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/2.16.840.1.113883.10.20.22.4.2 | Version: 2.1.0-draft1 | |||
| Active as of 2023-01-16 | Computable Name: ResultObservation | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.2:2015-08-01 | ||||
This template represents the results of a laboratory, radiology, or other study performed on a patient.
The result observation includes a statusCode to allow recording the status of an observation. Pending results (e.g., a test has been run but results have not been reported yet) should be represented as active ActStatus.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Observation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Observation | 1..1 | CDAR2.Observation | Base for all types and resources | |
  classCode | 1..1 | code | Required Pattern: OBS | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
  Slices for templateId | 0..* | II | Slice: Unordered, Open by value:extension, value:root | |
   templateId:primary | 1..1 | II | ||
  root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
  extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | 1198-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:1198-19212). |
| statusCode | 1..1 | CS | ||
 code | 1..1 | string | Binding: Result Status (required) | |
| effectiveTime | 1..1 | IVL_TS | Represents the biologically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
| value | C | 1..1 | BL, ED, ED, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | 1198-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:1198-32610). 1198-31866: A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:1198-31866). 1198-31484: If Observation/value is a physical quantity (**xsi:type="PQ"**), the unit of measure **SHALL** be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 **DYNAMIC** (CONF:1198-31484). |
| interpretationCode | 0..* | CE | ||
| code | 1..1 | string | Binding: Observation Interpretation (HL7) (required) | |
| methodCode | 0..1 | CE | ||
| targetSiteCode | 0..1 | CD | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
 referenceRange | 0..* | Element | ||
| observationRange | 1..1 | ObservationRange | ||
| code | 0..0 | |||
| value | 1..1 | BL, ED, ED, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.statusCode.code | required | Result Status |
| Observation.interpretationCode.code | required | Observation Interpretation (HL7) |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:1198-19212). : | |
| 1198-31484 | error | Observation.value | If Observation/value is a physical quantity (**xsi:type="PQ"**), the unit of measure **SHALL** be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 **DYNAMIC** (CONF:1198-31484). : | |
| 1198-31866 | warning | Observation.value | A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:1198-31866). : | |
| 1198-32610 | warning | Observation.value | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:1198-32610). : |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 1..1 | CDAR2.Observation | Base for all types and resources | |
 classCode | 1..1 | code | Binding: ActClassObservation (required) Required Pattern: OBS | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:extension, value:root | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: ObservationType (extensible) 1198-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:1198-19212). |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| code | 1..1 | string | Binding: Result Status (required) | |
| effectiveTime | 1..1 | IVL_TS | Represents the biologically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
 value | C | 1..1 | 1198-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:1198-32610). 1198-31866: A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:1198-31866). 1198-31484: If Observation/value is a physical quantity (**xsi:type="PQ"**), the unit of measure **SHALL** be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 **DYNAMIC** (CONF:1198-31484). | |
 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) | |
| code | 1..1 | string | Binding: Observation Interpretation (HL7) (required) | |
| methodCode | 0..1 | CE | Binding: ObservationMethod (extensible) | |
| targetSiteCode | 0..1 | CD | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| referenceRange | 0..* | Element | ||
| typeCode | 1..1 | code | Binding: ActRelationshipPertains (required) Fixed Value: REFV | |
| observationRange | 1..1 | ObservationRange | ||
| classCode | 1..1 | code | Binding: ActClassObservation (required) | |
| moodCode | 1..1 | code | Binding: ActMoodPredicate (required) Fixed Value: EVN.CRT | |
| value | 1..1 | |||
| value | BL | |||
| value | ED | |||
| value | ED | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Pattern: OBS |
| Observation.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.code | required | Result Status |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.interpretationCode.code | required | Observation Interpretation (HL7) |
| Observation.methodCode | extensible | ObservationMethod |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Observation.referenceRange.observationRange.classCode | required | ActClassObservation |
| Observation.referenceRange.observationRange.moodCode | required | Fixed Value: EVN.CRT |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:1198-19212). : | |
| 1198-31484 | error | Observation.value | If Observation/value is a physical quantity (**xsi:type="PQ"**), the unit of measure **SHALL** be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 **DYNAMIC** (CONF:1198-31484). : | |
| 1198-31866 | warning | Observation.value | A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:1198-31866). : | |
| 1198-32610 | warning | Observation.value | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:1198-32610). : | |
| 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 |
|---|---|---|---|---|
| Observation | 1..1 | CDAR2.Observation | Base for all types and resources | |
| classCode | 1..1 | code | Binding: ActClassObservation (required) Required Pattern: OBS | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| negationInd | 0..1 | boolean | ||
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:extension, 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: 2.16.840.1.113883.10.20.22.4.2 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: ObservationType (extensible) 1198-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:1198-19212). |
| derivationExpr | 0..1 | ED | ||
| text | 0..1 | ED | ||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Binding: Result Status (required) | |
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| effectiveTime | 1..1 | IVL_TS | Represents the biologically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| value | C | 1..1 | 1198-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:1198-32610). 1198-31866: A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:1198-31866). 1198-31484: If Observation/value is a physical quantity (**xsi:type="PQ"**), the unit of measure **SHALL** be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 **DYNAMIC** (CONF:1198-31484). | |
| 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) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Binding: Observation Interpretation (HL7) (required) | |
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| methodCode | 0..1 | CE | Binding: ObservationMethod (extensible) | |
| targetSiteCode | 0..1 | 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 | ||
| entryRelationship | 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 | ||
| 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 | ||
| reference | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| seperatableInd | 0..1 | BL | ||
| externalAct | 0..1 | ExternalAct | ||
| externalObservation | 0..1 | ExternalObservation | ||
| externalProcedure | 0..1 | ExternalProcedure | ||
| externalDocument | 0..1 | ExternalDocument | ||
| precondition | 0..* | Precondition | ||
| referenceRange | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ActRelationshipPertains (required) Fixed Value: REFV | |
| observationRange | 1..1 | ObservationRange | ||
| classCode | 1..1 | code | Binding: ActClassObservation (required) | |
| moodCode | 1..1 | code | Binding: ActMoodPredicate (required) Fixed Value: EVN.CRT | |
| templateId | 0..* | II | ||
| text | 0..1 | ED | ||
| value | 1..1 | |||
| value | BL | |||
| value | ED | |||
| value | ED | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| interpretationCode | 0..1 | CE | Binding: ObservationInterpretation (required) | |
| 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.statusCode.nullFlavor | required | NullFlavor |
| Observation.statusCode.code | required | Result Status |
| Observation.priorityCode | extensible | ActPriority |
| Observation.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.interpretationCode.nullFlavor | required | NullFlavor |
| Observation.interpretationCode.code | required | Observation Interpretation (HL7) |
| 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 |
| Observation.referenceRange.observationRange.classCode | required | ActClassObservation |
| Observation.referenceRange.observationRange.moodCode | required | Fixed Value: EVN.CRT |
| Observation.referenceRange.observationRange.interpretationCode | required | ObservationInterpretation |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:1198-19212). : | |
| 1198-31484 | error | Observation.value | If Observation/value is a physical quantity (**xsi:type="PQ"**), the unit of measure **SHALL** be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 **DYNAMIC** (CONF:1198-31484). : | |
| 1198-31866 | warning | Observation.value | A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:1198-31866). : | |
| 1198-32610 | warning | Observation.value | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:1198-32610). : | |
| 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 | 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: 11 elements (3 nested mandatory elements)
Prohibited: 1 element
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 | 1..1 | CDAR2.Observation | Base for all types and resources | |
| classCode | 1..1 | code | Required Pattern: OBS | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:extension, value:root | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | 1198-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:1198-19212). |
| statusCode | 1..1 | CS | ||
| code | 1..1 | string | Binding: Result Status (required) | |
| effectiveTime | 1..1 | IVL_TS | Represents the biologically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
| value | C | 1..1 | BL, ED, ED, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | 1198-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:1198-32610). 1198-31866: A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:1198-31866). 1198-31484: If Observation/value is a physical quantity (**xsi:type="PQ"**), the unit of measure **SHALL** be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 **DYNAMIC** (CONF:1198-31484). |
| interpretationCode | 0..* | CE | ||
| code | 1..1 | string | Binding: Observation Interpretation (HL7) (required) | |
| methodCode | 0..1 | CE | ||
| targetSiteCode | 0..1 | CD | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| referenceRange | 0..* | Element | ||
| observationRange | 1..1 | ObservationRange | ||
| code | 0..0 | |||
| value | 1..1 | BL, ED, ED, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.statusCode.code | required | Result Status |
| Observation.interpretationCode.code | required | Observation Interpretation (HL7) |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:1198-19212). : | |
| 1198-31484 | error | Observation.value | If Observation/value is a physical quantity (**xsi:type="PQ"**), the unit of measure **SHALL** be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 **DYNAMIC** (CONF:1198-31484). : | |
| 1198-31866 | warning | Observation.value | A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:1198-31866). : | |
| 1198-32610 | warning | Observation.value | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:1198-32610). : |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 1..1 | CDAR2.Observation | Base for all types and resources | |
| classCode | 1..1 | code | Binding: ActClassObservation (required) Required Pattern: OBS | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:extension, value:root | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.2 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: ObservationType (extensible) 1198-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:1198-19212). |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| code | 1..1 | string | Binding: Result Status (required) | |
| effectiveTime | 1..1 | IVL_TS | Represents the biologically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
| value | C | 1..1 | 1198-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:1198-32610). 1198-31866: A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:1198-31866). 1198-31484: If Observation/value is a physical quantity (**xsi:type="PQ"**), the unit of measure **SHALL** be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 **DYNAMIC** (CONF:1198-31484). | |
| 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) | |
| code | 1..1 | string | Binding: Observation Interpretation (HL7) (required) | |
| methodCode | 0..1 | CE | Binding: ObservationMethod (extensible) | |
| targetSiteCode | 0..1 | CD | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| referenceRange | 0..* | Element | ||
| typeCode | 1..1 | code | Binding: ActRelationshipPertains (required) Fixed Value: REFV | |
| observationRange | 1..1 | ObservationRange | ||
| classCode | 1..1 | code | Binding: ActClassObservation (required) | |
| moodCode | 1..1 | code | Binding: ActMoodPredicate (required) Fixed Value: EVN.CRT | |
| value | 1..1 | |||
| value | BL | |||
| value | ED | |||
| value | ED | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Pattern: OBS |
| Observation.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.code | required | Result Status |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.interpretationCode.code | required | Observation Interpretation (HL7) |
| Observation.methodCode | extensible | ObservationMethod |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Observation.referenceRange.observationRange.classCode | required | ActClassObservation |
| Observation.referenceRange.observationRange.moodCode | required | Fixed Value: EVN.CRT |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:1198-19212). : | |
| 1198-31484 | error | Observation.value | If Observation/value is a physical quantity (**xsi:type="PQ"**), the unit of measure **SHALL** be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 **DYNAMIC** (CONF:1198-31484). : | |
| 1198-31866 | warning | Observation.value | A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:1198-31866). : | |
| 1198-32610 | warning | Observation.value | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:1198-32610). : | |
| 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 |
|---|---|---|---|---|
| Observation | 1..1 | CDAR2.Observation | Base for all types and resources | |
| classCode | 1..1 | code | Binding: ActClassObservation (required) Required Pattern: OBS | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| negationInd | 0..1 | boolean | ||
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:extension, 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: 2.16.840.1.113883.10.20.22.4.2 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: ObservationType (extensible) 1198-19212: This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:1198-19212). |
| derivationExpr | 0..1 | ED | ||
| text | 0..1 | ED | ||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Binding: Result Status (required) | |
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| effectiveTime | 1..1 | IVL_TS | Represents the biologically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). | |
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| value | C | 1..1 | 1198-32610: If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:1198-32610). 1198-31866: A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:1198-31866). 1198-31484: If Observation/value is a physical quantity (**xsi:type="PQ"**), the unit of measure **SHALL** be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 **DYNAMIC** (CONF:1198-31484). | |
| 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) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Binding: Observation Interpretation (HL7) (required) | |
| codeSystem | 0..1 | string | ||
| codeSystemName | 0..1 | string | ||
| codeSystemVersion | 0..1 | string | ||
| displayName | 0..1 | string | ||
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | ||
| methodCode | 0..1 | CE | Binding: ObservationMethod (extensible) | |
| targetSiteCode | 0..1 | 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 | ||
| entryRelationship | 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 | ||
| 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 | ||
| reference | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| seperatableInd | 0..1 | BL | ||
| externalAct | 0..1 | ExternalAct | ||
| externalObservation | 0..1 | ExternalObservation | ||
| externalProcedure | 0..1 | ExternalProcedure | ||
| externalDocument | 0..1 | ExternalDocument | ||
| precondition | 0..* | Precondition | ||
| referenceRange | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ActRelationshipPertains (required) Fixed Value: REFV | |
| observationRange | 1..1 | ObservationRange | ||
| classCode | 1..1 | code | Binding: ActClassObservation (required) | |
| moodCode | 1..1 | code | Binding: ActMoodPredicate (required) Fixed Value: EVN.CRT | |
| templateId | 0..* | II | ||
| text | 0..1 | ED | ||
| value | 1..1 | |||
| value | BL | |||
| value | ED | |||
| value | ED | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| interpretationCode | 0..1 | CE | Binding: ObservationInterpretation (required) | |
| 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.statusCode.nullFlavor | required | NullFlavor |
| Observation.statusCode.code | required | Result Status |
| Observation.priorityCode | extensible | ActPriority |
| Observation.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.interpretationCode.nullFlavor | required | NullFlavor |
| Observation.interpretationCode.code | required | Observation Interpretation (HL7) |
| 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 |
| Observation.referenceRange.observationRange.classCode | required | ActClassObservation |
| Observation.referenceRange.observationRange.moodCode | required | Fixed Value: EVN.CRT |
| Observation.referenceRange.observationRange.interpretationCode | required | ObservationInterpretation |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-19212 | warning | Observation.code | This code **SHOULD** be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result **SHALL** be sent (CONF:1198-19212). : | |
| 1198-31484 | error | Observation.value | If Observation/value is a physical quantity (**xsi:type="PQ"**), the unit of measure **SHALL** be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 **DYNAMIC** (CONF:1198-31484). : | |
| 1198-31866 | warning | Observation.value | A coded or physical quantity value **MAY** contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:1198-31866). : | |
| 1198-32610 | warning | Observation.value | If Observation/value is a CD (**xsi:type="CD"**) the value **SHOULD** be SNOMED-CT (CONF:1198-32610). : | |
| 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 | 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: 11 elements (3 nested mandatory elements)
Prohibited: 1 element
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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