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/TreatmentInterventionPreference | Version: 3.0.0-ballot | |||
| Draft as of 2023-12-21 | Computable Name: TreatmentInterventionPreference | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.510:2024-05-01 | ||||
This Treatment Intervention Preference template represents personal health goals, preferences, and priorities for medical treatments or interventions in the event of a future health scenario where a person is unable to make medical decisions because of a serious illness or injury. This does not represent actual orders or formal advance directives, but holds observations about wishes. These observations may inform the placement of future orders or creation of advance directives. While observation.code is encoded to support system queries, the answers represented at observation.value are likley to be text. Precondition.Criterion is required to represent the situation when a person would prefer the stated intervention preferences. This template may be used directly in any section, such as Care Plan Document Sections, Social History, or Advance Directives, and may be used inside any entry such as Procedure or Medication Activity.
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 |
  Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:treatment-intervention-pref | 1..1 | II | ||
  @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.510 | |
  @extension | 1..1 | st | Required Pattern: 2024-05-01 | |
 @classCode | 1..1 | cs | Fixed Value: OBS | |
| @moodCode | 1..1 | cs | Fixed Value: INT | |
| @negationInd | 0..0 | |||
| id | 1..* | II | ||
| code | 1..1 | CD | Goals, preferences, and priorities for medical treatment | |
| @code | 1..1 | cs | Required Pattern: 75773-2 | |
 @codeSystem | 1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| 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 |
 value | 1..1 | Most of the time, the value will be a string representing the person's words. | ||
 value | ED | |||
| value | CD | |||
 sdtcPrecondition2 | 1..1 | Precondition2 | ||
| criterion | 1..1 | Criterion | ||
| code | 1..1 | CD | Binding: AD Conditions and Prognosis Scenarios (preferred) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.sdtcPrecondition2.criterion.code | preferred | ADConditionsAndPrognosisScenarios |
| Id | Grade | Path(s) | Details | Requirements |
| 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 |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:treatment-intervention-pref | 1..1 | II | ||
 @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.510 | |
| @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: INT | |
 id | 1..* | II | ||
| code | 1..1 | CD | Goals, preferences, and priorities for medical treatment Binding: ObservationType (example) | |
| @code | 1..1 | cs | Required Pattern: 75773-2 | |
| @codeSystem | 1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| 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 |
| value | 1..1 | Most of the time, the value will be a string representing the person's words. | ||
| value | ED | |||
| value | CD | |||
| sdtcPrecondition2 | 1..1 | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| conjunctionCode | 1..1 | CS | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc Binding: RelationshipConjunction (2.0.0) (required) | |
| criterion | 1..1 | Criterion | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| @classCode | 1..1 | cs | Binding: ActClassObservation (required) | |
| code | 1..1 | CD | Binding: AD Conditions and Prognosis Scenarios (preferred) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Fixed Value: INT |
| Observation.code | example | ObservationType |
| Observation.sdtcPrecondition2.conjunctionCode | required | RelationshipConjunction |
| Observation.sdtcPrecondition2.criterion.classCode | required | ActClassObservation |
| Observation.sdtcPrecondition2.criterion.code | preferred | ADConditionsAndPrognosisScenarios |
| Id | Grade | Path(s) | Details | Requirements |
| 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 |
| @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:treatment-intervention-pref | 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: 2.16.840.1.113883.10.20.22.4.510 | |
| @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: INT | |
| id | 1..* | II | ||
| code | 1..1 | CD | Goals, preferences, and priorities for medical treatment Binding: ObservationType (example) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: 75773-2 | |
| @codeSystem | 1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| @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 | ||
| 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 | 0..1 | CS | Binding: ActStatus (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: AllLanguages (required) | |
| value | 1..1 | Most of the time, the value will be a string representing the person's words. | ||
| value | ED | |||
| value | 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..* | Author | ||
| informant | 0..* | Informant | ||
| participant | 0..* | Participant2 | ||
| entryRelationship | 0..* | EntryRelationship | ||
| reference | 0..* | Reference | ||
| precondition | 0..* | Precondition | ||
| sdtcPrecondition2 | 1..1 | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| @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 (required) Fixed Value: PRCN | |
| @negationInd | 0..1 | bl | ||
| conjunctionCode | 1..1 | CS | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc Binding: RelationshipConjunction (2.0.0) (required) | |
| allTrue | 0..1 | PreconditionBase | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| allFalse | 0..1 | PreconditionBase | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| atLeastOneTrue | 0..1 | PreconditionBase | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| atLeastOneFalse | 0..1 | PreconditionBase | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| onlyOneTrue | 0..1 | PreconditionBase | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| onlyOneFalse | 0..1 | PreconditionBase | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| criterion | 1..1 | Criterion | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| @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 | ||
| @classCode | 1..1 | cs | Binding: ActClassObservation (required) | |
| @moodCode | 0..1 | cs | Binding: ActMoodPredicate (required) Fixed Value: EVN.CRT | |
| code | 1..1 | CD | Binding: AD Conditions and Prognosis Scenarios (preferred) | |
| text | 0..1 | ED | ||
| value | 0..1 | |||
| value | BL | |||
| value | ED | |||
| value | ST | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| 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:treatment-intervention-pref.nullFlavor | required | CDANullFlavor |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Fixed Value: INT |
| Observation.code | example | ObservationType |
| Observation.code.nullFlavor | required | CDANullFlavor |
| 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.priorityCode | example | ActPriority |
| Observation.languageCode | required | AllLanguages |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | example | ObservationMethod |
| Observation.sdtcPrecondition2.nullFlavor | required | CDANullFlavor |
| Observation.sdtcPrecondition2.typeId.nullFlavor | required | CDANullFlavor |
| Observation.sdtcPrecondition2.typeCode | required | Fixed Value: PRCN |
| Observation.sdtcPrecondition2.conjunctionCode | required | RelationshipConjunction |
| Observation.sdtcPrecondition2.criterion.nullFlavor | required | CDANullFlavor |
| Observation.sdtcPrecondition2.criterion.typeId.nullFlavor | required | CDANullFlavor |
| Observation.sdtcPrecondition2.criterion.classCode | required | ActClassObservation |
| Observation.sdtcPrecondition2.criterion.moodCode | required | Fixed Value: EVN.CRT |
| Observation.sdtcPrecondition2.criterion.code | preferred | ADConditionsAndPrognosisScenarios |
| Observation.referenceRange.nullFlavor | required | CDANullFlavor |
| Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavor |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 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('#') |
This structure is derived from Observation
Summary
Mandatory: 11 elements
Fixed Value: 2 elements
Prohibited: 1 element
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 |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:treatment-intervention-pref | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.510 | |
| @extension | 1..1 | st | Required Pattern: 2024-05-01 | |
| @classCode | 1..1 | cs | Fixed Value: OBS | |
| @moodCode | 1..1 | cs | Fixed Value: INT | |
| @negationInd | 0..0 | |||
| id | 1..* | II | ||
| code | 1..1 | CD | Goals, preferences, and priorities for medical treatment | |
| @code | 1..1 | cs | Required Pattern: 75773-2 | |
| @codeSystem | 1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| 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 |
| value | 1..1 | Most of the time, the value will be a string representing the person's words. | ||
| value | ED | |||
| value | CD | |||
| sdtcPrecondition2 | 1..1 | Precondition2 | ||
| criterion | 1..1 | Criterion | ||
| code | 1..1 | CD | Binding: AD Conditions and Prognosis Scenarios (preferred) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.sdtcPrecondition2.criterion.code | preferred | ADConditionsAndPrognosisScenarios |
| Id | Grade | Path(s) | Details | Requirements |
| 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 |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:treatment-intervention-pref | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.510 | |
| @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: INT | |
| id | 1..* | II | ||
| code | 1..1 | CD | Goals, preferences, and priorities for medical treatment Binding: ObservationType (example) | |
| @code | 1..1 | cs | Required Pattern: 75773-2 | |
| @codeSystem | 1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| 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 |
| value | 1..1 | Most of the time, the value will be a string representing the person's words. | ||
| value | ED | |||
| value | CD | |||
| sdtcPrecondition2 | 1..1 | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| conjunctionCode | 1..1 | CS | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc Binding: RelationshipConjunction (2.0.0) (required) | |
| criterion | 1..1 | Criterion | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| @classCode | 1..1 | cs | Binding: ActClassObservation (required) | |
| code | 1..1 | CD | Binding: AD Conditions and Prognosis Scenarios (preferred) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Fixed Value: INT |
| Observation.code | example | ObservationType |
| Observation.sdtcPrecondition2.conjunctionCode | required | RelationshipConjunction |
| Observation.sdtcPrecondition2.criterion.classCode | required | ActClassObservation |
| Observation.sdtcPrecondition2.criterion.code | preferred | ADConditionsAndPrognosisScenarios |
| Id | Grade | Path(s) | Details | Requirements |
| 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('#') |
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 |
| @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:treatment-intervention-pref | 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: 2.16.840.1.113883.10.20.22.4.510 | |
| @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: INT | |
| id | 1..* | II | ||
| code | 1..1 | CD | Goals, preferences, and priorities for medical treatment Binding: ObservationType (example) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: 75773-2 | |
| @codeSystem | 1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| @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 | ||
| 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 | 0..1 | CS | Binding: ActStatus (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: AllLanguages (required) | |
| value | 1..1 | Most of the time, the value will be a string representing the person's words. | ||
| value | ED | |||
| value | 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..* | Author | ||
| informant | 0..* | Informant | ||
| participant | 0..* | Participant2 | ||
| entryRelationship | 0..* | EntryRelationship | ||
| reference | 0..* | Reference | ||
| precondition | 0..* | Precondition | ||
| sdtcPrecondition2 | 1..1 | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| @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 (required) Fixed Value: PRCN | |
| @negationInd | 0..1 | bl | ||
| conjunctionCode | 1..1 | CS | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc Binding: RelationshipConjunction (2.0.0) (required) | |
| allTrue | 0..1 | PreconditionBase | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| allFalse | 0..1 | PreconditionBase | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| atLeastOneTrue | 0..1 | PreconditionBase | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| atLeastOneFalse | 0..1 | PreconditionBase | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| onlyOneTrue | 0..1 | PreconditionBase | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| onlyOneFalse | 0..1 | PreconditionBase | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| criterion | 1..1 | Criterion | XML Namespace: urn:hl7-org:sdtc XML Namespace: urn:hl7-org:sdtc | |
| @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 | ||
| @classCode | 1..1 | cs | Binding: ActClassObservation (required) | |
| @moodCode | 0..1 | cs | Binding: ActMoodPredicate (required) Fixed Value: EVN.CRT | |
| code | 1..1 | CD | Binding: AD Conditions and Prognosis Scenarios (preferred) | |
| text | 0..1 | ED | ||
| value | 0..1 | |||
| value | BL | |||
| value | ED | |||
| value | ST | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| 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:treatment-intervention-pref.nullFlavor | required | CDANullFlavor |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Fixed Value: INT |
| Observation.code | example | ObservationType |
| Observation.code.nullFlavor | required | CDANullFlavor |
| 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.priorityCode | example | ActPriority |
| Observation.languageCode | required | AllLanguages |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | example | ObservationMethod |
| Observation.sdtcPrecondition2.nullFlavor | required | CDANullFlavor |
| Observation.sdtcPrecondition2.typeId.nullFlavor | required | CDANullFlavor |
| Observation.sdtcPrecondition2.typeCode | required | Fixed Value: PRCN |
| Observation.sdtcPrecondition2.conjunctionCode | required | RelationshipConjunction |
| Observation.sdtcPrecondition2.criterion.nullFlavor | required | CDANullFlavor |
| Observation.sdtcPrecondition2.criterion.typeId.nullFlavor | required | CDANullFlavor |
| Observation.sdtcPrecondition2.criterion.classCode | required | ActClassObservation |
| Observation.sdtcPrecondition2.criterion.moodCode | required | Fixed Value: EVN.CRT |
| Observation.sdtcPrecondition2.criterion.code | preferred | ADConditionsAndPrognosisScenarios |
| Observation.referenceRange.nullFlavor | required | CDANullFlavor |
| Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavor |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 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('#') |
This structure is derived from Observation
Summary
Mandatory: 11 elements
Fixed Value: 2 elements
Prohibited: 1 element
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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