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/2.16.840.1.113883.10.20.22.4.69 | Version: 2.1.0-draft1 | |||
| Active as of 2023-01-16 | Computable Name: AssessmentScaleObservation | |||
| Other Identifiers: id: urn:oid:2.16.840.1.113883.10.20.22.4.69 | ||||
An assessment scale is a collection of observations that together yield a summary evaluation of a particular condition. Examples include the Braden Scale (assesses pressure ulcer risk), APACHE Score (estimates mortality in critically ill patients), Mini-Mental Status Exam (assesses cognitive function), APGAR Score (assesses the health of a newborn), and Glasgow Coma Scale (assesses coma and impaired consciousness).
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:root | |
   templateId:primary | 1..1 | II | ||
  root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.69 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | 81-14440: **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440). |
| derivationExpr | 0..1 | ED | Such derivation expression can contain a text calculation of how the components total up to the summed score | |
| statusCode | 1..1 | CS | ||
 code | 1..1 | string | Required Pattern: completed | |
| effectiveTime | 1..1 | IVL_TS | Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards) | |
| 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, RTO_PQ_PQ | ||
| interpretationCode | 0..* | CE | ||
| translation | 0..* | CD | ||
| author | 0..* | Author | ||
| Slices for entryRelationship | 0..* | Element | Slice: Unordered, Open by profile:observation | |
| entryRelationship:supporting | 0..* | Element | ||
 typeCode | 1..1 | code | Required Pattern: COMP | |
| observation | 1..1 | AssessmentScaleSupportingObservation | Base for all types and resources | |
 referenceRange | 0..* | Element | The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
| observationRange | 1..1 | ObservationRange | ||
| text | 0..1 | ED | The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
| reference | 0..1 | TEL | ||
| value | C | 0..1 | uri | 81-16804: 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:81-16804). |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| 81-14440 | warning | Observation.code | **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440). : | |
| 81-16804 | error | Observation.referenceRange.observationRange.text.reference.value | 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:81-16804). : |
| 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:root | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.69 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: ObservationType (extensible) 81-14440: **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440). |
| derivationExpr | 0..1 | ED | Such derivation expression can contain a text calculation of how the components total up to the summed score | |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| code | 1..1 | string | Required Pattern: completed | |
| effectiveTime | 1..1 | IVL_TS | Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards) | |
 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 | |||
| value | RTO_PQ_PQ | |||
| interpretationCode | 0..* | CE | Binding: ObservationInterpretation (required) | |
| translation | 0..* | CD | ||
| author | 0..* | Author | ||
| Slices for entryRelationship | C | 0..* | Element | Slice: Unordered, Open by profile:observation |
 entryRelationship:All Slices | Content/Rules for all slices | |||
  typeCode | 1..1 | code | ||
 contextConductionInd | 1..1 | boolean | ||
| entryRelationship:supporting | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | AssessmentScaleSupportingObservation | Base for all types and resources | |
| referenceRange | 0..* | Element | The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
| 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 | |
| text | 0..1 | ED | The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
| reference | 0..1 | TEL | ||
| value | C | 0..1 | uri | 81-16804: 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:81-16804). |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Pattern: OBS |
| Observation.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.interpretationCode | required | ObservationInterpretation |
| 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 |
| 81-14440 | warning | Observation.code | **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440). : | |
| 81-16804 | error | Observation.referenceRange.observationRange.text.reference.value | 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:81-16804). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| obs-er-1 | error | Observation.entryRelationship, Observation.entryRelationship:supporting | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 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: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: 2.16.840.1.113883.10.20.22.4.69 | |
 extension | 0..1 | string | ||
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: ObservationType (extensible) 81-14440: **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440). |
| derivationExpr | 0..1 | ED | Such derivation expression can contain a text calculation of how the components total up to the summed score | |
| text | 0..1 | ED | ||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: completed | |
| 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 clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards) | |
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| 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 | |||
| value | RTO_PQ_PQ | |||
| interpretationCode | 0..* | CE | Binding: ObservationInterpretation (required) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 0..1 | string | ||
| 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..* | CE | Binding: ObservationMethod (extensible) | |
| targetSiteCode | 0..* | CD | ||
| subject | 0..1 | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| awarenessCode | 0..1 | CE | Binding: TargetAwareness (extensible) | |
| relatedSubject | 1..1 | RelatedSubject | ||
| specimen | 0..* | Specimen | ||
| performer | 0..* | Performer2 | ||
| author | 0..* | Author | ||
| informant | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 0..1 | RelatedEntity | ||
| participant | 0..* | Participant2 | ||
| Slices for entryRelationship | C | 0..* | Element | Slice: Unordered, Open by profile:observation |
| entryRelationship:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| (Choice of one) | 1..1 | |||
| observation | 0..1 | Observation | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| observationMedia | 0..1 | ObservationMedia | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| procedure | 0..1 | Procedure | ||
| encounter | 0..1 | Encounter | ||
| organizer | 0..1 | Organizer | ||
| act | 0..1 | Act | ||
| entryRelationship:supporting | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | AssessmentScaleSupportingObservation | Base for all types and resources | |
| reference | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| 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 | The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
| 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 | ||
| code | 0..1 | CD | Binding: v3 Code System ActCode (extensible) | |
| text | 0..1 | ED | The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| charset | 0..1 | code | ||
| compression | 0..1 | code | Binding: CompressionAlgorithm (required) | |
| integrityCheck | 0..1 | base64Binary | ||
| integrityCheckAlgorithm | 0..1 | code | Binding: IntegrityCheckAlgorithm (required) | |
| language | 0..1 | code | ||
| mediaType | 0..1 | code | ||
| representation | 0..1 | code | ||
| data[x] | 0..1 | |||
| dataString | string | |||
| dataBase64Binary | base64Binary | |||
| reference | 0..1 | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | C | 0..1 | uri | 81-16804: 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:81-16804). |
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..* | code | Binding: AddressUse (required) | |
| thumbnail | 0..1 | ED | ||
| value | 0..1 | |||
| value | BL | |||
| value | ED | |||
| value | ED | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| 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.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.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.code | extensible | ActCode |
| Observation.referenceRange.observationRange.text.nullFlavor | required | NullFlavor |
| Observation.referenceRange.observationRange.text.compression | required | CompressionAlgorithm |
| Observation.referenceRange.observationRange.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
| Observation.referenceRange.observationRange.text.reference.nullFlavor | required | NullFlavor |
| Observation.referenceRange.observationRange.text.reference.use | required | AddressUse |
| Observation.referenceRange.observationRange.interpretationCode | required | ObservationInterpretation |
| Id | Grade | Path(s) | Details | Requirements |
| 81-14440 | warning | Observation.code | **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440). : | |
| 81-16804 | error | Observation.referenceRange.observationRange.text.reference.value | 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:81-16804). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-er-1 | error | Observation.entryRelationship, Observation.entryRelationship:supporting | 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: 10 elements (3 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CDAR2.Observation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 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:root | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.69 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | 81-14440: **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440). |
| derivationExpr | 0..1 | ED | Such derivation expression can contain a text calculation of how the components total up to the summed score | |
| statusCode | 1..1 | CS | ||
| code | 1..1 | string | Required Pattern: completed | |
| effectiveTime | 1..1 | IVL_TS | Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards) | |
| 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, RTO_PQ_PQ | ||
| interpretationCode | 0..* | CE | ||
| translation | 0..* | CD | ||
| author | 0..* | Author | ||
| Slices for entryRelationship | 0..* | Element | Slice: Unordered, Open by profile:observation | |
| entryRelationship:supporting | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: COMP | |
| observation | 1..1 | AssessmentScaleSupportingObservation | Base for all types and resources | |
| referenceRange | 0..* | Element | The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
| observationRange | 1..1 | ObservationRange | ||
| text | 0..1 | ED | The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
| reference | 0..1 | TEL | ||
| value | C | 0..1 | uri | 81-16804: 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:81-16804). |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| 81-14440 | warning | Observation.code | **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440). : | |
| 81-16804 | error | Observation.referenceRange.observationRange.text.reference.value | 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:81-16804). : |
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:root | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.69 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: ObservationType (extensible) 81-14440: **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440). |
| derivationExpr | 0..1 | ED | Such derivation expression can contain a text calculation of how the components total up to the summed score | |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| code | 1..1 | string | Required Pattern: completed | |
| effectiveTime | 1..1 | IVL_TS | Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards) | |
| 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 | |||
| value | RTO_PQ_PQ | |||
| interpretationCode | 0..* | CE | Binding: ObservationInterpretation (required) | |
| translation | 0..* | CD | ||
| author | 0..* | Author | ||
| Slices for entryRelationship | C | 0..* | Element | Slice: Unordered, Open by profile:observation |
| entryRelationship:All Slices | Content/Rules for all slices | |||
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| entryRelationship:supporting | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | AssessmentScaleSupportingObservation | Base for all types and resources | |
| referenceRange | 0..* | Element | The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
| 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 | |
| text | 0..1 | ED | The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
| reference | 0..1 | TEL | ||
| value | C | 0..1 | uri | 81-16804: 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:81-16804). |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Pattern: OBS |
| Observation.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.interpretationCode | required | ObservationInterpretation |
| 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 |
| 81-14440 | warning | Observation.code | **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440). : | |
| 81-16804 | error | Observation.referenceRange.observationRange.text.reference.value | 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:81-16804). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| obs-er-1 | error | Observation.entryRelationship, Observation.entryRelationship:supporting | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 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: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: 2.16.840.1.113883.10.20.22.4.69 | |
| extension | 0..1 | string | ||
| id | 1..* | II | ||
| code | C | 1..1 | CD | Binding: ObservationType (extensible) 81-14440: **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440). |
| derivationExpr | 0..1 | ED | Such derivation expression can contain a text calculation of how the components total up to the summed score | |
| text | 0..1 | ED | ||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: completed | |
| 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 clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards) | |
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| 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 | |||
| value | RTO_PQ_PQ | |||
| interpretationCode | 0..* | CE | Binding: ObservationInterpretation (required) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 0..1 | string | ||
| 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..* | CE | Binding: ObservationMethod (extensible) | |
| targetSiteCode | 0..* | CD | ||
| subject | 0..1 | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| awarenessCode | 0..1 | CE | Binding: TargetAwareness (extensible) | |
| relatedSubject | 1..1 | RelatedSubject | ||
| specimen | 0..* | Specimen | ||
| performer | 0..* | Performer2 | ||
| author | 0..* | Author | ||
| informant | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 0..1 | RelatedEntity | ||
| participant | 0..* | Participant2 | ||
| Slices for entryRelationship | C | 0..* | Element | Slice: Unordered, Open by profile:observation |
| entryRelationship:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| (Choice of one) | 1..1 | |||
| observation | 0..1 | Observation | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| observationMedia | 0..1 | ObservationMedia | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| procedure | 0..1 | Procedure | ||
| encounter | 0..1 | Encounter | ||
| organizer | 0..1 | Organizer | ||
| act | 0..1 | Act | ||
| entryRelationship:supporting | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | AssessmentScaleSupportingObservation | Base for all types and resources | |
| reference | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| 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 | The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
| 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 | ||
| code | 0..1 | CD | Binding: v3 Code System ActCode (extensible) | |
| text | 0..1 | ED | The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| charset | 0..1 | code | ||
| compression | 0..1 | code | Binding: CompressionAlgorithm (required) | |
| integrityCheck | 0..1 | base64Binary | ||
| integrityCheckAlgorithm | 0..1 | code | Binding: IntegrityCheckAlgorithm (required) | |
| language | 0..1 | code | ||
| mediaType | 0..1 | code | ||
| representation | 0..1 | code | ||
| data[x] | 0..1 | |||
| dataString | string | |||
| dataBase64Binary | base64Binary | |||
| reference | 0..1 | TEL | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| value | C | 0..1 | uri | 81-16804: 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:81-16804). |
| useablePeriod | 0..* | |||
| useablePeriod | IVL_TS | |||
| useablePeriod | EIVL_TS | |||
| useablePeriod | PIVL_TS | |||
| useablePeriod | SXPR_TS | |||
| use | 0..* | code | Binding: AddressUse (required) | |
| thumbnail | 0..1 | ED | ||
| value | 0..1 | |||
| value | BL | |||
| value | ED | |||
| value | ED | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| 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.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.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.code | extensible | ActCode |
| Observation.referenceRange.observationRange.text.nullFlavor | required | NullFlavor |
| Observation.referenceRange.observationRange.text.compression | required | CompressionAlgorithm |
| Observation.referenceRange.observationRange.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
| Observation.referenceRange.observationRange.text.reference.nullFlavor | required | NullFlavor |
| Observation.referenceRange.observationRange.text.reference.use | required | AddressUse |
| Observation.referenceRange.observationRange.interpretationCode | required | ObservationInterpretation |
| Id | Grade | Path(s) | Details | Requirements |
| 81-14440 | warning | Observation.code | **SHOULD** be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:81-14440). : | |
| 81-16804 | error | Observation.referenceRange.observationRange.text.reference.value | 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:81-16804). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-er-1 | error | Observation.entryRelationship, Observation.entryRelationship:supporting | 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: 10 elements (3 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#2.1.0-draft1 based on FHIR 5.0.0-snapshot3. Generated 2023-01-16
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