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/GoalObservation | Version: 3.0.0-ballot | |||
| Draft as of 2023-12-21 | Computable Name: GoalObservation | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.121:2022-06-01 | ||||
This template represents a patient health goal. A Goal Observation template may have related components that are acts, encounters, observations, procedures, substance administrations, or supplies. A goal identifies a future desired condition or state. Goals are often related to physical or mental health conditions or diseases, but also may be related to a Social Determinant of Health (SDOH) risks or states. For example, to have adequate quality meals and snacks, gain transportation security - able to access health and social needs). SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes. A Goal is established by the patient or provider.
A goal may be a patient or provider goal. If the author is set to the recordTarget (patient), this is a patient goal. If the author is set to a provider, this is a provider goal. If both patient and provider are set as authors, this is a negotiated goal.
A goal usually has a related health concern and/or risk.
A goal may have components consisting of other goals (milestones). These milestones are related to the overall goal through entryRelationships.
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-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author |
  Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:goal-obs | 1..1 | II | ||
  @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.121 | |
  @extension | 1..1 | st | Required Pattern: 2022-06-01 | |
 @classCode | 1..1 | cs | Fixed Value: OBS | |
| @moodCode | 1..1 | cs | Fixed Value: GOL | |
| id | 1..* | II | ||
| code | 1..1 | CD | When the Goal is a Social Determinant of Health Goal, use @code="8689-2" (History of Social function), @codeSystem="2.16.840.1.113883.6.1" (LOINC) | |
| 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 | Binding: ActStatus (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
| value | 0..1 | ANY, BL, ED, ST, CD, CV, CE, CO, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | When the Goal is Social Determinant of Health Goal, the observation/value **SHOULD** be selected from ValueSet [Social Determinant of Health Goals](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1247.71/expansion) **DYNAMIC** (CONF:4515-32963). | |
 author | 0..* | AuthorParticipation | If the author is the recordTarget (patient), this is a patient goal. If the author is a provider, this is a provider goal. If both patient and provider are authors, this is a negotiated goal. If no author is present, it is assumed the document or section author(s) is the author of this goal. | |
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation, value:typeCode | |
 entryRelationship:entryRelationship1 | 0..* | EntryRelationship | The following entryRelationship represents the relationship between a Goal Observation and a Health Concern Act (Goal Observation REFERS TO Health Concern Act). As Health Concern Act is already defined in Health Concerns Section, rather than clone the whole Health Concern Act template, an Entry Reference may be used in entryRelationship to refer the template. | |
 @typeCode | 1..1 | cs | Fixed Value: REFR | |
| act | 1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:entryRelationship2 | 0..* | EntryRelationship | The following entryRelationship represents a planned component of the goal such as Planned Encounter (V2), Planned Observation (V2), Planned Procedure (V2), Planned Medication Activity (V2), Planned Supply (V2), Planned Act (V2) or Planned Immunization Activity. Because these entries are already described in the Interventions Section of the CDA document instance, rather than repeating the full content of the entries, the Entry Reference template may be used to reference the entries. | |
| @typeCode | 1..1 | cs | Fixed Value: COMP | |
| act | 1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:entryRelationship3 | 0..1 | EntryRelationship | The following entryRelationship represents the priority that the patient or a provider puts on the goal. | |
| @typeCode | 1..1 | cs | Fixed Value: REFR | |
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:entryRelationship4 | 0..* | EntryRelationship | The following entryRelationship represents the relationship between two Goal Observations where the target is a component of the source (Goal Observation HAS COMPONENT Goal Observation). The component goal (target) is a Milestone. | |
| @typeCode | 1..1 | cs | Fixed Value: COMP | |
| observation | 1..1 | GoalObservation | Base for all types and resources | |
| entryRelationship:entryRelationship5 | 0..* | EntryRelationship | Where a Goal Observation needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. | |
| @typeCode | 1..1 | cs | Fixed Value: REFR | |
| act | 1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:entryRelationship6 | 0..* | EntryRelationship | entryRelationship | |
| @typeCode | 1..1 | cs | Fixed Value: REFR | |
| observation | 1..1 | ProgressTowardGoalObservation | act | |
 reference | 0..* | Reference | Where it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. | |
| @typeCode | 1..1 | cs | Fixed Value: REFR | |
| externalDocument | 1..1 | ExternalDocumentReference | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.statusCode.code | required | ActStatus |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Observation | SHOULD contain effectiveTime : effectiveTime.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-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:goal-obs | 1..1 | II | ||
 @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.121 | |
| @extension | 1..1 | st | Required Pattern: 2022-06-01 | |
| @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: GOL | |
| id | 1..* | II | ||
| code | 1..1 | CD | When the Goal is a Social Determinant of Health Goal, use @code="8689-2" (History of Social function), @codeSystem="2.16.840.1.113883.6.1" (LOINC) Binding: ObservationType (example) | |
| 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 | Binding: ActStatus (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
 value | 0..1 | When the Goal is Social Determinant of Health Goal, the observation/value **SHOULD** be selected from ValueSet [Social Determinant of Health Goals](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1247.71/expansion) **DYNAMIC** (CONF:4515-32963). | ||
 value | ANY | |||
| value | BL | |||
| value | ED | |||
| value | ST | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | CO | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| value | RTO_PQ_PQ | |||
| author | 0..* | AuthorParticipation | If the author is the recordTarget (patient), this is a patient goal. If the author is a provider, this is a provider goal. If both patient and provider are authors, this is a negotiated goal. If no author is present, it is assumed the document or section author(s) is the author of this goal. | |
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation, value:typeCode | |
| entryRelationship:entryRelationship1 | 0..* | EntryRelationship | The following entryRelationship represents the relationship between a Goal Observation and a Health Concern Act (Goal Observation REFERS TO Health Concern Act). As Health Concern Act is already defined in Health Concerns Section, rather than clone the whole Health Concern Act template, an Entry Reference may be used in entryRelationship to refer the template. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| act | C | 1..1 | EntryReference | Base for all types and resources |
| entryRelationship:entryRelationship2 | 0..* | EntryRelationship | The following entryRelationship represents a planned component of the goal such as Planned Encounter (V2), Planned Observation (V2), Planned Procedure (V2), Planned Medication Activity (V2), Planned Supply (V2), Planned Act (V2) or Planned Immunization Activity. Because these entries are already described in the Interventions Section of the CDA document instance, rather than repeating the full content of the entries, the Entry Reference template may be used to reference the entries. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| act | C | 1..1 | EntryReference | Base for all types and resources |
| entryRelationship:entryRelationship3 | 0..1 | EntryRelationship | The following entryRelationship represents the priority that the patient or a provider puts on the goal. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| observation | C | 1..1 | PriorityPreference | Base for all types and resources |
| entryRelationship:entryRelationship4 | 0..* | EntryRelationship | The following entryRelationship represents the relationship between two Goal Observations where the target is a component of the source (Goal Observation HAS COMPONENT Goal Observation). The component goal (target) is a Milestone. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| observation | C | 1..1 | GoalObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author |
| entryRelationship:entryRelationship5 | 0..* | EntryRelationship | Where a Goal Observation needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| act | C | 1..1 | EntryReference | Base for all types and resources |
| entryRelationship:entryRelationship6 | 0..* | EntryRelationship | entryRelationship | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| observation | C | 1..1 | ProgressTowardGoalObservation | act |
| reference | 0..* | Reference | Where it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipExternalReference (required) Fixed Value: REFR | |
| externalDocument | C | 1..1 | ExternalDocumentReference | 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: GOL |
| Observation.code | example | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.code | required | ActStatus |
| Observation.entryRelationship:entryRelationship1.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:entryRelationship2.typeCode | required | Fixed Value: COMP |
| Observation.entryRelationship:entryRelationship3.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:entryRelationship4.typeCode | required | Fixed Value: COMP |
| Observation.entryRelationship:entryRelationship5.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:entryRelationship6.typeCode | required | Fixed Value: REFR |
| Observation.reference.typeCode | required | Fixed Value: REFR |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Observation, Observation.entryRelationship:entryRelationship4.observation | SHOULD contain author : author.exists() | |
| should-author | warning | Observation.entryRelationship:entryRelationship3.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Observation, Observation.entryRelationship:entryRelationship4.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-effectiveTime | warning | Observation.entryRelationship:entryRelationship3.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-setId | warning | Observation.reference.externalDocument | SHOULD contain setId : setId.exists() | |
| should-text-ref-value | warning | Observation, Observation.entryRelationship:entryRelationship4.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Observation.entryRelationship:entryRelationship1.act, Observation.entryRelationship:entryRelationship2.act, Observation.entryRelationship:entryRelationship3.observation, Observation.entryRelationship:entryRelationship5.act, Observation.entryRelationship:entryRelationship6.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-versionNumber | warning | Observation.reference.externalDocument | SHOULD contain versionNumber : versionNumber.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-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:goal-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: 2.16.840.1.113883.10.20.22.4.121 | |
| @extension | 1..1 | st | Required Pattern: 2022-06-01 | |
| @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: GOL | |
| @negationInd | 0..1 | bl | ||
| id | 1..* | II | ||
| code | 1..1 | CD | When the Goal is a Social Determinant of Health Goal, use @code="8689-2" (History of Social function), @codeSystem="2.16.840.1.113883.6.1" (LOINC) Binding: ObservationType (example) | |
| derivationExpr | 0..1 | ST | ||
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @compression | 0..1 | cs | Binding: CompressionAlgorithm (required) | |
| @integrityCheck | 0..1 | bin | ||
| @integrityCheckAlgorithm | 0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |
| @language | 0..1 | cs | ||
| @mediaType | 0..1 | cs | Binding: MediaType (example) | |
| @representation | 0..1 | cs | Binding: Binary Data Encoding Value Set (required) | |
| xmlText | 0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |
| reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| thumbnail | 0..1 | ED | ||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 1..1 | cs | Binding: ActStatus (required) | |
| @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 | 0..1 | IVL_TS | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: AllLanguages (required) | |
| value | 0..1 | When the Goal is Social Determinant of Health Goal, the observation/value **SHOULD** be selected from ValueSet [Social Determinant of Health Goals](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1247.71/expansion) **DYNAMIC** (CONF:4515-32963). | ||
| value | ANY | |||
| value | BL | |||
| value | ED | |||
| value | ST | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | CO | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| value | RTO_PQ_PQ | |||
| 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 | If the author is the recordTarget (patient), this is a patient goal. If the author is a provider, this is a provider goal. If both patient and provider are authors, this is a negotiated goal. If no author is present, it is assumed the document or section author(s) is the author of this goal. | |
| informant | 0..* | Informant | ||
| participant | 0..* | Participant2 | ||
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation, value:typeCode | |
| entryRelationship:entryRelationship1 | 0..* | EntryRelationship | The following entryRelationship represents the relationship between a Goal Observation and a Health Concern Act (Goal Observation REFERS TO Health Concern Act). As Health Concern Act is already defined in Health Concerns Section, rather than clone the whole Health Concern Act template, an Entry Reference may be used in entryRelationship to refer the template. | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
 typeId | 0..1 | II | ||
 @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | C | 1..1 | EntryReference | Base for all types and resources |
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:entryRelationship2 | 0..* | EntryRelationship | The following entryRelationship represents a planned component of the goal such as Planned Encounter (V2), Planned Observation (V2), Planned Procedure (V2), Planned Medication Activity (V2), Planned Supply (V2), Planned Act (V2) or Planned Immunization Activity. Because these entries are already described in the Interventions Section of the CDA document instance, rather than repeating the full content of the entries, the Entry Reference template may be used to reference the entries. | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | C | 1..1 | EntryReference | Base for all types and resources |
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:entryRelationship3 | 0..1 | EntryRelationship | The following entryRelationship represents the priority that the patient or a provider puts on the goal. | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | C | 1..1 | PriorityPreference | Base for all types and resources |
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:entryRelationship4 | 0..* | EntryRelationship | The following entryRelationship represents the relationship between two Goal Observations where the target is a component of the source (Goal Observation HAS COMPONENT Goal Observation). The component goal (target) is a Milestone. | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | C | 1..1 | GoalObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author |
| 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:entryRelationship5 | 0..* | EntryRelationship | Where a Goal Observation needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | C | 1..1 | EntryReference | Base for all types and resources |
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:entryRelationship6 | 0..* | EntryRelationship | entryRelationship | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | C | 1..1 | ProgressTowardGoalObservation | act |
| 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 | Where it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. | |
| @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_ActRelationshipExternalReference (required) Fixed Value: REFR | |
| seperatableInd | 0..1 | BL | ||
| externalAct | 0..1 | ExternalAct | ||
| externalObservation | 0..1 | ExternalObservation | ||
| externalProcedure | 0..1 | ExternalProcedure | ||
| externalDocument | C | 1..1 | ExternalDocumentReference | Base for all types and resources |
| 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:goal-obs.nullFlavor | required | CDANullFlavor |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Fixed Value: GOL |
| Observation.code | example | ObservationType |
| 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.statusCode.code | required | ActStatus |
| Observation.priorityCode | example | ActPriority |
| Observation.languageCode | required | AllLanguages |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | example | ObservationMethod |
| Observation.entryRelationship:entryRelationship1.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship1.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship1.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:entryRelationship2.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship2.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship2.typeCode | required | Fixed Value: COMP |
| Observation.entryRelationship:entryRelationship3.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship3.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship3.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:entryRelationship4.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship4.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship4.typeCode | required | Fixed Value: COMP |
| Observation.entryRelationship:entryRelationship5.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship5.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship5.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:entryRelationship6.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship6.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship6.typeCode | required | Fixed Value: REFR |
| Observation.reference.nullFlavor | required | CDANullFlavor |
| Observation.reference.typeId.nullFlavor | required | CDANullFlavor |
| Observation.reference.typeCode | required | Fixed Value: REFR |
| 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, Observation.entryRelationship:entryRelationship4.observation | SHOULD contain author : author.exists() | |
| should-author | warning | Observation.entryRelationship:entryRelationship3.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Observation, Observation.entryRelationship:entryRelationship4.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-effectiveTime | warning | Observation.entryRelationship:entryRelationship3.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-setId | warning | Observation.reference.externalDocument | SHOULD contain setId : setId.exists() | |
| should-text-ref-value | warning | Observation, Observation.entryRelationship:entryRelationship4.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Observation.entryRelationship:entryRelationship1.act, Observation.entryRelationship:entryRelationship2.act, Observation.entryRelationship:entryRelationship3.observation, Observation.entryRelationship:entryRelationship5.act, Observation.entryRelationship:entryRelationship6.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-versionNumber | warning | Observation.reference.externalDocument | SHOULD contain versionNumber : versionNumber.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: 7 elements (7 nested mandatory elements)
Fixed Value: 9 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-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:goal-obs | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.121 | |
| @extension | 1..1 | st | Required Pattern: 2022-06-01 | |
| @classCode | 1..1 | cs | Fixed Value: OBS | |
| @moodCode | 1..1 | cs | Fixed Value: GOL | |
| id | 1..* | II | ||
| code | 1..1 | CD | When the Goal is a Social Determinant of Health Goal, use @code="8689-2" (History of Social function), @codeSystem="2.16.840.1.113883.6.1" (LOINC) | |
| 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 | Binding: ActStatus (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
| value | 0..1 | ANY, BL, ED, ST, CD, CV, CE, CO, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | When the Goal is Social Determinant of Health Goal, the observation/value **SHOULD** be selected from ValueSet [Social Determinant of Health Goals](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1247.71/expansion) **DYNAMIC** (CONF:4515-32963). | |
| author | 0..* | AuthorParticipation | If the author is the recordTarget (patient), this is a patient goal. If the author is a provider, this is a provider goal. If both patient and provider are authors, this is a negotiated goal. If no author is present, it is assumed the document or section author(s) is the author of this goal. | |
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation, value:typeCode | |
| entryRelationship:entryRelationship1 | 0..* | EntryRelationship | The following entryRelationship represents the relationship between a Goal Observation and a Health Concern Act (Goal Observation REFERS TO Health Concern Act). As Health Concern Act is already defined in Health Concerns Section, rather than clone the whole Health Concern Act template, an Entry Reference may be used in entryRelationship to refer the template. | |
| @typeCode | 1..1 | cs | Fixed Value: REFR | |
| act | 1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:entryRelationship2 | 0..* | EntryRelationship | The following entryRelationship represents a planned component of the goal such as Planned Encounter (V2), Planned Observation (V2), Planned Procedure (V2), Planned Medication Activity (V2), Planned Supply (V2), Planned Act (V2) or Planned Immunization Activity. Because these entries are already described in the Interventions Section of the CDA document instance, rather than repeating the full content of the entries, the Entry Reference template may be used to reference the entries. | |
| @typeCode | 1..1 | cs | Fixed Value: COMP | |
| act | 1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:entryRelationship3 | 0..1 | EntryRelationship | The following entryRelationship represents the priority that the patient or a provider puts on the goal. | |
| @typeCode | 1..1 | cs | Fixed Value: REFR | |
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:entryRelationship4 | 0..* | EntryRelationship | The following entryRelationship represents the relationship between two Goal Observations where the target is a component of the source (Goal Observation HAS COMPONENT Goal Observation). The component goal (target) is a Milestone. | |
| @typeCode | 1..1 | cs | Fixed Value: COMP | |
| observation | 1..1 | GoalObservation | Base for all types and resources | |
| entryRelationship:entryRelationship5 | 0..* | EntryRelationship | Where a Goal Observation needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. | |
| @typeCode | 1..1 | cs | Fixed Value: REFR | |
| act | 1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:entryRelationship6 | 0..* | EntryRelationship | entryRelationship | |
| @typeCode | 1..1 | cs | Fixed Value: REFR | |
| observation | 1..1 | ProgressTowardGoalObservation | act | |
| reference | 0..* | Reference | Where it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. | |
| @typeCode | 1..1 | cs | Fixed Value: REFR | |
| externalDocument | 1..1 | ExternalDocumentReference | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.statusCode.code | required | ActStatus |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Observation | SHOULD contain effectiveTime : effectiveTime.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-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:goal-obs | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.121 | |
| @extension | 1..1 | st | Required Pattern: 2022-06-01 | |
| @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: GOL | |
| id | 1..* | II | ||
| code | 1..1 | CD | When the Goal is a Social Determinant of Health Goal, use @code="8689-2" (History of Social function), @codeSystem="2.16.840.1.113883.6.1" (LOINC) Binding: ObservationType (example) | |
| 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 | Binding: ActStatus (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
| value | 0..1 | When the Goal is Social Determinant of Health Goal, the observation/value **SHOULD** be selected from ValueSet [Social Determinant of Health Goals](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1247.71/expansion) **DYNAMIC** (CONF:4515-32963). | ||
| value | ANY | |||
| value | BL | |||
| value | ED | |||
| value | ST | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | CO | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| value | RTO_PQ_PQ | |||
| author | 0..* | AuthorParticipation | If the author is the recordTarget (patient), this is a patient goal. If the author is a provider, this is a provider goal. If both patient and provider are authors, this is a negotiated goal. If no author is present, it is assumed the document or section author(s) is the author of this goal. | |
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation, value:typeCode | |
| entryRelationship:entryRelationship1 | 0..* | EntryRelationship | The following entryRelationship represents the relationship between a Goal Observation and a Health Concern Act (Goal Observation REFERS TO Health Concern Act). As Health Concern Act is already defined in Health Concerns Section, rather than clone the whole Health Concern Act template, an Entry Reference may be used in entryRelationship to refer the template. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| act | C | 1..1 | EntryReference | Base for all types and resources |
| entryRelationship:entryRelationship2 | 0..* | EntryRelationship | The following entryRelationship represents a planned component of the goal such as Planned Encounter (V2), Planned Observation (V2), Planned Procedure (V2), Planned Medication Activity (V2), Planned Supply (V2), Planned Act (V2) or Planned Immunization Activity. Because these entries are already described in the Interventions Section of the CDA document instance, rather than repeating the full content of the entries, the Entry Reference template may be used to reference the entries. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| act | C | 1..1 | EntryReference | Base for all types and resources |
| entryRelationship:entryRelationship3 | 0..1 | EntryRelationship | The following entryRelationship represents the priority that the patient or a provider puts on the goal. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| observation | C | 1..1 | PriorityPreference | Base for all types and resources |
| entryRelationship:entryRelationship4 | 0..* | EntryRelationship | The following entryRelationship represents the relationship between two Goal Observations where the target is a component of the source (Goal Observation HAS COMPONENT Goal Observation). The component goal (target) is a Milestone. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| observation | C | 1..1 | GoalObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author |
| entryRelationship:entryRelationship5 | 0..* | EntryRelationship | Where a Goal Observation needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| act | C | 1..1 | EntryReference | Base for all types and resources |
| entryRelationship:entryRelationship6 | 0..* | EntryRelationship | entryRelationship | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| observation | C | 1..1 | ProgressTowardGoalObservation | act |
| reference | 0..* | Reference | Where it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipExternalReference (required) Fixed Value: REFR | |
| externalDocument | C | 1..1 | ExternalDocumentReference | 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: GOL |
| Observation.code | example | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.code | required | ActStatus |
| Observation.entryRelationship:entryRelationship1.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:entryRelationship2.typeCode | required | Fixed Value: COMP |
| Observation.entryRelationship:entryRelationship3.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:entryRelationship4.typeCode | required | Fixed Value: COMP |
| Observation.entryRelationship:entryRelationship5.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:entryRelationship6.typeCode | required | Fixed Value: REFR |
| Observation.reference.typeCode | required | Fixed Value: REFR |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Observation, Observation.entryRelationship:entryRelationship4.observation | SHOULD contain author : author.exists() | |
| should-author | warning | Observation.entryRelationship:entryRelationship3.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Observation, Observation.entryRelationship:entryRelationship4.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-effectiveTime | warning | Observation.entryRelationship:entryRelationship3.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-setId | warning | Observation.reference.externalDocument | SHOULD contain setId : setId.exists() | |
| should-text-ref-value | warning | Observation, Observation.entryRelationship:entryRelationship4.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Observation.entryRelationship:entryRelationship1.act, Observation.entryRelationship:entryRelationship2.act, Observation.entryRelationship:entryRelationship3.observation, Observation.entryRelationship:entryRelationship5.act, Observation.entryRelationship:entryRelationship6.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-versionNumber | warning | Observation.reference.externalDocument | SHOULD contain versionNumber : versionNumber.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:goal-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: 2.16.840.1.113883.10.20.22.4.121 | |
| @extension | 1..1 | st | Required Pattern: 2022-06-01 | |
| @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: GOL | |
| @negationInd | 0..1 | bl | ||
| id | 1..* | II | ||
| code | 1..1 | CD | When the Goal is a Social Determinant of Health Goal, use @code="8689-2" (History of Social function), @codeSystem="2.16.840.1.113883.6.1" (LOINC) Binding: ObservationType (example) | |
| derivationExpr | 0..1 | ST | ||
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @compression | 0..1 | cs | Binding: CompressionAlgorithm (required) | |
| @integrityCheck | 0..1 | bin | ||
| @integrityCheckAlgorithm | 0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |
| @language | 0..1 | cs | ||
| @mediaType | 0..1 | cs | Binding: MediaType (example) | |
| @representation | 0..1 | cs | Binding: Binary Data Encoding Value Set (required) | |
| xmlText | 0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |
| reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| thumbnail | 0..1 | ED | ||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 1..1 | cs | Binding: ActStatus (required) | |
| @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 | 0..1 | IVL_TS | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber | 0..1 | IVL_INT | ||
| languageCode | 0..1 | CS | Binding: AllLanguages (required) | |
| value | 0..1 | When the Goal is Social Determinant of Health Goal, the observation/value **SHOULD** be selected from ValueSet [Social Determinant of Health Goals](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1247.71/expansion) **DYNAMIC** (CONF:4515-32963). | ||
| value | ANY | |||
| value | BL | |||
| value | ED | |||
| value | ST | |||
| value | CD | |||
| value | CV | |||
| value | CE | |||
| value | CO | |||
| value | SC | |||
| value | II | |||
| value | TEL | |||
| value | AD | |||
| value | EN | |||
| value | INT | |||
| value | REAL | |||
| value | PQ | |||
| value | MO | |||
| value | TS | |||
| value | IVL_PQ | |||
| value | IVL_TS | |||
| value | PIVL_TS | |||
| value | EIVL_TS | |||
| value | SXPR_TS | |||
| value | RTO_PQ_PQ | |||
| 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 | If the author is the recordTarget (patient), this is a patient goal. If the author is a provider, this is a provider goal. If both patient and provider are authors, this is a negotiated goal. If no author is present, it is assumed the document or section author(s) is the author of this goal. | |
| informant | 0..* | Informant | ||
| participant | 0..* | Participant2 | ||
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation, value:typeCode | |
| entryRelationship:entryRelationship1 | 0..* | EntryRelationship | The following entryRelationship represents the relationship between a Goal Observation and a Health Concern Act (Goal Observation REFERS TO Health Concern Act). As Health Concern Act is already defined in Health Concerns Section, rather than clone the whole Health Concern Act template, an Entry Reference may be used in entryRelationship to refer the template. | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | C | 1..1 | EntryReference | Base for all types and resources |
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:entryRelationship2 | 0..* | EntryRelationship | The following entryRelationship represents a planned component of the goal such as Planned Encounter (V2), Planned Observation (V2), Planned Procedure (V2), Planned Medication Activity (V2), Planned Supply (V2), Planned Act (V2) or Planned Immunization Activity. Because these entries are already described in the Interventions Section of the CDA document instance, rather than repeating the full content of the entries, the Entry Reference template may be used to reference the entries. | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | C | 1..1 | EntryReference | Base for all types and resources |
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:entryRelationship3 | 0..1 | EntryRelationship | The following entryRelationship represents the priority that the patient or a provider puts on the goal. | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | C | 1..1 | PriorityPreference | Base for all types and resources |
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:entryRelationship4 | 0..* | EntryRelationship | The following entryRelationship represents the relationship between two Goal Observations where the target is a component of the source (Goal Observation HAS COMPONENT Goal Observation). The component goal (target) is a Milestone. | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | C | 1..1 | GoalObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author |
| 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:entryRelationship5 | 0..* | EntryRelationship | Where a Goal Observation needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry. | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | C | 1..1 | EntryReference | Base for all types and resources |
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:entryRelationship6 | 0..* | EntryRelationship | entryRelationship | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension | 1..1 | st | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | C | 1..1 | ProgressTowardGoalObservation | act |
| 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 | Where it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument. | |
| @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_ActRelationshipExternalReference (required) Fixed Value: REFR | |
| seperatableInd | 0..1 | BL | ||
| externalAct | 0..1 | ExternalAct | ||
| externalObservation | 0..1 | ExternalObservation | ||
| externalProcedure | 0..1 | ExternalProcedure | ||
| externalDocument | C | 1..1 | ExternalDocumentReference | Base for all types and resources |
| 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:goal-obs.nullFlavor | required | CDANullFlavor |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Fixed Value: GOL |
| Observation.code | example | ObservationType |
| 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.statusCode.code | required | ActStatus |
| Observation.priorityCode | example | ActPriority |
| Observation.languageCode | required | AllLanguages |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | example | ObservationMethod |
| Observation.entryRelationship:entryRelationship1.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship1.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship1.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:entryRelationship2.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship2.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship2.typeCode | required | Fixed Value: COMP |
| Observation.entryRelationship:entryRelationship3.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship3.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship3.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:entryRelationship4.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship4.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship4.typeCode | required | Fixed Value: COMP |
| Observation.entryRelationship:entryRelationship5.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship5.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship5.typeCode | required | Fixed Value: REFR |
| Observation.entryRelationship:entryRelationship6.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship6.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:entryRelationship6.typeCode | required | Fixed Value: REFR |
| Observation.reference.nullFlavor | required | CDANullFlavor |
| Observation.reference.typeId.nullFlavor | required | CDANullFlavor |
| Observation.reference.typeCode | required | Fixed Value: REFR |
| 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, Observation.entryRelationship:entryRelationship4.observation | SHOULD contain author : author.exists() | |
| should-author | warning | Observation.entryRelationship:entryRelationship3.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Observation, Observation.entryRelationship:entryRelationship4.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-effectiveTime | warning | Observation.entryRelationship:entryRelationship3.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-setId | warning | Observation.reference.externalDocument | SHOULD contain setId : setId.exists() | |
| should-text-ref-value | warning | Observation, Observation.entryRelationship:entryRelationship4.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Observation.entryRelationship:entryRelationship1.act, Observation.entryRelationship:entryRelationship2.act, Observation.entryRelationship:entryRelationship3.observation, Observation.entryRelationship:entryRelationship5.act, Observation.entryRelationship:entryRelationship6.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-versionNumber | warning | Observation.reference.externalDocument | SHOULD contain versionNumber : versionNumber.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: 7 elements (7 nested mandatory elements)
Fixed Value: 9 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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