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

Resource Profile: Planned Observation

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.44 Version: 2.1.0-draft1
Active as of 2023-01-16 Computable Name: PlannedObservation
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.44:2014-06-09

This template represents planned observations that result in new information about the patient which cannot be classified as a procedure according to the HL7 RIM, i.e., procedures alter the patient’s body. Examples of these observations are laboratory tests, diagnostic imaging tests, EEGs, and EKGs.

The importance of the planned observation to the patient and provider is communicated through Priority Preference. The effectiveTime indicates the time when the observation is intended to take place and authorTime indicates when the documentation of the plan occurred. The Planned Observation template may also indicate the potential insurance coverage for the observation.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationBase for all types and resources
... classCode 1..1codeRequired Pattern: OBS
... moodCode 1..1codeBinding: Planned moodCode (Observation) (required)
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.44
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CD
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: active
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned observation represents the time that the observation should occur.
... value 0..1BL, 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
... methodCode 0..1CEIn a planned observation the provider may suggest that an observation should be performed using a particular method.
... targetSiteCode 0..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned observation.
Binding: Body Site Value Set (required)
... performer 0..*Performer2The clinician who is expected to perform the observation could be identified using procedure/performer.
... author 0..*AuthorParticipationThe author in a planned observation represents the clinician who is requesting or planning the observation.
... Slices for entryRelationship 0..*ElementThe following entryRelationship represents the insurance coverage the patient may have for the observation.
Slice: Unordered, Open by profile:observation, profile:act
.... entryRelationship:priorityPreference 0..*ElementThe following entryRelationship represents the priority that a patient or a provider places on the observation.
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1PriorityPreferenceBase for all types and resources
.... entryRelationship:indication 0..*ElementThe following entryRelationship represents the indication for the observation.
..... typeCode 1..1codeRequired Pattern: RSON
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:instruction 0..*ElementThe following entryRelationship captures any instructions associated with the planned observation.
..... typeCode 1..1codeRequired Pattern: SUBJ
..... act 1..1InstructionBase for all types and resources
.... entryRelationship:plannedCoverage 0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... act 1..1PlannedCoverageBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.moodCoderequiredPlanned moodCode (Observation)
Observation.targetSiteCoderequiredBody Site Value Set
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationBase for all types and resources
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeBinding: Planned moodCode (Observation) (required)
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.44
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CDBinding: ObservationType (extensible)
... statusCode 1..1CSBinding: ActStatus (required)
.... code 1..1stringRequired Pattern: active
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned observation represents the time that the observation should occur.
... value 0..1
.... valueBL
.... valueED
.... valueED
.... valueCD
.... valueCV
.... valueCE
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
... methodCode 0..1CEIn a planned observation the provider may suggest that an observation should be performed using a particular method.
Binding: ObservationMethod (extensible)
... targetSiteCode 0..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned observation.
Binding: Body Site Value Set (required)
... performer 0..*Performer2The clinician who is expected to perform the observation could be identified using procedure/performer.
... author 0..*AuthorParticipationThe author in a planned observation represents the clinician who is requesting or planning the observation.
... Slices for entryRelationship C0..*ElementThe following entryRelationship represents the insurance coverage the patient may have for the observation.
Slice: Unordered, Open by profile:observation, profile:act
.... entryRelationship:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
.... entryRelationship:priorityPreference C0..*ElementThe following entryRelationship represents the priority that a patient or a provider places on the observation.
..... typeCode 1..1codeRequired Pattern: REFR
..... contextConductionInd 1..1boolean
..... observation 1..1PriorityPreferenceBase for all types and resources
.... entryRelationship:indication C0..*ElementThe following entryRelationship represents the indication for the observation.
..... typeCode 1..1codeRequired Pattern: RSON
..... contextConductionInd 1..1boolean
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:instruction C0..*ElementThe following entryRelationship captures any instructions associated with the planned observation.
..... typeCode 1..1codeRequired Pattern: SUBJ
..... contextConductionInd 1..1boolean
..... act 1..1InstructionBase for all types and resources
.... entryRelationship:plannedCoverage C0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... contextConductionInd 1..1boolean
..... act 1..1PlannedCoverageBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredPattern: OBS
Observation.moodCoderequiredPlanned moodCode (Observation)
Observation.codeextensibleObservationType
Observation.statusCoderequiredActStatus
Observation.methodCodeextensibleObservationMethod
Observation.targetSiteCoderequiredBody Site Value Set

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
obs-er-1errorObservation.entryRelationship, Observation.entryRelationship:priorityPreference, Observation.entryRelationship:indication, Observation.entryRelationship:instruction, Observation.entryRelationship:plannedCoverageOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationBase for all types and resources
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeBinding: Planned moodCode (Observation) (required)
... negationInd 0..1boolean
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.44
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
... derivationExpr 0..1ED
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: active
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned observation represents the time that the observation should occur.
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 0..1
.... valueBL
.... valueED
.... valueED
.... valueCD
.... valueCV
.... valueCE
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..1CEIn a planned observation the provider may suggest that an observation should be performed using a particular method.
Binding: ObservationMethod (extensible)
... targetSiteCode 0..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned observation.
Binding: Body Site Value Set (required)
... subject 0..1Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2The clinician who is expected to perform the observation could be identified using procedure/performer.
... author 0..*AuthorParticipationThe author in a planned observation represents the clinician who is requesting or planning the observation.
... informant 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... Slices for entryRelationship C0..*ElementThe following entryRelationship represents the insurance coverage the patient may have for the observation.
Slice: Unordered, Open by profile:observation, profile:act
.... entryRelationship:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1code
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entryRelationship:priorityPreference C0..*ElementThe following entryRelationship represents the priority that a patient or a provider places on the observation.
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1PriorityPreferenceBase for all types and resources
.... entryRelationship:indication C0..*ElementThe following entryRelationship represents the indication for the observation.
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeRequired Pattern: RSON
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:instruction C0..*ElementThe following entryRelationship captures any instructions associated with the planned observation.
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1InstructionBase for all types and resources
.... entryRelationship:plannedCoverage C0..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1PlannedCoverageBase for all types and resources
... reference 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition
... referenceRange 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredPattern: OBS
Observation.moodCoderequiredPlanned moodCode (Observation)
Observation.templateId:primary.nullFlavorrequiredNullFlavor
Observation.codeextensibleObservationType
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeextensibleObservationMethod
Observation.targetSiteCoderequiredBody Site Value Set
Observation.subject.typeCoderequiredFixed Value: SBJ
Observation.subject.contextControlCoderequiredFixed Value: OP
Observation.subject.awarenessCodeextensibleTargetAwareness
Observation.informant.typeCoderequiredFixed Value: INF
Observation.informant.contextControlCoderequiredFixed Value: OP
Observation.referenceRange.typeCoderequiredFixed Value: REFV

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
obs-er-1errorObservation.entryRelationship, Observation.entryRelationship:priorityPreference, Observation.entryRelationship:indication, Observation.entryRelationship:instruction, Observation.entryRelationship:plannedCoverageOnly 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: 9 elements (8 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Observation.templateId is sliced based on the values of value:root, value:extension
  • The element Observation.entryRelationship is sliced based on the values of profile:observation, profile:act

Differential View

This structure is derived from CDAR2.Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationBase for all types and resources
... classCode 1..1codeRequired Pattern: OBS
... moodCode 1..1codeBinding: Planned moodCode (Observation) (required)
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.44
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CD
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: active
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned observation represents the time that the observation should occur.
... value 0..1BL, 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
... methodCode 0..1CEIn a planned observation the provider may suggest that an observation should be performed using a particular method.
... targetSiteCode 0..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned observation.
Binding: Body Site Value Set (required)
... performer 0..*Performer2The clinician who is expected to perform the observation could be identified using procedure/performer.
... author 0..*AuthorParticipationThe author in a planned observation represents the clinician who is requesting or planning the observation.
... Slices for entryRelationship 0..*ElementThe following entryRelationship represents the insurance coverage the patient may have for the observation.
Slice: Unordered, Open by profile:observation, profile:act
.... entryRelationship:priorityPreference 0..*ElementThe following entryRelationship represents the priority that a patient or a provider places on the observation.
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1PriorityPreferenceBase for all types and resources
.... entryRelationship:indication 0..*ElementThe following entryRelationship represents the indication for the observation.
..... typeCode 1..1codeRequired Pattern: RSON
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:instruction 0..*ElementThe following entryRelationship captures any instructions associated with the planned observation.
..... typeCode 1..1codeRequired Pattern: SUBJ
..... act 1..1InstructionBase for all types and resources
.... entryRelationship:plannedCoverage 0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... act 1..1PlannedCoverageBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.moodCoderequiredPlanned moodCode (Observation)
Observation.targetSiteCoderequiredBody Site Value Set

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationBase for all types and resources
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeBinding: Planned moodCode (Observation) (required)
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.44
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CDBinding: ObservationType (extensible)
... statusCode 1..1CSBinding: ActStatus (required)
.... code 1..1stringRequired Pattern: active
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned observation represents the time that the observation should occur.
... value 0..1
.... valueBL
.... valueED
.... valueED
.... valueCD
.... valueCV
.... valueCE
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
... methodCode 0..1CEIn a planned observation the provider may suggest that an observation should be performed using a particular method.
Binding: ObservationMethod (extensible)
... targetSiteCode 0..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned observation.
Binding: Body Site Value Set (required)
... performer 0..*Performer2The clinician who is expected to perform the observation could be identified using procedure/performer.
... author 0..*AuthorParticipationThe author in a planned observation represents the clinician who is requesting or planning the observation.
... Slices for entryRelationship C0..*ElementThe following entryRelationship represents the insurance coverage the patient may have for the observation.
Slice: Unordered, Open by profile:observation, profile:act
.... entryRelationship:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
.... entryRelationship:priorityPreference C0..*ElementThe following entryRelationship represents the priority that a patient or a provider places on the observation.
..... typeCode 1..1codeRequired Pattern: REFR
..... contextConductionInd 1..1boolean
..... observation 1..1PriorityPreferenceBase for all types and resources
.... entryRelationship:indication C0..*ElementThe following entryRelationship represents the indication for the observation.
..... typeCode 1..1codeRequired Pattern: RSON
..... contextConductionInd 1..1boolean
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:instruction C0..*ElementThe following entryRelationship captures any instructions associated with the planned observation.
..... typeCode 1..1codeRequired Pattern: SUBJ
..... contextConductionInd 1..1boolean
..... act 1..1InstructionBase for all types and resources
.... entryRelationship:plannedCoverage C0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... contextConductionInd 1..1boolean
..... act 1..1PlannedCoverageBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredPattern: OBS
Observation.moodCoderequiredPlanned moodCode (Observation)
Observation.codeextensibleObservationType
Observation.statusCoderequiredActStatus
Observation.methodCodeextensibleObservationMethod
Observation.targetSiteCoderequiredBody Site Value Set

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
obs-er-1errorObservation.entryRelationship, Observation.entryRelationship:priorityPreference, Observation.entryRelationship:indication, Observation.entryRelationship:instruction, Observation.entryRelationship:plannedCoverageOnly 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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationBase for all types and resources
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeBinding: Planned moodCode (Observation) (required)
... negationInd 0..1boolean
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.44
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
... derivationExpr 0..1ED
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: active
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned observation represents the time that the observation should occur.
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 0..1
.... valueBL
.... valueED
.... valueED
.... valueCD
.... valueCV
.... valueCE
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..1CEIn a planned observation the provider may suggest that an observation should be performed using a particular method.
Binding: ObservationMethod (extensible)
... targetSiteCode 0..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned observation.
Binding: Body Site Value Set (required)
... subject 0..1Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2The clinician who is expected to perform the observation could be identified using procedure/performer.
... author 0..*AuthorParticipationThe author in a planned observation represents the clinician who is requesting or planning the observation.
... informant 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... Slices for entryRelationship C0..*ElementThe following entryRelationship represents the insurance coverage the patient may have for the observation.
Slice: Unordered, Open by profile:observation, profile:act
.... entryRelationship:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1code
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entryRelationship:priorityPreference C0..*ElementThe following entryRelationship represents the priority that a patient or a provider places on the observation.
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1PriorityPreferenceBase for all types and resources
.... entryRelationship:indication C0..*ElementThe following entryRelationship represents the indication for the observation.
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeRequired Pattern: RSON
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:instruction C0..*ElementThe following entryRelationship captures any instructions associated with the planned observation.
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1InstructionBase for all types and resources
.... entryRelationship:plannedCoverage C0..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1PlannedCoverageBase for all types and resources
... reference 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition
... referenceRange 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredPattern: OBS
Observation.moodCoderequiredPlanned moodCode (Observation)
Observation.templateId:primary.nullFlavorrequiredNullFlavor
Observation.codeextensibleObservationType
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeextensibleObservationMethod
Observation.targetSiteCoderequiredBody Site Value Set
Observation.subject.typeCoderequiredFixed Value: SBJ
Observation.subject.contextControlCoderequiredFixed Value: OP
Observation.subject.awarenessCodeextensibleTargetAwareness
Observation.informant.typeCoderequiredFixed Value: INF
Observation.informant.contextControlCoderequiredFixed Value: OP
Observation.referenceRange.typeCoderequiredFixed Value: REFV

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
obs-er-1errorObservation.entryRelationship, Observation.entryRelationship:priorityPreference, Observation.entryRelationship:indication, Observation.entryRelationship:instruction, Observation.entryRelationship:plannedCoverageOnly 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: 9 elements (8 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Observation.templateId is sliced based on the values of value:root, value:extension
  • The element Observation.entryRelationship is sliced based on the values of profile:observation, profile:act

 

​Other representations of profile: CSV, Excel, Schematron