Consolidated CDA
3.0.0-ballot - ballot United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v3.0.0-ballot: CCDA 3.0 Ballot 1) based on FHIR (HL7® FHIR® Standard) v5.0.0. . For a full list of available versions, see the Directory of published versions

Logical Model: Health Status Evaluations and Outcomes Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/HealthStatusEvaluationsandOutcomesSection Version: 3.0.0-ballot
Draft as of 2023-12-21 Computable Name: HealthStatusEvaluationsandOutcomesSection
Other Identifiers: id: urn:oid:2.16.840.1.113883.10.20.22.2.61

This template represents observations regarding the outcome of care from the interventions used to treat the patient. These observations represent status, at points in time, related to established care plan goals and/or interventions.

Usage:

Formal Views of Profile Content

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

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-outcome-obs: SHALL contain at least one Outcome Observation
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
... Slices for templateId 1..*IISlice: Unordered, Open by value:root
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.61
..... @extension 0..0
... code 1..1CEPatient Problem Outcome
.... @code 1..1csRequired Pattern: 11383-7
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 0..*EntryIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:observation
.... entry:outcome 0..*Entry
..... observation 1..1OutcomeObservationBase for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
shall-outcome-obserrorSectionSHALL contain at least one Outcome Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation'))
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-outcome-obs: SHALL contain at least one Outcome Observation
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
Binding: CDANullFlavor (required)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.61
... code 1..1CEPatient Problem Outcome
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 11383-7
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 0..*EntryIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:observation
.... entry:outcome 0..*Entry
..... observation C1..1OutcomeObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.nullFlavorrequiredCDANullFlavor
Section.codeexampleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
shall-outcome-obserrorSectionSHALL contain at least one Outcome Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation'))
should-authorwarningSection.entry:outcome.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningSection.entry:outcome.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningSection.entry:outcome.observationSHOULD contain value
: value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-outcome-obs: SHALL contain at least one Outcome Observation
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
Binding: 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:section 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.61
... @ID 0..1xs:ID
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... id 0..1II
... code 1..1CEPatient Problem Outcome
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 11383-7
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ST
... text 1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 0..*EntryIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:observation
.... entry:outcome 0..*Entry
..... @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: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation C1..1OutcomeObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... component 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..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredCDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeexampleDocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
Section.languageCoderequiredAllLanguages
Section.entry:outcome.nullFlavorrequiredCDANullFlavor
Section.entry:outcome.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:outcome.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
shall-outcome-obserrorSectionSHALL contain at least one Outcome Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation'))
should-authorwarningSection.entry:outcome.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningSection.entry:outcome.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningSection.entry:outcome.observationSHOULD contain value
: value.exists()

This structure is derived from Section

Summary

Mandatory: 8 elements (1 nested mandatory element)
Prohibited: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the value of value:root
  • The element Section.entry is sliced based on the value of value:observation

Differential View

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-outcome-obs: SHALL contain at least one Outcome Observation
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
... Slices for templateId 1..*IISlice: Unordered, Open by value:root
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.61
..... @extension 0..0
... code 1..1CEPatient Problem Outcome
.... @code 1..1csRequired Pattern: 11383-7
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 0..*EntryIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:observation
.... entry:outcome 0..*Entry
..... observation 1..1OutcomeObservationBase for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
shall-outcome-obserrorSectionSHALL contain at least one Outcome Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation'))

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-outcome-obs: SHALL contain at least one Outcome Observation
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
Binding: CDANullFlavor (required)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.61
... code 1..1CEPatient Problem Outcome
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 11383-7
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 0..*EntryIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:observation
.... entry:outcome 0..*Entry
..... observation C1..1OutcomeObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.nullFlavorrequiredCDANullFlavor
Section.codeexampleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
shall-outcome-obserrorSectionSHALL contain at least one Outcome Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation'))
should-authorwarningSection.entry:outcome.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningSection.entry:outcome.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningSection.entry:outcome.observationSHOULD contain value
: value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-outcome-obs: SHALL contain at least one Outcome Observation
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
Binding: 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:section 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.61
... @ID 0..1xs:ID
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... id 0..1II
... code 1..1CEPatient Problem Outcome
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 11383-7
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ST
... text 1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 0..*EntryIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:observation
.... entry:outcome 0..*Entry
..... @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: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation C1..1OutcomeObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... component 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..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredCDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeexampleDocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
Section.languageCoderequiredAllLanguages
Section.entry:outcome.nullFlavorrequiredCDANullFlavor
Section.entry:outcome.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:outcome.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
shall-outcome-obserrorSectionSHALL contain at least one Outcome Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation'))
should-authorwarningSection.entry:outcome.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningSection.entry:outcome.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningSection.entry:outcome.observationSHOULD contain value
: value.exists()

This structure is derived from Section

Summary

Mandatory: 8 elements (1 nested mandatory element)
Prohibited: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the value of value:root
  • The element Section.entry is sliced based on the value of value:observation

 

Other representations of profile: CSV, Excel