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/2.16.840.1.113883.10.20.22.4.144 | Version: 2.1.0-draft1 | |||
| Active as of 2023-01-16 | Computable Name: OutcomeObservation | |||
| Other Identifiers: id: urn:oid:2.16.840.1.113883.10.20.22.4.144 | ||||
This template represents the outcome of care resulting from the interventions used to treat the patient. In the Care Planning workflow, the judgment about how well the person is progressing towards the goal is based on the observations made about the status of the patient with respect to interventions performed in the pursuit of achieving that goal.
Often thought of as an “actual outcome”, the Outcome Observation may be related to goals, progression toward goals, and the associated interventions. For example, an observation outcome of a blood oxygen saturation level of 95% is related to the goal of “Maintain Pulse Ox greater than 92”, which in turn is related to the health concern of respiratory insufficiency and the problem of pneumonia. The template makes use of the Entry Reference (templateId:2.16.840.1.113883.10.20.22.4.122) to reference the interventions and goals defined elsewhere in the Care Plan CDA instance.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Observation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Observation | C | 1..1 | CDAR2.Observation | Base for all types and resources 1098-32782: SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). |
  classCode | 1..1 | code | Required Pattern: OBS | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
  Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root | |
   templateId:primary | 1..1 | II | ||
  root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.144 | |
| id | 1..* | II | ||
| code | 1..1 | CD | ||
| value | 0..1 | BL, ED, ED, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | Element | Where an Outcome Observation needs to reference an Intervention Act already described in the CDA document instance, rather than repeating the full content of the Intervention Act, the Entry Reference template may be used to reference this entry. Slice: Unordered, Open by profile:act, profile:observation | |
 entryRelationship:entryReference | C | 0..* | Element | The following entryRelationship represents the relationship between an Outcome Observation and a Goal Observation. Because the Goal Observation is already described in the CDA document instance's Goals section, rather than repeating the full content of the Goal Observation, the Entry Reference template can be used to reference this entry. 1098-32461: This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). |
  typeCode | 1..1 | code | Required Pattern: GEVL | |
| act | 1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:progressTowardGoalObservation | 0..1 | Element | The following entryRelationship represents the relationship between an Outcome Observation and a Progress Toward Goal Observation (Outcome Observation SUPPORTS Progress Toward Goal Observation). In the Care Planning workflow, the judgment about how well the person is progressing towards the goal is based on the observations made about the status of the patient with respect to interventions performed in the pursuit of achieving that goal. | |
| typeCode | 1..1 | code | Required Pattern: SPRT | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| observation | 1..1 | ProgressTowardGoalObservation | Base for all types and resources | |
| entryRelationship:entryReference | C | 0..* | Element | 1098-32462: This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). |
| typeCode | 1..1 | code | Required Pattern: RSON | |
| 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 | ||||
| Id | Grade | Path(s) | Details | Requirements |
| 1098-32461 | error | Observation.entryRelationship:entryReference | This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). : | |
| 1098-32462 | error | Observation.entryRelationship:entryReference | This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). : | |
| 1098-32782 | error | Observation | SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). : |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | C | 1..1 | CDAR2.Observation | Base for all types and resources 1098-32782: SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). |
 classCode | 1..1 | code | Binding: ActClassObservation (required) Required Pattern: OBS | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.144 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: ObservationType (extensible) | |
 value | 0..1 | |||
 value | BL | |||
| value | ED | |||
| value | ED | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| value | RTO_PQ_PQ | |||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | C | 0..* | Element | Where an Outcome Observation needs to reference an Intervention Act already described in the CDA document instance, rather than repeating the full content of the Intervention Act, the Entry Reference template may be used to reference this entry. Slice: Unordered, Open by profile:act, profile:observation |
| entryRelationship:All Slices | Content/Rules for all slices | |||
 typeCode | 1..1 | code | ||
 contextConductionInd | 1..1 | boolean | ||
| entryRelationship:entryReference | C | 0..* | Element | The following entryRelationship represents the relationship between an Outcome Observation and a Goal Observation. Because the Goal Observation is already described in the CDA document instance's Goals section, rather than repeating the full content of the Goal Observation, the Entry Reference template can be used to reference this entry. 1098-32461: This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). |
| typeCode | 1..1 | code | Required Pattern: GEVL | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:progressTowardGoalObservation | C | 0..1 | Element | The following entryRelationship represents the relationship between an Outcome Observation and a Progress Toward Goal Observation (Outcome Observation SUPPORTS Progress Toward Goal Observation). In the Care Planning workflow, the judgment about how well the person is progressing towards the goal is based on the observations made about the status of the patient with respect to interventions performed in the pursuit of achieving that goal. |
| typeCode | 1..1 | code | Required Pattern: SPRT | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | ProgressTowardGoalObservation | Base for all types and resources | |
| entryRelationship:entryReference | C | 0..* | Element | 1098-32462: This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). |
| typeCode | 1..1 | code | Required Pattern: RSON | |
| 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 / Code |
| Observation.classCode | required | Pattern: OBS |
| Observation.code | extensible | ObservationType |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-32461 | error | Observation.entryRelationship:entryReference | This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). : | |
| 1098-32462 | error | Observation.entryRelationship:entryReference | This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). : | |
| 1098-32782 | error | Observation | SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| obs-er-1 | error | Observation.entryRelationship, Observation.entryRelationship:entryReference, Observation.entryRelationship:progressTowardGoalObservation, Observation.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 |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | C | 1..1 | CDAR2.Observation | Base for all types and resources 1098-32782: SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). |
| classCode | 1..1 | code | Binding: ActClassObservation (required) Required Pattern: OBS | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| negationInd | 0..1 | boolean | ||
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root | |
| 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: 2.16.840.1.113883.10.20.22.4.144 | |
 extension | 0..1 | string | ||
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: ObservationType (extensible) | |
| derivationExpr | 0..1 | ED | ||
| text | 0..1 | ED | ||
| statusCode | 0..1 | CS | Binding: ActStatus (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| value | 0..1 | |||
| value | BL | |||
| value | ED | |||
| value | ED | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| value | RTO_PQ_PQ | |||
| interpretationCode | 0..* | CE | Binding: ObservationInterpretation (required) | |
| methodCode | 0..* | CE | Binding: ObservationMethod (extensible) | |
| targetSiteCode | 0..* | CD | ||
| subject | 0..1 | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| awarenessCode | 0..1 | CE | Binding: TargetAwareness (extensible) | |
| relatedSubject | 1..1 | RelatedSubject | ||
| specimen | 0..* | Specimen | ||
| performer | 0..* | Performer2 | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| informant | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 0..1 | RelatedEntity | ||
| participant | 0..* | Participant2 | ||
| Slices for entryRelationship | C | 0..* | Element | Where an Outcome Observation needs to reference an Intervention Act already described in the CDA document instance, rather than repeating the full content of the Intervention Act, the Entry Reference template may be used to reference this entry. Slice: Unordered, Open by profile:act, profile:observation |
| 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:entryReference | C | 0..* | Element | The following entryRelationship represents the relationship between an Outcome Observation and a Goal Observation. Because the Goal Observation is already described in the CDA document instance's Goals section, rather than repeating the full content of the Goal Observation, the Entry Reference template can be used to reference this entry. 1098-32461: This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). |
| 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: GEVL | |
| 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:progressTowardGoalObservation | C | 0..1 | Element | The following entryRelationship represents the relationship between an Outcome Observation and a Progress Toward Goal Observation (Outcome Observation SUPPORTS Progress Toward Goal Observation). In the Care Planning workflow, the judgment about how well the person is progressing towards the goal is based on the observations made about the status of the patient with respect to interventions performed in the pursuit of achieving that goal. |
| 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 | 1..1 | boolean | Required Pattern: true | |
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | ProgressTowardGoalObservation | Base for all types and resources | |
| entryRelationship:entryReference | C | 0..* | Element | 1098-32462: This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: RSON | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| 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 | ||
| referenceRange | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ActRelationshipPertains (required) Fixed Value: REFV | |
| observationRange | 1..1 | ObservationRange | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Pattern: OBS |
| Observation.templateId:primary.nullFlavor | required | NullFlavor |
| Observation.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.priorityCode | extensible | ActPriority |
| Observation.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | extensible | ObservationMethod |
| Observation.subject.typeCode | required | Fixed Value: SBJ |
| Observation.subject.contextControlCode | required | Fixed Value: OP |
| Observation.subject.awarenessCode | extensible | TargetAwareness |
| Observation.informant.typeCode | required | Fixed Value: INF |
| Observation.informant.contextControlCode | required | Fixed Value: OP |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-32461 | error | Observation.entryRelationship:entryReference | This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). : | |
| 1098-32462 | error | Observation.entryRelationship:entryReference | This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-er-1 | error | Observation.entryRelationship, Observation.entryRelationship:entryReference, Observation.entryRelationship:progressTowardGoalObservation, Observation.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 |
This structure is derived from CDAR2.Observation
Summary
Mandatory: 6 elements (9 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.Observation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | C | 1..1 | CDAR2.Observation | Base for all types and resources 1098-32782: SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). |
| classCode | 1..1 | code | Required Pattern: OBS | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.144 | |
| id | 1..* | II | ||
| code | 1..1 | CD | ||
| value | 0..1 | BL, ED, ED, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | Element | Where an Outcome Observation needs to reference an Intervention Act already described in the CDA document instance, rather than repeating the full content of the Intervention Act, the Entry Reference template may be used to reference this entry. Slice: Unordered, Open by profile:act, profile:observation | |
| entryRelationship:entryReference | C | 0..* | Element | The following entryRelationship represents the relationship between an Outcome Observation and a Goal Observation. Because the Goal Observation is already described in the CDA document instance's Goals section, rather than repeating the full content of the Goal Observation, the Entry Reference template can be used to reference this entry. 1098-32461: This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). |
| typeCode | 1..1 | code | Required Pattern: GEVL | |
| act | 1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:progressTowardGoalObservation | 0..1 | Element | The following entryRelationship represents the relationship between an Outcome Observation and a Progress Toward Goal Observation (Outcome Observation SUPPORTS Progress Toward Goal Observation). In the Care Planning workflow, the judgment about how well the person is progressing towards the goal is based on the observations made about the status of the patient with respect to interventions performed in the pursuit of achieving that goal. | |
| typeCode | 1..1 | code | Required Pattern: SPRT | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| observation | 1..1 | ProgressTowardGoalObservation | Base for all types and resources | |
| entryRelationship:entryReference | C | 0..* | Element | 1098-32462: This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). |
| typeCode | 1..1 | code | Required Pattern: RSON | |
| 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 | ||||
| Id | Grade | Path(s) | Details | Requirements |
| 1098-32461 | error | Observation.entryRelationship:entryReference | This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). : | |
| 1098-32462 | error | Observation.entryRelationship:entryReference | This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). : | |
| 1098-32782 | error | Observation | SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). : |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | C | 1..1 | CDAR2.Observation | Base for all types and resources 1098-32782: SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). |
| classCode | 1..1 | code | Binding: ActClassObservation (required) Required Pattern: OBS | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.144 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: ObservationType (extensible) | |
| value | 0..1 | |||
| value | BL | |||
| value | ED | |||
| value | ED | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| value | RTO_PQ_PQ | |||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | C | 0..* | Element | Where an Outcome Observation needs to reference an Intervention Act already described in the CDA document instance, rather than repeating the full content of the Intervention Act, the Entry Reference template may be used to reference this entry. Slice: Unordered, Open by profile:act, profile:observation |
| entryRelationship:All Slices | Content/Rules for all slices | |||
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| entryRelationship:entryReference | C | 0..* | Element | The following entryRelationship represents the relationship between an Outcome Observation and a Goal Observation. Because the Goal Observation is already described in the CDA document instance's Goals section, rather than repeating the full content of the Goal Observation, the Entry Reference template can be used to reference this entry. 1098-32461: This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). |
| typeCode | 1..1 | code | Required Pattern: GEVL | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:progressTowardGoalObservation | C | 0..1 | Element | The following entryRelationship represents the relationship between an Outcome Observation and a Progress Toward Goal Observation (Outcome Observation SUPPORTS Progress Toward Goal Observation). In the Care Planning workflow, the judgment about how well the person is progressing towards the goal is based on the observations made about the status of the patient with respect to interventions performed in the pursuit of achieving that goal. |
| typeCode | 1..1 | code | Required Pattern: SPRT | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | ProgressTowardGoalObservation | Base for all types and resources | |
| entryRelationship:entryReference | C | 0..* | Element | 1098-32462: This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). |
| typeCode | 1..1 | code | Required Pattern: RSON | |
| 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 / Code |
| Observation.classCode | required | Pattern: OBS |
| Observation.code | extensible | ObservationType |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-32461 | error | Observation.entryRelationship:entryReference | This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). : | |
| 1098-32462 | error | Observation.entryRelationship:entryReference | This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). : | |
| 1098-32782 | error | Observation | SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| obs-er-1 | error | Observation.entryRelationship, Observation.entryRelationship:entryReference, Observation.entryRelationship:progressTowardGoalObservation, Observation.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 |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | C | 1..1 | CDAR2.Observation | Base for all types and resources 1098-32782: SHALL contain at least one [1..*] entryRelationships (CONF:1098-32782). |
| classCode | 1..1 | code | Binding: ActClassObservation (required) Required Pattern: OBS | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| negationInd | 0..1 | boolean | ||
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root | |
| 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: 2.16.840.1.113883.10.20.22.4.144 | |
| extension | 0..1 | string | ||
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: ObservationType (extensible) | |
| derivationExpr | 0..1 | ED | ||
| text | 0..1 | ED | ||
| statusCode | 0..1 | CS | Binding: ActStatus (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| value | 0..1 | |||
| value | BL | |||
| value | ED | |||
| value | ED | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| value | RTO_PQ_PQ | |||
| interpretationCode | 0..* | CE | Binding: ObservationInterpretation (required) | |
| methodCode | 0..* | CE | Binding: ObservationMethod (extensible) | |
| targetSiteCode | 0..* | CD | ||
| subject | 0..1 | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| awarenessCode | 0..1 | CE | Binding: TargetAwareness (extensible) | |
| relatedSubject | 1..1 | RelatedSubject | ||
| specimen | 0..* | Specimen | ||
| performer | 0..* | Performer2 | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| informant | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 0..1 | RelatedEntity | ||
| participant | 0..* | Participant2 | ||
| Slices for entryRelationship | C | 0..* | Element | Where an Outcome Observation needs to reference an Intervention Act already described in the CDA document instance, rather than repeating the full content of the Intervention Act, the Entry Reference template may be used to reference this entry. Slice: Unordered, Open by profile:act, profile:observation |
| 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:entryReference | C | 0..* | Element | The following entryRelationship represents the relationship between an Outcome Observation and a Goal Observation. Because the Goal Observation is already described in the CDA document instance's Goals section, rather than repeating the full content of the Goal Observation, the Entry Reference template can be used to reference this entry. 1098-32461: This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). |
| 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: GEVL | |
| 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:progressTowardGoalObservation | C | 0..1 | Element | The following entryRelationship represents the relationship between an Outcome Observation and a Progress Toward Goal Observation (Outcome Observation SUPPORTS Progress Toward Goal Observation). In the Care Planning workflow, the judgment about how well the person is progressing towards the goal is based on the observations made about the status of the patient with respect to interventions performed in the pursuit of achieving that goal. |
| 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 | 1..1 | boolean | Required Pattern: true | |
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | ProgressTowardGoalObservation | Base for all types and resources | |
| entryRelationship:entryReference | C | 0..* | Element | 1098-32462: This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: RSON | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| 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 | ||
| referenceRange | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ActRelationshipPertains (required) Fixed Value: REFV | |
| observationRange | 1..1 | ObservationRange | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Pattern: OBS |
| Observation.templateId:primary.nullFlavor | required | NullFlavor |
| Observation.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.priorityCode | extensible | ActPriority |
| Observation.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | extensible | ObservationMethod |
| Observation.subject.typeCode | required | Fixed Value: SBJ |
| Observation.subject.contextControlCode | required | Fixed Value: OP |
| Observation.subject.awarenessCode | extensible | TargetAwareness |
| Observation.informant.typeCode | required | Fixed Value: INF |
| Observation.informant.contextControlCode | required | Fixed Value: OP |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-32461 | error | Observation.entryRelationship:entryReference | This entryReference template **SHALL** reference an instance of a Goal Observation template (CONF:1098-32461). : | |
| 1098-32462 | error | Observation.entryRelationship:entryReference | This entryReference template **SHALL** reference an instance of a Intervention Act template (CONF:1098-32462). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-er-1 | error | Observation.entryRelationship, Observation.entryRelationship:entryReference, Observation.entryRelationship:progressTowardGoalObservation, Observation.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 |
This structure is derived from CDAR2.Observation
Summary
Mandatory: 6 elements (9 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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