Consolidated CDA
3.0.0-ballot - ballot
Consolidated CDA
3.0.0-ballot - ballot
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
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ProblemObservation | Version: 3.0.0-ballot | |||
| Draft as of 2023-12-21 | Computable Name: ProblemObservation | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2024-05-01 | ||||
This template reflects a discrete observation about a patient’s problem. 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 heart attack that occurred five years ago, the effectiveTime is five years ago.
The effectiveTime of the Problem Observation is the definitive indication of whether or not the underlying condition is resolved. If the problem is 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:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
  Observation | C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author | ||||||
  Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
   templateId:problem-obs | 1..1 | II | ||||||||
  @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.4 | |||||||
  @extension | 1..1 | st | Required Pattern: 2024-05-01 | |||||||
 @classCode | 1..1 | cs | Fixed Value: OBS | |||||||
| @moodCode | 1..1 | cs | Fixed Value: EVN | |||||||
| @negationInd | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |||||||
| id | 1..* | II | ||||||||
| code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred) 1198-32950: If code is selected from ValueSet Problem Type (SNOMEDCT) urn:id:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950). | ||||||
 translation | 0..* | CD | Binding: Problem Type (LOINC) (preferred) | |||||||
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
| reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| statusCode | 1..1 | CS | ||||||||
| @code | 1..1 | cs | Fixed Value: completed | |||||||
| effectiveTime | 1..1 | IVL_TS | If the problem 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'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. | |||||||
| low | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |||||||
| high | 0..1 | IVXB_TS | (USCDI) Date of Resolution - The effectiveTime/high (a.k.a. resolution date) asserts when the condition became biologically resolved. | |||||||
 value | 1..1 | CD | Binding: US Core Condition Codes (preferred) | |||||||
| @code | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951). Binding: (unbound) (example): See additional binding
| |||||||
| qualifier | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo - Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML. | |||||||
| author | 0..* | AuthorParticipation | Base for all types and resources | |||||||
 Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |||||||
 entryRelationship:age | 0..1 | EntryRelationship | ||||||||
 @typeCode | 1..1 | cs | Fixed Value: SUBJ | |||||||
| @inversionInd | 1..1 | bl | Fixed Value: true | |||||||
| observation | 1..1 | AgeObservation | Base for all types and resources | |||||||
| entryRelationship:prognosis | 0..1 | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Fixed Value: REFR | |||||||
| observation | 1..1 | PrognosisObservation | Base for all types and resources | |||||||
| entryRelationship:priority | 0..* | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Fixed Value: REFR | |||||||
| observation | 1..1 | PriorityPreference | Base for all types and resources | |||||||
| entryRelationship:status | 0..1 | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Fixed Value: REFR | |||||||
| observation | 1..1 | ProblemStatus | Base for all types and resources | |||||||
| entryRelationship:reference | 0..1 | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Fixed Value: SPRT | |||||||
| act | 1..1 | EntryReference | Base for all types and resources | |||||||
| entryRelationship:assessment | 0..1 | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Fixed Value: SPRT | |||||||
| observation | 1..1 | AssessmentScaleObservation | Base for all types and resources | |||||||
| entryRelationship:dateOfDiagnosis | 0..1 | EntryRelationship | (USCDI) Date of Diagnosis | |||||||
| @typeCode | 1..1 | cs | Fixed Value: COMP | |||||||
| act | 1..1 | DateOfDiagnosisAct | Base for all types and resources | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet |
| Observation.code | preferred | ProblemTypeSNOMEDCT |
| Observation.code.translation | preferred | ProblemTypeLOINC |
| Observation.value | preferred | USCoreConditionCodes |
| Observation.value.code | example | |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32950 | warning | Observation.code | If code is selected from ValueSet Problem Type (SNOMEDCT) urn:id:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950). : code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.7.2') implies translation.where(code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.28')).exists() | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation | C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author | ||||||
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:problem-obs | 1..1 | II | ||||||||
 @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.4 | |||||||
| @extension | 1..1 | st | Required Pattern: 2024-05-01 | |||||||
| @classCode | 1..1 | cs | Binding: ActClassObservation (2.0.0) (required) Fixed Value: OBS | |||||||
| @moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||
| @negationInd | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |||||||
| id | 1..* | II | ||||||||
| code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred) 1198-32950: If code is selected from ValueSet Problem Type (SNOMEDCT) urn:id:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950). | ||||||
| translation | 0..* | CD | Binding: Problem Type (LOINC) (preferred) | |||||||
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
| reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |||||||
| @code | 1..1 | cs | Fixed Value: completed | |||||||
| effectiveTime | 1..1 | IVL_TS | If the problem 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'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. | |||||||
| low | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |||||||
| high | 0..1 | IVXB_TS | (USCDI) Date of Resolution - The effectiveTime/high (a.k.a. resolution date) asserts when the condition became biologically resolved. | |||||||
| value | 1..1 | CD | Binding: US Core Condition Codes (preferred) | |||||||
| @code | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951). Binding: (unbound) (example): See additional binding
| |||||||
| qualifier | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined.
In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo -
Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML. | |||||||
| author | 0..* | AuthorParticipation | Base for all types and resources | |||||||
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |||||||
| entryRelationship:age | 0..1 | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |||||||
| @inversionInd | 1..1 | bl | Fixed Value: true | |||||||
| observation | C | 1..1 | AgeObservation | Base for all types and resources | ||||||
| entryRelationship:prognosis | 0..1 | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| observation | C | 1..1 | PrognosisObservation | Base for all types and resources | ||||||
| entryRelationship:priority | 0..* | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| observation | C | 1..1 | PriorityPreference | Base for all types and resources | ||||||
| entryRelationship:status | 0..1 | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| observation | C | 1..1 | ProblemStatus | Base for all types and resources | ||||||
| entryRelationship:reference | 0..1 | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| act | C | 1..1 | EntryReference | Base for all types and resources | ||||||
| entryRelationship:assessment | 0..1 | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| observation | C | 1..1 | AssessmentScaleObservation | Base for all types and resources | ||||||
| entryRelationship:dateOfDiagnosis | 0..1 | EntryRelationship | (USCDI) Date of Diagnosis | |||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |||||||
| act | C | 1..1 | DateOfDiagnosisAct | Base for all types and resources | ||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Fixed Value: EVN |
| Observation.code | preferred | ProblemTypeSNOMEDCT |
| Observation.code.translation | preferred | ProblemTypeLOINC |
| Observation.statusCode | required | ActStatus |
| Observation.value | preferred | USCoreConditionCodes |
| Observation.value.code | example | |
| Observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJ |
| Observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:priority.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:status.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:reference.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:assessment.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:dateOfDiagnosis.typeCode | required | Fixed Value: COMP |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32950 | warning | Observation.code | If code is selected from ValueSet Problem Type (SNOMEDCT) urn:id:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950). : code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.7.2') implies translation.where(code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.28')).exists() | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-author | warning | Observation.entryRelationship:priority.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Observation.entryRelationship:priority.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Observation.entryRelationship:age.observation, Observation.entryRelationship:prognosis.observation, Observation.entryRelationship:priority.observation, Observation.entryRelationship:status.observation, Observation.entryRelationship:reference.act, Observation.entryRelationship:assessment.observation, Observation.entryRelationship:dateOfDiagnosis.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation | C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author | ||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:problem-obs | 1..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.4 | |||||||
| @extension | 1..1 | st | Required Pattern: 2024-05-01 | |||||||
| @classCode | 1..1 | cs | Binding: ActClassObservation (2.0.0) (required) Fixed Value: OBS | |||||||
| @moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||
| @negationInd | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |||||||
| id | 1..* | II | ||||||||
| code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred) 1198-32950: If code is selected from ValueSet Problem Type (SNOMEDCT) urn:id:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950). | ||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code | 0..1 | cs | ||||||||
| @codeSystem | 0..1 | oid, uuid, ruid | ||||||||
| @codeSystemName | 0..1 | st | ||||||||
| @codeSystemVersion | 0..1 | st | ||||||||
| @displayName | 0..1 | st | ||||||||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |||||||
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |||||||
| originalText | 0..1 | ED | ||||||||
| qualifier | 0..* | CR | ||||||||
| translation | 0..* | CD | Binding: Problem Type (LOINC) (preferred) | |||||||
| derivationExpr | 0..1 | ST | ||||||||
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @compression | 0..1 | cs | Binding: CompressionAlgorithm (required) | |||||||
| @integrityCheck | 0..1 | bin | ||||||||
| @integrityCheckAlgorithm | 0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |||||||
| @language | 0..1 | cs | ||||||||
| @mediaType | 0..1 | cs | Binding: MediaType (example) | |||||||
| @representation | 0..1 | cs | Binding: Binary Data Encoding Value Set (required) | |||||||
| xmlText | 0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |||||||
| reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| thumbnail | 0..1 | ED | ||||||||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code | 1..1 | cs | Fixed Value: completed | |||||||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |||||||
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |||||||
| effectiveTime | 1..1 | IVL_TS | If the problem 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'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. | |||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |||||||
| @operator | 0..1 | cs | Binding: SetOperator (required) | |||||||
| low | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |||||||
| center | 0..1 | TS | ||||||||
| width | 0..1 | PQ | ||||||||
| high | 0..1 | IVXB_TS | (USCDI) Date of Resolution - The effectiveTime/high (a.k.a. resolution date) asserts when the condition became biologically resolved. | |||||||
| priorityCode | 0..1 | CE | Binding: ActPriority (example) | |||||||
| repeatNumber | 0..1 | IVL_INT | ||||||||
| languageCode | 0..1 | CS | Binding: AllLanguages (required) | |||||||
| value | 1..1 | CD | Binding: US Core Condition Codes (preferred) | |||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951). Binding: (unbound) (example): See additional binding
| |||||||
| @codeSystem | 0..1 | oid, uuid, ruid | ||||||||
| @codeSystemName | 0..1 | st | ||||||||
| @codeSystemVersion | 0..1 | st | ||||||||
| @displayName | 0..1 | st | ||||||||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |||||||
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |||||||
| originalText | 0..1 | ED | ||||||||
| qualifier | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined.
In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo -
Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML. | |||||||
| translation | 0..* | CD | ||||||||
| interpretationCode | 0..* | CE | Binding: ObservationInterpretation (required) | |||||||
| methodCode | 0..* | CE | Binding: ObservationMethod (example) | |||||||
| targetSiteCode | 0..* | CD | ||||||||
| subject | 0..1 | Subject | ||||||||
| specimen | 0..* | Specimen | ||||||||
| performer | 0..* | Performer2 | ||||||||
| author | 0..* | AuthorParticipation | Base for all types and resources | |||||||
| informant | 0..* | Informant | ||||||||
| participant | 0..* | Participant2 | ||||||||
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |||||||
| entryRelationship:age | 0..1 | EntryRelationship | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
 typeId | 0..1 | II | ||||||||
 @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| templateId | 0..* | II | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |||||||
| @inversionInd | 1..1 | bl | Fixed Value: true | |||||||
| @contextConductionInd | 0..1 | bl | ||||||||
| @negationInd | 0..1 | bl | ||||||||
| sequenceNumber | 0..1 | INT | ||||||||
| seperatableInd | 0..1 | BL | ||||||||
| act | 0..1 | Act | ||||||||
| encounter | 0..1 | Encounter | ||||||||
| observation | C | 1..1 | AgeObservation | Base for all types and resources | ||||||
| observationMedia | 0..1 | ObservationMedia | ||||||||
| organizer | 0..1 | Organizer | ||||||||
| procedure | 0..1 | Procedure | ||||||||
| regionOfInterest | 0..1 | RegionOfInterest | ||||||||
| substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
| supply | 0..1 | Supply | ||||||||
| entryRelationship:prognosis | 0..1 | EntryRelationship | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| templateId | 0..* | II | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| @inversionInd | 0..1 | bl | ||||||||
| @contextConductionInd | 0..1 | bl | ||||||||
| @negationInd | 0..1 | bl | ||||||||
| sequenceNumber | 0..1 | INT | ||||||||
| seperatableInd | 0..1 | BL | ||||||||
| act | 0..1 | Act | ||||||||
| encounter | 0..1 | Encounter | ||||||||
| observation | C | 1..1 | PrognosisObservation | Base for all types and resources | ||||||
| observationMedia | 0..1 | ObservationMedia | ||||||||
| organizer | 0..1 | Organizer | ||||||||
| procedure | 0..1 | Procedure | ||||||||
| regionOfInterest | 0..1 | RegionOfInterest | ||||||||
| substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
| supply | 0..1 | Supply | ||||||||
| entryRelationship:priority | 0..* | EntryRelationship | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| templateId | 0..* | II | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| @inversionInd | 0..1 | bl | ||||||||
| @contextConductionInd | 0..1 | bl | ||||||||
| @negationInd | 0..1 | bl | ||||||||
| sequenceNumber | 0..1 | INT | ||||||||
| seperatableInd | 0..1 | BL | ||||||||
| act | 0..1 | Act | ||||||||
| encounter | 0..1 | Encounter | ||||||||
| observation | C | 1..1 | PriorityPreference | Base for all types and resources | ||||||
| observationMedia | 0..1 | ObservationMedia | ||||||||
| organizer | 0..1 | Organizer | ||||||||
| procedure | 0..1 | Procedure | ||||||||
| regionOfInterest | 0..1 | RegionOfInterest | ||||||||
| substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
| supply | 0..1 | Supply | ||||||||
| entryRelationship:status | 0..1 | EntryRelationship | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| templateId | 0..* | II | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| @inversionInd | 0..1 | bl | ||||||||
| @contextConductionInd | 0..1 | bl | ||||||||
| @negationInd | 0..1 | bl | ||||||||
| sequenceNumber | 0..1 | INT | ||||||||
| seperatableInd | 0..1 | BL | ||||||||
| act | 0..1 | Act | ||||||||
| encounter | 0..1 | Encounter | ||||||||
| observation | C | 1..1 | ProblemStatus | Base for all types and resources | ||||||
| observationMedia | 0..1 | ObservationMedia | ||||||||
| organizer | 0..1 | Organizer | ||||||||
| procedure | 0..1 | Procedure | ||||||||
| regionOfInterest | 0..1 | RegionOfInterest | ||||||||
| substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
| supply | 0..1 | Supply | ||||||||
| entryRelationship:reference | 0..1 | EntryRelationship | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| templateId | 0..* | II | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| @inversionInd | 0..1 | bl | ||||||||
| @contextConductionInd | 0..1 | bl | ||||||||
| @negationInd | 0..1 | bl | ||||||||
| sequenceNumber | 0..1 | INT | ||||||||
| seperatableInd | 0..1 | BL | ||||||||
| act | C | 1..1 | EntryReference | Base for all types and resources | ||||||
| encounter | 0..1 | Encounter | ||||||||
| observation | 0..1 | Observation | ||||||||
| observationMedia | 0..1 | ObservationMedia | ||||||||
| organizer | 0..1 | Organizer | ||||||||
| procedure | 0..1 | Procedure | ||||||||
| regionOfInterest | 0..1 | RegionOfInterest | ||||||||
| substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
| supply | 0..1 | Supply | ||||||||
| entryRelationship:assessment | 0..1 | EntryRelationship | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| templateId | 0..* | II | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| @inversionInd | 0..1 | bl | ||||||||
| @contextConductionInd | 0..1 | bl | ||||||||
| @negationInd | 0..1 | bl | ||||||||
| sequenceNumber | 0..1 | INT | ||||||||
| seperatableInd | 0..1 | BL | ||||||||
| act | 0..1 | Act | ||||||||
| encounter | 0..1 | Encounter | ||||||||
| observation | C | 1..1 | AssessmentScaleObservation | Base for all types and resources | ||||||
| observationMedia | 0..1 | ObservationMedia | ||||||||
| organizer | 0..1 | Organizer | ||||||||
| procedure | 0..1 | Procedure | ||||||||
| regionOfInterest | 0..1 | RegionOfInterest | ||||||||
| substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
| supply | 0..1 | Supply | ||||||||
| entryRelationship:dateOfDiagnosis | 0..1 | EntryRelationship | (USCDI) Date of Diagnosis | |||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| templateId | 0..* | II | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |||||||
| @inversionInd | 0..1 | bl | ||||||||
| @contextConductionInd | 0..1 | bl | ||||||||
| @negationInd | 0..1 | bl | ||||||||
| sequenceNumber | 0..1 | INT | ||||||||
| seperatableInd | 0..1 | BL | ||||||||
| act | C | 1..1 | DateOfDiagnosisAct | Base for all types and resources | ||||||
| encounter | 0..1 | Encounter | ||||||||
| observation | 0..1 | Observation | ||||||||
| observationMedia | 0..1 | ObservationMedia | ||||||||
| organizer | 0..1 | Organizer | ||||||||
| procedure | 0..1 | Procedure | ||||||||
| regionOfInterest | 0..1 | RegionOfInterest | ||||||||
| substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
| supply | 0..1 | Supply | ||||||||
| reference | 0..* | Reference | ||||||||
| precondition | 0..* | Precondition | ||||||||
| sdtcPrecondition2 | 0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |||||||
| referenceRange | 0..* | InfrastructureRoot | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| templateId | 0..* | II | ||||||||
| @typeCode | 0..1 | cs | Binding: ActRelationshipType (2.0.0) (required) Fixed Value: REFV | |||||||
| observationRange | 1..1 | ObservationRange | ||||||||
| sdtcInFulfillmentOf1 | 0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code |
| Observation.nullFlavor | required | CDANullFlavor |
| Observation.typeId.nullFlavor | required | CDANullFlavor |
| Observation.templateId:problem-obs.nullFlavor | required | CDANullFlavor |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Fixed Value: EVN |
| Observation.code | preferred | ProblemTypeSNOMEDCT |
| Observation.code.nullFlavor | required | CDANullFlavor |
| Observation.code.translation | preferred | ProblemTypeLOINC |
| Observation.text.nullFlavor | required | CDANullFlavor |
| Observation.text.compression | required | CDACompressionAlgorithm |
| Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
| Observation.text.mediaType | example | MediaType |
| Observation.text.representation | required | BinaryDataEncoding |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.nullFlavor | required | CDANullFlavor |
| Observation.effectiveTime.nullFlavor | required | CDANullFlavor |
| Observation.effectiveTime.operator | required | SetOperator |
| Observation.priorityCode | example | ActPriority |
| Observation.languageCode | required | AllLanguages |
| Observation.value | preferred | USCoreConditionCodes |
| Observation.value.nullFlavor | required | CDANullFlavor |
| Observation.value.code | example | |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | example | ObservationMethod |
| Observation.entryRelationship:age.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:age.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJ |
| Observation.entryRelationship:prognosis.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:prognosis.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:priority.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:priority.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:priority.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:status.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:status.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:status.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:reference.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:reference.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:reference.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:assessment.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:assessment.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:assessment.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:dateOfDiagnosis.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:dateOfDiagnosis.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:dateOfDiagnosis.typeCode | required | Fixed Value: COMP |
| Observation.referenceRange.nullFlavor | required | CDANullFlavor |
| Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavor |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32950 | warning | Observation.code | If code is selected from ValueSet Problem Type (SNOMEDCT) urn:id:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950). : code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.7.2') implies translation.where(code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.28')).exists() | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-author | warning | Observation.entryRelationship:priority.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Observation.entryRelationship:priority.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Observation.entryRelationship:age.observation, Observation.entryRelationship:prognosis.observation, Observation.entryRelationship:priority.observation, Observation.entryRelationship:status.observation, Observation.entryRelationship:reference.act, Observation.entryRelationship:assessment.observation, Observation.entryRelationship:dateOfDiagnosis.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from Observation
Summary
Mandatory: 10 elements (8 nested mandatory elements)
Fixed Value: 11 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Observation
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation | C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author | ||||||
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:problem-obs | 1..1 | II | ||||||||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.4 | |||||||
| @extension | 1..1 | st | Required Pattern: 2024-05-01 | |||||||
| @classCode | 1..1 | cs | Fixed Value: OBS | |||||||
| @moodCode | 1..1 | cs | Fixed Value: EVN | |||||||
| @negationInd | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |||||||
| id | 1..* | II | ||||||||
| code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred) 1198-32950: If code is selected from ValueSet Problem Type (SNOMEDCT) urn:id:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950). | ||||||
| translation | 0..* | CD | Binding: Problem Type (LOINC) (preferred) | |||||||
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
| reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| statusCode | 1..1 | CS | ||||||||
| @code | 1..1 | cs | Fixed Value: completed | |||||||
| effectiveTime | 1..1 | IVL_TS | If the problem 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'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. | |||||||
| low | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |||||||
| high | 0..1 | IVXB_TS | (USCDI) Date of Resolution - The effectiveTime/high (a.k.a. resolution date) asserts when the condition became biologically resolved. | |||||||
| value | 1..1 | CD | Binding: US Core Condition Codes (preferred) | |||||||
| @code | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951). Binding: (unbound) (example): See additional binding
| |||||||
| qualifier | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo - Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML. | |||||||
| author | 0..* | AuthorParticipation | Base for all types and resources | |||||||
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |||||||
| entryRelationship:age | 0..1 | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Fixed Value: SUBJ | |||||||
| @inversionInd | 1..1 | bl | Fixed Value: true | |||||||
| observation | 1..1 | AgeObservation | Base for all types and resources | |||||||
| entryRelationship:prognosis | 0..1 | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Fixed Value: REFR | |||||||
| observation | 1..1 | PrognosisObservation | Base for all types and resources | |||||||
| entryRelationship:priority | 0..* | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Fixed Value: REFR | |||||||
| observation | 1..1 | PriorityPreference | Base for all types and resources | |||||||
| entryRelationship:status | 0..1 | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Fixed Value: REFR | |||||||
| observation | 1..1 | ProblemStatus | Base for all types and resources | |||||||
| entryRelationship:reference | 0..1 | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Fixed Value: SPRT | |||||||
| act | 1..1 | EntryReference | Base for all types and resources | |||||||
| entryRelationship:assessment | 0..1 | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Fixed Value: SPRT | |||||||
| observation | 1..1 | AssessmentScaleObservation | Base for all types and resources | |||||||
| entryRelationship:dateOfDiagnosis | 0..1 | EntryRelationship | (USCDI) Date of Diagnosis | |||||||
| @typeCode | 1..1 | cs | Fixed Value: COMP | |||||||
| act | 1..1 | DateOfDiagnosisAct | Base for all types and resources | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet |
| Observation.code | preferred | ProblemTypeSNOMEDCT |
| Observation.code.translation | preferred | ProblemTypeLOINC |
| Observation.value | preferred | USCoreConditionCodes |
| Observation.value.code | example | |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32950 | warning | Observation.code | If code is selected from ValueSet Problem Type (SNOMEDCT) urn:id:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950). : code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.7.2') implies translation.where(code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.28')).exists() | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation | C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author | ||||||
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:problem-obs | 1..1 | II | ||||||||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.4 | |||||||
| @extension | 1..1 | st | Required Pattern: 2024-05-01 | |||||||
| @classCode | 1..1 | cs | Binding: ActClassObservation (2.0.0) (required) Fixed Value: OBS | |||||||
| @moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||
| @negationInd | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |||||||
| id | 1..* | II | ||||||||
| code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred) 1198-32950: If code is selected from ValueSet Problem Type (SNOMEDCT) urn:id:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950). | ||||||
| translation | 0..* | CD | Binding: Problem Type (LOINC) (preferred) | |||||||
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
| reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |||||||
| @code | 1..1 | cs | Fixed Value: completed | |||||||
| effectiveTime | 1..1 | IVL_TS | If the problem 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'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. | |||||||
| low | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |||||||
| high | 0..1 | IVXB_TS | (USCDI) Date of Resolution - The effectiveTime/high (a.k.a. resolution date) asserts when the condition became biologically resolved. | |||||||
| value | 1..1 | CD | Binding: US Core Condition Codes (preferred) | |||||||
| @code | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951). Binding: (unbound) (example): See additional binding
| |||||||
| qualifier | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined.
In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo -
Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML. | |||||||
| author | 0..* | AuthorParticipation | Base for all types and resources | |||||||
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |||||||
| entryRelationship:age | 0..1 | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |||||||
| @inversionInd | 1..1 | bl | Fixed Value: true | |||||||
| observation | C | 1..1 | AgeObservation | Base for all types and resources | ||||||
| entryRelationship:prognosis | 0..1 | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| observation | C | 1..1 | PrognosisObservation | Base for all types and resources | ||||||
| entryRelationship:priority | 0..* | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| observation | C | 1..1 | PriorityPreference | Base for all types and resources | ||||||
| entryRelationship:status | 0..1 | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| observation | C | 1..1 | ProblemStatus | Base for all types and resources | ||||||
| entryRelationship:reference | 0..1 | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| act | C | 1..1 | EntryReference | Base for all types and resources | ||||||
| entryRelationship:assessment | 0..1 | EntryRelationship | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| observation | C | 1..1 | AssessmentScaleObservation | Base for all types and resources | ||||||
| entryRelationship:dateOfDiagnosis | 0..1 | EntryRelationship | (USCDI) Date of Diagnosis | |||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |||||||
| act | C | 1..1 | DateOfDiagnosisAct | Base for all types and resources | ||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Fixed Value: EVN |
| Observation.code | preferred | ProblemTypeSNOMEDCT |
| Observation.code.translation | preferred | ProblemTypeLOINC |
| Observation.statusCode | required | ActStatus |
| Observation.value | preferred | USCoreConditionCodes |
| Observation.value.code | example | |
| Observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJ |
| Observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:priority.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:status.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:reference.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:assessment.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:dateOfDiagnosis.typeCode | required | Fixed Value: COMP |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32950 | warning | Observation.code | If code is selected from ValueSet Problem Type (SNOMEDCT) urn:id:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950). : code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.7.2') implies translation.where(code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.28')).exists() | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-author | warning | Observation.entryRelationship:priority.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Observation.entryRelationship:priority.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Observation.entryRelationship:age.observation, Observation.entryRelationship:prognosis.observation, Observation.entryRelationship:priority.observation, Observation.entryRelationship:status.observation, Observation.entryRelationship:reference.act, Observation.entryRelationship:assessment.observation, Observation.entryRelationship:dateOfDiagnosis.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation | C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author | ||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:problem-obs | 1..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.4 | |||||||
| @extension | 1..1 | st | Required Pattern: 2024-05-01 | |||||||
| @classCode | 1..1 | cs | Binding: ActClassObservation (2.0.0) (required) Fixed Value: OBS | |||||||
| @moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||
| @negationInd | 0..1 | bl | The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. | |||||||
| id | 1..* | II | ||||||||
| code | C | 1..1 | CD | Binding: Problem Type (SNOMEDCT) (preferred) 1198-32950: If code is selected from ValueSet Problem Type (SNOMEDCT) urn:id:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950). | ||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code | 0..1 | cs | ||||||||
| @codeSystem | 0..1 | oid, uuid, ruid | ||||||||
| @codeSystemName | 0..1 | st | ||||||||
| @codeSystemVersion | 0..1 | st | ||||||||
| @displayName | 0..1 | st | ||||||||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |||||||
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |||||||
| originalText | 0..1 | ED | ||||||||
| qualifier | 0..* | CR | ||||||||
| translation | 0..* | CD | Binding: Problem Type (LOINC) (preferred) | |||||||
| derivationExpr | 0..1 | ST | ||||||||
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @compression | 0..1 | cs | Binding: CompressionAlgorithm (required) | |||||||
| @integrityCheck | 0..1 | bin | ||||||||
| @integrityCheckAlgorithm | 0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |||||||
| @language | 0..1 | cs | ||||||||
| @mediaType | 0..1 | cs | Binding: MediaType (example) | |||||||
| @representation | 0..1 | cs | Binding: Binary Data Encoding Value Set (required) | |||||||
| xmlText | 0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |||||||
| reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| thumbnail | 0..1 | ED | ||||||||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code | 1..1 | cs | Fixed Value: completed | |||||||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |||||||
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |||||||
| effectiveTime | 1..1 | IVL_TS | If the problem 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'. Therefore, the existence of a high element within a problem does indicate that the problem has been resolved. | |||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |||||||
| @operator | 0..1 | cs | Binding: SetOperator (required) | |||||||
| low | 1..1 | IVXB_TS | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | |||||||
| center | 0..1 | TS | ||||||||
| width | 0..1 | PQ | ||||||||
| high | 0..1 | IVXB_TS | (USCDI) Date of Resolution - The effectiveTime/high (a.k.a. resolution date) asserts when the condition became biologically resolved. | |||||||
| priorityCode | 0..1 | CE | Binding: ActPriority (example) | |||||||
| repeatNumber | 0..1 | IVL_INT | ||||||||
| languageCode | 0..1 | CS | Binding: AllLanguages (required) | |||||||
| value | 1..1 | CD | Binding: US Core Condition Codes (preferred) | |||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code | 0..1 | cs | A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. When the Problem is Social Determinant of Health Observation, the observation/value SHOULD be a SNOMED code selected from ValueSet Social Determinant of Health Conditions 2.16.840.1.113762.1.4.1196.788 DYNAMIC (CONF:4515-32951). Binding: (unbound) (example): See additional binding
| |||||||
| @codeSystem | 0..1 | oid, uuid, ruid | ||||||||
| @codeSystemName | 0..1 | st | ||||||||
| @codeSystemVersion | 0..1 | st | ||||||||
| @displayName | 0..1 | st | ||||||||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |||||||
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |||||||
| originalText | 0..1 | ED | ||||||||
| qualifier | 0..* | CR | The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined.
In cases where SNOMED CT does not have a precoordinated code that would be appropriate for the problem list, concept post coordination may be used in CDA following the principles outlined in HL7 Version 3 Implementation Guide: TermInfo -
Using SNOMED CT in CDA R2 Models, Release 1 using the V3 CD Data type 1 style. This is shown in the sample XML. | |||||||
| translation | 0..* | CD | ||||||||
| interpretationCode | 0..* | CE | Binding: ObservationInterpretation (required) | |||||||
| methodCode | 0..* | CE | Binding: ObservationMethod (example) | |||||||
| targetSiteCode | 0..* | CD | ||||||||
| subject | 0..1 | Subject | ||||||||
| specimen | 0..* | Specimen | ||||||||
| performer | 0..* | Performer2 | ||||||||
| author | 0..* | AuthorParticipation | Base for all types and resources | |||||||
| informant | 0..* | Informant | ||||||||
| participant | 0..* | Participant2 | ||||||||
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |||||||
| entryRelationship:age | 0..1 | EntryRelationship | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| templateId | 0..* | II | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |||||||
| @inversionInd | 1..1 | bl | Fixed Value: true | |||||||
| @contextConductionInd | 0..1 | bl | ||||||||
| @negationInd | 0..1 | bl | ||||||||
| sequenceNumber | 0..1 | INT | ||||||||
| seperatableInd | 0..1 | BL | ||||||||
| act | 0..1 | Act | ||||||||
| encounter | 0..1 | Encounter | ||||||||
| observation | C | 1..1 | AgeObservation | Base for all types and resources | ||||||
| observationMedia | 0..1 | ObservationMedia | ||||||||
| organizer | 0..1 | Organizer | ||||||||
| procedure | 0..1 | Procedure | ||||||||
| regionOfInterest | 0..1 | RegionOfInterest | ||||||||
| substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
| supply | 0..1 | Supply | ||||||||
| entryRelationship:prognosis | 0..1 | EntryRelationship | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| templateId | 0..* | II | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| @inversionInd | 0..1 | bl | ||||||||
| @contextConductionInd | 0..1 | bl | ||||||||
| @negationInd | 0..1 | bl | ||||||||
| sequenceNumber | 0..1 | INT | ||||||||
| seperatableInd | 0..1 | BL | ||||||||
| act | 0..1 | Act | ||||||||
| encounter | 0..1 | Encounter | ||||||||
| observation | C | 1..1 | PrognosisObservation | Base for all types and resources | ||||||
| observationMedia | 0..1 | ObservationMedia | ||||||||
| organizer | 0..1 | Organizer | ||||||||
| procedure | 0..1 | Procedure | ||||||||
| regionOfInterest | 0..1 | RegionOfInterest | ||||||||
| substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
| supply | 0..1 | Supply | ||||||||
| entryRelationship:priority | 0..* | EntryRelationship | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| templateId | 0..* | II | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| @inversionInd | 0..1 | bl | ||||||||
| @contextConductionInd | 0..1 | bl | ||||||||
| @negationInd | 0..1 | bl | ||||||||
| sequenceNumber | 0..1 | INT | ||||||||
| seperatableInd | 0..1 | BL | ||||||||
| act | 0..1 | Act | ||||||||
| encounter | 0..1 | Encounter | ||||||||
| observation | C | 1..1 | PriorityPreference | Base for all types and resources | ||||||
| observationMedia | 0..1 | ObservationMedia | ||||||||
| organizer | 0..1 | Organizer | ||||||||
| procedure | 0..1 | Procedure | ||||||||
| regionOfInterest | 0..1 | RegionOfInterest | ||||||||
| substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
| supply | 0..1 | Supply | ||||||||
| entryRelationship:status | 0..1 | EntryRelationship | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| templateId | 0..* | II | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| @inversionInd | 0..1 | bl | ||||||||
| @contextConductionInd | 0..1 | bl | ||||||||
| @negationInd | 0..1 | bl | ||||||||
| sequenceNumber | 0..1 | INT | ||||||||
| seperatableInd | 0..1 | BL | ||||||||
| act | 0..1 | Act | ||||||||
| encounter | 0..1 | Encounter | ||||||||
| observation | C | 1..1 | ProblemStatus | Base for all types and resources | ||||||
| observationMedia | 0..1 | ObservationMedia | ||||||||
| organizer | 0..1 | Organizer | ||||||||
| procedure | 0..1 | Procedure | ||||||||
| regionOfInterest | 0..1 | RegionOfInterest | ||||||||
| substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
| supply | 0..1 | Supply | ||||||||
| entryRelationship:reference | 0..1 | EntryRelationship | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| templateId | 0..* | II | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| @inversionInd | 0..1 | bl | ||||||||
| @contextConductionInd | 0..1 | bl | ||||||||
| @negationInd | 0..1 | bl | ||||||||
| sequenceNumber | 0..1 | INT | ||||||||
| seperatableInd | 0..1 | BL | ||||||||
| act | C | 1..1 | EntryReference | Base for all types and resources | ||||||
| encounter | 0..1 | Encounter | ||||||||
| observation | 0..1 | Observation | ||||||||
| observationMedia | 0..1 | ObservationMedia | ||||||||
| organizer | 0..1 | Organizer | ||||||||
| procedure | 0..1 | Procedure | ||||||||
| regionOfInterest | 0..1 | RegionOfInterest | ||||||||
| substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
| supply | 0..1 | Supply | ||||||||
| entryRelationship:assessment | 0..1 | EntryRelationship | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| templateId | 0..* | II | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| @inversionInd | 0..1 | bl | ||||||||
| @contextConductionInd | 0..1 | bl | ||||||||
| @negationInd | 0..1 | bl | ||||||||
| sequenceNumber | 0..1 | INT | ||||||||
| seperatableInd | 0..1 | BL | ||||||||
| act | 0..1 | Act | ||||||||
| encounter | 0..1 | Encounter | ||||||||
| observation | C | 1..1 | AssessmentScaleObservation | Base for all types and resources | ||||||
| observationMedia | 0..1 | ObservationMedia | ||||||||
| organizer | 0..1 | Organizer | ||||||||
| procedure | 0..1 | Procedure | ||||||||
| regionOfInterest | 0..1 | RegionOfInterest | ||||||||
| substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
| supply | 0..1 | Supply | ||||||||
| entryRelationship:dateOfDiagnosis | 0..1 | EntryRelationship | (USCDI) Date of Diagnosis | |||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| templateId | 0..* | II | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |||||||
| @inversionInd | 0..1 | bl | ||||||||
| @contextConductionInd | 0..1 | bl | ||||||||
| @negationInd | 0..1 | bl | ||||||||
| sequenceNumber | 0..1 | INT | ||||||||
| seperatableInd | 0..1 | BL | ||||||||
| act | C | 1..1 | DateOfDiagnosisAct | Base for all types and resources | ||||||
| encounter | 0..1 | Encounter | ||||||||
| observation | 0..1 | Observation | ||||||||
| observationMedia | 0..1 | ObservationMedia | ||||||||
| organizer | 0..1 | Organizer | ||||||||
| procedure | 0..1 | Procedure | ||||||||
| regionOfInterest | 0..1 | RegionOfInterest | ||||||||
| substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
| supply | 0..1 | Supply | ||||||||
| reference | 0..* | Reference | ||||||||
| precondition | 0..* | Precondition | ||||||||
| sdtcPrecondition2 | 0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |||||||
| referenceRange | 0..* | InfrastructureRoot | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| templateId | 0..* | II | ||||||||
| @typeCode | 0..1 | cs | Binding: ActRelationshipType (2.0.0) (required) Fixed Value: REFV | |||||||
| observationRange | 1..1 | ObservationRange | ||||||||
| sdtcInFulfillmentOf1 | 0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code |
| Observation.nullFlavor | required | CDANullFlavor |
| Observation.typeId.nullFlavor | required | CDANullFlavor |
| Observation.templateId:problem-obs.nullFlavor | required | CDANullFlavor |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Fixed Value: EVN |
| Observation.code | preferred | ProblemTypeSNOMEDCT |
| Observation.code.nullFlavor | required | CDANullFlavor |
| Observation.code.translation | preferred | ProblemTypeLOINC |
| Observation.text.nullFlavor | required | CDANullFlavor |
| Observation.text.compression | required | CDACompressionAlgorithm |
| Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
| Observation.text.mediaType | example | MediaType |
| Observation.text.representation | required | BinaryDataEncoding |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.nullFlavor | required | CDANullFlavor |
| Observation.effectiveTime.nullFlavor | required | CDANullFlavor |
| Observation.effectiveTime.operator | required | SetOperator |
| Observation.priorityCode | example | ActPriority |
| Observation.languageCode | required | AllLanguages |
| Observation.value | preferred | USCoreConditionCodes |
| Observation.value.nullFlavor | required | CDANullFlavor |
| Observation.value.code | example | |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | example | ObservationMethod |
| Observation.entryRelationship:age.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:age.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:age.typeCode | required | Fixed Value: SUBJ |
| Observation.entryRelationship:prognosis.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:prognosis.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:prognosis.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:priority.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:priority.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:priority.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:status.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:status.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:status.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:reference.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:reference.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:reference.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:assessment.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:assessment.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:assessment.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:dateOfDiagnosis.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:dateOfDiagnosis.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:dateOfDiagnosis.typeCode | required | Fixed Value: COMP |
| Observation.referenceRange.nullFlavor | required | CDANullFlavor |
| Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavor |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 1198-32950 | warning | Observation.code | If code is selected from ValueSet Problem Type (SNOMEDCT) urn:id:2.16.840.1.113883.3.88.12.3221.7.2 **DYNAMIC**, then it **SHALL** have at least one [1..*] translation, which **SHOULD** be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113762.1.4.1099.28 **DYNAMIC** (CONF:1198-32950). : code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.7.2') implies translation.where(code.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.28')).exists() | |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-author | warning | Observation.entryRelationship:priority.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Observation.entryRelationship:priority.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Observation.entryRelationship:age.observation, Observation.entryRelationship:prognosis.observation, Observation.entryRelationship:priority.observation, Observation.entryRelationship:status.observation, Observation.entryRelationship:reference.act, Observation.entryRelationship:assessment.observation, Observation.entryRelationship:dateOfDiagnosis.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from Observation
Summary
Mandatory: 10 elements (8 nested mandatory elements)
Fixed Value: 11 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#3.0.0-ballot based on FHIR 5.0.0. Generated 2023-12-21
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