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) generated with FHIR v5.0.0. . For a full list of available versions, see the Directory of published versions

Resource Profile: Substance or Device Allergy - Intolerance Observation

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.24.3.90 Version: 2.1.0-draft1
Active as of 2023-01-16 Computable Name: SubstanceOrDeviceAllergyIntoleranceObservation
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.24.3.90:2014-06-09

This template reflects a discrete observation about a patient’s allergy or intolerance to a substance or device. Because it is a discrete observation, it will have a statusCode of “completed”. The effectiveTime, also referred to as the ‘biologically relevant time’ is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of penicillin allergy that developed five years ago, the effectiveTime is five years ago.

The effectiveTime of the Substance or Device Allergy - Intolerance Observation is the definitive indication of whether or not the underlying allergy/intolerance is resolved. If known to be resolved, then an effectiveTime/high would be present. If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of “UNK”.

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
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.24.3.90
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CD
.... code 1..1stringRequired Pattern: ASSERTION
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.5.4
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: completed
... effectiveTime 1..1IVL_TSThe effectiveTime/low (a.k.a. "onset date") asserts when the allergy/intolerance became biologically active. The effectiveTime/high (a.k.a. "resolution date") asserts when the allergy/intolerance became biologically resolved. If the allergy/intolerance is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'.
.... low 1..1TS
.... high 0..1TS
... value 1..1CD
.... code 1..1stringMany systems will simply assign a fixed value here (e.g., "allergy to substance").
Binding: Allergy and Intolerance Type (required)
... author 0..*AuthorParticipationBase for all types and resources
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:typeCode
.... participant:participant1 0..*Participant2
..... typeCode 1..1codeRequired Pattern: CSM
..... participantRole 1..1ParticipantRole
...... classCode 1..1codeRequired Pattern: MANU
...... playingEntity 1..1PlayingEntity
....... classCode 1..1codeRequired Pattern: MMAT
....... code 1..1CEBinding: Substance Reactant for Intolerance (example)
... Slices for entryRelationship 0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:allergyStatus 0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... observation 1..1AllergyStatusObservationBase for all types and resources
.... entryRelationship:reaction 0..*Element
..... typeCode 1..1codeRequired Pattern: MFST
..... inversionInd 1..1booleanRequired Pattern: true
..... observation 1..1ReactionObservationBase for all types and resources
.... entryRelationship:severity 0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... observation 1..1SeverityObservationBase for all types and resources
.... entryRelationship:criticality 0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... observation 1..1CriticalityObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.value.coderequiredAllergy and Intolerance Type
Observation.participant:participant1.participantRole.playingEntity.codeexampleSubstance Reactant for Intolerance
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
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.24.3.90
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CDBinding: ObservationType (extensible)
.... code 1..1stringRequired Pattern: ASSERTION
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.5.4
... statusCode 1..1CSBinding: ActStatus (required)
.... code 1..1stringRequired Pattern: completed
... effectiveTime 1..1IVL_TSThe effectiveTime/low (a.k.a. "onset date") asserts when the allergy/intolerance became biologically active. The effectiveTime/high (a.k.a. "resolution date") asserts when the allergy/intolerance became biologically resolved. If the allergy/intolerance is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'.
.... low 1..1TS
.... high 0..1TS
... value 1..1CD
.... code 1..1stringMany systems will simply assign a fixed value here (e.g., "allergy to substance").
Binding: Allergy and Intolerance Type (required)
... author 0..*AuthorParticipationBase for all types and resources
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:typeCode
.... participant:participant1 0..*Participant2
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: CSM
..... participantRole 1..1ParticipantRole
...... classCode 1..1codeBinding: RoleClassRoot (required)
Required Pattern: MANU
...... playingEntity 1..1PlayingEntity
....... classCode 1..1codeBinding: EntityClassRoot (required)
Required Pattern: MMAT
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... code 1..1CEBinding: Substance Reactant for Intolerance (example)
... Slices for entryRelationship C0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
.... entryRelationship:allergyStatus C0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... observation 1..1AllergyStatusObservationBase for all types and resources
.... entryRelationship:reaction C0..*Element
..... typeCode 1..1codeRequired Pattern: MFST
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... observation 1..1ReactionObservationBase for all types and resources
.... entryRelationship:severity C0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... observation 1..1SeverityObservationBase for all types and resources
.... entryRelationship:criticality C0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... observation 1..1CriticalityObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredPattern: OBS
Observation.codeextensibleObservationType
Observation.statusCoderequiredActStatus
Observation.value.coderequiredAllergy and Intolerance Type
Observation.participant:participant1.typeCoderequiredPattern: CSM
Observation.participant:participant1.participantRole.classCoderequiredPattern: MANU
Observation.participant:participant1.participantRole.playingEntity.classCoderequiredPattern: MMAT
Observation.participant:participant1.participantRole.playingEntity.determinerCoderequiredFixed Value: INSTANCE
Observation.participant:participant1.participantRole.playingEntity.codeexampleSubstance Reactant for Intolerance

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
obs-er-1errorObservation.entryRelationship, Observation.entryRelationship:allergyStatus, Observation.entryRelationship:reaction, Observation.entryRelationship:severity, Observation.entryRelationship:criticalityOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationBase for all types and resources
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... negationInd 0..1boolean
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.24.3.90
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: ASSERTION
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.5.4
.... 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
... 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 1..1IVL_TSThe effectiveTime/low (a.k.a. "onset date") asserts when the allergy/intolerance became biologically active. The effectiveTime/high (a.k.a. "resolution date") asserts when the allergy/intolerance became biologically resolved. If the allergy/intolerance is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... value 0..1dateTime
.... inclusive 0..1boolean
.... operator 0..1code
.... low 1..1TS
.... high 0..1TS
.... width 0..1PQ
.... center 0..1TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 1..1CD
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringMany systems will simply assign a fixed value here (e.g., "allergy to substance").
Binding: Allergy and Intolerance Type (required)
.... 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..*CEBinding: 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..*AuthorParticipationBase for all types and resources
... 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
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:typeCode
.... participant:participant1 0..*Participant2
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: CSM
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... sdtcFunctionCode 0..1CEXML: functionCode (urn:hl7-org:sdtc)
..... time 0..1IVL_TS
..... awarenessCode 0..1CE
..... participantRole 1..1ParticipantRole
...... classCode 1..1codeBinding: RoleClassRoot (required)
Required Pattern: MANU
...... templateId 0..*II
...... id 0..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
...... addr 0..*AD
...... telecom 0..*TEL
...... playingDevice 0..1Device
...... playingEntity 1..1PlayingEntity
....... classCode 1..1codeBinding: EntityClassRoot (required)
Required Pattern: MMAT
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... code 1..1CEBinding: Substance Reactant for Intolerance (example)
....... quantity 0..*PQ
....... name 0..*EN
....... desc 0..1ED
...... scopingEntity 0..1Entity
... Slices for entryRelationship C0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1code
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entryRelationship:allergyStatus C0..1Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1AllergyStatusObservationBase for all types and resources
.... entryRelationship:reaction C0..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeRequired Pattern: MFST
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1ReactionObservationBase for all types and resources
.... entryRelationship:severity C0..1Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1SeverityObservationBase for all types and resources
.... entryRelationship:criticality C0..1Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1CriticalityObservationBase for all types and resources
... reference 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition
... referenceRange 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredPattern: OBS
Observation.templateId:primary.nullFlavorrequiredNullFlavor
Observation.codeextensibleObservationType
Observation.code.nullFlavorrequiredNullFlavor
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.effectiveTime.nullFlavorrequiredNullFlavor
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Observation.value.nullFlavorrequiredNullFlavor
Observation.value.coderequiredAllergy and Intolerance Type
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.participant:participant1.nullFlavorrequiredNullFlavor
Observation.participant:participant1.typeCoderequiredPattern: CSM
Observation.participant:participant1.contextControlCoderequiredFixed Value: OP
Observation.participant:participant1.participantRole.classCoderequiredPattern: MANU
Observation.participant:participant1.participantRole.codeextensibleRoleCode
Observation.participant:participant1.participantRole.playingEntity.classCoderequiredPattern: MMAT
Observation.participant:participant1.participantRole.playingEntity.determinerCoderequiredFixed Value: INSTANCE
Observation.participant:participant1.participantRole.playingEntity.codeexampleSubstance Reactant for Intolerance
Observation.referenceRange.typeCoderequiredFixed Value: REFV

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
obs-er-1errorObservation.entryRelationship, Observation.entryRelationship:allergyStatus, Observation.entryRelationship:reaction, Observation.entryRelationship:severity, Observation.entryRelationship:criticalityOnly 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: 15 elements (18 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

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
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.24.3.90
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CD
.... code 1..1stringRequired Pattern: ASSERTION
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.5.4
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: completed
... effectiveTime 1..1IVL_TSThe effectiveTime/low (a.k.a. "onset date") asserts when the allergy/intolerance became biologically active. The effectiveTime/high (a.k.a. "resolution date") asserts when the allergy/intolerance became biologically resolved. If the allergy/intolerance is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'.
.... low 1..1TS
.... high 0..1TS
... value 1..1CD
.... code 1..1stringMany systems will simply assign a fixed value here (e.g., "allergy to substance").
Binding: Allergy and Intolerance Type (required)
... author 0..*AuthorParticipationBase for all types and resources
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:typeCode
.... participant:participant1 0..*Participant2
..... typeCode 1..1codeRequired Pattern: CSM
..... participantRole 1..1ParticipantRole
...... classCode 1..1codeRequired Pattern: MANU
...... playingEntity 1..1PlayingEntity
....... classCode 1..1codeRequired Pattern: MMAT
....... code 1..1CEBinding: Substance Reactant for Intolerance (example)
... Slices for entryRelationship 0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:allergyStatus 0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... observation 1..1AllergyStatusObservationBase for all types and resources
.... entryRelationship:reaction 0..*Element
..... typeCode 1..1codeRequired Pattern: MFST
..... inversionInd 1..1booleanRequired Pattern: true
..... observation 1..1ReactionObservationBase for all types and resources
.... entryRelationship:severity 0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... observation 1..1SeverityObservationBase for all types and resources
.... entryRelationship:criticality 0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... observation 1..1CriticalityObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.value.coderequiredAllergy and Intolerance Type
Observation.participant:participant1.participantRole.playingEntity.codeexampleSubstance Reactant for Intolerance

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
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.24.3.90
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CDBinding: ObservationType (extensible)
.... code 1..1stringRequired Pattern: ASSERTION
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.5.4
... statusCode 1..1CSBinding: ActStatus (required)
.... code 1..1stringRequired Pattern: completed
... effectiveTime 1..1IVL_TSThe effectiveTime/low (a.k.a. "onset date") asserts when the allergy/intolerance became biologically active. The effectiveTime/high (a.k.a. "resolution date") asserts when the allergy/intolerance became biologically resolved. If the allergy/intolerance is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'.
.... low 1..1TS
.... high 0..1TS
... value 1..1CD
.... code 1..1stringMany systems will simply assign a fixed value here (e.g., "allergy to substance").
Binding: Allergy and Intolerance Type (required)
... author 0..*AuthorParticipationBase for all types and resources
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:typeCode
.... participant:participant1 0..*Participant2
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: CSM
..... participantRole 1..1ParticipantRole
...... classCode 1..1codeBinding: RoleClassRoot (required)
Required Pattern: MANU
...... playingEntity 1..1PlayingEntity
....... classCode 1..1codeBinding: EntityClassRoot (required)
Required Pattern: MMAT
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... code 1..1CEBinding: Substance Reactant for Intolerance (example)
... Slices for entryRelationship C0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
.... entryRelationship:allergyStatus C0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... observation 1..1AllergyStatusObservationBase for all types and resources
.... entryRelationship:reaction C0..*Element
..... typeCode 1..1codeRequired Pattern: MFST
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... observation 1..1ReactionObservationBase for all types and resources
.... entryRelationship:severity C0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... observation 1..1SeverityObservationBase for all types and resources
.... entryRelationship:criticality C0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... observation 1..1CriticalityObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredPattern: OBS
Observation.codeextensibleObservationType
Observation.statusCoderequiredActStatus
Observation.value.coderequiredAllergy and Intolerance Type
Observation.participant:participant1.typeCoderequiredPattern: CSM
Observation.participant:participant1.participantRole.classCoderequiredPattern: MANU
Observation.participant:participant1.participantRole.playingEntity.classCoderequiredPattern: MMAT
Observation.participant:participant1.participantRole.playingEntity.determinerCoderequiredFixed Value: INSTANCE
Observation.participant:participant1.participantRole.playingEntity.codeexampleSubstance Reactant for Intolerance

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
obs-er-1errorObservation.entryRelationship, Observation.entryRelationship:allergyStatus, Observation.entryRelationship:reaction, Observation.entryRelationship:severity, Observation.entryRelationship:criticalityOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1CDAR2.ObservationBase for all types and resources
... classCode 1..1codeBinding: ActClassObservation (required)
Required Pattern: OBS
... moodCode 1..1codeRequired Pattern: EVN
... negationInd 0..1boolean
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.24.3.90
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 1..1CDBinding: ObservationType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: ASSERTION
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.5.4
.... 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
... 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 1..1IVL_TSThe effectiveTime/low (a.k.a. "onset date") asserts when the allergy/intolerance became biologically active. The effectiveTime/high (a.k.a. "resolution date") asserts when the allergy/intolerance became biologically resolved. If the allergy/intolerance is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'.
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... value 0..1dateTime
.... inclusive 0..1boolean
.... operator 0..1code
.... low 1..1TS
.... high 0..1TS
.... width 0..1PQ
.... center 0..1TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: HumanLanguage (required)
... value 1..1CD
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringMany systems will simply assign a fixed value here (e.g., "allergy to substance").
Binding: Allergy and Intolerance Type (required)
.... 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..*CEBinding: 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..*AuthorParticipationBase for all types and resources
... 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
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:typeCode
.... participant:participant1 0..*Participant2
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: CSM
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... sdtcFunctionCode 0..1CEXML: functionCode (urn:hl7-org:sdtc)
..... time 0..1IVL_TS
..... awarenessCode 0..1CE
..... participantRole 1..1ParticipantRole
...... classCode 1..1codeBinding: RoleClassRoot (required)
Required Pattern: MANU
...... templateId 0..*II
...... id 0..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
...... addr 0..*AD
...... telecom 0..*TEL
...... playingDevice 0..1Device
...... playingEntity 1..1PlayingEntity
....... classCode 1..1codeBinding: EntityClassRoot (required)
Required Pattern: MMAT
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... code 1..1CEBinding: Substance Reactant for Intolerance (example)
....... quantity 0..*PQ
....... name 0..*EN
....... desc 0..1ED
...... scopingEntity 0..1Entity
... Slices for entryRelationship C0..*ElementSlice: Unordered, Open by profile:observation
.... entryRelationship:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1code
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entryRelationship:allergyStatus C0..1Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1AllergyStatusObservationBase for all types and resources
.... entryRelationship:reaction C0..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeRequired Pattern: MFST
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1ReactionObservationBase for all types and resources
.... entryRelationship:severity C0..1Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1SeverityObservationBase for all types and resources
.... entryRelationship:criticality C0..1Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1CriticalityObservationBase for all types and resources
... reference 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition
... referenceRange 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredPattern: OBS
Observation.templateId:primary.nullFlavorrequiredNullFlavor
Observation.codeextensibleObservationType
Observation.code.nullFlavorrequiredNullFlavor
Observation.statusCoderequiredActStatus
Observation.statusCode.nullFlavorrequiredNullFlavor
Observation.effectiveTime.nullFlavorrequiredNullFlavor
Observation.priorityCodeextensibleActPriority
Observation.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Observation.value.nullFlavorrequiredNullFlavor
Observation.value.coderequiredAllergy and Intolerance Type
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.participant:participant1.nullFlavorrequiredNullFlavor
Observation.participant:participant1.typeCoderequiredPattern: CSM
Observation.participant:participant1.contextControlCoderequiredFixed Value: OP
Observation.participant:participant1.participantRole.classCoderequiredPattern: MANU
Observation.participant:participant1.participantRole.codeextensibleRoleCode
Observation.participant:participant1.participantRole.playingEntity.classCoderequiredPattern: MMAT
Observation.participant:participant1.participantRole.playingEntity.determinerCoderequiredFixed Value: INSTANCE
Observation.participant:participant1.participantRole.playingEntity.codeexampleSubstance Reactant for Intolerance
Observation.referenceRange.typeCoderequiredFixed Value: REFV

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
obs-er-1errorObservation.entryRelationship, Observation.entryRelationship:allergyStatus, Observation.entryRelationship:reaction, Observation.entryRelationship:severity, Observation.entryRelationship:criticalityOnly 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: 15 elements (18 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

 

​Other representations of profile: CSV, Excel, Schematron