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

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

Logical Model: Encounter Activity

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/EncounterActivity Version: 3.0.0-ballot
Draft as of 2023-12-21 Computable Name: EncounterActivity
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01

This clinical statement describes an interaction between a patient and clinician. Interactions may include in-person encounters, telephone conversations, and email exchanges.

Usage:

Formal Views of Profile Content

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

This structure is derived from Encounter

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter C1..1EncounterXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, 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..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:encounter-activity 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.49
..... @extension 1..1stRequired Pattern: 2015-08-01
... @classCode 1..1cs
... @moodCode 1..1csFixed Value: EVN
... code C1..1CDBinding: EncounterTypeCode (preferred)
should-otext-ref-value: SHOULD contain originalText/reference/@value
.... originalText 0..1EDSHOULD reference the portion of narrative corresponding to this code
..... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
.... translation 0..1CDThe translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) value set to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) value set.
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... effectiveTime 1..1IVL_TS
... sdtcDischargeDispositionCode 0..1CEBinding: NUBC UB-04 FL17 Patient Status (preferred)
... performer 0..*Performer2
.... assignedEntity 1..1AssignedEntity
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
... Slices for participant 0..*Participant2Slice: Unordered, Open by profile:participantRole, value:typeCode
.... participant:location 0..*Participant2
..... @typeCode 1..1csFixed Value: LOC
..... participantRole 1..1ServiceDeliveryLocationBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:indication 0..*EntryRelationship
..... @typeCode 1..1csFixed Value: RSON
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:diagnosis 0..*EntryRelationship
..... act 1..1EncounterDiagnosisBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Encounter.codepreferredEncounterTypeCode
Encounter.sdtcDischargeDispositionCodepreferredPatientStatus
Encounter.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)

Constraints

IdGradePath(s)DetailsRequirements
should-otext-ref-valuewarningEncounter.codeSHOULD contain originalText/reference/@value
: originalText.reference.value.exists()
should-text-ref-valuewarningEncounterSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorEncounter.code.originalText.reference, Encounter.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')
NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter C1..1EncounterXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, 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..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:encounter-activity 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.49
..... @extension 1..1stRequired Pattern: 2015-08-01
... @classCode 1..1csBinding: ActClass (2.0.0) (required)
Fixed Value: ENC
... @moodCode 1..1csBinding: XDocumentEncounterMood (2.0.0) (required)
Fixed Value: EVN
... code C1..1CDBinding: EncounterTypeCode (preferred)
should-otext-ref-value: SHOULD contain originalText/reference/@value
.... originalText 0..1EDSHOULD reference the portion of narrative corresponding to this code
..... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
.... translation 0..1CDThe translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) value set to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) value set.
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... effectiveTime 1..1IVL_TS
... sdtcDischargeDispositionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: dischargeDispositionCode (urn:hl7-org:sdtc)
Binding: NUBC UB-04 FL17 Patient Status (preferred)
... performer 0..*Performer2
.... assignedEntity 1..1AssignedEntity
..... id 1..*II
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
... Slices for participant 0..*Participant2Slice: Unordered, Open by profile:participantRole, value:typeCode
.... participant:location 0..*Participant2
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: LOC
..... participantRole C1..1ServiceDeliveryLocationBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:indication 0..*EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... observation C1..1IndicationBase for all types and resources
.... entryRelationship:diagnosis 0..*EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
..... act C1..1EncounterDiagnosisBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Encounter.classCoderequiredFixed Value: ENC
Encounter.moodCoderequiredFixed Value: EVN
Encounter.codepreferredEncounterTypeCode
Encounter.sdtcDischargeDispositionCodepreferredPatientStatus
Encounter.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
Encounter.participant:location.typeCoderequiredFixed Value: LOC
Encounter.entryRelationship:indication.typeCoderequiredFixed Value: RSON
Encounter.entryRelationship:diagnosis.typeCoderequiredXActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
role-choiceerrorEncounter.participant:location.participantRoleplayingDevice and playingEntity are mutually exclusive
: (playingDevice | playingEntity).count() <= 1
should-addrwarningEncounter.participant:location.participantRoleSHOULD contain addr
: addr.exists()
should-effectiveTimewarningEncounter.entryRelationship:indication.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-otext-ref-valuewarningEncounter.codeSHOULD contain originalText/reference/@value
: originalText.reference.value.exists()
should-telecomwarningEncounter.participant:location.participantRoleSHOULD contain telecom
: telecom.exists()
should-text-ref-valuewarningEncounterSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningEncounter.entryRelationship:indication.observation, Encounter.entryRelationship:diagnosis.actSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorEncounter.code.originalText.reference, Encounter.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')
NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter C1..1EncounterXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, 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..1csBinding: CDANullFlavor (required)
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1st
.... templateId:encounter-activity 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.49
..... @extension 1..1stRequired Pattern: 2015-08-01
... @classCode 1..1csBinding: ActClass (2.0.0) (required)
Fixed Value: ENC
... @moodCode 1..1csBinding: XDocumentEncounterMood (2.0.0) (required)
Fixed Value: EVN
... id 1..*II
... code C1..1CDBinding: EncounterTypeCode (preferred)
should-otext-ref-value: SHOULD contain originalText/reference/@value
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 0..1cs
.... @codeSystem 0..1oid, uuid, ruid
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1EDSHOULD reference the portion of narrative corresponding to this code
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @compression 0..1csBinding: CompressionAlgorithm (required)
..... @integrityCheck 0..1bin
..... @integrityCheckAlgorithm 0..1csBinding: IntegrityCheckAlgorithm (2.0.0) (required)
..... @language 0..1cs
..... @mediaType 0..1csBinding: MediaType (example)
..... @representation 0..1csBinding: Binary Data Encoding Value Set (required)
..... xmlText 0..1stAllows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
..... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
..... thumbnail 0..1ED
.... qualifier 0..*CR
.... translation 0..1CDThe translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) value set to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) value set.
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @compression 0..1csBinding: CompressionAlgorithm (required)
.... @integrityCheck 0..1bin
.... @integrityCheckAlgorithm 0..1csBinding: IntegrityCheckAlgorithm (2.0.0) (required)
.... @language 0..1cs
.... @mediaType 0..1csBinding: MediaType (example)
.... @representation 0..1csBinding: Binary Data Encoding Value Set (required)
.... xmlText 0..1stAllows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
.... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
.... thumbnail 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 1..1IVL_TS
... sdtcDischargeDispositionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: dischargeDispositionCode (urn:hl7-org:sdtc)
Binding: NUBC UB-04 FL17 Patient Status (preferred)
... priorityCode 0..1CEBinding: ActPriority (example)
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... sdtcFunctionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: functionCode (urn:hl7-org:sdtc)
.... time 0..1IVL_TS
.... modeCode 0..1CE
.... assignedEntity 1..1AssignedEntity
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
..... addr 0..*AD
..... telecom 0..*TEL
..... assignedPerson 0..1Person
..... representedOrganization 0..1Organization
..... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... author 0..*Author
... informant 0..*Informant
... Slices for participant 0..*Participant2Slice: Unordered, Open by profile:participantRole, value:typeCode
.... participant:location 0..*Participant2
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: LOC
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... sdtcFunctionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: functionCode (urn:hl7-org:sdtc)
..... time 0..1IVL_TS
..... awarenessCode 0..1CE
..... participantRole C1..1ServiceDeliveryLocationBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:indication 0..*EntryRelationship
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation C1..1IndicationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:diagnosis 0..*EntryRelationship
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act C1..1EncounterDiagnosisBase for all types and resources
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... reference 0..*Reference
... precondition 0..*Precondition
... sdtcPrecondition2 0..*Precondition2XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... sdtcInFulfillmentOf1 0..*InFulfillmentOf1XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Encounter.nullFlavorrequiredCDANullFlavor
Encounter.typeId.nullFlavorrequiredCDANullFlavor
Encounter.templateId:encounter-activity.nullFlavorrequiredCDANullFlavor
Encounter.classCoderequiredFixed Value: ENC
Encounter.moodCoderequiredFixed Value: EVN
Encounter.codepreferredEncounterTypeCode
Encounter.code.nullFlavorrequiredCDANullFlavor
Encounter.code.originalText.nullFlavorrequiredCDANullFlavor
Encounter.code.originalText.compressionrequiredCDACompressionAlgorithm
Encounter.code.originalText.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
Encounter.code.originalText.mediaTypeexampleMediaType
Encounter.code.originalText.representationrequiredBinaryDataEncoding
Encounter.text.nullFlavorrequiredCDANullFlavor
Encounter.text.compressionrequiredCDACompressionAlgorithm
Encounter.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
Encounter.text.mediaTypeexampleMediaType
Encounter.text.representationrequiredBinaryDataEncoding
Encounter.statusCoderequiredActStatus
Encounter.sdtcDischargeDispositionCodepreferredPatientStatus
Encounter.priorityCodeexampleActPriority
Encounter.performer.nullFlavorrequiredCDANullFlavor
Encounter.performer.typeId.nullFlavorrequiredCDANullFlavor
Encounter.performer.typeCoderequiredFixed Value: PRF
Encounter.performer.assignedEntity.nullFlavorrequiredCDANullFlavor
Encounter.performer.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
Encounter.performer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
Encounter.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
Encounter.participant:location.nullFlavorrequiredCDANullFlavor
Encounter.participant:location.typeId.nullFlavorrequiredCDANullFlavor
Encounter.participant:location.typeCoderequiredFixed Value: LOC
Encounter.participant:location.contextControlCoderequiredFixed Value: OP
Encounter.entryRelationship:indication.nullFlavorrequiredCDANullFlavor
Encounter.entryRelationship:indication.typeId.nullFlavorrequiredCDANullFlavor
Encounter.entryRelationship:indication.typeCoderequiredFixed Value: RSON
Encounter.entryRelationship:diagnosis.nullFlavorrequiredCDANullFlavor
Encounter.entryRelationship:diagnosis.typeId.nullFlavorrequiredCDANullFlavor
Encounter.entryRelationship:diagnosis.typeCoderequiredXActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
role-choiceerrorEncounter.participant:location.participantRoleplayingDevice and playingEntity are mutually exclusive
: (playingDevice | playingEntity).count() <= 1
should-addrwarningEncounter.participant:location.participantRoleSHOULD contain addr
: addr.exists()
should-effectiveTimewarningEncounter.entryRelationship:indication.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-otext-ref-valuewarningEncounter.codeSHOULD contain originalText/reference/@value
: originalText.reference.value.exists()
should-telecomwarningEncounter.participant:location.participantRoleSHOULD contain telecom
: telecom.exists()
should-text-ref-valuewarningEncounterSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningEncounter.entryRelationship:indication.observation, Encounter.entryRelationship:diagnosis.actSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorEncounter.code.originalText.reference, Encounter.text.referenceIf 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 Encounter

Summary

Mandatory: 7 elements (2 nested mandatory elements)
Fixed Value: 3 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Encounter.templateId is sliced based on the values of value:root, value:extension
  • The element Encounter.participant is sliced based on the values of profile:participantRole, value:typeCode
  • The element Encounter.entryRelationship is sliced based on the values of profile:act, profile:observation

Differential View

This structure is derived from Encounter

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter C1..1EncounterXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, 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..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:encounter-activity 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.49
..... @extension 1..1stRequired Pattern: 2015-08-01
... @classCode 1..1cs
... @moodCode 1..1csFixed Value: EVN
... code C1..1CDBinding: EncounterTypeCode (preferred)
should-otext-ref-value: SHOULD contain originalText/reference/@value
.... originalText 0..1EDSHOULD reference the portion of narrative corresponding to this code
..... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
.... translation 0..1CDThe translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) value set to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) value set.
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... effectiveTime 1..1IVL_TS
... sdtcDischargeDispositionCode 0..1CEBinding: NUBC UB-04 FL17 Patient Status (preferred)
... performer 0..*Performer2
.... assignedEntity 1..1AssignedEntity
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
... Slices for participant 0..*Participant2Slice: Unordered, Open by profile:participantRole, value:typeCode
.... participant:location 0..*Participant2
..... @typeCode 1..1csFixed Value: LOC
..... participantRole 1..1ServiceDeliveryLocationBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:indication 0..*EntryRelationship
..... @typeCode 1..1csFixed Value: RSON
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:diagnosis 0..*EntryRelationship
..... act 1..1EncounterDiagnosisBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Encounter.codepreferredEncounterTypeCode
Encounter.sdtcDischargeDispositionCodepreferredPatientStatus
Encounter.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)

Constraints

IdGradePath(s)DetailsRequirements
should-otext-ref-valuewarningEncounter.codeSHOULD contain originalText/reference/@value
: originalText.reference.value.exists()
should-text-ref-valuewarningEncounterSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorEncounter.code.originalText.reference, Encounter.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter C1..1EncounterXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, 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..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:encounter-activity 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.49
..... @extension 1..1stRequired Pattern: 2015-08-01
... @classCode 1..1csBinding: ActClass (2.0.0) (required)
Fixed Value: ENC
... @moodCode 1..1csBinding: XDocumentEncounterMood (2.0.0) (required)
Fixed Value: EVN
... code C1..1CDBinding: EncounterTypeCode (preferred)
should-otext-ref-value: SHOULD contain originalText/reference/@value
.... originalText 0..1EDSHOULD reference the portion of narrative corresponding to this code
..... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
.... translation 0..1CDThe translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) value set to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) value set.
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... effectiveTime 1..1IVL_TS
... sdtcDischargeDispositionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: dischargeDispositionCode (urn:hl7-org:sdtc)
Binding: NUBC UB-04 FL17 Patient Status (preferred)
... performer 0..*Performer2
.... assignedEntity 1..1AssignedEntity
..... id 1..*II
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
... Slices for participant 0..*Participant2Slice: Unordered, Open by profile:participantRole, value:typeCode
.... participant:location 0..*Participant2
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: LOC
..... participantRole C1..1ServiceDeliveryLocationBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:indication 0..*EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... observation C1..1IndicationBase for all types and resources
.... entryRelationship:diagnosis 0..*EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
..... act C1..1EncounterDiagnosisBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Encounter.classCoderequiredFixed Value: ENC
Encounter.moodCoderequiredFixed Value: EVN
Encounter.codepreferredEncounterTypeCode
Encounter.sdtcDischargeDispositionCodepreferredPatientStatus
Encounter.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
Encounter.participant:location.typeCoderequiredFixed Value: LOC
Encounter.entryRelationship:indication.typeCoderequiredFixed Value: RSON
Encounter.entryRelationship:diagnosis.typeCoderequiredXActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
role-choiceerrorEncounter.participant:location.participantRoleplayingDevice and playingEntity are mutually exclusive
: (playingDevice | playingEntity).count() <= 1
should-addrwarningEncounter.participant:location.participantRoleSHOULD contain addr
: addr.exists()
should-effectiveTimewarningEncounter.entryRelationship:indication.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-otext-ref-valuewarningEncounter.codeSHOULD contain originalText/reference/@value
: originalText.reference.value.exists()
should-telecomwarningEncounter.participant:location.participantRoleSHOULD contain telecom
: telecom.exists()
should-text-ref-valuewarningEncounterSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningEncounter.entryRelationship:indication.observation, Encounter.entryRelationship:diagnosis.actSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorEncounter.code.originalText.reference, Encounter.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter C1..1EncounterXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, 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..1csBinding: CDANullFlavor (required)
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1st
.... templateId:encounter-activity 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.49
..... @extension 1..1stRequired Pattern: 2015-08-01
... @classCode 1..1csBinding: ActClass (2.0.0) (required)
Fixed Value: ENC
... @moodCode 1..1csBinding: XDocumentEncounterMood (2.0.0) (required)
Fixed Value: EVN
... id 1..*II
... code C1..1CDBinding: EncounterTypeCode (preferred)
should-otext-ref-value: SHOULD contain originalText/reference/@value
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 0..1cs
.... @codeSystem 0..1oid, uuid, ruid
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1EDSHOULD reference the portion of narrative corresponding to this code
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @compression 0..1csBinding: CompressionAlgorithm (required)
..... @integrityCheck 0..1bin
..... @integrityCheckAlgorithm 0..1csBinding: IntegrityCheckAlgorithm (2.0.0) (required)
..... @language 0..1cs
..... @mediaType 0..1csBinding: MediaType (example)
..... @representation 0..1csBinding: Binary Data Encoding Value Set (required)
..... xmlText 0..1stAllows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
..... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
..... thumbnail 0..1ED
.... qualifier 0..*CR
.... translation 0..1CDThe translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) value set to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) value set.
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @compression 0..1csBinding: CompressionAlgorithm (required)
.... @integrityCheck 0..1bin
.... @integrityCheckAlgorithm 0..1csBinding: IntegrityCheckAlgorithm (2.0.0) (required)
.... @language 0..1cs
.... @mediaType 0..1csBinding: MediaType (example)
.... @representation 0..1csBinding: Binary Data Encoding Value Set (required)
.... xmlText 0..1stAllows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
.... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
.... thumbnail 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 1..1IVL_TS
... sdtcDischargeDispositionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: dischargeDispositionCode (urn:hl7-org:sdtc)
Binding: NUBC UB-04 FL17 Patient Status (preferred)
... priorityCode 0..1CEBinding: ActPriority (example)
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... sdtcFunctionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: functionCode (urn:hl7-org:sdtc)
.... time 0..1IVL_TS
.... modeCode 0..1CE
.... assignedEntity 1..1AssignedEntity
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... id 1..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: Healthcare Provider Taxonomy (preferred)
..... addr 0..*AD
..... telecom 0..*TEL
..... assignedPerson 0..1Person
..... representedOrganization 0..1Organization
..... sdtcPatient 0..1BaseXML Namespace: urn:hl7-org:sdtc
XML: patient (urn:hl7-org:sdtc)
...... id 1..1IIXML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
... author 0..*Author
... informant 0..*Informant
... Slices for participant 0..*Participant2Slice: Unordered, Open by profile:participantRole, value:typeCode
.... participant:location 0..*Participant2
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: LOC
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... sdtcFunctionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: functionCode (urn:hl7-org:sdtc)
..... time 0..1IVL_TS
..... awarenessCode 0..1CE
..... participantRole C1..1ServiceDeliveryLocationBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:indication 0..*EntryRelationship
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation C1..1IndicationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:diagnosis 0..*EntryRelationship
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act C1..1EncounterDiagnosisBase for all types and resources
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... reference 0..*Reference
... precondition 0..*Precondition
... sdtcPrecondition2 0..*Precondition2XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... sdtcInFulfillmentOf1 0..*InFulfillmentOf1XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Encounter.nullFlavorrequiredCDANullFlavor
Encounter.typeId.nullFlavorrequiredCDANullFlavor
Encounter.templateId:encounter-activity.nullFlavorrequiredCDANullFlavor
Encounter.classCoderequiredFixed Value: ENC
Encounter.moodCoderequiredFixed Value: EVN
Encounter.codepreferredEncounterTypeCode
Encounter.code.nullFlavorrequiredCDANullFlavor
Encounter.code.originalText.nullFlavorrequiredCDANullFlavor
Encounter.code.originalText.compressionrequiredCDACompressionAlgorithm
Encounter.code.originalText.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
Encounter.code.originalText.mediaTypeexampleMediaType
Encounter.code.originalText.representationrequiredBinaryDataEncoding
Encounter.text.nullFlavorrequiredCDANullFlavor
Encounter.text.compressionrequiredCDACompressionAlgorithm
Encounter.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
Encounter.text.mediaTypeexampleMediaType
Encounter.text.representationrequiredBinaryDataEncoding
Encounter.statusCoderequiredActStatus
Encounter.sdtcDischargeDispositionCodepreferredPatientStatus
Encounter.priorityCodeexampleActPriority
Encounter.performer.nullFlavorrequiredCDANullFlavor
Encounter.performer.typeId.nullFlavorrequiredCDANullFlavor
Encounter.performer.typeCoderequiredFixed Value: PRF
Encounter.performer.assignedEntity.nullFlavorrequiredCDANullFlavor
Encounter.performer.assignedEntity.typeId.nullFlavorrequiredCDANullFlavor
Encounter.performer.assignedEntity.classCoderequiredFixed Value: ASSIGNED
Encounter.performer.assignedEntity.codepreferredHealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy)
Encounter.participant:location.nullFlavorrequiredCDANullFlavor
Encounter.participant:location.typeId.nullFlavorrequiredCDANullFlavor
Encounter.participant:location.typeCoderequiredFixed Value: LOC
Encounter.participant:location.contextControlCoderequiredFixed Value: OP
Encounter.entryRelationship:indication.nullFlavorrequiredCDANullFlavor
Encounter.entryRelationship:indication.typeId.nullFlavorrequiredCDANullFlavor
Encounter.entryRelationship:indication.typeCoderequiredFixed Value: RSON
Encounter.entryRelationship:diagnosis.nullFlavorrequiredCDANullFlavor
Encounter.entryRelationship:diagnosis.typeId.nullFlavorrequiredCDANullFlavor
Encounter.entryRelationship:diagnosis.typeCoderequiredXActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
role-choiceerrorEncounter.participant:location.participantRoleplayingDevice and playingEntity are mutually exclusive
: (playingDevice | playingEntity).count() <= 1
should-addrwarningEncounter.participant:location.participantRoleSHOULD contain addr
: addr.exists()
should-effectiveTimewarningEncounter.entryRelationship:indication.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-otext-ref-valuewarningEncounter.codeSHOULD contain originalText/reference/@value
: originalText.reference.value.exists()
should-telecomwarningEncounter.participant:location.participantRoleSHOULD contain telecom
: telecom.exists()
should-text-ref-valuewarningEncounterSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningEncounter.entryRelationship:indication.observation, Encounter.entryRelationship:diagnosis.actSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorEncounter.code.originalText.reference, Encounter.text.referenceIf 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 Encounter

Summary

Mandatory: 7 elements (2 nested mandatory elements)
Fixed Value: 3 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Encounter.templateId is sliced based on the values of value:root, value:extension
  • The element Encounter.participant is sliced based on the values of profile:participantRole, value:typeCode
  • The element Encounter.entryRelationship is sliced based on the values of profile:act, profile:observation

 

Other representations of profile: CSV, Excel