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: Functional Status Problem Observation (DEPRECATED)

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.68 Version: 2.1.0-draft1
Draft as of 2023-01-16 Computable Name: FunctionalStatusProblemObservation
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.68:2014-06-09

A functional status problem observation is a clinical statement that represents a patient’s functional perfomance and ability.

THIS TEMPLATE HAS BEEN DEPRECATED IN C-CDA R2 AND MAY BE DELETED FROM A FUTURE RELEASE OF THIS IMPLEMENTATION GUIDE. USE OF THIS TEMPLATE IS NOT RECOMMENDED.

Reason for deprecation: Functional Status Problem Observation has been merged, without loss of expressivity, into Functional Status Observation (2.16.840.1.113883.10.20.22.4.67:2014-06-09).

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..1codeRequired Pattern: EVN
... negationInd 0..1booleanUse negationInd="true" to indicate that the problem was not observed.
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.68
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CD
.... code 0..1stringRequired Pattern: 248536006
... text 0..1ED
.... reference 0..1TEL
..... value C0..1uri1098-15554: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15554).
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: completed
... effectiveTime 0..1IVL_TS
.... low 1..1TSThe value of effectiveTime/low represents onset date.
.... high 0..1TSIf the problem is resolved, record the resolution date in effectiveTime/high. If the problem is known to be resolved but the resolution date is not known, use @nullFlavor="UNK". If the problem is not resolved, do not include the high element.
... value 1..1CDBinding: Problem (preferred)
.... nullFlavor C0..1code1098-14293: If the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the diagnosis is known but the code cannot be found in the Value Set, @nullFlavor SHOULD be “OTH” and the known diagnosis code SHOULD be placed in the translation element (CONF:1098-14293).
... methodCode 0..1CE

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.valuepreferredProblem

Constraints

IdGradePath(s)DetailsRequirements
1098-14293warningObservation.value.nullFlavorIf the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the diagnosis is known but the code cannot be found in the Value Set, @nullFlavor SHOULD be “OTH” and the known diagnosis code SHOULD be placed in the translation element (CONF:1098-14293).
:
1098-15554errorObservation.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15554).
:
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationBase for all types and resources
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... negationInd 0..1booleanUse negationInd="true" to indicate that the problem was not observed.
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.68
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
.... code 0..1stringRequired Pattern: 248536006
... text 0..1ED
.... reference 0..1TEL
..... value C0..1uri1098-15554: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15554).
... statusCode 1..1CSBinding: ActStatus (required)
.... code 1..1stringRequired Pattern: completed
... effectiveTime 0..1IVL_TS
.... low 1..1TSThe value of effectiveTime/low represents onset date.
.... high 0..1TSIf the problem is resolved, record the resolution date in effectiveTime/high. If the problem is known to be resolved but the resolution date is not known, use @nullFlavor="UNK". If the problem is not resolved, do not include the high element.
... value 1..1CDBinding: Problem (preferred)
.... nullFlavor C0..1codeBinding: NullFlavor (required)
1098-14293: If the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the diagnosis is known but the code cannot be found in the Value Set, @nullFlavor SHOULD be “OTH” and the known diagnosis code SHOULD be placed in the translation element (CONF:1098-14293).
... methodCode 0..1CEBinding: ObservationMethod (extensible)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredPattern: OBS
Observation.codeextensibleObservationType
Observation.statusCoderequiredActStatus
Observation.valuepreferredProblem
Observation.value.nullFlavorrequiredNullFlavor
Observation.methodCodeextensibleObservationMethod

Constraints

IdGradePath(s)DetailsRequirements
1098-14293warningObservation.value.nullFlavorIf the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the diagnosis is known but the code cannot be found in the Value Set, @nullFlavor SHOULD be “OTH” and the known diagnosis code SHOULD be placed in the translation element (CONF:1098-14293).
:
1098-15554errorObservation.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15554).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationBase for all types and resources
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... negationInd 0..1booleanUse negationInd="true" to indicate that the problem was not observed.
... 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: 2.16.840.1.113883.10.20.22.4.68
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 0..1stringRequired Pattern: 248536006
.... codeSystem 0..1string
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... qualifier 0..*CR
.... translation 0..*CD
... derivationExpr 0..1ED
... text 0..1ED
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... charset 0..1code
.... compression 0..1codeBinding: CompressionAlgorithm (required)
.... integrityCheck 0..1base64Binary
.... integrityCheckAlgorithm 0..1codeBinding: IntegrityCheckAlgorithm (required)
.... language 0..1code
.... mediaType 0..1code
.... representation 0..1code
.... data[x] 0..1
..... dataStringstring
..... dataBase64Binarybase64Binary
.... reference 0..1TEL
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... value C0..1uri1098-15554: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15554).
..... useablePeriod 0..*
...... useablePeriodIVL_TS
...... useablePeriodEIVL_TS
...... useablePeriodPIVL_TS
...... useablePeriodSXPR_TS
..... use 0..*codeBinding: AddressUse (required)
.... thumbnail 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: completed
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 0..1IVL_TS
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... value 0..1dateTime
.... inclusive 0..1boolean
.... operator 0..1code
.... low 1..1TSThe value of effectiveTime/low represents onset date.
.... high 0..1TSIf the problem is resolved, record the resolution date in effectiveTime/high. If the problem is known to be resolved but the resolution date is not known, use @nullFlavor="UNK". If the problem is not resolved, do not include the high element.
.... width 0..1PQ
.... center 0..1TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 1..1CDBinding: Problem (preferred)
.... nullFlavor C0..1codeBinding: NullFlavor (required)
1098-14293: If the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the diagnosis is known but the code cannot be found in the Value Set, @nullFlavor SHOULD be “OTH” and the known diagnosis code SHOULD be placed in the translation element (CONF:1098-14293).
.... code 0..1string
.... codeSystem 0..1string
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... qualifier 0..*CR
.... translation 0..*CD
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..1CEBinding: ObservationMethod (extensible)
... targetSiteCode 0..*CD
... 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..*Performer2
... author 0..*Author
... 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
... entryRelationship 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..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
... 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.templateId:primary.nullFlavorrequiredNullFlavor
Observation.codeextensibleObservationType
Observation.code.nullFlavorrequiredNullFlavor
Observation.text.nullFlavorrequiredNullFlavor
Observation.text.compressionrequiredCompressionAlgorithm
Observation.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
Observation.text.reference.nullFlavorrequiredNullFlavor
Observation.text.reference.userequiredAddressUse
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.effectiveTime.nullFlavorrequiredNullFlavor
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Observation.valuepreferredProblem
Observation.value.nullFlavorrequiredNullFlavor
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeextensibleObservationMethod
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
1098-14293warningObservation.value.nullFlavorIf the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the diagnosis is known but the code cannot be found in the Value Set, @nullFlavor SHOULD be “OTH” and the known diagnosis code SHOULD be placed in the translation element (CONF:1098-14293).
:
1098-15554errorObservation.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15554).
:
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.entryRelationshipOnly 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: 10 elements (1 nested mandatory element)

Slices

This structure defines the following Slices:

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

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..1codeRequired Pattern: EVN
... negationInd 0..1booleanUse negationInd="true" to indicate that the problem was not observed.
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.68
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CD
.... code 0..1stringRequired Pattern: 248536006
... text 0..1ED
.... reference 0..1TEL
..... value C0..1uri1098-15554: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15554).
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: completed
... effectiveTime 0..1IVL_TS
.... low 1..1TSThe value of effectiveTime/low represents onset date.
.... high 0..1TSIf the problem is resolved, record the resolution date in effectiveTime/high. If the problem is known to be resolved but the resolution date is not known, use @nullFlavor="UNK". If the problem is not resolved, do not include the high element.
... value 1..1CDBinding: Problem (preferred)
.... nullFlavor C0..1code1098-14293: If the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the diagnosis is known but the code cannot be found in the Value Set, @nullFlavor SHOULD be “OTH” and the known diagnosis code SHOULD be placed in the translation element (CONF:1098-14293).
... methodCode 0..1CE

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.valuepreferredProblem

Constraints

IdGradePath(s)DetailsRequirements
1098-14293warningObservation.value.nullFlavorIf the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the diagnosis is known but the code cannot be found in the Value Set, @nullFlavor SHOULD be “OTH” and the known diagnosis code SHOULD be placed in the translation element (CONF:1098-14293).
:
1098-15554errorObservation.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15554).
:

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..1codeRequired Pattern: EVN
... negationInd 0..1booleanUse negationInd="true" to indicate that the problem was not observed.
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.68
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
.... code 0..1stringRequired Pattern: 248536006
... text 0..1ED
.... reference 0..1TEL
..... value C0..1uri1098-15554: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15554).
... statusCode 1..1CSBinding: ActStatus (required)
.... code 1..1stringRequired Pattern: completed
... effectiveTime 0..1IVL_TS
.... low 1..1TSThe value of effectiveTime/low represents onset date.
.... high 0..1TSIf the problem is resolved, record the resolution date in effectiveTime/high. If the problem is known to be resolved but the resolution date is not known, use @nullFlavor="UNK". If the problem is not resolved, do not include the high element.
... value 1..1CDBinding: Problem (preferred)
.... nullFlavor C0..1codeBinding: NullFlavor (required)
1098-14293: If the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the diagnosis is known but the code cannot be found in the Value Set, @nullFlavor SHOULD be “OTH” and the known diagnosis code SHOULD be placed in the translation element (CONF:1098-14293).
... methodCode 0..1CEBinding: ObservationMethod (extensible)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredPattern: OBS
Observation.codeextensibleObservationType
Observation.statusCoderequiredActStatus
Observation.valuepreferredProblem
Observation.value.nullFlavorrequiredNullFlavor
Observation.methodCodeextensibleObservationMethod

Constraints

IdGradePath(s)DetailsRequirements
1098-14293warningObservation.value.nullFlavorIf the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the diagnosis is known but the code cannot be found in the Value Set, @nullFlavor SHOULD be “OTH” and the known diagnosis code SHOULD be placed in the translation element (CONF:1098-14293).
:
1098-15554errorObservation.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15554).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationBase for all types and resources
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... negationInd 0..1booleanUse negationInd="true" to indicate that the problem was not observed.
... 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: 2.16.840.1.113883.10.20.22.4.68
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 0..1stringRequired Pattern: 248536006
.... codeSystem 0..1string
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... qualifier 0..*CR
.... translation 0..*CD
... derivationExpr 0..1ED
... text 0..1ED
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... charset 0..1code
.... compression 0..1codeBinding: CompressionAlgorithm (required)
.... integrityCheck 0..1base64Binary
.... integrityCheckAlgorithm 0..1codeBinding: IntegrityCheckAlgorithm (required)
.... language 0..1code
.... mediaType 0..1code
.... representation 0..1code
.... data[x] 0..1
..... dataStringstring
..... dataBase64Binarybase64Binary
.... reference 0..1TEL
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... value C0..1uri1098-15554: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15554).
..... useablePeriod 0..*
...... useablePeriodIVL_TS
...... useablePeriodEIVL_TS
...... useablePeriodPIVL_TS
...... useablePeriodSXPR_TS
..... use 0..*codeBinding: AddressUse (required)
.... thumbnail 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: completed
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 0..1IVL_TS
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... value 0..1dateTime
.... inclusive 0..1boolean
.... operator 0..1code
.... low 1..1TSThe value of effectiveTime/low represents onset date.
.... high 0..1TSIf the problem is resolved, record the resolution date in effectiveTime/high. If the problem is known to be resolved but the resolution date is not known, use @nullFlavor="UNK". If the problem is not resolved, do not include the high element.
.... width 0..1PQ
.... center 0..1TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 1..1CDBinding: Problem (preferred)
.... nullFlavor C0..1codeBinding: NullFlavor (required)
1098-14293: If the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the diagnosis is known but the code cannot be found in the Value Set, @nullFlavor SHOULD be “OTH” and the known diagnosis code SHOULD be placed in the translation element (CONF:1098-14293).
.... code 0..1string
.... codeSystem 0..1string
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... qualifier 0..*CR
.... translation 0..*CD
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..1CEBinding: ObservationMethod (extensible)
... targetSiteCode 0..*CD
... 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..*Performer2
... author 0..*Author
... 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
... entryRelationship 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..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
... 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.templateId:primary.nullFlavorrequiredNullFlavor
Observation.codeextensibleObservationType
Observation.code.nullFlavorrequiredNullFlavor
Observation.text.nullFlavorrequiredNullFlavor
Observation.text.compressionrequiredCompressionAlgorithm
Observation.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
Observation.text.reference.nullFlavorrequiredNullFlavor
Observation.text.reference.userequiredAddressUse
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.effectiveTime.nullFlavorrequiredNullFlavor
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Observation.valuepreferredProblem
Observation.value.nullFlavorrequiredNullFlavor
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeextensibleObservationMethod
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
1098-14293warningObservation.value.nullFlavorIf the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the diagnosis is known but the code cannot be found in the Value Set, @nullFlavor SHOULD be “OTH” and the known diagnosis code SHOULD be placed in the translation element (CONF:1098-14293).
:
1098-15554errorObservation.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15554).
:
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.entryRelationshipOnly 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: 10 elements (1 nested mandatory element)

Slices

This structure defines the following Slices:

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

 

​Other representations of profile: CSV, Excel, Schematron