Consolidated CDA (C-CDA)
3.0.0 - STU3 United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v3.0.0: CCDA 3.0) generated with FHIR (HL7® FHIR® Standard) v5.0.0. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Logical Model: Health Status Evaluations and Outcomes Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/HealthStatusEvaluationsandOutcomesSection Version: 3.0.0
Draft as of 2024-05-18 Computable Name: HealthStatusEvaluationsandOutcomesSection
Other Identifiers: OID:2.16.840.1.113883.10.20.22.2.61

This section represents observations regarding the evaluation or assessment of the patient, and the outcome of care from the interventions used to treat the patient. These observations represent status information, at points in time, related to established goals or related to new care plan goals and/or interventions.

Usage:

Formal Views of Template Content

Description of Template, Differentials, Snapshots and how the different presentations work.

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-outcome-obs: If section/@nullFlavor is not present, SHALL contain at least one Outcome Observation
... @nullFlavor 0..1 cs If a required section contains no information, the @nullFlavor MAY be set to NI
... Slices for templateId 1..* II Slice: Unordered, Open by value:root
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.61
..... @extension 0..0
... code 1..1 CE Patient problem outcome Narrative
.... @code 1..1 cs Required Pattern: 11383-7
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... text 1..1 xhtml
... Slices for entry 0..* Entry If section/@nullFlavor is not present:
Slice: Unordered, Open by profile:observation
.... entry:outcome 0..* Entry
..... observation 1..1 OutcomeObservation Base for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
shall-outcome-obserrorSectionIf section/@nullFlavor is not present, SHALL contain at least one Outcome Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation')).exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-outcome-obs: If section/@nullFlavor is not present, SHALL contain at least one Outcome Observation
... @nullFlavor 0..1 cs If a required section contains no information, the @nullFlavor MAY be set to NI
Binding: CDANullFlavor (required)
... Slices for templateId 1..* II Slice: Unordered, Open by value:root
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.61
... code 1..1 CE Patient problem outcome Narrative
Binding: DocumentSectionType (example)
.... @code 1..1 cs Required Pattern: 11383-7
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... text 1..1 xhtml
... Slices for entry 0..* Entry If section/@nullFlavor is not present:
Slice: Unordered, Open by profile:observation
.... entry:outcome 0..* Entry
..... observation C 1..1 OutcomeObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-value: SHOULD contain value
should-author: SHOULD contain author

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
shall-outcome-obserrorSectionIf section/@nullFlavor is not present, SHALL contain at least one Outcome Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation')).exists()
should-authorwarningSection.entry:outcome.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningSection.entry:outcome.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningSection.entry:outcome.observationSHOULD contain value
: value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-outcome-obs: If section/@nullFlavor is not present, SHALL contain at least one Outcome Observation
... @nullFlavor 0..1 cs If a required section contains no information, the @nullFlavor MAY be set to NI
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:section 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: 2.16.840.1.113883.10.20.22.2.61
... @ID 0..1 xs:ID
... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... id 0..1 II
... code 1..1 CE Patient problem outcome Narrative
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 11383-7
.... @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
.... translation 0..* CD
... title 1..1 ST
... text 1..1 xhtml
... confidentialityCode 0..1 CE
... languageCode 0..1 CS Binding: AllLanguages (required)
... subject 0..1 Subject
... author 0..* Author
... informant 0..* Informant
... Slices for entry 0..* Entry If section/@nullFlavor is not present:
Slice: Unordered, Open by profile:observation
.... entry:outcome 0..* Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1 bl Fixed Value: true
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 OutcomeObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-value: SHOULD contain value
should-author: SHOULD contain author
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
... component 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 Fixed Value: COMP
.... @contextConductionInd 0..1 bl Fixed Value: true
.... section 1..1 Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.entry:outcome.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:outcome.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:outcome.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
shall-outcome-obserrorSectionIf section/@nullFlavor is not present, SHALL contain at least one Outcome Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation')).exists()
should-authorwarningSection.entry:outcome.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningSection.entry:outcome.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningSection.entry:outcome.observationSHOULD contain value
: value.exists()

This structure is derived from Section

Summary

Mandatory: 8 elements(1 nested mandatory element)
Prohibited: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Section.templateId
  • The element 1 is sliced based on the value of Section.entry

Differential View

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-outcome-obs: If section/@nullFlavor is not present, SHALL contain at least one Outcome Observation
... @nullFlavor 0..1 cs If a required section contains no information, the @nullFlavor MAY be set to NI
... Slices for templateId 1..* II Slice: Unordered, Open by value:root
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.61
..... @extension 0..0
... code 1..1 CE Patient problem outcome Narrative
.... @code 1..1 cs Required Pattern: 11383-7
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... text 1..1 xhtml
... Slices for entry 0..* Entry If section/@nullFlavor is not present:
Slice: Unordered, Open by profile:observation
.... entry:outcome 0..* Entry
..... observation 1..1 OutcomeObservation Base for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
shall-outcome-obserrorSectionIf section/@nullFlavor is not present, SHALL contain at least one Outcome Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation')).exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-outcome-obs: If section/@nullFlavor is not present, SHALL contain at least one Outcome Observation
... @nullFlavor 0..1 cs If a required section contains no information, the @nullFlavor MAY be set to NI
Binding: CDANullFlavor (required)
... Slices for templateId 1..* II Slice: Unordered, Open by value:root
.... templateId:section 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.2.61
... code 1..1 CE Patient problem outcome Narrative
Binding: DocumentSectionType (example)
.... @code 1..1 cs Required Pattern: 11383-7
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... text 1..1 xhtml
... Slices for entry 0..* Entry If section/@nullFlavor is not present:
Slice: Unordered, Open by profile:observation
.... entry:outcome 0..* Entry
..... observation C 1..1 OutcomeObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-value: SHOULD contain value
should-author: SHOULD contain author

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
shall-outcome-obserrorSectionIf section/@nullFlavor is not present, SHALL contain at least one Outcome Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation')).exists()
should-authorwarningSection.entry:outcome.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningSection.entry:outcome.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningSection.entry:outcome.observationSHOULD contain value
: value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C 1..1 Section XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-outcome-obs: If section/@nullFlavor is not present, SHALL contain at least one Outcome Observation
... @nullFlavor 0..1 cs If a required section contains no information, the @nullFlavor MAY be set to NI
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:section 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: 2.16.840.1.113883.10.20.22.2.61
... @ID 0..1 xs:ID
... @classCode 0..1 cs Binding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1 cs Binding: CDAActMood (required)
Fixed Value: EVN
... id 0..1 II
... code 1..1 CE Patient problem outcome Narrative
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 11383-7
.... @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
.... translation 0..* CD
... title 1..1 ST
... text 1..1 xhtml
... confidentialityCode 0..1 CE
... languageCode 0..1 CS Binding: AllLanguages (required)
... subject 0..1 Subject
... author 0..* Author
... informant 0..* Informant
... Slices for entry 0..* Entry If section/@nullFlavor is not present:
Slice: Unordered, Open by profile:observation
.... entry:outcome 0..* Entry
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 0..1 cs Binding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1 bl Fixed Value: true
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 OutcomeObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-value: SHOULD contain value
should-author: SHOULD contain author
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
... component 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 Fixed Value: COMP
.... @contextConductionInd 0..1 bl Fixed Value: true
.... section 1..1 Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer
Section.moodCoderequiredFixed Value: EVN
http://hl7.org/cda/stds/core/ValueSet/CDAActMood
Section.codeexampleDocumentSectionType
http://terminology.hl7.org/ValueSet/v3-DocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Section.entry:outcome.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:outcome.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.entry:outcome.typeCoderequiredXActRelationshipEntry
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
shall-outcome-obserrorSectionIf section/@nullFlavor is not present, SHALL contain at least one Outcome Observation
: nullFlavor.exists() or entry.where(observation.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/OutcomeObservation')).exists()
should-authorwarningSection.entry:outcome.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningSection.entry:outcome.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningSection.entry:outcome.observationSHOULD contain value
: value.exists()

This structure is derived from Section

Summary

Mandatory: 8 elements(1 nested mandatory element)
Prohibited: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Section.templateId
  • The element 1 is sliced based on the value of Section.entry

 

Other representations of profile: CSV, Excel