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/Reason | Version: 3.0.0-ballot | |||
Draft as of 2023-12-21 | Computable Name: Reason | |||
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.24.3.88:2023-05-01 |
This template describes the thought process or justification for an action or for not performing an action. Examples include patient, system, or non-problem/diagnosis medical-related reasons for declining to perform specific actions, or any reason for performing an action. Note that the parent template that calls this template can be asserted to have occurred or to not have occurred. Therefore, this template simply adds a reason to some other (possibly negated) act. As such, there is nothing in this template that says whether the parent act did or did not occur. It is expected that the primary use of this template within C-CDA is to provide the rationale for why something was not done. If this template is called by a template that is not negated, the Reason template should contain something other than a problem or a diagnosis, such as a patient preference. The Indication observation: 2.16.840.1.113883.10.20.22.4.19 should be used to represent a diagnosis or problem to indicate the diagnosis or problem is the rationale for an action. Immunization Refusal Reason: 2.16.840.1.113883.10.20.22.4.53 should be used to represent the rationale for the patient declining an immunization as the value set is crafted for the immunization use case.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:reason | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.24.3.88 | |
@extension | 1..1 | st | Required Pattern: 2023-05-01 | |
@classCode | 1..1 | cs | Fixed Value: OBS | |
@moodCode | 1..1 | cs | Fixed Value: EVN | |
id | 1..* | II | ||
code | 1..1 | CD | ||
@code | 1..1 | cs | Required Pattern: 77301-0 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
statusCode | 1..1 | CS | ||
@code | 1..1 | cs | Fixed Value: completed | |
effectiveTime | 1..1 | IVL_TS | ||
low | 1..1 | IVXB_TS | ||
high | 0..1 | IVXB_TS | ||
value | 1..1 | CD | ||
Documentation for this format |
Id | Grade | Path(s) | Details | Requirements |
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:reason | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.24.3.88 | |
@extension | 1..1 | st | Required Pattern: 2023-05-01 | |
@classCode | 1..1 | cs | Binding: ActClassObservation (2.0.0) (required) Fixed Value: OBS | |
@moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
id | 1..* | II | ||
code | 1..1 | CD | Binding: ObservationType (example) | |
@code | 1..1 | cs | Required Pattern: 77301-0 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
@code | 1..1 | cs | Fixed Value: completed | |
effectiveTime | 1..1 | IVL_TS | ||
low | 1..1 | IVXB_TS | ||
high | 0..1 | IVXB_TS | ||
value | 1..1 | CD | ||
Documentation for this format |
Path | Conformance | ValueSet / Code |
Observation.classCode | required | Fixed Value: OBS |
Observation.moodCode | required | Fixed Value: EVN |
Observation.code | example | ObservationType |
Observation.statusCode | required | ActStatus |
Id | Grade | Path(s) | Details | Requirements |
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Path | Conformance | ValueSet / Code |
Observation.nullFlavor | required | CDANullFlavor |
Observation.typeId.nullFlavor | required | CDANullFlavor |
Observation.templateId:reason.nullFlavor | required | CDANullFlavor |
Observation.classCode | required | Fixed Value: OBS |
Observation.moodCode | required | Fixed Value: EVN |
Observation.code | example | ObservationType |
Observation.code.nullFlavor | required | CDANullFlavor |
Observation.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.effectiveTime.nullFlavor | required | CDANullFlavor |
Observation.effectiveTime.operator | required | SetOperator |
Observation.priorityCode | example | ActPriority |
Observation.languageCode | required | AllLanguages |
Observation.interpretationCode | required | ObservationInterpretation |
Observation.methodCode | example | ObservationMethod |
Observation.referenceRange.nullFlavor | required | CDANullFlavor |
Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavor |
Observation.referenceRange.typeCode | required | Fixed Value: REFV |
Id | Grade | Path(s) | Details | Requirements |
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from Observation
Summary
Mandatory: 12 elements
Fixed Value: 3 elements
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:reason | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.24.3.88 | |
@extension | 1..1 | st | Required Pattern: 2023-05-01 | |
@classCode | 1..1 | cs | Fixed Value: OBS | |
@moodCode | 1..1 | cs | Fixed Value: EVN | |
id | 1..* | II | ||
code | 1..1 | CD | ||
@code | 1..1 | cs | Required Pattern: 77301-0 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
statusCode | 1..1 | CS | ||
@code | 1..1 | cs | Fixed Value: completed | |
effectiveTime | 1..1 | IVL_TS | ||
low | 1..1 | IVXB_TS | ||
high | 0..1 | IVXB_TS | ||
value | 1..1 | CD | ||
Documentation for this format |
Id | Grade | Path(s) | Details | Requirements |
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:reason | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.24.3.88 | |
@extension | 1..1 | st | Required Pattern: 2023-05-01 | |
@classCode | 1..1 | cs | Binding: ActClassObservation (2.0.0) (required) Fixed Value: OBS | |
@moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |
id | 1..* | II | ||
code | 1..1 | CD | Binding: ObservationType (example) | |
@code | 1..1 | cs | Required Pattern: 77301-0 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
@code | 1..1 | cs | Fixed Value: completed | |
effectiveTime | 1..1 | IVL_TS | ||
low | 1..1 | IVXB_TS | ||
high | 0..1 | IVXB_TS | ||
value | 1..1 | CD | ||
Documentation for this format |
Path | Conformance | ValueSet / Code |
Observation.classCode | required | Fixed Value: OBS |
Observation.moodCode | required | Fixed Value: EVN |
Observation.code | example | ObservationType |
Observation.statusCode | required | ActStatus |
Id | Grade | Path(s) | Details | Requirements |
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Snapshot View
Path | Conformance | ValueSet / Code |
Observation.nullFlavor | required | CDANullFlavor |
Observation.typeId.nullFlavor | required | CDANullFlavor |
Observation.templateId:reason.nullFlavor | required | CDANullFlavor |
Observation.classCode | required | Fixed Value: OBS |
Observation.moodCode | required | Fixed Value: EVN |
Observation.code | example | ObservationType |
Observation.code.nullFlavor | required | CDANullFlavor |
Observation.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.effectiveTime.nullFlavor | required | CDANullFlavor |
Observation.effectiveTime.operator | required | SetOperator |
Observation.priorityCode | example | ActPriority |
Observation.languageCode | required | AllLanguages |
Observation.interpretationCode | required | ObservationInterpretation |
Observation.methodCode | example | ObservationMethod |
Observation.referenceRange.nullFlavor | required | CDANullFlavor |
Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavor |
Observation.referenceRange.typeCode | required | Fixed Value: REFV |
Id | Grade | Path(s) | Details | Requirements |
should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from Observation
Summary
Mandatory: 12 elements
Fixed Value: 3 elements
Slices
This structure defines the following Slices: