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/SpecimenCollectionProcedure | Version: 3.0.0-ballot | |||
| Draft as of 2023-12-21 | Computable Name: SpecimenCollectionProcedure | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.415:2018-09-01 | ||||
This template represents clinical information about the specimen including when it was collected, the type and source of specimen, as well as related observations regarding the specimen.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Procedure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Procedure | C | 1..1 | Procedure | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-targetSiteCode: SHOULD contain targetSiteCode |
  Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:specimen-collection-proc | 1..1 | II | ||
  @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.415 | |
  @extension | 1..1 | st | Required Pattern: 2018-09-01 | |
 @moodCode | 1..1 | cs | Fixed Value: EVN | |
| code | 1..1 | CD | Specimen collection (procedure) | |
| @code | 1..1 | cs | Required Pattern: 17636008 | |
 @codeSystem | 1..1 | oid, uuid, ruid | SNOMED CT Required Pattern: 2.16.840.1.113883.6.96 | |
| 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 |
| targetSiteCode | 0..* | CD | (USCDI) Specimen Source Site Binding: Body Site Value Set (required) | |
 Slices for entryRelationship | 1..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |
 entryRelationship:specimenRef | 1..1 | EntryRelationship | References the specimen that is the subject of this procedure | |
 @typeCode | 1..1 | cs | Fixed Value: SUBJ | |
 act | 1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:rejectReason | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Fixed Value: COMP | |
| observation | 0..1 | SpecimenRejectReasonObservation | (USCDI) Specimen Condition Acceptability | |
| entryRelationship:condition | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Fixed Value: COMP | |
| observation | 0..1 | SpecimenConditionObservation | (USCDI) Specimen Condition Acceptability | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Procedure.targetSiteCode | required | BodySiteValueSet |
| Id | Grade | Path(s) | Details | Requirements |
| should-effectiveTime | warning | Procedure | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-targetSiteCode | warning | Procedure | SHOULD contain targetSiteCode : targetSiteCode.exists() | |
| should-text-ref-value | warning | Procedure | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Procedure.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 |
|---|---|---|---|---|
| Procedure | C | 1..1 | Procedure | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-targetSiteCode: SHOULD contain targetSiteCode |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:specimen-collection-proc | 1..1 | II | ||
 @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.415 | |
| @extension | 1..1 | st | Required Pattern: 2018-09-01 | |
| @classCode | 1..1 | cs | Binding: ActClassProcedure (required) Fixed Value: PROC | |
| @moodCode | 1..1 | cs | Binding: x_DocumentProcedureMood (required) Fixed Value: EVN | |
| code | 1..1 | CD | Specimen collection (procedure) | |
| @code | 1..1 | cs | Required Pattern: 17636008 | |
| @codeSystem | 1..1 | oid, uuid, ruid | SNOMED CT Required Pattern: 2.16.840.1.113883.6.96 | |
| 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 |
| targetSiteCode | 0..* | CD | (USCDI) Specimen Source Site Binding: Body Site Value Set (required) | |
| Slices for entryRelationship | 1..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |
| entryRelationship:specimenRef | 1..1 | EntryRelationship | References the specimen that is the subject of this procedure | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| act | C | 1..1 | EntryReference | Base for all types and resources |
| entryRelationship:rejectReason | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| observation | C | 0..1 | SpecimenRejectReasonObservation | (USCDI) Specimen Condition Acceptability |
| entryRelationship:condition | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| observation | C | 0..1 | SpecimenConditionObservation | (USCDI) Specimen Condition Acceptability |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Procedure.classCode | required | Fixed Value: PROC |
| Procedure.moodCode | required | Fixed Value: EVN |
| Procedure.targetSiteCode | required | BodySiteValueSet |
| Procedure.entryRelationship:specimenRef.typeCode | required | Fixed Value: SUBJ |
| Procedure.entryRelationship:rejectReason.typeCode | required | Fixed Value: COMP |
| Procedure.entryRelationship:condition.typeCode | required | Fixed Value: COMP |
| Id | Grade | Path(s) | Details | Requirements |
| should-effectiveTime | warning | Procedure | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-targetSiteCode | warning | Procedure | SHOULD contain targetSiteCode : targetSiteCode.exists() | |
| should-text-ref-value | warning | Procedure | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Procedure.entryRelationship:specimenRef.act, Procedure.entryRelationship:rejectReason.observation, Procedure.entryRelationship:condition.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Procedure.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 |
| Procedure.nullFlavor | required | CDANullFlavor |
| Procedure.typeId.nullFlavor | required | CDANullFlavor |
| Procedure.templateId:specimen-collection-proc.nullFlavor | required | CDANullFlavor |
| Procedure.classCode | required | Fixed Value: PROC |
| Procedure.moodCode | required | Fixed Value: EVN |
| Procedure.code.nullFlavor | required | CDANullFlavor |
| Procedure.text.nullFlavor | required | CDANullFlavor |
| Procedure.text.compression | required | CDACompressionAlgorithm |
| Procedure.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
| Procedure.text.mediaType | example | MediaType |
| Procedure.text.representation | required | BinaryDataEncoding |
| Procedure.statusCode | required | ActStatus |
| Procedure.priorityCode | example | ActPriority |
| Procedure.languageCode | required | AllLanguages |
| Procedure.targetSiteCode | required | BodySiteValueSet |
| Procedure.entryRelationship:specimenRef.nullFlavor | required | CDANullFlavor |
| Procedure.entryRelationship:specimenRef.typeId.nullFlavor | required | CDANullFlavor |
| Procedure.entryRelationship:specimenRef.typeCode | required | Fixed Value: SUBJ |
| Procedure.entryRelationship:rejectReason.nullFlavor | required | CDANullFlavor |
| Procedure.entryRelationship:rejectReason.typeId.nullFlavor | required | CDANullFlavor |
| Procedure.entryRelationship:rejectReason.typeCode | required | Fixed Value: COMP |
| Procedure.entryRelationship:condition.nullFlavor | required | CDANullFlavor |
| Procedure.entryRelationship:condition.typeId.nullFlavor | required | CDANullFlavor |
| Procedure.entryRelationship:condition.typeCode | required | Fixed Value: COMP |
| Id | Grade | Path(s) | Details | Requirements |
| should-effectiveTime | warning | Procedure | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-targetSiteCode | warning | Procedure | SHOULD contain targetSiteCode : targetSiteCode.exists() | |
| should-text-ref-value | warning | Procedure | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Procedure.entryRelationship:specimenRef.act, Procedure.entryRelationship:rejectReason.observation, Procedure.entryRelationship:condition.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Procedure.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 Procedure
Summary
Mandatory: 10 elements
Fixed Value: 4 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Procedure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | C | 1..1 | Procedure | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-targetSiteCode: SHOULD contain targetSiteCode |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:specimen-collection-proc | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.415 | |
| @extension | 1..1 | st | Required Pattern: 2018-09-01 | |
| @moodCode | 1..1 | cs | Fixed Value: EVN | |
| code | 1..1 | CD | Specimen collection (procedure) | |
| @code | 1..1 | cs | Required Pattern: 17636008 | |
| @codeSystem | 1..1 | oid, uuid, ruid | SNOMED CT Required Pattern: 2.16.840.1.113883.6.96 | |
| 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 |
| targetSiteCode | 0..* | CD | (USCDI) Specimen Source Site Binding: Body Site Value Set (required) | |
| Slices for entryRelationship | 1..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |
| entryRelationship:specimenRef | 1..1 | EntryRelationship | References the specimen that is the subject of this procedure | |
| @typeCode | 1..1 | cs | Fixed Value: SUBJ | |
| act | 1..1 | EntryReference | Base for all types and resources | |
| entryRelationship:rejectReason | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Fixed Value: COMP | |
| observation | 0..1 | SpecimenRejectReasonObservation | (USCDI) Specimen Condition Acceptability | |
| entryRelationship:condition | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Fixed Value: COMP | |
| observation | 0..1 | SpecimenConditionObservation | (USCDI) Specimen Condition Acceptability | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Procedure.targetSiteCode | required | BodySiteValueSet |
| Id | Grade | Path(s) | Details | Requirements |
| should-effectiveTime | warning | Procedure | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-targetSiteCode | warning | Procedure | SHOULD contain targetSiteCode : targetSiteCode.exists() | |
| should-text-ref-value | warning | Procedure | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Procedure.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 |
|---|---|---|---|---|
| Procedure | C | 1..1 | Procedure | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-targetSiteCode: SHOULD contain targetSiteCode |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:specimen-collection-proc | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.415 | |
| @extension | 1..1 | st | Required Pattern: 2018-09-01 | |
| @classCode | 1..1 | cs | Binding: ActClassProcedure (required) Fixed Value: PROC | |
| @moodCode | 1..1 | cs | Binding: x_DocumentProcedureMood (required) Fixed Value: EVN | |
| code | 1..1 | CD | Specimen collection (procedure) | |
| @code | 1..1 | cs | Required Pattern: 17636008 | |
| @codeSystem | 1..1 | oid, uuid, ruid | SNOMED CT Required Pattern: 2.16.840.1.113883.6.96 | |
| 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 |
| targetSiteCode | 0..* | CD | (USCDI) Specimen Source Site Binding: Body Site Value Set (required) | |
| Slices for entryRelationship | 1..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |
| entryRelationship:specimenRef | 1..1 | EntryRelationship | References the specimen that is the subject of this procedure | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| act | C | 1..1 | EntryReference | Base for all types and resources |
| entryRelationship:rejectReason | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| observation | C | 0..1 | SpecimenRejectReasonObservation | (USCDI) Specimen Condition Acceptability |
| entryRelationship:condition | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| observation | C | 0..1 | SpecimenConditionObservation | (USCDI) Specimen Condition Acceptability |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Procedure.classCode | required | Fixed Value: PROC |
| Procedure.moodCode | required | Fixed Value: EVN |
| Procedure.targetSiteCode | required | BodySiteValueSet |
| Procedure.entryRelationship:specimenRef.typeCode | required | Fixed Value: SUBJ |
| Procedure.entryRelationship:rejectReason.typeCode | required | Fixed Value: COMP |
| Procedure.entryRelationship:condition.typeCode | required | Fixed Value: COMP |
| Id | Grade | Path(s) | Details | Requirements |
| should-effectiveTime | warning | Procedure | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-targetSiteCode | warning | Procedure | SHOULD contain targetSiteCode : targetSiteCode.exists() | |
| should-text-ref-value | warning | Procedure | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Procedure.entryRelationship:specimenRef.act, Procedure.entryRelationship:rejectReason.observation, Procedure.entryRelationship:condition.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Procedure.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 |
| Procedure.nullFlavor | required | CDANullFlavor |
| Procedure.typeId.nullFlavor | required | CDANullFlavor |
| Procedure.templateId:specimen-collection-proc.nullFlavor | required | CDANullFlavor |
| Procedure.classCode | required | Fixed Value: PROC |
| Procedure.moodCode | required | Fixed Value: EVN |
| Procedure.code.nullFlavor | required | CDANullFlavor |
| Procedure.text.nullFlavor | required | CDANullFlavor |
| Procedure.text.compression | required | CDACompressionAlgorithm |
| Procedure.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
| Procedure.text.mediaType | example | MediaType |
| Procedure.text.representation | required | BinaryDataEncoding |
| Procedure.statusCode | required | ActStatus |
| Procedure.priorityCode | example | ActPriority |
| Procedure.languageCode | required | AllLanguages |
| Procedure.targetSiteCode | required | BodySiteValueSet |
| Procedure.entryRelationship:specimenRef.nullFlavor | required | CDANullFlavor |
| Procedure.entryRelationship:specimenRef.typeId.nullFlavor | required | CDANullFlavor |
| Procedure.entryRelationship:specimenRef.typeCode | required | Fixed Value: SUBJ |
| Procedure.entryRelationship:rejectReason.nullFlavor | required | CDANullFlavor |
| Procedure.entryRelationship:rejectReason.typeId.nullFlavor | required | CDANullFlavor |
| Procedure.entryRelationship:rejectReason.typeCode | required | Fixed Value: COMP |
| Procedure.entryRelationship:condition.nullFlavor | required | CDANullFlavor |
| Procedure.entryRelationship:condition.typeId.nullFlavor | required | CDANullFlavor |
| Procedure.entryRelationship:condition.typeCode | required | Fixed Value: COMP |
| Id | Grade | Path(s) | Details | Requirements |
| should-effectiveTime | warning | Procedure | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-targetSiteCode | warning | Procedure | SHOULD contain targetSiteCode : targetSiteCode.exists() | |
| should-text-ref-value | warning | Procedure | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Procedure.entryRelationship:specimenRef.act, Procedure.entryRelationship:rejectReason.observation, Procedure.entryRelationship:condition.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Procedure.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 Procedure
Summary
Mandatory: 10 elements
Fixed Value: 4 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
Links: Table of Contents |
QA Report
| Version History 
|
|
Propose a change
