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/VitalSignObservation | Version: 3.0.0-ballot | |||
| Draft as of 2023-12-21 | Computable Name: VitalSignObservation | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.27:2014-06-09 | ||||
This template represents measurement of common vital signs. Vital signs are represented with additional vocabulary constraints for type of vital sign and unit of measure.
The following is a list of recommended units for common types of vital sign measurements:
| Name | Unit |
|---|---|
| PulseOx | % |
| Height/Head Circumf | cm |
| Weight | kg |
| Temp | Cel |
| BP | mm[Hg] |
| Pulse/Resp Rate | /min |
| BMI | kg/m2 |
| BSA | m2 |
| inhaled oxygen concentration | % |
| Average Blood Pressure (Systolic and Diastolic) | mm[Hg] |
| Occipital Front Head Circumference Percentile (Birth -36 months) | % |
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-code: SHOULD contain code should-author: SHOULD contain author |
  Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:vital-sign-obs | 1..1 | II | ||
  @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.27 | |
  @extension | 1..1 | st | Required Pattern: 2014-06-09 | |
 @classCode | 1..1 | cs | Fixed Value: OBS | |
| @moodCode | 1..1 | cs | Fixed Value: EVN | |
| id | 1..* | II | ||
| code | 1..1 | CD | ||
 @code | 0..1 | cs | Binding: Vital Sign Result Type (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 | ||
 value | 1..1 | PQ | ||
| @unit | 1..1 | cs | NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (required) | |
| interpretationCode | 0..1 | CE | ||
| @code | 1..1 | cs | ||
| methodCode | 0..1 | CE | ||
| targetSiteCode | 0..1 | CD | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.code.code | preferred | VitalSignResultType |
| Observation.value.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM) |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-code | warning | Observation | SHOULD contain code : code.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-code: SHOULD contain code should-author: SHOULD contain author |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:vital-sign-obs | 1..1 | II | ||
 @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.27 | |
| @extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| @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 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: ObservationType (example) | |
| @code | 0..1 | cs | Binding: Vital Sign Result Type (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 | ||
| value | 1..1 | PQ | ||
| @unit | 1..1 | cs | NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (required) | |
| interpretationCode | 0..1 | CE | Binding: ObservationInterpretation (required) | |
| @code | 1..1 | cs | ||
| methodCode | 0..1 | CE | Binding: ObservationMethod (example) | |
| targetSiteCode | 0..1 | CD | ||
| author | 0..* | AuthorParticipation | 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 | example | ObservationType |
| Observation.code.code | preferred | VitalSignResultType |
| Observation.statusCode | required | ActStatus |
| Observation.value.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM) |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | example | ObservationMethod |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-code | warning | Observation | SHOULD contain code : code.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('#') |
| Path | Conformance | ValueSet / Code |
| Observation.nullFlavor | required | CDANullFlavor |
| Observation.typeId.nullFlavor | required | CDANullFlavor |
| Observation.templateId:vital-sign-obs.nullFlavor | required | CDANullFlavor |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Fixed Value: EVN |
| Observation.code | example | ObservationType |
| Observation.code.nullFlavor | required | CDANullFlavor |
| Observation.code.code | preferred | VitalSignResultType |
| 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.priorityCode | example | ActPriority |
| Observation.languageCode | required | AllLanguages |
| Observation.value.nullFlavor | required | CDANullFlavor |
| Observation.value.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM) |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.interpretationCode.nullFlavor | required | CDANullFlavor |
| Observation.methodCode | example | ObservationMethod |
| 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-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-code | warning | Observation | SHOULD contain code : code.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('#') |
This structure is derived from Observation
Summary
Mandatory: 10 elements (1 nested mandatory element)
Fixed Value: 3 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-code: SHOULD contain code should-author: SHOULD contain author |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:vital-sign-obs | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.27 | |
| @extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| @classCode | 1..1 | cs | Fixed Value: OBS | |
| @moodCode | 1..1 | cs | Fixed Value: EVN | |
| id | 1..* | II | ||
| code | 1..1 | CD | ||
| @code | 0..1 | cs | Binding: Vital Sign Result Type (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 | ||
| value | 1..1 | PQ | ||
| @unit | 1..1 | cs | NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (required) | |
| interpretationCode | 0..1 | CE | ||
| @code | 1..1 | cs | ||
| methodCode | 0..1 | CE | ||
| targetSiteCode | 0..1 | CD | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.code.code | preferred | VitalSignResultType |
| Observation.value.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM) |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-code | warning | Observation | SHOULD contain code : code.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-code: SHOULD contain code should-author: SHOULD contain author |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:vital-sign-obs | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.27 | |
| @extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| @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 | |
| id | 1..* | II | ||
| code | 1..1 | CD | Binding: ObservationType (example) | |
| @code | 0..1 | cs | Binding: Vital Sign Result Type (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 | ||
| value | 1..1 | PQ | ||
| @unit | 1..1 | cs | NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (required) | |
| interpretationCode | 0..1 | CE | Binding: ObservationInterpretation (required) | |
| @code | 1..1 | cs | ||
| methodCode | 0..1 | CE | Binding: ObservationMethod (example) | |
| targetSiteCode | 0..1 | CD | ||
| author | 0..* | AuthorParticipation | 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 | example | ObservationType |
| Observation.code.code | preferred | VitalSignResultType |
| Observation.statusCode | required | ActStatus |
| Observation.value.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM) |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | example | ObservationMethod |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-code | warning | Observation | SHOULD contain code : code.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('#') |
Snapshot View
| Path | Conformance | ValueSet / Code |
| Observation.nullFlavor | required | CDANullFlavor |
| Observation.typeId.nullFlavor | required | CDANullFlavor |
| Observation.templateId:vital-sign-obs.nullFlavor | required | CDANullFlavor |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Fixed Value: EVN |
| Observation.code | example | ObservationType |
| Observation.code.nullFlavor | required | CDANullFlavor |
| Observation.code.code | preferred | VitalSignResultType |
| 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.priorityCode | example | ActPriority |
| Observation.languageCode | required | AllLanguages |
| Observation.value.nullFlavor | required | CDANullFlavor |
| Observation.value.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM) |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.interpretationCode.nullFlavor | required | CDANullFlavor |
| Observation.methodCode | example | ObservationMethod |
| 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-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-code | warning | Observation | SHOULD contain code : code.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('#') |
This structure is derived from Observation
Summary
Mandatory: 10 elements (1 nested mandatory element)
Fixed Value: 3 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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