Clinical Document Architecture
2.0.0-sd-ballot - ballot

This page is part of the CDA: Clinical Document Architecture (v2.0.0-sd-ballot: CDA 2.0 Ballot 1) based on FHIR v5.0.0. . For a full list of available versions, see the Directory of published versions

Logical Model: Observation (CDA Class)

Official URL: http://hl7.org/cda/stds/core/StructureDefinition/Observation Version: 2.0.0-sd-ballot
Active as of 2023-10-27 Computable Name: Observation

A derivative of the RIM Observation class, used for representing coded and other observations. Observation.negationInd, when set to “true”, is a positive assertion that the Observation as a whole is negated. Some properties such as Observation.id, Observation.moodCode, and the participations are not negated. These properties always have the same meaning: i.e., the author remains the author of the negative Observation. An observation statement with negationInd is still a statement about the specific fact described by the Observation. For instance, a negated “finding of wheezing on July 1” means that the author positively denies that there was wheezing on July 1, and that he takes the same responsibility for such statement and the same requirement to have evidence for such statement than if he had not used negation.

Usage:

Formal Views of Profile Content

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

This structure is derived from InfrastructureRoot

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1InfrastructureRootXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId
Base for all types and resources
Instances of this type are validated by templateId
... @classCode 1..1csBinding: ActClassObservation (2.0.0) (required)
... @moodCode 1..1csBinding: XActMoodDocumentObservation (2.0.0) (required)
... @negationInd 0..1bl
... id 0..*II
... code 1..1CDBinding: ObservationType (example)
... derivationExpr 0..1ST
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (example)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: AllLanguages (required)
... value 0..*
.... valueANY
.... valueBL
.... valueED
.... valueST
.... valueCD
.... valueCV
.... valueCE
.... valueCO
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..*CEBinding: ObservationMethod (example)
... targetSiteCode 0..*CD
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Informant
... participant 0..*Participant2
... entryRelationship 0..*EntryRelationship
... reference 0..*Reference
... precondition 0..*Precondition
... sdtcPrecondition2 0..*Precondition2XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... referenceRange 0..*InfrastructureRoot
.... @typeCode 0..1csBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange
... sdtcInFulfillmentOf1 0..*InFulfillmentOf1XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / Code
Observation.classCoderequiredActClassObservation
Observation.moodCoderequiredXActMoodDocumentObservation
Observation.codeexampleObservationType
Observation.statusCoderequiredActStatus
Observation.priorityCodeexampleActPriority
Observation.languageCoderequiredAllLanguages
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeexampleObservationMethod
Observation.referenceRange.typeCoderequiredFixed Value: REFV
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1InfrastructureRootXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId
Base for all types and resources
Instances of this type are validated by templateId
... @classCode 1..1csBinding: ActClassObservation (2.0.0) (required)
... @moodCode 1..1csBinding: XActMoodDocumentObservation (2.0.0) (required)
... @negationInd 0..1bl
... id 0..*II
... code 1..1CDBinding: ObservationType (example)
... derivationExpr 0..1ST
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (example)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: AllLanguages (required)
... value 0..*
.... valueANY
.... valueBL
.... valueED
.... valueST
.... valueCD
.... valueCV
.... valueCE
.... valueCO
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..*CEBinding: ObservationMethod (example)
... targetSiteCode 0..*CD
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Informant
... participant 0..*Participant2
... entryRelationship 0..*EntryRelationship
... reference 0..*Reference
... precondition 0..*Precondition
... sdtcPrecondition2 0..*Precondition2XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... referenceRange 0..*InfrastructureRoot
.... @typeCode 0..1csBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange
... sdtcInFulfillmentOf1 0..*InFulfillmentOf1XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredActClassObservation
Observation.moodCoderequiredXActMoodDocumentObservation
Observation.codeexampleObservationType
Observation.statusCoderequiredActStatus
Observation.priorityCodeexampleActPriority
Observation.languageCoderequiredAllLanguages
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeexampleObservationMethod
Observation.referenceRange.typeCoderequiredFixed Value: REFV
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1InfrastructureRootXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId
Base for all types and resources
Instances of this type are validated by templateId
... @nullFlavor 0..1csBinding: CDANullFlavor (required)
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1st
... templateId 0..*II
... @classCode 1..1csBinding: ActClassObservation (2.0.0) (required)
... @moodCode 1..1csBinding: XActMoodDocumentObservation (2.0.0) (required)
... @negationInd 0..1bl
... id 0..*II
... code 1..1CDBinding: ObservationType (example)
... derivationExpr 0..1ST
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (example)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: AllLanguages (required)
... value 0..*
.... valueANY
.... valueBL
.... valueED
.... valueST
.... valueCD
.... valueCV
.... valueCE
.... valueCO
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..*CEBinding: ObservationMethod (example)
... targetSiteCode 0..*CD
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Informant
... participant 0..*Participant2
... entryRelationship 0..*EntryRelationship
... reference 0..*Reference
... precondition 0..*Precondition
... sdtcPrecondition2 0..*Precondition2XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... referenceRange 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange
... sdtcInFulfillmentOf1 0..*InFulfillmentOf1XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.nullFlavorrequiredCDANullFlavor
Observation.typeId.nullFlavorrequiredCDANullFlavor
Observation.classCoderequiredActClassObservation
Observation.moodCoderequiredXActMoodDocumentObservation
Observation.codeexampleObservationType
Observation.statusCoderequiredActStatus
Observation.priorityCodeexampleActPriority
Observation.languageCoderequiredAllLanguages
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeexampleObservationMethod
Observation.referenceRange.nullFlavorrequiredCDANullFlavor
Observation.referenceRange.typeId.nullFlavorrequiredCDANullFlavor
Observation.referenceRange.typeCoderequiredFixed Value: REFV

This structure is derived from InfrastructureRoot

Summary

Mandatory: 0 element (4 nested mandatory elements)
Fixed Value: 1 element

Structures

This structure refers to these other structures:

Differential View

This structure is derived from InfrastructureRoot

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1InfrastructureRootXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId
Base for all types and resources
Instances of this type are validated by templateId
... @classCode 1..1csBinding: ActClassObservation (2.0.0) (required)
... @moodCode 1..1csBinding: XActMoodDocumentObservation (2.0.0) (required)
... @negationInd 0..1bl
... id 0..*II
... code 1..1CDBinding: ObservationType (example)
... derivationExpr 0..1ST
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (example)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: AllLanguages (required)
... value 0..*
.... valueANY
.... valueBL
.... valueED
.... valueST
.... valueCD
.... valueCV
.... valueCE
.... valueCO
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..*CEBinding: ObservationMethod (example)
... targetSiteCode 0..*CD
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Informant
... participant 0..*Participant2
... entryRelationship 0..*EntryRelationship
... reference 0..*Reference
... precondition 0..*Precondition
... sdtcPrecondition2 0..*Precondition2XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... referenceRange 0..*InfrastructureRoot
.... @typeCode 0..1csBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange
... sdtcInFulfillmentOf1 0..*InFulfillmentOf1XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / Code
Observation.classCoderequiredActClassObservation
Observation.moodCoderequiredXActMoodDocumentObservation
Observation.codeexampleObservationType
Observation.statusCoderequiredActStatus
Observation.priorityCodeexampleActPriority
Observation.languageCoderequiredAllLanguages
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeexampleObservationMethod
Observation.referenceRange.typeCoderequiredFixed Value: REFV

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1InfrastructureRootXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId
Base for all types and resources
Instances of this type are validated by templateId
... @classCode 1..1csBinding: ActClassObservation (2.0.0) (required)
... @moodCode 1..1csBinding: XActMoodDocumentObservation (2.0.0) (required)
... @negationInd 0..1bl
... id 0..*II
... code 1..1CDBinding: ObservationType (example)
... derivationExpr 0..1ST
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (example)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: AllLanguages (required)
... value 0..*
.... valueANY
.... valueBL
.... valueED
.... valueST
.... valueCD
.... valueCV
.... valueCE
.... valueCO
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..*CEBinding: ObservationMethod (example)
... targetSiteCode 0..*CD
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Informant
... participant 0..*Participant2
... entryRelationship 0..*EntryRelationship
... reference 0..*Reference
... precondition 0..*Precondition
... sdtcPrecondition2 0..*Precondition2XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... referenceRange 0..*InfrastructureRoot
.... @typeCode 0..1csBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange
... sdtcInFulfillmentOf1 0..*InFulfillmentOf1XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.classCoderequiredActClassObservation
Observation.moodCoderequiredXActMoodDocumentObservation
Observation.codeexampleObservationType
Observation.statusCoderequiredActStatus
Observation.priorityCodeexampleActPriority
Observation.languageCoderequiredAllLanguages
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeexampleObservationMethod
Observation.referenceRange.typeCoderequiredFixed Value: REFV

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1InfrastructureRootXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId
Base for all types and resources
Instances of this type are validated by templateId
... @nullFlavor 0..1csBinding: CDANullFlavor (required)
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1st
... templateId 0..*II
... @classCode 1..1csBinding: ActClassObservation (2.0.0) (required)
... @moodCode 1..1csBinding: XActMoodDocumentObservation (2.0.0) (required)
... @negationInd 0..1bl
... id 0..*II
... code 1..1CDBinding: ObservationType (example)
... derivationExpr 0..1ST
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (example)
... repeatNumber 0..1IVL_INT
... languageCode 0..1CSBinding: AllLanguages (required)
... value 0..*
.... valueANY
.... valueBL
.... valueED
.... valueST
.... valueCD
.... valueCV
.... valueCE
.... valueCO
.... valueSC
.... valueII
.... valueTEL
.... valueAD
.... valueEN
.... valueINT
.... valueREAL
.... valuePQ
.... valueMO
.... valueTS
.... valueIVL_PQ
.... valueIVL_TS
.... valuePIVL_TS
.... valueEIVL_TS
.... valueSXPR_TS
.... valueRTO_PQ_PQ
... interpretationCode 0..*CEBinding: ObservationInterpretation (required)
... methodCode 0..*CEBinding: ObservationMethod (example)
... targetSiteCode 0..*CD
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Informant
... participant 0..*Participant2
... entryRelationship 0..*EntryRelationship
... reference 0..*Reference
... precondition 0..*Precondition
... sdtcPrecondition2 0..*Precondition2XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... referenceRange 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ActRelationshipPertains (required)
Fixed Value: REFV
.... observationRange 1..1ObservationRange
... sdtcInFulfillmentOf1 0..*InFulfillmentOf1XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.nullFlavorrequiredCDANullFlavor
Observation.typeId.nullFlavorrequiredCDANullFlavor
Observation.classCoderequiredActClassObservation
Observation.moodCoderequiredXActMoodDocumentObservation
Observation.codeexampleObservationType
Observation.statusCoderequiredActStatus
Observation.priorityCodeexampleActPriority
Observation.languageCoderequiredAllLanguages
Observation.interpretationCoderequiredObservationInterpretation
Observation.methodCodeexampleObservationMethod
Observation.referenceRange.nullFlavorrequiredCDANullFlavor
Observation.referenceRange.typeId.nullFlavorrequiredCDANullFlavor
Observation.referenceRange.typeCoderequiredFixed Value: REFV

This structure is derived from InfrastructureRoot

Summary

Mandatory: 0 element (4 nested mandatory elements)
Fixed Value: 1 element

Structures

This structure refers to these other structures:

 

Other representations of profile: CSV, Excel