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/TobaccoUse | Version: 3.0.0-ballot | |||
| Draft as of 2023-12-21 | Computable Name: TobaccoUse | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.85:2014-06-09 | ||||
This template represents a patient’s tobacco use.
All the types of tobacco use are represented using the codes from the tobacco use and exposure-finding hierarchy in SNOMED CT, including codes required for recording smoking status in Meaningful Use Stage 2.
The effectiveTime element is used to describe dates associated with the patient’s tobacco use. Whereas the Smoking Status - Meaningful Use template (2.16.840.1.113883.10.20.22.4.78:2014-06-09) represents a “snapshot in time” observation, simply reflecting what the patient’s current smoking status is at the time of the observation, this Tobacco Use template uses effectiveTime to represent the biologically relevant time of the observation. Thus, to record a former smoker, an observation of “cigarette smoker” will have an effectiveTime/low defining the time the patient started to smoke cigarettes and an effectiveTime/high defining the time the patient ceased to smoke cigarettes. To record a current smoker, the effectiveTime/low will define the time the patient started smoking and will have no effectiveTime/high to indicated that the patient is still smoking.
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-author: SHOULD contain author |
  Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:tobacco-use | 1..1 | II | ||
  @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.85 | |
  @extension | 1..1 | st | Required Pattern: 2014-06-09 | |
 @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: 11367-0 | |
 @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 | The effectiveTime represents the biologically relevant time of the observation. A "former smoker" is recorded with the proper code "current smoker" with an effectiveTime/low and effectiveTime/high defining the time during which the patient was a smoker. | |
| low | 1..1 | IVXB_TS | ||
| high | 0..1 | IVXB_TS | ||
 value | 1..1 | CD | ||
| @code | 1..1 | cs | Binding: Tobacco Use (required) | |
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.value.code | required | TobaccoUse |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Observation | SHOULD contain author : author.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-author: SHOULD contain author |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:tobacco-use | 1..1 | II | ||
 @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.85 | |
| @extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| @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: 11367-0 | |
| @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 | The effectiveTime represents the biologically relevant time of the observation. A "former smoker" is recorded with the proper code "current smoker" with an effectiveTime/low and effectiveTime/high defining the time during which the patient was a smoker. | |
| low | 1..1 | IVXB_TS | ||
| high | 0..1 | IVXB_TS | ||
| value | 1..1 | CD | ||
| @code | 1..1 | cs | Binding: Tobacco Use (required) | |
| author | 0..* | AuthorParticipation | 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 | example | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.value.code | required | TobaccoUse |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Observation | SHOULD contain author : author.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-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:tobacco-use | 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: 2.16.840.1.113883.10.20.22.4.85 | |
| @extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| @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 | 1..1 | CD | Binding: ObservationType (example) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: 11367-0 | |
| @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 | 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 | 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 biologically relevant time of the observation. A "former smoker" is recorded with the proper code "current smoker" with an effectiveTime/low and effectiveTime/high defining the time during which the patient was a smoker. | |
| @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 | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 1..1 | cs | Binding: Tobacco Use (required) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @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 | ||
| 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 | ||
| entryRelationship | 0..* | EntryRelationship | ||
| 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:tobacco-use.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.value.nullFlavor | required | CDANullFlavor |
| Observation.value.code | required | TobaccoUse |
| 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-author | warning | Observation | SHOULD contain author : author.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('#') |
This structure is derived from Observation
Summary
Mandatory: 13 elements
Fixed Value: 3 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-author: SHOULD contain author |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:tobacco-use | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.85 | |
| @extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| @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: 11367-0 | |
| @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 | The effectiveTime represents the biologically relevant time of the observation. A "former smoker" is recorded with the proper code "current smoker" with an effectiveTime/low and effectiveTime/high defining the time during which the patient was a smoker. | |
| low | 1..1 | IVXB_TS | ||
| high | 0..1 | IVXB_TS | ||
| value | 1..1 | CD | ||
| @code | 1..1 | cs | Binding: Tobacco Use (required) | |
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.value.code | required | TobaccoUse |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Observation | SHOULD contain author : author.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-author: SHOULD contain author |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:tobacco-use | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.85 | |
| @extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| @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: 11367-0 | |
| @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 | The effectiveTime represents the biologically relevant time of the observation. A "former smoker" is recorded with the proper code "current smoker" with an effectiveTime/low and effectiveTime/high defining the time during which the patient was a smoker. | |
| low | 1..1 | IVXB_TS | ||
| high | 0..1 | IVXB_TS | ||
| value | 1..1 | CD | ||
| @code | 1..1 | cs | Binding: Tobacco Use (required) | |
| author | 0..* | AuthorParticipation | 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 | example | ObservationType |
| Observation.statusCode | required | ActStatus |
| Observation.value.code | required | TobaccoUse |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Observation | SHOULD contain author : author.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('#') |
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-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:tobacco-use | 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: 2.16.840.1.113883.10.20.22.4.85 | |
| @extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| @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 | 1..1 | CD | Binding: ObservationType (example) | |
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 1..1 | cs | Required Pattern: 11367-0 | |
| @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 | 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 | 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 biologically relevant time of the observation. A "former smoker" is recorded with the proper code "current smoker" with an effectiveTime/low and effectiveTime/high defining the time during which the patient was a smoker. | |
| @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 | ||
| @nullFlavor | 0..1 | cs | Binding: CDANullFlavor (required) | |
| @code | 1..1 | cs | Binding: Tobacco Use (required) | |
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @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 | ||
| 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 | ||
| entryRelationship | 0..* | EntryRelationship | ||
| 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:tobacco-use.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.value.nullFlavor | required | CDANullFlavor |
| Observation.value.code | required | TobaccoUse |
| 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-author | warning | Observation | SHOULD contain author : author.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('#') |
This structure is derived from Observation
Summary
Mandatory: 13 elements
Fixed Value: 3 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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