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/BasicIndustryObservation | Version: 3.0.0-ballot | |||
| Draft as of 2023-12-21 | Computable Name: BasicIndustryObservation | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.504:2023-05-01 | ||||
This template represents a simple observation about the type of business that compensates for work or assigns work to an unpaid worker or volunteer (e.g., U.S. Army, cement manufacturing, children and youth services). Multiple occupation industry observation instances in a single document or derived from multiple documents, represent a basic historical industry record.
Implementers should use the Basic Industry Observation template for conveying Industry in support of USCDI. It is recommended systems include the Basic Industry Observation in the Social History section. Implementers wishing to convey more advanced Industry detail may consider using HL7 CDA R2 Implementation Guide: C-CDA R2.1 Supplemental Templates for Occupational Data for Health in addition to this Observation.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from SocialHistoryObservation
| Path | Conformance | ValueSet |
| Observation.value | required | PHVS_Industry_NAICS_Detail _ODH |
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
  Observation | C | 1..1 | SocialHistoryObservation | 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, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||||||
  Slices for templateId | 2..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
   templateId:social-history-obs | 1..1 | II | ||||||||
   @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.38 | |||||||
 @extension | 1..1 | st | Required Pattern: 2022-06-01 | |||||||
 templateId:basic-industry-obs | 1..1 | II | ||||||||
 @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.504 | |||||||
| @extension | 1..1 | st | Required Pattern: 2023-05-01 | |||||||
 @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 | |||||||
 id | 1..* | II | ||||||||
| code | C | 1..1 | CD | History of Occupation Industry Binding: Social History Type (preferred) | ||||||
| @code | 1..1 | cs | Required Pattern: 86188-0 | |||||||
 @codeSystem | 1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |||||||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |||||||
| @code | 1..1 | cs | Fixed Value: completed | |||||||
| effectiveTime | 1..1 | IVL_TS | ||||||||
| value | 1..1 | CD | NOTE for PQ values: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: Industry NAICS Detail (ODH) (required)
| |||||||
 Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |||||||
| entryRelationship:social-history-entry-sprt-obs | 0..* | EntryRelationship | When an Assessment Scale Observation is contained in a Social History Observation instance that is a Social Determinant of Health Social History Observation, that Assessment Scale Observation MAY contain Assessment Scale Supporting Observations that contain LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| observation | C | 1..1 | AssessmentScaleObservation | Base for all types and resources | ||||||
| entryRelationship:social-history-entry-sprt-act | 0..* | EntryRelationship | When an Entry Reference is contained in a Social History Template instance that is a Social Determinant of Health Social History, that Entry Reference **MAY** reference an Assessment Scale Observation elsewhere in the document that represent LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| act | C | 1..1 | EntryReference | 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 | SocialHistoryType |
| Observation.statusCode | required | ActStatus |
| Observation.value | required | PHVS_Industry_NAICS_Detail _ODH |
| Observation.entryRelationship:social-history-entry-sprt-obs.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:social-history-entry-sprt-act.typeCode | required | Fixed Value: SPRT |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-8555 | error | Observation | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4515-32956 | warning | Observation.code | If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). : codeSystem = '2.16.840.1.113883.6.1' or translation.where(codeSystem = '2.16.840.1.113883.6.1').exists() | |
| should-sh-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Observation, Observation.entryRelationship:social-history-entry-sprt-obs.observation, Observation.entryRelationship:social-history-entry-sprt-act.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-value | warning | Observation | SHOULD contain value : value.exists() |
| Path | Conformance | ValueSet / Code |
| Observation.nullFlavor | required | CDANullFlavor |
| Observation.typeId.nullFlavor | required | CDANullFlavor |
| Observation.templateId:social-history-obs.nullFlavor | required | CDANullFlavor |
| Observation.templateId:basic-industry-obs.nullFlavor | required | CDANullFlavor |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Fixed Value: EVN |
| Observation.code | preferred | SocialHistoryType |
| 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.statusCode.nullFlavor | required | CDANullFlavor |
| Observation.priorityCode | example | ActPriority |
| Observation.languageCode | required | AllLanguages |
| Observation.value | required | PHVS_Industry_NAICS_Detail _ODH |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | example | ObservationMethod |
| Observation.entryRelationship:social-history-entry-sprt-obs.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:social-history-entry-sprt-obs.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:social-history-entry-sprt-obs.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:social-history-entry-sprt-act.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:social-history-entry-sprt-act.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:social-history-entry-sprt-act.typeCode | required | Fixed Value: SPRT |
| Observation.referenceRange.nullFlavor | required | CDANullFlavor |
| Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavor |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-8555 | error | Observation | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4515-32956 | warning | Observation.code | If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). : codeSystem = '2.16.840.1.113883.6.1' or translation.where(codeSystem = '2.16.840.1.113883.6.1').exists() | |
| should-sh-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Observation, Observation.entryRelationship:social-history-entry-sprt-obs.observation, Observation.entryRelationship:social-history-entry-sprt-act.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-value | warning | Observation | SHOULD contain value : 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 SocialHistoryObservation
Differential View
This structure is derived from SocialHistoryObservation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 1..1 | SocialHistoryObservation | 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, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
| templateId | 2..* | II | ||
| templateId:basic-industry-obs | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.504 | |
 @extension | 1..1 | st | Required Pattern: 2023-05-01 | |
| @classCode | 1..1 | cs | ||
| @moodCode | 1..1 | cs | ||
| code | 1..1 | CD | History of Occupation Industry | |
| @code | 1..1 | cs | Required Pattern: 86188-0 | |
| @codeSystem | 1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| statusCode | 1..1 | CS | ||
| @code | 1..1 | cs | ||
| value | 1..1 | CD | NOTE for PQ values: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: Industry NAICS Detail (ODH) (required) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.value | required | PHVS_Industry_NAICS_Detail _ODH |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation | C | 1..1 | SocialHistoryObservation | 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, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||||||
| Slices for templateId | 2..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:social-history-obs | 1..1 | II | ||||||||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.38 | |||||||
| @extension | 1..1 | st | Required Pattern: 2022-06-01 | |||||||
| templateId:basic-industry-obs | 1..1 | II | ||||||||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.504 | |||||||
| @extension | 1..1 | st | Required Pattern: 2023-05-01 | |||||||
| @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 | |||||||
| id | 1..* | II | ||||||||
| code | C | 1..1 | CD | History of Occupation Industry Binding: Social History Type (preferred) | ||||||
| @code | 1..1 | cs | Required Pattern: 86188-0 | |||||||
| @codeSystem | 1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |||||||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |||||||
| @code | 1..1 | cs | Fixed Value: completed | |||||||
| effectiveTime | 1..1 | IVL_TS | ||||||||
| value | 1..1 | CD | NOTE for PQ values: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: Industry NAICS Detail (ODH) (required)
| |||||||
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |||||||
| entryRelationship:social-history-entry-sprt-obs | 0..* | EntryRelationship | When an Assessment Scale Observation is contained in a Social History Observation instance that is a Social Determinant of Health Social History Observation, that Assessment Scale Observation MAY contain Assessment Scale Supporting Observations that contain LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| observation | C | 1..1 | AssessmentScaleObservation | Base for all types and resources | ||||||
| entryRelationship:social-history-entry-sprt-act | 0..* | EntryRelationship | When an Entry Reference is contained in a Social History Template instance that is a Social Determinant of Health Social History, that Entry Reference **MAY** reference an Assessment Scale Observation elsewhere in the document that represent LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| act | C | 1..1 | EntryReference | 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 | SocialHistoryType |
| Observation.statusCode | required | ActStatus |
| Observation.value | required | PHVS_Industry_NAICS_Detail _ODH |
| Observation.entryRelationship:social-history-entry-sprt-obs.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:social-history-entry-sprt-act.typeCode | required | Fixed Value: SPRT |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-8555 | error | Observation | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4515-32956 | warning | Observation.code | If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). : codeSystem = '2.16.840.1.113883.6.1' or translation.where(codeSystem = '2.16.840.1.113883.6.1').exists() | |
| should-sh-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Observation, Observation.entryRelationship:social-history-entry-sprt-obs.observation, Observation.entryRelationship:social-history-entry-sprt-act.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-value | warning | Observation | SHOULD contain value : value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation | C | 1..1 | SocialHistoryObservation | 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, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||||||
| @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 | 2..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:social-history-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: 2.16.840.1.113883.10.20.22.4.38 | |||||||
| @extension | 1..1 | st | Required Pattern: 2022-06-01 | |||||||
| templateId:basic-industry-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: 2.16.840.1.113883.10.20.22.4.504 | |||||||
| @extension | 1..1 | st | Required Pattern: 2023-05-01 | |||||||
| @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 | ||||||||
| id | 1..* | II | ||||||||
| code | C | 1..1 | CD | History of Occupation Industry Binding: Social History Type (preferred) | ||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code | 1..1 | cs | Required Pattern: 86188-0 | |||||||
| @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 | |||||||
| 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 | ||||||||
| priorityCode | 0..1 | CE | Binding: ActPriority (example) | |||||||
| repeatNumber | 0..1 | IVL_INT | ||||||||
| languageCode | 0..1 | CS | Binding: AllLanguages (required) | |||||||
| value | 1..1 | CD | NOTE for PQ values: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: Industry NAICS Detail (ODH) (required)
| |||||||
| 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:act, profile:observation | |||||||
| entryRelationship:social-history-entry-sprt-obs | 0..* | EntryRelationship | When an Assessment Scale Observation is contained in a Social History Observation instance that is a Social Determinant of Health Social History Observation, that Assessment Scale Observation MAY contain Assessment Scale Supporting Observations that contain LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @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:social-history-entry-sprt-act | 0..* | EntryRelationship | When an Entry Reference is contained in a Social History Template instance that is a Social Determinant of Health Social History, that Entry Reference **MAY** reference an Assessment Scale Observation elsewhere in the document that represent LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @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 | ||||||||
| 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:social-history-obs.nullFlavor | required | CDANullFlavor |
| Observation.templateId:basic-industry-obs.nullFlavor | required | CDANullFlavor |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Fixed Value: EVN |
| Observation.code | preferred | SocialHistoryType |
| 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.statusCode.nullFlavor | required | CDANullFlavor |
| Observation.priorityCode | example | ActPriority |
| Observation.languageCode | required | AllLanguages |
| Observation.value | required | PHVS_Industry_NAICS_Detail _ODH |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | example | ObservationMethod |
| Observation.entryRelationship:social-history-entry-sprt-obs.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:social-history-entry-sprt-obs.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:social-history-entry-sprt-obs.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:social-history-entry-sprt-act.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:social-history-entry-sprt-act.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:social-history-entry-sprt-act.typeCode | required | Fixed Value: SPRT |
| Observation.referenceRange.nullFlavor | required | CDANullFlavor |
| Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavor |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-8555 | error | Observation | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4515-32956 | warning | Observation.code | If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). : codeSystem = '2.16.840.1.113883.6.1' or translation.where(codeSystem = '2.16.840.1.113883.6.1').exists() | |
| should-sh-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Observation, Observation.entryRelationship:social-history-entry-sprt-obs.observation, Observation.entryRelationship:social-history-entry-sprt-act.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-value | warning | Observation | SHOULD contain value : 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 SocialHistoryObservation
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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