2.16.840.1.113883.10.20.22.4.136 | |
| 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: 281694009 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| 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 | Base for all types and resources | |
| informant | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 0..1 | RelatedEntity | ||
| participant | 0..* | Participant2 | ||
| Slices for entryRelationship | C | 0..* | Element | 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 RELATES TO Health Concern). 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 | 1..1 | EntryReference | Base for all types and resources | |
| 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). The Enry 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 | 1..1 | EntryReference | Base for all types and resources | |
| 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: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: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:entryRelationship11 | 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:resultOrganizer | 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 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:priorityPreference | C | 0..* | Element | The following entryRelationship represents the priority that the 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 | ||
| 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 |
| act-er-1 | error | Act.entryRelationship, Act.entryRelationship:problemObservation, Act.entryRelationship:allergy-IntoleranceObservation, Act.entryRelationship:entryReference, Act.entryRelationship:entryReference, Act.entryRelationship:assessmentScaleObservation, Act.entryRelationship:mentalStatusObservation, Act.entryRelationship:self-CareActivities(ADLandIADL), Act.entryRelationship:mentalStatusObservation, Act.entryRelationship:smokingStatus-MeaningfulUse, Act.entryRelationship:encounterDiagnosis, Act.entryRelationship:entryRelationship11, 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:resultOrganizer, Act.entryRelationship:priorityPreference, 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 (72 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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