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/2.16.840.1.113883.10.20.22.4.74 | Version: 2.1.0-draft1 | |||
| Active as of 2023-01-16 | Computable Name: MentalStatusObservation | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.74:2015-08-01 | ||||
The Mental Status Observation template represents an observation about mental status that can come from a broad range of subjective and objective information (including measured data) to address those categories described in the Mental Status Section. See also Assessment Scale Observation for specific collections of observations that together yield a summary evaluation of a particular condition.
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, value:extension | |
   templateId:primary | 1..1 | II | ||
  root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.74 | |
  extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | ||
| code | 1..1 | string | Required Pattern: 373930000 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
 Slices for translation | 0..* | CD | Slice: Unordered, Open by value:code, value:codeSystem | |
| translation:cognitiveFunction | 1..1 | CD | ||
| code | 1..1 | string | Required Pattern: 75275-8 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
| statusCode | 1..1 | CS | ||
 code | 1..1 | string | Required Pattern: completed | |
| effectiveTime | 1..1 | IVL_TS | ||
| value | C | 1..1 | BL, ED, ED, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | 1198-14271: If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). |
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | Element | Slice: Unordered, Open by profile:observation | |
| entryRelationship:assessmentScale | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: COMP | |
| observation | 1..1 | AssessmentScaleObservation | Base for all types and resources | |
| referenceRange | 0..* | Element | The referenceRange could be used to represent normal or expected capability for the mental function being evaluated. | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| 1198-14271 | warning | Observation.value | If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). : |
| 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, value:extension | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.74 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: ObservationType (extensible) | |
| code | 1..1 | string | Required Pattern: 373930000 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
| Slices for translation | 0..* | CD | Slice: Unordered, Open by value:code, value:codeSystem | |
| translation:cognitiveFunction | 1..1 | CD | ||
| code | 1..1 | string | Required Pattern: 75275-8 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| code | 1..1 | string | Required Pattern: completed | |
| effectiveTime | 1..1 | IVL_TS | ||
 value | C | 1..1 | 1198-14271: If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). | |
 value | BL | |||
| value | ED | |||
| value | ED | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| value | RTO_PQ_PQ | |||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | C | 0..* | Element | Slice: Unordered, Open by profile:observation |
 entryRelationship:All Slices | Content/Rules for all slices | |||
  typeCode | 1..1 | code | ||
 contextConductionInd | 1..1 | boolean | ||
| entryRelationship:assessmentScale | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | AssessmentScaleObservation | Base for all types and resources | |
| referenceRange | 0..* | Element | The referenceRange could be used to represent normal or expected capability for the mental function being evaluated. | |
| typeCode | 1..1 | code | Binding: ActRelationshipPertains (required) Fixed Value: REFV | |
| observationRange | 1..1 | ObservationRange | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Pattern: OBS |
| Observation.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-14271 | warning | Observation.value | If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). : | |
| 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:assessmentScale | 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, value:extension | |
| 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: 2.16.840.1.113883.10.20.22.4.74 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: ObservationType (extensible) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: 373930000 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
| 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 | ||
| qualifier | 0..* | CR | ||
| Slices for translation | 0..* | CD | Slice: Unordered, Open by value:code, value:codeSystem | |
| translation:cognitiveFunction | 1..1 | CD | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: 75275-8 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
| 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 | ||
| qualifier | 0..* | CR | ||
| translation | 0..* | CD | ||
| derivationExpr | 0..1 | ED | ||
| text | 0..1 | ED | ||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | 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 | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| value | C | 1..1 | 1198-14271: If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). | |
| value | BL | |||
| value | ED | |||
| value | ED | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| value | RTO_PQ_PQ | |||
| interpretationCode | 0..* | CE | Binding: ObservationInterpretation (required) | |
| methodCode | 0..* | CE | Binding: ObservationMethod (extensible) | |
| targetSiteCode | 0..* | CD | ||
| subject | 0..1 | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| awarenessCode | 0..1 | CE | Binding: TargetAwareness (extensible) | |
| relatedSubject | 1..1 | RelatedSubject | ||
| specimen | 0..* | Specimen | ||
| performer | 0..* | Performer2 | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| informant | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 0..1 | RelatedEntity | ||
| participant | 0..* | Participant2 | ||
| Slices for entryRelationship | C | 0..* | Element | 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:assessmentScale | 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 | AssessmentScaleObservation | 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 could be used to represent normal or expected capability for the mental function being evaluated. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ActRelationshipPertains (required) Fixed Value: REFV | |
| observationRange | 1..1 | ObservationRange | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Pattern: OBS |
| Observation.templateId:primary.nullFlavor | required | NullFlavor |
| Observation.code | extensible | ObservationType |
| Observation.code.nullFlavor | required | NullFlavor |
| Observation.code.translation:cognitiveFunction.nullFlavor | required | NullFlavor |
| 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.methodCode | extensible | ObservationMethod |
| Observation.subject.typeCode | required | Fixed Value: SBJ |
| Observation.subject.contextControlCode | required | Fixed Value: OP |
| Observation.subject.awarenessCode | extensible | TargetAwareness |
| Observation.informant.typeCode | required | Fixed Value: INF |
| Observation.informant.contextControlCode | required | Fixed Value: OP |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-14271 | warning | Observation.value | If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). : | |
| 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:assessmentScale | 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: 16 elements (2 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, value:extension | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.74 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | ||
| code | 1..1 | string | Required Pattern: 373930000 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
| Slices for translation | 0..* | CD | Slice: Unordered, Open by value:code, value:codeSystem | |
| translation:cognitiveFunction | 1..1 | CD | ||
| code | 1..1 | string | Required Pattern: 75275-8 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
| statusCode | 1..1 | CS | ||
| code | 1..1 | string | Required Pattern: completed | |
| effectiveTime | 1..1 | IVL_TS | ||
| value | C | 1..1 | BL, ED, ED, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | 1198-14271: If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). |
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | 0..* | Element | Slice: Unordered, Open by profile:observation | |
| entryRelationship:assessmentScale | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: COMP | |
| observation | 1..1 | AssessmentScaleObservation | Base for all types and resources | |
| referenceRange | 0..* | Element | The referenceRange could be used to represent normal or expected capability for the mental function being evaluated. | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| 1198-14271 | warning | Observation.value | If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). : |
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, value:extension | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.74 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: ObservationType (extensible) | |
| code | 1..1 | string | Required Pattern: 373930000 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
| Slices for translation | 0..* | CD | Slice: Unordered, Open by value:code, value:codeSystem | |
| translation:cognitiveFunction | 1..1 | CD | ||
| code | 1..1 | string | Required Pattern: 75275-8 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| code | 1..1 | string | Required Pattern: completed | |
| effectiveTime | 1..1 | IVL_TS | ||
| value | C | 1..1 | 1198-14271: If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). | |
| value | BL | |||
| value | ED | |||
| value | ED | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| value | RTO_PQ_PQ | |||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for entryRelationship | C | 0..* | Element | Slice: Unordered, Open by profile:observation |
| entryRelationship:All Slices | Content/Rules for all slices | |||
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| entryRelationship:assessmentScale | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | AssessmentScaleObservation | Base for all types and resources | |
| referenceRange | 0..* | Element | The referenceRange could be used to represent normal or expected capability for the mental function being evaluated. | |
| typeCode | 1..1 | code | Binding: ActRelationshipPertains (required) Fixed Value: REFV | |
| observationRange | 1..1 | ObservationRange | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Pattern: OBS |
| Observation.code | extensible | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-14271 | warning | Observation.value | If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). : | |
| 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:assessmentScale | 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, value:extension | |
| 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: 2.16.840.1.113883.10.20.22.4.74 | |
| extension | 1..1 | string | Required Pattern: 2015-08-01 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: ObservationType (extensible) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: 373930000 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
| 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 | ||
| qualifier | 0..* | CR | ||
| Slices for translation | 0..* | CD | Slice: Unordered, Open by value:code, value:codeSystem | |
| translation:cognitiveFunction | 1..1 | CD | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: 75275-8 | |
| codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
| 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 | ||
| qualifier | 0..* | CR | ||
| translation | 0..* | CD | ||
| derivationExpr | 0..1 | ED | ||
| text | 0..1 | ED | ||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | 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 | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| value | C | 1..1 | 1198-14271: If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). | |
| value | BL | |||
| value | ED | |||
| value | ED | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| value | RTO_PQ_PQ | |||
| interpretationCode | 0..* | CE | Binding: ObservationInterpretation (required) | |
| methodCode | 0..* | CE | Binding: ObservationMethod (extensible) | |
| targetSiteCode | 0..* | CD | ||
| subject | 0..1 | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| awarenessCode | 0..1 | CE | Binding: TargetAwareness (extensible) | |
| relatedSubject | 1..1 | RelatedSubject | ||
| specimen | 0..* | Specimen | ||
| performer | 0..* | Performer2 | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| informant | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 0..1 | RelatedEntity | ||
| participant | 0..* | Participant2 | ||
| Slices for entryRelationship | C | 0..* | Element | 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:assessmentScale | 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 | AssessmentScaleObservation | 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 could be used to represent normal or expected capability for the mental function being evaluated. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ActRelationshipPertains (required) Fixed Value: REFV | |
| observationRange | 1..1 | ObservationRange | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Pattern: OBS |
| Observation.templateId:primary.nullFlavor | required | NullFlavor |
| Observation.code | extensible | ObservationType |
| Observation.code.nullFlavor | required | NullFlavor |
| Observation.code.translation:cognitiveFunction.nullFlavor | required | NullFlavor |
| 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.methodCode | extensible | ObservationMethod |
| Observation.subject.typeCode | required | Fixed Value: SBJ |
| Observation.subject.contextControlCode | required | Fixed Value: OP |
| Observation.subject.awarenessCode | extensible | TargetAwareness |
| Observation.informant.typeCode | required | Fixed Value: INF |
| Observation.informant.contextControlCode | required | Fixed Value: OP |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-14271 | warning | Observation.value | If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). : | |
| 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:assessmentScale | 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: 16 elements (2 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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