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/SexualOrientationObservation | Version: 3.0.0-ballot | |||
| Draft as of 2023-12-21 | Computable Name: SexualOrientationObservation | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.501:2023-05-01 | ||||
This observation represents the sexual orientation of the patient, defined as:
A persons identification of their emotional, romantic, sexual, or affectional attraction to another person.
This template was informed by the HL7 Gender Harmony project.
This observation is not appropriate for recording patient gender (administrativeGender), Gender Identity (Gender Identity Observation), or birth sex (Birth Sex Observation).
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from SocialHistoryObservation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Observation | 1..1 | SocialHistoryObservation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
 templateId | 2..* | II | ||
  templateId:sexual-orientation-obs | 1..1 | II | ||
  @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.501 | |
  @extension | 1..1 | st | Required Pattern: 2023-05-01 | |
| @classCode | 1..1 | cs | ||
| @moodCode | 1..1 | cs | ||
| code | 1..1 | CD | ||
| @code | 1..1 | cs | Required Pattern: 76690-7 | |
 @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| statusCode | 1..1 | CS | ||
| @code | 1..1 | cs | ||
| effectiveTime | 1..1 | IVL_TS | The effectiveTime represents the relevant time of the observation. A patient's "sexual orientation" may change and using effectiveTime/low and effectiveTime/high defines the time during which the patient had identified their emotional, romantic, sexual, or affectional attraction to another person. | |
| low | 1..1 | IVXB_TS | ||
| high | 0..1 | IVXB_TS | ||
 value | 1..1 | CD | NOTE for PQ values: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: Sexual Orientation Including nulls and Data Absent Reason (required) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.value | required | SexualOrientationIncludingNullsAndDataAbsentReason |
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation | C | 1..1 | SocialHistoryObservation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||||||
 Slices for templateId | 2..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
 templateId:social-history-obs | 1..1 | II | ||||||||
  @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.38 | |||||||
| @extension | 1..1 | st | Required Pattern: 2022-06-01 | |||||||
 templateId:sexual-orientation-obs | 1..1 | II | ||||||||
 @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.501 | |||||||
| @extension | 1..1 | st | Required Pattern: 2023-05-01 | |||||||
| @classCode | 1..1 | cs | Binding: ActClassObservation (2.0.0) (required) Fixed Value: OBS | |||||||
| @moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||
| id | 1..* | II | ||||||||
| code | C | 1..1 | CD | Binding: Social History Type (preferred) | ||||||
| @code | 1..1 | cs | Required Pattern: 76690-7 | |||||||
| @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |||||||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |||||||
| @code | 1..1 | cs | Fixed Value: completed | |||||||
| effectiveTime | 1..1 | IVL_TS | The effectiveTime represents the relevant time of the observation. A patient's "sexual orientation" may change and using effectiveTime/low and effectiveTime/high defines the time during which the patient had identified their emotional, romantic, sexual, or affectional attraction to another person. | |||||||
| low | 1..1 | IVXB_TS | ||||||||
| high | 0..1 | IVXB_TS | ||||||||
| value | 1..1 | CD | NOTE for PQ values: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: Sexual Orientation Including nulls and Data Absent Reason (required)
| |||||||
 Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |||||||
| entryRelationship:social-history-entry-sprt-obs | 0..* | EntryRelationship | When an Assessment Scale Observation is contained in a Social History Observation instance that is a Social Determinant of Health Social History Observation, that Assessment Scale Observation MAY contain Assessment Scale Supporting Observations that contain LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| observation | C | 1..1 | AssessmentScaleObservation | Base for all types and resources | ||||||
| entryRelationship:social-history-entry-sprt-act | 0..* | EntryRelationship | When an Entry Reference is contained in a Social History Template instance that is a Social Determinant of Health Social History, that Entry Reference **MAY** reference an Assessment Scale Observation elsewhere in the document that represent LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| act | C | 1..1 | EntryReference | Base for all types and resources | ||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Fixed Value: EVN |
| Observation.code | preferred | SocialHistoryType |
| Observation.statusCode | required | ActStatus |
| Observation.value | required | SexualOrientationIncludingNullsAndDataAbsentReason |
| Observation.entryRelationship:social-history-entry-sprt-obs.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:social-history-entry-sprt-act.typeCode | required | Fixed Value: SPRT |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-8555 | error | Observation | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4515-32956 | warning | Observation.code | If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). : codeSystem = '2.16.840.1.113883.6.1' or translation.where(codeSystem = '2.16.840.1.113883.6.1').exists() | |
| should-sh-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Observation, Observation.entryRelationship:social-history-entry-sprt-obs.observation, Observation.entryRelationship:social-history-entry-sprt-act.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-value | warning | Observation | SHOULD contain value : value.exists() |
| Path | Conformance | ValueSet / Code |
| Observation.nullFlavor | required | CDANullFlavor |
| Observation.typeId.nullFlavor | required | CDANullFlavor |
| Observation.templateId:social-history-obs.nullFlavor | required | CDANullFlavor |
| Observation.templateId:sexual-orientation-obs.nullFlavor | required | CDANullFlavor |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Fixed Value: EVN |
| Observation.code | preferred | SocialHistoryType |
| Observation.code.nullFlavor | required | CDANullFlavor |
| Observation.text.nullFlavor | required | CDANullFlavor |
| Observation.text.compression | required | CDACompressionAlgorithm |
| Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
| Observation.text.mediaType | example | MediaType |
| Observation.text.representation | required | BinaryDataEncoding |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.nullFlavor | required | CDANullFlavor |
| Observation.effectiveTime.nullFlavor | required | CDANullFlavor |
| Observation.effectiveTime.operator | required | SetOperator |
| Observation.priorityCode | example | ActPriority |
| Observation.languageCode | required | AllLanguages |
| Observation.value | required | SexualOrientationIncludingNullsAndDataAbsentReason |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | example | ObservationMethod |
| Observation.entryRelationship:social-history-entry-sprt-obs.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:social-history-entry-sprt-obs.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:social-history-entry-sprt-obs.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:social-history-entry-sprt-act.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:social-history-entry-sprt-act.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:social-history-entry-sprt-act.typeCode | required | Fixed Value: SPRT |
| Observation.referenceRange.nullFlavor | required | CDANullFlavor |
| Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavor |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-8555 | error | Observation | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4515-32956 | warning | Observation.code | If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). : codeSystem = '2.16.840.1.113883.6.1' or translation.where(codeSystem = '2.16.840.1.113883.6.1').exists() | |
| should-sh-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Observation, Observation.entryRelationship:social-history-entry-sprt-obs.observation, Observation.entryRelationship:social-history-entry-sprt-act.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-value | warning | Observation | SHOULD contain value : value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from SocialHistoryObservation
Differential View
This structure is derived from SocialHistoryObservation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 1..1 | SocialHistoryObservation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
| templateId | 2..* | II | ||
| templateId:sexual-orientation-obs | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.501 | |
| @extension | 1..1 | st | Required Pattern: 2023-05-01 | |
| @classCode | 1..1 | cs | ||
| @moodCode | 1..1 | cs | ||
| code | 1..1 | CD | ||
| @code | 1..1 | cs | Required Pattern: 76690-7 | |
| @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
| statusCode | 1..1 | CS | ||
| @code | 1..1 | cs | ||
| effectiveTime | 1..1 | IVL_TS | The effectiveTime represents the relevant time of the observation. A patient's "sexual orientation" may change and using effectiveTime/low and effectiveTime/high defines the time during which the patient had identified their emotional, romantic, sexual, or affectional attraction to another person. | |
| low | 1..1 | IVXB_TS | ||
| high | 0..1 | IVXB_TS | ||
| value | 1..1 | CD | NOTE for PQ values: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: Sexual Orientation Including nulls and Data Absent Reason (required) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.value | required | SexualOrientationIncludingNullsAndDataAbsentReason |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation | C | 1..1 | SocialHistoryObservation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||||||
| Slices for templateId | 2..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:social-history-obs | 1..1 | II | ||||||||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.38 | |||||||
| @extension | 1..1 | st | Required Pattern: 2022-06-01 | |||||||
| templateId:sexual-orientation-obs | 1..1 | II | ||||||||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.501 | |||||||
| @extension | 1..1 | st | Required Pattern: 2023-05-01 | |||||||
| @classCode | 1..1 | cs | Binding: ActClassObservation (2.0.0) (required) Fixed Value: OBS | |||||||
| @moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||
| id | 1..* | II | ||||||||
| code | C | 1..1 | CD | Binding: Social History Type (preferred) | ||||||
| @code | 1..1 | cs | Required Pattern: 76690-7 | |||||||
| @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |||||||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |||||||
| @code | 1..1 | cs | Fixed Value: completed | |||||||
| effectiveTime | 1..1 | IVL_TS | The effectiveTime represents the relevant time of the observation. A patient's "sexual orientation" may change and using effectiveTime/low and effectiveTime/high defines the time during which the patient had identified their emotional, romantic, sexual, or affectional attraction to another person. | |||||||
| low | 1..1 | IVXB_TS | ||||||||
| high | 0..1 | IVXB_TS | ||||||||
| value | 1..1 | CD | NOTE for PQ values: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: Sexual Orientation Including nulls and Data Absent Reason (required)
| |||||||
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |||||||
| entryRelationship:social-history-entry-sprt-obs | 0..* | EntryRelationship | When an Assessment Scale Observation is contained in a Social History Observation instance that is a Social Determinant of Health Social History Observation, that Assessment Scale Observation MAY contain Assessment Scale Supporting Observations that contain LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| observation | C | 1..1 | AssessmentScaleObservation | Base for all types and resources | ||||||
| entryRelationship:social-history-entry-sprt-act | 0..* | EntryRelationship | When an Entry Reference is contained in a Social History Template instance that is a Social Determinant of Health Social History, that Entry Reference **MAY** reference an Assessment Scale Observation elsewhere in the document that represent LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| act | C | 1..1 | EntryReference | Base for all types and resources | ||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Fixed Value: EVN |
| Observation.code | preferred | SocialHistoryType |
| Observation.statusCode | required | ActStatus |
| Observation.value | required | SexualOrientationIncludingNullsAndDataAbsentReason |
| Observation.entryRelationship:social-history-entry-sprt-obs.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:social-history-entry-sprt-act.typeCode | required | Fixed Value: SPRT |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-8555 | error | Observation | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4515-32956 | warning | Observation.code | If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). : codeSystem = '2.16.840.1.113883.6.1' or translation.where(codeSystem = '2.16.840.1.113883.6.1').exists() | |
| should-sh-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Observation, Observation.entryRelationship:social-history-entry-sprt-obs.observation, Observation.entryRelationship:social-history-entry-sprt-act.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-value | warning | Observation | SHOULD contain value : value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation | C | 1..1 | SocialHistoryObservation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, author, entryRelationship, entryRelationship, entryRelationship Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| Slices for templateId | 2..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:social-history-obs | 1..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.38 | |||||||
| @extension | 1..1 | st | Required Pattern: 2022-06-01 | |||||||
| templateId:sexual-orientation-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: 2.16.840.1.113883.10.20.22.4.501 | |||||||
| @extension | 1..1 | st | Required Pattern: 2023-05-01 | |||||||
| @classCode | 1..1 | cs | Binding: ActClassObservation (2.0.0) (required) Fixed Value: OBS | |||||||
| @moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||
| @negationInd | 0..1 | bl | ||||||||
| id | 1..* | II | ||||||||
| code | C | 1..1 | CD | Binding: Social History Type (preferred) | ||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code | 1..1 | cs | Required Pattern: 76690-7 | |||||||
| @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |||||||
| @codeSystemName | 0..1 | st | ||||||||
| @codeSystemVersion | 0..1 | st | ||||||||
| @displayName | 0..1 | st | ||||||||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |||||||
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |||||||
| originalText | 0..1 | ED | ||||||||
| qualifier | 0..* | CR | ||||||||
| translation | 0..* | CD | ||||||||
| derivationExpr | 0..1 | ST | ||||||||
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @compression | 0..1 | cs | Binding: CompressionAlgorithm (required) | |||||||
| @integrityCheck | 0..1 | bin | ||||||||
| @integrityCheckAlgorithm | 0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |||||||
| @language | 0..1 | cs | ||||||||
| @mediaType | 0..1 | cs | Binding: MediaType (example) | |||||||
| @representation | 0..1 | cs | Binding: Binary Data Encoding Value Set (required) | |||||||
| xmlText | 0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |||||||
| reference | C | 0..1 | TEL | |||||||
| thumbnail | 0..1 | ED | ||||||||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code | 1..1 | cs | Fixed Value: completed | |||||||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |||||||
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |||||||
| effectiveTime | 1..1 | IVL_TS | The effectiveTime represents the relevant time of the observation. A patient's "sexual orientation" may change and using effectiveTime/low and effectiveTime/high defines the time during which the patient had identified their emotional, romantic, sexual, or affectional attraction to another person. | |||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @value | 0..1 | ts | Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |||||||
| @operator | 0..1 | cs | Binding: SetOperator (required) | |||||||
| low | 1..1 | IVXB_TS | ||||||||
| center | 0..1 | TS | ||||||||
| width | 0..1 | PQ | ||||||||
| high | 0..1 | IVXB_TS | ||||||||
| priorityCode | 0..1 | CE | Binding: ActPriority (example) | |||||||
| repeatNumber | 0..1 | IVL_INT | ||||||||
| languageCode | 0..1 | CS | Binding: AllLanguages (required) | |||||||
| value | 1..1 | CD | NOTE for PQ values: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: Sexual Orientation Including nulls and Data Absent Reason (required)
| |||||||
| interpretationCode | 0..* | CE | Binding: ObservationInterpretation (required) | |||||||
| methodCode | 0..* | CE | Binding: ObservationMethod (example) | |||||||
| targetSiteCode | 0..* | CD | ||||||||
| subject | 0..1 | Subject | ||||||||
| specimen | 0..* | Specimen | ||||||||
| performer | 0..* | Performer2 | ||||||||
| author | 0..* | AuthorParticipation | Base for all types and resources | |||||||
| informant | 0..* | Informant | ||||||||
| participant | 0..* | Participant2 | ||||||||
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |||||||
| entryRelationship:social-history-entry-sprt-obs | 0..* | EntryRelationship | When an Assessment Scale Observation is contained in a Social History Observation instance that is a Social Determinant of Health Social History Observation, that Assessment Scale Observation MAY contain Assessment Scale Supporting Observations that contain LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
 typeId | 0..1 | II | ||||||||
 @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| templateId | 0..* | II | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| @inversionInd | 0..1 | bl | ||||||||
| @contextConductionInd | 0..1 | bl | ||||||||
| @negationInd | 0..1 | bl | ||||||||
| sequenceNumber | 0..1 | INT | ||||||||
| seperatableInd | 0..1 | BL | ||||||||
| act | 0..1 | Act | ||||||||
| encounter | 0..1 | Encounter | ||||||||
| observation | C | 1..1 | AssessmentScaleObservation | Base for all types and resources | ||||||
| observationMedia | 0..1 | ObservationMedia | ||||||||
| organizer | 0..1 | Organizer | ||||||||
| procedure | 0..1 | Procedure | ||||||||
| regionOfInterest | 0..1 | RegionOfInterest | ||||||||
| substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
| supply | 0..1 | Supply | ||||||||
| entryRelationship:social-history-entry-sprt-act | 0..* | EntryRelationship | When an Entry Reference is contained in a Social History Template instance that is a Social Determinant of Health Social History, that Entry Reference **MAY** reference an Assessment Scale Observation elsewhere in the document that represent LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| templateId | 0..* | II | ||||||||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| @inversionInd | 0..1 | bl | ||||||||
| @contextConductionInd | 0..1 | bl | ||||||||
| @negationInd | 0..1 | bl | ||||||||
| sequenceNumber | 0..1 | INT | ||||||||
| seperatableInd | 0..1 | BL | ||||||||
| act | C | 1..1 | EntryReference | Base for all types and resources | ||||||
| encounter | 0..1 | Encounter | ||||||||
| observation | 0..1 | Observation | ||||||||
| observationMedia | 0..1 | ObservationMedia | ||||||||
| organizer | 0..1 | Organizer | ||||||||
| procedure | 0..1 | Procedure | ||||||||
| regionOfInterest | 0..1 | RegionOfInterest | ||||||||
| substanceAdministration | 0..1 | SubstanceAdministration | ||||||||
| supply | 0..1 | Supply | ||||||||
| reference | 0..* | Reference | ||||||||
| precondition | 0..* | Precondition | ||||||||
| sdtcPrecondition2 | 0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |||||||
| referenceRange | 0..* | InfrastructureRoot | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode | 0..* | CS | ||||||||
| typeId | 0..1 | II | ||||||||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName | 0..1 | st | ||||||||
| @displayable | 0..1 | bl | ||||||||
| @root | 1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension | 1..1 | st | ||||||||
| templateId | 0..* | II | ||||||||
| @typeCode | 0..1 | cs | Binding: ActRelationshipType (2.0.0) (required) Fixed Value: REFV | |||||||
| observationRange | 1..1 | ObservationRange | ||||||||
| sdtcInFulfillmentOf1 | 0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code |
| Observation.nullFlavor | required | CDANullFlavor |
| Observation.typeId.nullFlavor | required | CDANullFlavor |
| Observation.templateId:social-history-obs.nullFlavor | required | CDANullFlavor |
| Observation.templateId:sexual-orientation-obs.nullFlavor | required | CDANullFlavor |
| Observation.classCode | required | Fixed Value: OBS |
| Observation.moodCode | required | Fixed Value: EVN |
| Observation.code | preferred | SocialHistoryType |
| Observation.code.nullFlavor | required | CDANullFlavor |
| Observation.text.nullFlavor | required | CDANullFlavor |
| Observation.text.compression | required | CDACompressionAlgorithm |
| Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
| Observation.text.mediaType | example | MediaType |
| Observation.text.representation | required | BinaryDataEncoding |
| Observation.statusCode | required | ActStatus |
| Observation.statusCode.nullFlavor | required | CDANullFlavor |
| Observation.effectiveTime.nullFlavor | required | CDANullFlavor |
| Observation.effectiveTime.operator | required | SetOperator |
| Observation.priorityCode | example | ActPriority |
| Observation.languageCode | required | AllLanguages |
| Observation.value | required | SexualOrientationIncludingNullsAndDataAbsentReason |
| Observation.interpretationCode | required | ObservationInterpretation |
| Observation.methodCode | example | ObservationMethod |
| Observation.entryRelationship:social-history-entry-sprt-obs.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:social-history-entry-sprt-obs.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:social-history-entry-sprt-obs.typeCode | required | Fixed Value: SPRT |
| Observation.entryRelationship:social-history-entry-sprt-act.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:social-history-entry-sprt-act.typeId.nullFlavor | required | CDANullFlavor |
| Observation.entryRelationship:social-history-entry-sprt-act.typeCode | required | Fixed Value: SPRT |
| Observation.referenceRange.nullFlavor | required | CDANullFlavor |
| Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavor |
| Observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-8555 | error | Observation | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4515-32956 | warning | Observation.code | If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). : codeSystem = '2.16.840.1.113883.6.1' or translation.where(codeSystem = '2.16.840.1.113883.6.1').exists() | |
| should-sh-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Observation, Observation.entryRelationship:social-history-entry-sprt-obs.observation, Observation.entryRelationship:social-history-entry-sprt-act.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-value | warning | Observation | SHOULD contain value : value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from SocialHistoryObservation
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#3.0.0-ballot based on FHIR 5.0.0. Generated 2023-12-21
Links: Table of Contents |
QA Report
| Version History 
|
|
Propose a change