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: Risk Concern Act

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/RiskConcernAct Version: 3.0.0
Draft as of 2024-05-18 Computable Name: RiskConcernAct
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.136:2015-08-01

This template represents a risk concern.

It is a wrapper for a single risk concern which may be derived from a variety of sources within an EHR (such as Problem List, Family History, Social History, Social Worker Note, etc.).

A Risk Concern Act represents a health concern that is a risk. A risk is a clinical or socioeconomic condition that the patient does not currently have, but the probability of developing that condition rises to the level of concern such that an intervention and/or monitoring is needed.

Usage:

Formal Views of Template Content

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

This structure is derived from Act

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C 1..1 Act XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance 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:risk-concern-act 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.136
..... @extension 1..1 st Required Pattern: 2015-08-01
... @classCode 1..1 cs Fixed Value: ACT
... @moodCode 1..1 cs Fixed Value: EVN
... code 1..1 CD At risk - finding
.... @code 1..1 cs Required Pattern: 281694009
.... @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
... statusCode 1..1 CS
.... @nullFlavor 0..0
.... @code 1..1 cs Binding: ProblemAct statusCode . (required)
... effectiveTime 0..1 IVL_TS
... author 0..* AuthorParticipation Base for all types and resources
... Slices for entryRelationship 0..* EntryRelationship Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry.
Slice: Unordered, Open by value:typeCode, profile:observation, profile:act, profile:organizer
.... entryRelationship:problemObservation1 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 ProblemObservation Base for all types and resources
.... entryRelationship:allergy-IntoleranceObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 AllergyIntoleranceObservation Base for all types and resources
.... entryRelationship:entryReferenceRefr 0..* EntryRelationship The following entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern RELATES TO Health Concern). It can also represent the relationship between a Health Concern and another entry already described in the CDA document instance. The Entry Reference template is used here because the target entry will be defined elsewhere and thus a reference to that instance is all that is required.
..... @typeCode 1..1 cs Fixed Value: REFR
..... act 1..1 EntryReference Base for all types and resources
.... entryRelationship:entryReferenceComp 0..* EntryRelationship The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). The Enry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required.
..... @typeCode 1..1 cs Fixed Value: COMP
..... act 1..1 EntryReference Base for all types and resources
.... entryRelationship:assessmentScaleObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 AssessmentScaleObservation Base for all types and resources
.... entryRelationship:mentalStatusObservation1 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 MentalStatusObservation Base for all types and resources
.... entryRelationship:self-CareActivitiesADLandIADL 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 SelfCareActivitiesADLandIADL Base for all types and resources
.... entryRelationship:mentalStatusObservation2 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 MentalStatusObservation Base for all types and resources
.... entryRelationship:smokingStatus 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 SmokingStatus Base for all types and resources
.... entryRelationship:encounterDiagnosis 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... act 1..1 EncounterDiagnosis Base for all types and resources
.... entryRelationship:entryRelationship11 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... organizer 1..1 FamilyHistoryOrganizer Base for all types and resources
.... entryRelationship:functionalStatusObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 FunctionalStatusObservation Base for all types and resources
.... entryRelationship:hospitalAdmissionDiagnosis 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... act 1..1 HospitalAdmissionDiagnosis Base for all types and resources
.... entryRelationship:nutritionAssessment 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 NutritionAssessment Base for all types and resources
.... entryRelationship:postprocedureDiagnosis 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... act 1..1 PostprocedureDiagnosis Base for all types and resources
.... entryRelationship:pregnancyObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 PregnancyObservation Base for all types and resources
.... entryRelationship:preoperativeDiagnosis 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... act 1..1 PreoperativeDiagnosis Base for all types and resources
.... entryRelationship:reactionObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 ReactionObservation Base for all types and resources
.... entryRelationship:resultObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 ResultObservation Base for all types and resources
.... entryRelationship:sensoryStatus 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 SensoryStatus Base for all types and resources
.... entryRelationship:socialHistoryObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 SocialHistoryObservation Base for all types and resources
.... entryRelationship:substanceorDeviceAllergy-IntoleranceObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 SubstanceOrDeviceAllergyIntoleranceObservation Base for all types and resources
.... entryRelationship:vitalSignObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 VitalSignObservation Base for all types and resources
.... entryRelationship:longitudinalCareWoundObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 LongitudinalCareWoundObservation Base for all types and resources
.... entryRelationship:problemObservation2 0..* EntryRelationship The following entryRelationship represents the relationship Health Concern HAS SUPPORT Observation.
..... @typeCode 1..1 cs Fixed Value: SPRT
..... observation 1..1 ProblemObservation Base for all types and resources
.... entryRelationship:caregiverCharacteristics 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 CaregiverCharacteristics Base for all types and resources
.... entryRelationship:culturalandReligiousObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 CulturalandReligiousObservation Base for all types and resources
.... entryRelationship:characteristicsofHomeEnvironment 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 CharacteristicsofHomeEnvironment Base for all types and resources
.... entryRelationship:nutritionalStatusObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 NutritionalStatusObservation Base for all types and resources
.... entryRelationship:resultOrganizer 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... organizer 1..1 ResultOrganizer Base for all types and resources
.... entryRelationship:priorityPreference1 0..* EntryRelationship The following entryRelationship represents the priority that the patient puts on the health concern.
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 PriorityPreference Base for all types and resources
.... entryRelationship:priorityPreference2 0..* EntryRelationship The following entryRelationship represents the priority that the provider puts on the health concern.
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 PriorityPreference Base for all types and resources
.... entryRelationship:problemConcernAct 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... act 1..1 ProblemConcernAct Base for all types and resources
... reference 0..* Reference
.... @typeCode 1..1 cs Fixed Value: REFR
.... externalDocument 1..1 ExternalDocumentReference Base for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Act.statusCode.coderequiredProblemActStatusCode .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.19

Constraints

IdGradePath(s)DetailsRequirements
should-authorwarningActSHOULD contain author
: author.exists()
should-text-ref-valuewarningActSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorAct.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')
NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C 1..1 Act XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance 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:risk-concern-act 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.136
..... @extension 1..1 st Required Pattern: 2015-08-01
... @classCode 1..1 cs Binding: XActClassDocumentEntryAct (2.0.0) (required)
Fixed Value: ACT
... @moodCode 1..1 cs Binding: XDocumentActMood (2.0.0) (required)
Fixed Value: EVN
... code 1..1 CD At risk - finding
Binding: v3 Code System ActCode (example)
.... @code 1..1 cs Required Pattern: 281694009
.... @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
... statusCode 1..1 CS Binding: ActStatus (required)
.... @code 1..1 cs Binding: ProblemAct statusCode . (required)
... effectiveTime 0..1 IVL_TS
... author 0..* AuthorParticipation Base for all types and resources
... Slices for entryRelationship 0..* EntryRelationship Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry.
Slice: Unordered, Open by value:typeCode, profile:observation, profile:act, profile:organizer
.... entryRelationship:problemObservation1 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 ProblemObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:allergy-IntoleranceObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 AllergyIntoleranceObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
should-not-severity: Allergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level.
.... entryRelationship:entryReferenceRefr 0..* EntryRelationship The following entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern RELATES TO Health Concern). It can also represent the relationship between a Health Concern and another entry already described in the CDA document instance. The Entry Reference template is used here because the target entry will be defined elsewhere and thus a reference to that instance is all that is required.
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... act C 1..1 EntryReference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:entryReferenceComp 0..* EntryRelationship The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). The Enry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required.
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... act C 1..1 EntryReference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:assessmentScaleObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 AssessmentScaleObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:mentalStatusObservation1 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 MentalStatusObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:self-CareActivitiesADLandIADL 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 SelfCareActivitiesADLandIADL Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:mentalStatusObservation2 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 MentalStatusObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:smokingStatus 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 SmokingStatus Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
coded-value: When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded
.... entryRelationship:encounterDiagnosis 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... act C 1..1 EncounterDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:entryRelationship11 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... organizer C 1..1 FamilyHistoryOrganizer Base for all types and resources
should-sdtctext-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:functionalStatusObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 FunctionalStatusObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:hospitalAdmissionDiagnosis 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... act C 1..1 HospitalAdmissionDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:nutritionAssessment 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 NutritionAssessment Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:postprocedureDiagnosis 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... act C 1..1 PostprocedureDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:pregnancyObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 PregnancyObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
.... entryRelationship:preoperativeDiagnosis 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... act C 1..1 PreoperativeDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:reactionObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 ReactionObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
.... entryRelationship:resultObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 ResultObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-interpretationCode: SHOULD contain interpretationCode
should-author: SHOULD contain author
should-referenceRange: SHOULD contain referenceRange
.... entryRelationship:sensoryStatus 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 SensoryStatus Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:socialHistoryObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 SocialHistoryObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-value: SHOULD contain value
4515-8555: 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.
should-sh-author: SHOULD contain author
.... entryRelationship:substanceorDeviceAllergy-IntoleranceObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 SubstanceOrDeviceAllergyIntoleranceObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
should-not-severity: Allergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level.
.... entryRelationship:vitalSignObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 VitalSignObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-code: SHOULD contain code
should-author: SHOULD contain author
should-percent: Percentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with %
should-cm: Height & Head Circumference should be represented in cm
should-kg: Weight should be represented in kg
should-cel: Temperature should be represented in Celcius (Cel)
should-bp: Blood pressure should be represented in mm[Hg]
should-rates: Rates should be represented in /min
should-bmi: BMI should be represented in kg/m2
should-bsa: BSA should be represented in m2
.... entryRelationship:longitudinalCareWoundObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 LongitudinalCareWoundObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:problemObservation2 0..* EntryRelationship The following entryRelationship represents the relationship Health Concern HAS SUPPORT Observation.
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SPRT
..... observation C 1..1 ProblemObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:caregiverCharacteristics 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 CaregiverCharacteristics Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:culturalandReligiousObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 CulturalandReligiousObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:characteristicsofHomeEnvironment 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 CharacteristicsofHomeEnvironment Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:nutritionalStatusObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 NutritionalStatusObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:resultOrganizer 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... organizer C 1..1 ResultOrganizer Base for all types and resources
should-sdtctext-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:priorityPreference1 0..* EntryRelationship The following entryRelationship represents the priority that the patient puts on the health concern.
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 PriorityPreference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-author: SHOULD contain author
.... entryRelationship:priorityPreference2 0..* EntryRelationship The following entryRelationship represents the priority that the provider puts on the health concern.
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 PriorityPreference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-author: SHOULD contain author
.... entryRelationship:problemConcernAct 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... act C 1..1 ProblemConcernAct Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
... reference 0..* Reference
.... @typeCode 1..1 cs Binding: x_ActRelationshipExternalReference (required)
Fixed Value: REFR
.... externalDocument C 1..1 ExternalDocumentReference Base for all types and resources
should-setId: SHOULD contain setId
should-versionNumber: SHOULD contain versionNumber

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Act.classCoderequiredFixed Value: ACT
http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0
Act.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0
Act.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Act.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Act.statusCode.coderequiredProblemActStatusCode .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.19
Act.entryRelationship:problemObservation1.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:allergy-IntoleranceObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:entryReferenceRefr.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:entryReferenceComp.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:assessmentScaleObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:mentalStatusObservation1.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:self-CareActivitiesADLandIADL.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:mentalStatusObservation2.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:smokingStatus.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:encounterDiagnosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:entryRelationship11.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:functionalStatusObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:hospitalAdmissionDiagnosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:nutritionAssessment.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:postprocedureDiagnosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:pregnancyObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:preoperativeDiagnosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:reactionObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:resultObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:sensoryStatus.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:socialHistoryObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:vitalSignObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:longitudinalCareWoundObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:problemObservation2.typeCoderequiredFixed Value: SPRT
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:caregiverCharacteristics.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:culturalandReligiousObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:characteristicsofHomeEnvironment.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:nutritionalStatusObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:resultOrganizer.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:priorityPreference1.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:priorityPreference2.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:problemConcernAct.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.reference.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipExternalReference

Constraints

IdGradePath(s)DetailsRequirements
4515-8555errorAct.entryRelationship:socialHistoryObservation.observationIf 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.
:
coded-valueerrorAct.entryRelationship:smokingStatus.observationWhen code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded
: (code.code = '72166-2' or code.code = '11367-0') implies value.code.exists()
should-authorwarningActSHOULD contain author
: author.exists()
should-authorwarningAct.entryRelationship:problemObservation1.observation, Act.entryRelationship:allergy-IntoleranceObservation.observation, Act.entryRelationship:mentalStatusObservation1.observation, Act.entryRelationship:self-CareActivitiesADLandIADL.observation, Act.entryRelationship:mentalStatusObservation2.observation, Act.entryRelationship:functionalStatusObservation.observation, Act.entryRelationship:nutritionAssessment.observation, Act.entryRelationship:resultObservation.observation, Act.entryRelationship:sensoryStatus.observation, Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.observation, Act.entryRelationship:vitalSignObservation.observation, Act.entryRelationship:longitudinalCareWoundObservation.observation, Act.entryRelationship:problemObservation2.observation, Act.entryRelationship:resultOrganizer.organizer, Act.entryRelationship:priorityPreference1.observation, Act.entryRelationship:priorityPreference2.observation, Act.entryRelationship:problemConcernAct.actSHOULD contain author
: author.exists()
should-bmiwarningAct.entryRelationship:vitalSignObservation.observationBMI should be represented in kg/m2
: (code.code = '39156-5') implies value.unit = 'kg/m2'
should-bpwarningAct.entryRelationship:vitalSignObservation.observationBlood pressure should be represented in mm[Hg]
: (code.code in ('8480-6' | '8462-4' | '8478-0' | '96608-5' | '96609-3')) implies value.unit = 'mm[Hg]'
should-bsawarningAct.entryRelationship:vitalSignObservation.observationBSA should be represented in m2
: (code.code = '3140-1') implies value.unit = 'm2'
should-celwarningAct.entryRelationship:vitalSignObservation.observationTemperature should be represented in Celcius (Cel)
: (code.code = '8310-5') implies value.unit = 'Cel'
should-cmwarningAct.entryRelationship:vitalSignObservation.observationHeight & Head Circumference should be represented in cm
: (code.code in ('8287-5' | '8302-2' | '8306-3' | '9843-4')) implies value.unit = 'cm'
should-codewarningAct.entryRelationship:vitalSignObservation.observationSHOULD contain code
: code.exists()
should-effectiveTimewarningAct.entryRelationship:pregnancyObservation.observation, Act.entryRelationship:reactionObservation.observation, Act.entryRelationship:priorityPreference1.observation, Act.entryRelationship:priorityPreference2.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-interpretationCodewarningAct.entryRelationship:resultObservation.observationSHOULD contain interpretationCode
: interpretationCode.exists()
should-kgwarningAct.entryRelationship:vitalSignObservation.observationWeight should be represented in kg
: (code.code = '29463-7') implies value.unit = 'kg'
should-not-severitywarningAct.entryRelationship:allergy-IntoleranceObservation.observation, Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.observationAllergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level.
: entryRelationship.observation.where(code.code = 'SEV' and code.codeSystem = '2.16.840.1.113883.5.4').empty()
should-percentwarningAct.entryRelationship:vitalSignObservation.observationPercentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with %
: (code.code in ('2708-6' | '3150-0' | '59408-5' | '8289-1' | '59575-1' | '59576-9')) implies value.unit = '%'
should-rateswarningAct.entryRelationship:vitalSignObservation.observationRates should be represented in /min
: (code.code in ('8867-4' | '9279-1')) implies value.unit = '/min'
should-referenceRangewarningAct.entryRelationship:resultObservation.observationSHOULD contain referenceRange
: referenceRange.exists()
should-sdtctext-ref-valuewarningAct.entryRelationship:entryRelationship11.organizer, Act.entryRelationship:resultOrganizer.organizerSHOULD contain text/reference/@value
: sdtcText.reference.value.exists()
should-setIdwarningAct.reference.externalDocumentSHOULD contain setId
: setId.exists()
should-sh-authorwarningAct.entryRelationship:socialHistoryObservation.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningActSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningAct.entryRelationship:problemObservation1.observation, Act.entryRelationship:allergy-IntoleranceObservation.observation, Act.entryRelationship:entryReferenceRefr.act, Act.entryRelationship:entryReferenceComp.act, Act.entryRelationship:assessmentScaleObservation.observation, Act.entryRelationship:mentalStatusObservation1.observation, Act.entryRelationship:self-CareActivitiesADLandIADL.observation, Act.entryRelationship:mentalStatusObservation2.observation, Act.entryRelationship:smokingStatus.observation, Act.entryRelationship:encounterDiagnosis.act, Act.entryRelationship:functionalStatusObservation.observation, Act.entryRelationship:hospitalAdmissionDiagnosis.act, Act.entryRelationship:nutritionAssessment.observation, Act.entryRelationship:postprocedureDiagnosis.act, Act.entryRelationship:pregnancyObservation.observation, Act.entryRelationship:preoperativeDiagnosis.act, Act.entryRelationship:reactionObservation.observation, Act.entryRelationship:resultObservation.observation, Act.entryRelationship:sensoryStatus.observation, Act.entryRelationship:socialHistoryObservation.observation, Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.observation, Act.entryRelationship:vitalSignObservation.observation, Act.entryRelationship:longitudinalCareWoundObservation.observation, Act.entryRelationship:problemObservation2.observation, Act.entryRelationship:caregiverCharacteristics.observation, Act.entryRelationship:culturalandReligiousObservation.observation, Act.entryRelationship:characteristicsofHomeEnvironment.observation, Act.entryRelationship:nutritionalStatusObservation.observation, Act.entryRelationship:priorityPreference1.observation, Act.entryRelationship:priorityPreference2.observation, Act.entryRelationship:problemConcernAct.actSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningAct.entryRelationship:socialHistoryObservation.observationSHOULD contain value
: value.exists()
should-versionNumberwarningAct.reference.externalDocumentSHOULD contain versionNumber
: versionNumber.exists()
value-starts-octothorpeerrorAct.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')
NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C 1..1 Act XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance 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
.... templateId:risk-concern-act 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: 2.16.840.1.113883.10.20.22.4.136
..... @extension 1..1 st Required Pattern: 2015-08-01
... @classCode 1..1 cs Binding: XActClassDocumentEntryAct (2.0.0) (required)
Fixed Value: ACT
... @moodCode 1..1 cs Binding: XDocumentActMood (2.0.0) (required)
Fixed Value: EVN
... @negationInd 0..1 bl
... id 1..* II
... code 1..1 CD At risk - finding
Binding: v3 Code System ActCode (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 281694009
.... @codeSystem 1..1 oid, uuid, ruid SNOMED CT
Required Pattern: 2.16.840.1.113883.6.96
.... @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
... 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: CDACompressionAlgorithm (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: CDABinaryDataEncoding (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)
.... @code 1..1 cs Binding: ProblemAct statusCode . (required)
.... @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 0..1 IVL_TS
... priorityCode 0..1 CE Binding: ActPriority (example)
... languageCode 0..1 CS Binding: AllLanguages (required)
... 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 Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry.
Slice: Unordered, Open by value:typeCode, profile:observation, profile:act, profile:organizer
.... entryRelationship:problemObservation1 0..* EntryRelationship
..... @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: REFR
..... @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 ProblemObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@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
.... entryRelationship:allergy-IntoleranceObservation 0..* EntryRelationship
..... @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: REFR
..... @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 AllergyIntoleranceObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
should-not-severity: Allergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level.
..... 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:entryReferenceRefr 0..* EntryRelationship The following entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern RELATES TO Health Concern). It can also represent the relationship between a Health Concern and another entry already described in the CDA document instance. The Entry Reference template is used here because the target entry will be defined elsewhere and thus a reference to that instance is all that is required.
..... @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: REFR
..... @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
should-text-ref-value: SHOULD contain text/reference/@value
..... 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
.... entryRelationship:entryReferenceComp 0..* EntryRelationship The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). The Enry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required.
..... @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: COMP
..... @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
should-text-ref-value: SHOULD contain text/reference/@value
..... 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
.... entryRelationship:assessmentScaleObservation 0..* EntryRelationship
..... @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: REFR
..... @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
should-text-ref-value: SHOULD contain text/reference/@value
..... 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:mentalStatusObservation1 0..* EntryRelationship
..... @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: REFR
..... @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 MentalStatusObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@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
.... entryRelationship:self-CareActivitiesADLandIADL 0..* EntryRelationship
..... @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: REFR
..... @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 SelfCareActivitiesADLandIADL Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@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
.... entryRelationship:mentalStatusObservation2 0..* EntryRelationship
..... @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: REFR
..... @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 MentalStatusObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@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
.... entryRelationship:smokingStatus 0..* EntryRelationship
..... @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: REFR
..... @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 SmokingStatus Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
coded-value: When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded
..... 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:encounterDiagnosis 0..* EntryRelationship
..... @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: REFR
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act C 1..1 EncounterDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... 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
.... entryRelationship:entryRelationship11 0..* EntryRelationship
..... @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: REFR
..... @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 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer C 1..1 FamilyHistoryOrganizer Base for all types and resources
should-sdtctext-ref-value: SHOULD contain text/reference/@value
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:functionalStatusObservation 0..* EntryRelationship
..... @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: REFR
..... @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 FunctionalStatusObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@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
.... entryRelationship:hospitalAdmissionDiagnosis 0..* EntryRelationship
..... @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: REFR
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act C 1..1 HospitalAdmissionDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... 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
.... entryRelationship:nutritionAssessment 0..* EntryRelationship
..... @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: REFR
..... @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 NutritionAssessment Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@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
.... entryRelationship:postprocedureDiagnosis 0..* EntryRelationship
..... @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: REFR
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act C 1..1 PostprocedureDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... 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
.... entryRelationship:pregnancyObservation 0..* EntryRelationship
..... @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: REFR
..... @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 PregnancyObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
..... 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:preoperativeDiagnosis 0..* EntryRelationship
..... @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: REFR
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act C 1..1 PreoperativeDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... 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
.... entryRelationship:reactionObservation 0..* EntryRelationship
..... @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: REFR
..... @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 ReactionObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
..... 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:resultObservation 0..* EntryRelationship
..... @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: REFR
..... @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 ResultObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-interpretationCode: SHOULD contain interpretationCode
should-author: SHOULD contain author
should-referenceRange: SHOULD contain referenceRange
..... 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:sensoryStatus 0..* EntryRelationship
..... @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: REFR
..... @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 SensoryStatus Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@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
.... entryRelationship:socialHistoryObservation 0..* EntryRelationship
..... @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: REFR
..... @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 SocialHistoryObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-value: SHOULD contain value
4515-8555: 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.
should-sh-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
.... entryRelationship:substanceorDeviceAllergy-IntoleranceObservation 0..* EntryRelationship
..... @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: REFR
..... @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 SubstanceOrDeviceAllergyIntoleranceObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
should-not-severity: Allergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level.
..... 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:vitalSignObservation 0..* EntryRelationship
..... @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: REFR
..... @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 VitalSignObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-code: SHOULD contain code
should-author: SHOULD contain author
should-percent: Percentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with %
should-cm: Height & Head Circumference should be represented in cm
should-kg: Weight should be represented in kg
should-cel: Temperature should be represented in Celcius (Cel)
should-bp: Blood pressure should be represented in mm[Hg]
should-rates: Rates should be represented in /min
should-bmi: BMI should be represented in kg/m2
should-bsa: BSA should be represented in m2
..... 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:longitudinalCareWoundObservation 0..* EntryRelationship
..... @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: REFR
..... @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 LongitudinalCareWoundObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@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
.... entryRelationship:problemObservation2 0..* EntryRelationship The following entryRelationship represents the relationship Health Concern HAS SUPPORT Observation.
..... @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 ProblemObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@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
.... entryRelationship:caregiverCharacteristics 0..* EntryRelationship
..... @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: REFR
..... @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 CaregiverCharacteristics Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... 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:culturalandReligiousObservation 0..* EntryRelationship
..... @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: REFR
..... @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 CulturalandReligiousObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... 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:characteristicsofHomeEnvironment 0..* EntryRelationship
..... @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: REFR
..... @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 CharacteristicsofHomeEnvironment Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... 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:nutritionalStatusObservation 0..* EntryRelationship
..... @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: REFR
..... @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 NutritionalStatusObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... 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:resultOrganizer 0..* EntryRelationship
..... @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: REFR
..... @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 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer C 1..1 ResultOrganizer Base for all types and resources
should-sdtctext-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:priorityPreference1 0..* EntryRelationship The following entryRelationship represents the priority that the patient puts on the health concern.
..... @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: REFR
..... @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 PriorityPreference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
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
.... entryRelationship:priorityPreference2 0..* EntryRelationship The following entryRelationship represents the priority that the provider puts on the health concern.
..... @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: REFR
..... @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 PriorityPreference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
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
.... entryRelationship:problemConcernAct 0..* EntryRelationship
..... @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: REFR
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act C 1..1 ProblemConcernAct Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
..... 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
.... @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_ActRelationshipExternalReference (required)
Fixed Value: REFR
.... seperatableInd 0..1 BL
.... externalAct 0..1 ExternalAct
.... externalObservation 0..1 ExternalObservation
.... externalProcedure 0..1 ExternalProcedure
.... externalDocument C 1..1 ExternalDocumentReference Base for all types and resources
should-setId: SHOULD contain setId
should-versionNumber: SHOULD contain versionNumber
... precondition 0..* Precondition
... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Act.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.templateId:risk-concern-act.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.classCoderequiredFixed Value: ACT
http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0
Act.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0
Act.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Act.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Act.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Act.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Act.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Act.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Act.statusCode.coderequiredProblemActStatusCode .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.19
Act.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Act.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Act.entryRelationship:problemObservation1.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemObservation1.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemObservation1.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:allergy-IntoleranceObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:allergy-IntoleranceObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:allergy-IntoleranceObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:entryReferenceRefr.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:entryReferenceRefr.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:entryReferenceRefr.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:entryReferenceComp.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:entryReferenceComp.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:entryReferenceComp.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:assessmentScaleObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:assessmentScaleObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:assessmentScaleObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:mentalStatusObservation1.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:mentalStatusObservation1.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:mentalStatusObservation1.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:self-CareActivitiesADLandIADL.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:self-CareActivitiesADLandIADL.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:self-CareActivitiesADLandIADL.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:mentalStatusObservation2.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:mentalStatusObservation2.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:mentalStatusObservation2.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:smokingStatus.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:smokingStatus.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:smokingStatus.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:encounterDiagnosis.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:encounterDiagnosis.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:encounterDiagnosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:entryRelationship11.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:entryRelationship11.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:entryRelationship11.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:functionalStatusObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:functionalStatusObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:functionalStatusObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:hospitalAdmissionDiagnosis.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:hospitalAdmissionDiagnosis.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:hospitalAdmissionDiagnosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:nutritionAssessment.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:nutritionAssessment.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:nutritionAssessment.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:postprocedureDiagnosis.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:postprocedureDiagnosis.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:postprocedureDiagnosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:pregnancyObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:pregnancyObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:pregnancyObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:preoperativeDiagnosis.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:preoperativeDiagnosis.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:preoperativeDiagnosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:reactionObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:reactionObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:reactionObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:resultObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:resultObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:resultObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:sensoryStatus.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:sensoryStatus.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:sensoryStatus.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:socialHistoryObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:socialHistoryObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:socialHistoryObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:vitalSignObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:vitalSignObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:vitalSignObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:longitudinalCareWoundObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:longitudinalCareWoundObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:longitudinalCareWoundObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:problemObservation2.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemObservation2.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemObservation2.typeCoderequiredFixed Value: SPRT
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:caregiverCharacteristics.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:caregiverCharacteristics.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:caregiverCharacteristics.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:culturalandReligiousObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:culturalandReligiousObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:culturalandReligiousObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:characteristicsofHomeEnvironment.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:characteristicsofHomeEnvironment.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:characteristicsofHomeEnvironment.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:nutritionalStatusObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:nutritionalStatusObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:nutritionalStatusObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:resultOrganizer.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:resultOrganizer.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:resultOrganizer.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:priorityPreference1.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:priorityPreference1.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:priorityPreference1.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:priorityPreference2.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:priorityPreference2.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:priorityPreference2.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:problemConcernAct.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemConcernAct.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemConcernAct.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.reference.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.reference.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.reference.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipExternalReference

Constraints

IdGradePath(s)DetailsRequirements
4515-8555errorAct.entryRelationship:socialHistoryObservation.observationIf 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.
:
coded-valueerrorAct.entryRelationship:smokingStatus.observationWhen code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded
: (code.code = '72166-2' or code.code = '11367-0') implies value.code.exists()
should-authorwarningActSHOULD contain author
: author.exists()
should-authorwarningAct.entryRelationship:problemObservation1.observation, Act.entryRelationship:allergy-IntoleranceObservation.observation, Act.entryRelationship:mentalStatusObservation1.observation, Act.entryRelationship:self-CareActivitiesADLandIADL.observation, Act.entryRelationship:mentalStatusObservation2.observation, Act.entryRelationship:functionalStatusObservation.observation, Act.entryRelationship:nutritionAssessment.observation, Act.entryRelationship:resultObservation.observation, Act.entryRelationship:sensoryStatus.observation, Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.observation, Act.entryRelationship:vitalSignObservation.observation, Act.entryRelationship:longitudinalCareWoundObservation.observation, Act.entryRelationship:problemObservation2.observation, Act.entryRelationship:resultOrganizer.organizer, Act.entryRelationship:priorityPreference1.observation, Act.entryRelationship:priorityPreference2.observation, Act.entryRelationship:problemConcernAct.actSHOULD contain author
: author.exists()
should-bmiwarningAct.entryRelationship:vitalSignObservation.observationBMI should be represented in kg/m2
: (code.code = '39156-5') implies value.unit = 'kg/m2'
should-bpwarningAct.entryRelationship:vitalSignObservation.observationBlood pressure should be represented in mm[Hg]
: (code.code in ('8480-6' | '8462-4' | '8478-0' | '96608-5' | '96609-3')) implies value.unit = 'mm[Hg]'
should-bsawarningAct.entryRelationship:vitalSignObservation.observationBSA should be represented in m2
: (code.code = '3140-1') implies value.unit = 'm2'
should-celwarningAct.entryRelationship:vitalSignObservation.observationTemperature should be represented in Celcius (Cel)
: (code.code = '8310-5') implies value.unit = 'Cel'
should-cmwarningAct.entryRelationship:vitalSignObservation.observationHeight & Head Circumference should be represented in cm
: (code.code in ('8287-5' | '8302-2' | '8306-3' | '9843-4')) implies value.unit = 'cm'
should-codewarningAct.entryRelationship:vitalSignObservation.observationSHOULD contain code
: code.exists()
should-effectiveTimewarningAct.entryRelationship:pregnancyObservation.observation, Act.entryRelationship:reactionObservation.observation, Act.entryRelationship:priorityPreference1.observation, Act.entryRelationship:priorityPreference2.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-interpretationCodewarningAct.entryRelationship:resultObservation.observationSHOULD contain interpretationCode
: interpretationCode.exists()
should-kgwarningAct.entryRelationship:vitalSignObservation.observationWeight should be represented in kg
: (code.code = '29463-7') implies value.unit = 'kg'
should-not-severitywarningAct.entryRelationship:allergy-IntoleranceObservation.observation, Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.observationAllergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level.
: entryRelationship.observation.where(code.code = 'SEV' and code.codeSystem = '2.16.840.1.113883.5.4').empty()
should-percentwarningAct.entryRelationship:vitalSignObservation.observationPercentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with %
: (code.code in ('2708-6' | '3150-0' | '59408-5' | '8289-1' | '59575-1' | '59576-9')) implies value.unit = '%'
should-rateswarningAct.entryRelationship:vitalSignObservation.observationRates should be represented in /min
: (code.code in ('8867-4' | '9279-1')) implies value.unit = '/min'
should-referenceRangewarningAct.entryRelationship:resultObservation.observationSHOULD contain referenceRange
: referenceRange.exists()
should-sdtctext-ref-valuewarningAct.entryRelationship:entryRelationship11.organizer, Act.entryRelationship:resultOrganizer.organizerSHOULD contain text/reference/@value
: sdtcText.reference.value.exists()
should-setIdwarningAct.reference.externalDocumentSHOULD contain setId
: setId.exists()
should-sh-authorwarningAct.entryRelationship:socialHistoryObservation.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningActSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningAct.entryRelationship:problemObservation1.observation, Act.entryRelationship:allergy-IntoleranceObservation.observation, Act.entryRelationship:entryReferenceRefr.act, Act.entryRelationship:entryReferenceComp.act, Act.entryRelationship:assessmentScaleObservation.observation, Act.entryRelationship:mentalStatusObservation1.observation, Act.entryRelationship:self-CareActivitiesADLandIADL.observation, Act.entryRelationship:mentalStatusObservation2.observation, Act.entryRelationship:smokingStatus.observation, Act.entryRelationship:encounterDiagnosis.act, Act.entryRelationship:functionalStatusObservation.observation, Act.entryRelationship:hospitalAdmissionDiagnosis.act, Act.entryRelationship:nutritionAssessment.observation, Act.entryRelationship:postprocedureDiagnosis.act, Act.entryRelationship:pregnancyObservation.observation, Act.entryRelationship:preoperativeDiagnosis.act, Act.entryRelationship:reactionObservation.observation, Act.entryRelationship:resultObservation.observation, Act.entryRelationship:sensoryStatus.observation, Act.entryRelationship:socialHistoryObservation.observation, Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.observation, Act.entryRelationship:vitalSignObservation.observation, Act.entryRelationship:longitudinalCareWoundObservation.observation, Act.entryRelationship:problemObservation2.observation, Act.entryRelationship:caregiverCharacteristics.observation, Act.entryRelationship:culturalandReligiousObservation.observation, Act.entryRelationship:characteristicsofHomeEnvironment.observation, Act.entryRelationship:nutritionalStatusObservation.observation, Act.entryRelationship:priorityPreference1.observation, Act.entryRelationship:priorityPreference2.observation, Act.entryRelationship:problemConcernAct.actSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningAct.entryRelationship:socialHistoryObservation.observationSHOULD contain value
: value.exists()
should-versionNumberwarningAct.reference.externalDocumentSHOULD contain versionNumber
: versionNumber.exists()
value-starts-octothorpeerrorAct.text.referenceIf 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 Act

Summary

Mandatory: 9 elements(34 nested mandatory elements)
Fixed: 36 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of Act.templateId
  • The element 4 is sliced based on the values of Act.entryRelationship

Differential View

This structure is derived from Act

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C 1..1 Act XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance 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:risk-concern-act 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.136
..... @extension 1..1 st Required Pattern: 2015-08-01
... @classCode 1..1 cs Fixed Value: ACT
... @moodCode 1..1 cs Fixed Value: EVN
... code 1..1 CD At risk - finding
.... @code 1..1 cs Required Pattern: 281694009
.... @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
... statusCode 1..1 CS
.... @nullFlavor 0..0
.... @code 1..1 cs Binding: ProblemAct statusCode . (required)
... effectiveTime 0..1 IVL_TS
... author 0..* AuthorParticipation Base for all types and resources
... Slices for entryRelationship 0..* EntryRelationship Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry.
Slice: Unordered, Open by value:typeCode, profile:observation, profile:act, profile:organizer
.... entryRelationship:problemObservation1 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 ProblemObservation Base for all types and resources
.... entryRelationship:allergy-IntoleranceObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 AllergyIntoleranceObservation Base for all types and resources
.... entryRelationship:entryReferenceRefr 0..* EntryRelationship The following entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern RELATES TO Health Concern). It can also represent the relationship between a Health Concern and another entry already described in the CDA document instance. The Entry Reference template is used here because the target entry will be defined elsewhere and thus a reference to that instance is all that is required.
..... @typeCode 1..1 cs Fixed Value: REFR
..... act 1..1 EntryReference Base for all types and resources
.... entryRelationship:entryReferenceComp 0..* EntryRelationship The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). The Enry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required.
..... @typeCode 1..1 cs Fixed Value: COMP
..... act 1..1 EntryReference Base for all types and resources
.... entryRelationship:assessmentScaleObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 AssessmentScaleObservation Base for all types and resources
.... entryRelationship:mentalStatusObservation1 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 MentalStatusObservation Base for all types and resources
.... entryRelationship:self-CareActivitiesADLandIADL 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 SelfCareActivitiesADLandIADL Base for all types and resources
.... entryRelationship:mentalStatusObservation2 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 MentalStatusObservation Base for all types and resources
.... entryRelationship:smokingStatus 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 SmokingStatus Base for all types and resources
.... entryRelationship:encounterDiagnosis 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... act 1..1 EncounterDiagnosis Base for all types and resources
.... entryRelationship:entryRelationship11 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... organizer 1..1 FamilyHistoryOrganizer Base for all types and resources
.... entryRelationship:functionalStatusObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 FunctionalStatusObservation Base for all types and resources
.... entryRelationship:hospitalAdmissionDiagnosis 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... act 1..1 HospitalAdmissionDiagnosis Base for all types and resources
.... entryRelationship:nutritionAssessment 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 NutritionAssessment Base for all types and resources
.... entryRelationship:postprocedureDiagnosis 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... act 1..1 PostprocedureDiagnosis Base for all types and resources
.... entryRelationship:pregnancyObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 PregnancyObservation Base for all types and resources
.... entryRelationship:preoperativeDiagnosis 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... act 1..1 PreoperativeDiagnosis Base for all types and resources
.... entryRelationship:reactionObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 ReactionObservation Base for all types and resources
.... entryRelationship:resultObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 ResultObservation Base for all types and resources
.... entryRelationship:sensoryStatus 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 SensoryStatus Base for all types and resources
.... entryRelationship:socialHistoryObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 SocialHistoryObservation Base for all types and resources
.... entryRelationship:substanceorDeviceAllergy-IntoleranceObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 SubstanceOrDeviceAllergyIntoleranceObservation Base for all types and resources
.... entryRelationship:vitalSignObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 VitalSignObservation Base for all types and resources
.... entryRelationship:longitudinalCareWoundObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 LongitudinalCareWoundObservation Base for all types and resources
.... entryRelationship:problemObservation2 0..* EntryRelationship The following entryRelationship represents the relationship Health Concern HAS SUPPORT Observation.
..... @typeCode 1..1 cs Fixed Value: SPRT
..... observation 1..1 ProblemObservation Base for all types and resources
.... entryRelationship:caregiverCharacteristics 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 CaregiverCharacteristics Base for all types and resources
.... entryRelationship:culturalandReligiousObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 CulturalandReligiousObservation Base for all types and resources
.... entryRelationship:characteristicsofHomeEnvironment 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 CharacteristicsofHomeEnvironment Base for all types and resources
.... entryRelationship:nutritionalStatusObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 NutritionalStatusObservation Base for all types and resources
.... entryRelationship:resultOrganizer 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... organizer 1..1 ResultOrganizer Base for all types and resources
.... entryRelationship:priorityPreference1 0..* EntryRelationship The following entryRelationship represents the priority that the patient puts on the health concern.
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 PriorityPreference Base for all types and resources
.... entryRelationship:priorityPreference2 0..* EntryRelationship The following entryRelationship represents the priority that the provider puts on the health concern.
..... @typeCode 1..1 cs Fixed Value: REFR
..... observation 1..1 PriorityPreference Base for all types and resources
.... entryRelationship:problemConcernAct 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... act 1..1 ProblemConcernAct Base for all types and resources
... reference 0..* Reference
.... @typeCode 1..1 cs Fixed Value: REFR
.... externalDocument 1..1 ExternalDocumentReference Base for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Act.statusCode.coderequiredProblemActStatusCode .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.19

Constraints

IdGradePath(s)DetailsRequirements
should-authorwarningActSHOULD contain author
: author.exists()
should-text-ref-valuewarningActSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorAct.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C 1..1 Act XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance 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:risk-concern-act 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.136
..... @extension 1..1 st Required Pattern: 2015-08-01
... @classCode 1..1 cs Binding: XActClassDocumentEntryAct (2.0.0) (required)
Fixed Value: ACT
... @moodCode 1..1 cs Binding: XDocumentActMood (2.0.0) (required)
Fixed Value: EVN
... code 1..1 CD At risk - finding
Binding: v3 Code System ActCode (example)
.... @code 1..1 cs Required Pattern: 281694009
.... @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
... statusCode 1..1 CS Binding: ActStatus (required)
.... @code 1..1 cs Binding: ProblemAct statusCode . (required)
... effectiveTime 0..1 IVL_TS
... author 0..* AuthorParticipation Base for all types and resources
... Slices for entryRelationship 0..* EntryRelationship Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry.
Slice: Unordered, Open by value:typeCode, profile:observation, profile:act, profile:organizer
.... entryRelationship:problemObservation1 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 ProblemObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:allergy-IntoleranceObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 AllergyIntoleranceObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
should-not-severity: Allergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level.
.... entryRelationship:entryReferenceRefr 0..* EntryRelationship The following entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern RELATES TO Health Concern). It can also represent the relationship between a Health Concern and another entry already described in the CDA document instance. The Entry Reference template is used here because the target entry will be defined elsewhere and thus a reference to that instance is all that is required.
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... act C 1..1 EntryReference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:entryReferenceComp 0..* EntryRelationship The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). The Enry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required.
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... act C 1..1 EntryReference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:assessmentScaleObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 AssessmentScaleObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:mentalStatusObservation1 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 MentalStatusObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:self-CareActivitiesADLandIADL 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 SelfCareActivitiesADLandIADL Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:mentalStatusObservation2 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 MentalStatusObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:smokingStatus 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 SmokingStatus Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
coded-value: When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded
.... entryRelationship:encounterDiagnosis 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... act C 1..1 EncounterDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:entryRelationship11 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... organizer C 1..1 FamilyHistoryOrganizer Base for all types and resources
should-sdtctext-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:functionalStatusObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 FunctionalStatusObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:hospitalAdmissionDiagnosis 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... act C 1..1 HospitalAdmissionDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:nutritionAssessment 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 NutritionAssessment Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:postprocedureDiagnosis 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... act C 1..1 PostprocedureDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:pregnancyObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 PregnancyObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
.... entryRelationship:preoperativeDiagnosis 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... act C 1..1 PreoperativeDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:reactionObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 ReactionObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
.... entryRelationship:resultObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 ResultObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-interpretationCode: SHOULD contain interpretationCode
should-author: SHOULD contain author
should-referenceRange: SHOULD contain referenceRange
.... entryRelationship:sensoryStatus 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 SensoryStatus Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:socialHistoryObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 SocialHistoryObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-value: SHOULD contain value
4515-8555: 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.
should-sh-author: SHOULD contain author
.... entryRelationship:substanceorDeviceAllergy-IntoleranceObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 SubstanceOrDeviceAllergyIntoleranceObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
should-not-severity: Allergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level.
.... entryRelationship:vitalSignObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 VitalSignObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-code: SHOULD contain code
should-author: SHOULD contain author
should-percent: Percentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with %
should-cm: Height & Head Circumference should be represented in cm
should-kg: Weight should be represented in kg
should-cel: Temperature should be represented in Celcius (Cel)
should-bp: Blood pressure should be represented in mm[Hg]
should-rates: Rates should be represented in /min
should-bmi: BMI should be represented in kg/m2
should-bsa: BSA should be represented in m2
.... entryRelationship:longitudinalCareWoundObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 LongitudinalCareWoundObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:problemObservation2 0..* EntryRelationship The following entryRelationship represents the relationship Health Concern HAS SUPPORT Observation.
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SPRT
..... observation C 1..1 ProblemObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:caregiverCharacteristics 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 CaregiverCharacteristics Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:culturalandReligiousObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 CulturalandReligiousObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:characteristicsofHomeEnvironment 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 CharacteristicsofHomeEnvironment Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:nutritionalStatusObservation 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 NutritionalStatusObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:resultOrganizer 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... organizer C 1..1 ResultOrganizer Base for all types and resources
should-sdtctext-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
.... entryRelationship:priorityPreference1 0..* EntryRelationship The following entryRelationship represents the priority that the patient puts on the health concern.
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 PriorityPreference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-author: SHOULD contain author
.... entryRelationship:priorityPreference2 0..* EntryRelationship The following entryRelationship represents the priority that the provider puts on the health concern.
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C 1..1 PriorityPreference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-author: SHOULD contain author
.... entryRelationship:problemConcernAct 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... act C 1..1 ProblemConcernAct Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
... reference 0..* Reference
.... @typeCode 1..1 cs Binding: x_ActRelationshipExternalReference (required)
Fixed Value: REFR
.... externalDocument C 1..1 ExternalDocumentReference Base for all types and resources
should-setId: SHOULD contain setId
should-versionNumber: SHOULD contain versionNumber

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Act.classCoderequiredFixed Value: ACT
http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0
Act.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0
Act.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Act.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Act.statusCode.coderequiredProblemActStatusCode .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.19
Act.entryRelationship:problemObservation1.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:allergy-IntoleranceObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:entryReferenceRefr.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:entryReferenceComp.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:assessmentScaleObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:mentalStatusObservation1.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:self-CareActivitiesADLandIADL.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:mentalStatusObservation2.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:smokingStatus.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:encounterDiagnosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:entryRelationship11.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:functionalStatusObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:hospitalAdmissionDiagnosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:nutritionAssessment.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:postprocedureDiagnosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:pregnancyObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:preoperativeDiagnosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:reactionObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:resultObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:sensoryStatus.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:socialHistoryObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:vitalSignObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:longitudinalCareWoundObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:problemObservation2.typeCoderequiredFixed Value: SPRT
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:caregiverCharacteristics.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:culturalandReligiousObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:characteristicsofHomeEnvironment.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:nutritionalStatusObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:resultOrganizer.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:priorityPreference1.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:priorityPreference2.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:problemConcernAct.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.reference.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipExternalReference

Constraints

IdGradePath(s)DetailsRequirements
4515-8555errorAct.entryRelationship:socialHistoryObservation.observationIf 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.
:
coded-valueerrorAct.entryRelationship:smokingStatus.observationWhen code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded
: (code.code = '72166-2' or code.code = '11367-0') implies value.code.exists()
should-authorwarningActSHOULD contain author
: author.exists()
should-authorwarningAct.entryRelationship:problemObservation1.observation, Act.entryRelationship:allergy-IntoleranceObservation.observation, Act.entryRelationship:mentalStatusObservation1.observation, Act.entryRelationship:self-CareActivitiesADLandIADL.observation, Act.entryRelationship:mentalStatusObservation2.observation, Act.entryRelationship:functionalStatusObservation.observation, Act.entryRelationship:nutritionAssessment.observation, Act.entryRelationship:resultObservation.observation, Act.entryRelationship:sensoryStatus.observation, Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.observation, Act.entryRelationship:vitalSignObservation.observation, Act.entryRelationship:longitudinalCareWoundObservation.observation, Act.entryRelationship:problemObservation2.observation, Act.entryRelationship:resultOrganizer.organizer, Act.entryRelationship:priorityPreference1.observation, Act.entryRelationship:priorityPreference2.observation, Act.entryRelationship:problemConcernAct.actSHOULD contain author
: author.exists()
should-bmiwarningAct.entryRelationship:vitalSignObservation.observationBMI should be represented in kg/m2
: (code.code = '39156-5') implies value.unit = 'kg/m2'
should-bpwarningAct.entryRelationship:vitalSignObservation.observationBlood pressure should be represented in mm[Hg]
: (code.code in ('8480-6' | '8462-4' | '8478-0' | '96608-5' | '96609-3')) implies value.unit = 'mm[Hg]'
should-bsawarningAct.entryRelationship:vitalSignObservation.observationBSA should be represented in m2
: (code.code = '3140-1') implies value.unit = 'm2'
should-celwarningAct.entryRelationship:vitalSignObservation.observationTemperature should be represented in Celcius (Cel)
: (code.code = '8310-5') implies value.unit = 'Cel'
should-cmwarningAct.entryRelationship:vitalSignObservation.observationHeight & Head Circumference should be represented in cm
: (code.code in ('8287-5' | '8302-2' | '8306-3' | '9843-4')) implies value.unit = 'cm'
should-codewarningAct.entryRelationship:vitalSignObservation.observationSHOULD contain code
: code.exists()
should-effectiveTimewarningAct.entryRelationship:pregnancyObservation.observation, Act.entryRelationship:reactionObservation.observation, Act.entryRelationship:priorityPreference1.observation, Act.entryRelationship:priorityPreference2.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-interpretationCodewarningAct.entryRelationship:resultObservation.observationSHOULD contain interpretationCode
: interpretationCode.exists()
should-kgwarningAct.entryRelationship:vitalSignObservation.observationWeight should be represented in kg
: (code.code = '29463-7') implies value.unit = 'kg'
should-not-severitywarningAct.entryRelationship:allergy-IntoleranceObservation.observation, Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.observationAllergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level.
: entryRelationship.observation.where(code.code = 'SEV' and code.codeSystem = '2.16.840.1.113883.5.4').empty()
should-percentwarningAct.entryRelationship:vitalSignObservation.observationPercentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with %
: (code.code in ('2708-6' | '3150-0' | '59408-5' | '8289-1' | '59575-1' | '59576-9')) implies value.unit = '%'
should-rateswarningAct.entryRelationship:vitalSignObservation.observationRates should be represented in /min
: (code.code in ('8867-4' | '9279-1')) implies value.unit = '/min'
should-referenceRangewarningAct.entryRelationship:resultObservation.observationSHOULD contain referenceRange
: referenceRange.exists()
should-sdtctext-ref-valuewarningAct.entryRelationship:entryRelationship11.organizer, Act.entryRelationship:resultOrganizer.organizerSHOULD contain text/reference/@value
: sdtcText.reference.value.exists()
should-setIdwarningAct.reference.externalDocumentSHOULD contain setId
: setId.exists()
should-sh-authorwarningAct.entryRelationship:socialHistoryObservation.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningActSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningAct.entryRelationship:problemObservation1.observation, Act.entryRelationship:allergy-IntoleranceObservation.observation, Act.entryRelationship:entryReferenceRefr.act, Act.entryRelationship:entryReferenceComp.act, Act.entryRelationship:assessmentScaleObservation.observation, Act.entryRelationship:mentalStatusObservation1.observation, Act.entryRelationship:self-CareActivitiesADLandIADL.observation, Act.entryRelationship:mentalStatusObservation2.observation, Act.entryRelationship:smokingStatus.observation, Act.entryRelationship:encounterDiagnosis.act, Act.entryRelationship:functionalStatusObservation.observation, Act.entryRelationship:hospitalAdmissionDiagnosis.act, Act.entryRelationship:nutritionAssessment.observation, Act.entryRelationship:postprocedureDiagnosis.act, Act.entryRelationship:pregnancyObservation.observation, Act.entryRelationship:preoperativeDiagnosis.act, Act.entryRelationship:reactionObservation.observation, Act.entryRelationship:resultObservation.observation, Act.entryRelationship:sensoryStatus.observation, Act.entryRelationship:socialHistoryObservation.observation, Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.observation, Act.entryRelationship:vitalSignObservation.observation, Act.entryRelationship:longitudinalCareWoundObservation.observation, Act.entryRelationship:problemObservation2.observation, Act.entryRelationship:caregiverCharacteristics.observation, Act.entryRelationship:culturalandReligiousObservation.observation, Act.entryRelationship:characteristicsofHomeEnvironment.observation, Act.entryRelationship:nutritionalStatusObservation.observation, Act.entryRelationship:priorityPreference1.observation, Act.entryRelationship:priorityPreference2.observation, Act.entryRelationship:problemConcernAct.actSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningAct.entryRelationship:socialHistoryObservation.observationSHOULD contain value
: value.exists()
should-versionNumberwarningAct.reference.externalDocumentSHOULD contain versionNumber
: versionNumber.exists()
value-starts-octothorpeerrorAct.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C 1..1 Act XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance 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
.... templateId:risk-concern-act 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: 2.16.840.1.113883.10.20.22.4.136
..... @extension 1..1 st Required Pattern: 2015-08-01
... @classCode 1..1 cs Binding: XActClassDocumentEntryAct (2.0.0) (required)
Fixed Value: ACT
... @moodCode 1..1 cs Binding: XDocumentActMood (2.0.0) (required)
Fixed Value: EVN
... @negationInd 0..1 bl
... id 1..* II
... code 1..1 CD At risk - finding
Binding: v3 Code System ActCode (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 281694009
.... @codeSystem 1..1 oid, uuid, ruid SNOMED CT
Required Pattern: 2.16.840.1.113883.6.96
.... @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
... 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: CDACompressionAlgorithm (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: CDABinaryDataEncoding (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)
.... @code 1..1 cs Binding: ProblemAct statusCode . (required)
.... @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 0..1 IVL_TS
... priorityCode 0..1 CE Binding: ActPriority (example)
... languageCode 0..1 CS Binding: AllLanguages (required)
... 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 Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry.
Slice: Unordered, Open by value:typeCode, profile:observation, profile:act, profile:organizer
.... entryRelationship:problemObservation1 0..* EntryRelationship
..... @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: REFR
..... @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 ProblemObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@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
.... entryRelationship:allergy-IntoleranceObservation 0..* EntryRelationship
..... @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: REFR
..... @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 AllergyIntoleranceObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
should-not-severity: Allergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level.
..... 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:entryReferenceRefr 0..* EntryRelationship The following entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern RELATES TO Health Concern). It can also represent the relationship between a Health Concern and another entry already described in the CDA document instance. The Entry Reference template is used here because the target entry will be defined elsewhere and thus a reference to that instance is all that is required.
..... @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: REFR
..... @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
should-text-ref-value: SHOULD contain text/reference/@value
..... 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
.... entryRelationship:entryReferenceComp 0..* EntryRelationship The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). The Enry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required.
..... @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: COMP
..... @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
should-text-ref-value: SHOULD contain text/reference/@value
..... 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
.... entryRelationship:assessmentScaleObservation 0..* EntryRelationship
..... @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: REFR
..... @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
should-text-ref-value: SHOULD contain text/reference/@value
..... 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:mentalStatusObservation1 0..* EntryRelationship
..... @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: REFR
..... @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 MentalStatusObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@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
.... entryRelationship:self-CareActivitiesADLandIADL 0..* EntryRelationship
..... @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: REFR
..... @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 SelfCareActivitiesADLandIADL Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@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
.... entryRelationship:mentalStatusObservation2 0..* EntryRelationship
..... @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: REFR
..... @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 MentalStatusObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@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
.... entryRelationship:smokingStatus 0..* EntryRelationship
..... @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: REFR
..... @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 SmokingStatus Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
coded-value: When code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded
..... 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:encounterDiagnosis 0..* EntryRelationship
..... @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: REFR
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act C 1..1 EncounterDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... 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
.... entryRelationship:entryRelationship11 0..* EntryRelationship
..... @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: REFR
..... @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 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer C 1..1 FamilyHistoryOrganizer Base for all types and resources
should-sdtctext-ref-value: SHOULD contain text/reference/@value
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:functionalStatusObservation 0..* EntryRelationship
..... @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: REFR
..... @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 FunctionalStatusObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@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
.... entryRelationship:hospitalAdmissionDiagnosis 0..* EntryRelationship
..... @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: REFR
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act C 1..1 HospitalAdmissionDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... 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
.... entryRelationship:nutritionAssessment 0..* EntryRelationship
..... @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: REFR
..... @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 NutritionAssessment Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@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
.... entryRelationship:postprocedureDiagnosis 0..* EntryRelationship
..... @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: REFR
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act C 1..1 PostprocedureDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... 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
.... entryRelationship:pregnancyObservation 0..* EntryRelationship
..... @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: REFR
..... @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 PregnancyObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
..... 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:preoperativeDiagnosis 0..* EntryRelationship
..... @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: REFR
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act C 1..1 PreoperativeDiagnosis Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... 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
.... entryRelationship:reactionObservation 0..* EntryRelationship
..... @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: REFR
..... @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 ReactionObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
..... 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:resultObservation 0..* EntryRelationship
..... @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: REFR
..... @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 ResultObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-interpretationCode: SHOULD contain interpretationCode
should-author: SHOULD contain author
should-referenceRange: SHOULD contain referenceRange
..... 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:sensoryStatus 0..* EntryRelationship
..... @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: REFR
..... @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 SensoryStatus Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@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
.... entryRelationship:socialHistoryObservation 0..* EntryRelationship
..... @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: REFR
..... @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 SocialHistoryObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-value: SHOULD contain value
4515-8555: 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.
should-sh-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
.... entryRelationship:substanceorDeviceAllergy-IntoleranceObservation 0..* EntryRelationship
..... @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: REFR
..... @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 SubstanceOrDeviceAllergyIntoleranceObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
should-not-severity: Allergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level.
..... 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:vitalSignObservation 0..* EntryRelationship
..... @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: REFR
..... @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 VitalSignObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-code: SHOULD contain code
should-author: SHOULD contain author
should-percent: Percentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with %
should-cm: Height & Head Circumference should be represented in cm
should-kg: Weight should be represented in kg
should-cel: Temperature should be represented in Celcius (Cel)
should-bp: Blood pressure should be represented in mm[Hg]
should-rates: Rates should be represented in /min
should-bmi: BMI should be represented in kg/m2
should-bsa: BSA should be represented in m2
..... 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:longitudinalCareWoundObservation 0..* EntryRelationship
..... @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: REFR
..... @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 LongitudinalCareWoundObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@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
.... entryRelationship:problemObservation2 0..* EntryRelationship The following entryRelationship represents the relationship Health Concern HAS SUPPORT Observation.
..... @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 ProblemObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@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
.... entryRelationship:caregiverCharacteristics 0..* EntryRelationship
..... @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: REFR
..... @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 CaregiverCharacteristics Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... 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:culturalandReligiousObservation 0..* EntryRelationship
..... @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: REFR
..... @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 CulturalandReligiousObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... 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:characteristicsofHomeEnvironment 0..* EntryRelationship
..... @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: REFR
..... @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 CharacteristicsofHomeEnvironment Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... 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:nutritionalStatusObservation 0..* EntryRelationship
..... @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: REFR
..... @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 NutritionalStatusObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... 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:resultOrganizer 0..* EntryRelationship
..... @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: REFR
..... @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 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer C 1..1 ResultOrganizer Base for all types and resources
should-sdtctext-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:priorityPreference1 0..* EntryRelationship The following entryRelationship represents the priority that the patient puts on the health concern.
..... @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: REFR
..... @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 PriorityPreference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
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
.... entryRelationship:priorityPreference2 0..* EntryRelationship The following entryRelationship represents the priority that the provider puts on the health concern.
..... @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: REFR
..... @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 PriorityPreference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
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
.... entryRelationship:problemConcernAct 0..* EntryRelationship
..... @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: REFR
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act C 1..1 ProblemConcernAct Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-author: SHOULD contain author
..... 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
.... @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_ActRelationshipExternalReference (required)
Fixed Value: REFR
.... seperatableInd 0..1 BL
.... externalAct 0..1 ExternalAct
.... externalObservation 0..1 ExternalObservation
.... externalProcedure 0..1 ExternalProcedure
.... externalDocument C 1..1 ExternalDocumentReference Base for all types and resources
should-setId: SHOULD contain setId
should-versionNumber: SHOULD contain versionNumber
... precondition 0..* Precondition
... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Act.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.templateId:risk-concern-act.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.classCoderequiredFixed Value: ACT
http://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0
Act.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0
Act.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Act.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Act.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Act.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Act.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Act.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Act.statusCode.coderequiredProblemActStatusCode .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.19
Act.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Act.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Act.entryRelationship:problemObservation1.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemObservation1.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemObservation1.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:allergy-IntoleranceObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:allergy-IntoleranceObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:allergy-IntoleranceObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:entryReferenceRefr.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:entryReferenceRefr.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:entryReferenceRefr.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:entryReferenceComp.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:entryReferenceComp.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:entryReferenceComp.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:assessmentScaleObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:assessmentScaleObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:assessmentScaleObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:mentalStatusObservation1.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:mentalStatusObservation1.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:mentalStatusObservation1.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:self-CareActivitiesADLandIADL.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:self-CareActivitiesADLandIADL.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:self-CareActivitiesADLandIADL.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:mentalStatusObservation2.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:mentalStatusObservation2.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:mentalStatusObservation2.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:smokingStatus.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:smokingStatus.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:smokingStatus.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:encounterDiagnosis.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:encounterDiagnosis.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:encounterDiagnosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:entryRelationship11.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:entryRelationship11.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:entryRelationship11.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:functionalStatusObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:functionalStatusObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:functionalStatusObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:hospitalAdmissionDiagnosis.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:hospitalAdmissionDiagnosis.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:hospitalAdmissionDiagnosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:nutritionAssessment.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:nutritionAssessment.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:nutritionAssessment.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:postprocedureDiagnosis.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:postprocedureDiagnosis.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:postprocedureDiagnosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:pregnancyObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:pregnancyObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:pregnancyObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:preoperativeDiagnosis.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:preoperativeDiagnosis.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:preoperativeDiagnosis.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:reactionObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:reactionObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:reactionObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:resultObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:resultObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:resultObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:sensoryStatus.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:sensoryStatus.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:sensoryStatus.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:socialHistoryObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:socialHistoryObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:socialHistoryObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:vitalSignObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:vitalSignObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:vitalSignObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:longitudinalCareWoundObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:longitudinalCareWoundObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:longitudinalCareWoundObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:problemObservation2.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemObservation2.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemObservation2.typeCoderequiredFixed Value: SPRT
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:caregiverCharacteristics.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:caregiverCharacteristics.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:caregiverCharacteristics.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:culturalandReligiousObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:culturalandReligiousObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:culturalandReligiousObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:characteristicsofHomeEnvironment.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:characteristicsofHomeEnvironment.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:characteristicsofHomeEnvironment.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:nutritionalStatusObservation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:nutritionalStatusObservation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:nutritionalStatusObservation.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:resultOrganizer.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:resultOrganizer.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:resultOrganizer.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:priorityPreference1.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:priorityPreference1.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:priorityPreference1.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:priorityPreference2.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:priorityPreference2.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:priorityPreference2.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.entryRelationship:problemConcernAct.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemConcernAct.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.entryRelationship:problemConcernAct.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Act.reference.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.reference.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Act.reference.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipExternalReference

Constraints

IdGradePath(s)DetailsRequirements
4515-8555errorAct.entryRelationship:socialHistoryObservation.observationIf 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.
:
coded-valueerrorAct.entryRelationship:smokingStatus.observationWhen code is Smoking Status (72166-2) or Tobacco Use (11367-0), the value SHALL be coded
: (code.code = '72166-2' or code.code = '11367-0') implies value.code.exists()
should-authorwarningActSHOULD contain author
: author.exists()
should-authorwarningAct.entryRelationship:problemObservation1.observation, Act.entryRelationship:allergy-IntoleranceObservation.observation, Act.entryRelationship:mentalStatusObservation1.observation, Act.entryRelationship:self-CareActivitiesADLandIADL.observation, Act.entryRelationship:mentalStatusObservation2.observation, Act.entryRelationship:functionalStatusObservation.observation, Act.entryRelationship:nutritionAssessment.observation, Act.entryRelationship:resultObservation.observation, Act.entryRelationship:sensoryStatus.observation, Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.observation, Act.entryRelationship:vitalSignObservation.observation, Act.entryRelationship:longitudinalCareWoundObservation.observation, Act.entryRelationship:problemObservation2.observation, Act.entryRelationship:resultOrganizer.organizer, Act.entryRelationship:priorityPreference1.observation, Act.entryRelationship:priorityPreference2.observation, Act.entryRelationship:problemConcernAct.actSHOULD contain author
: author.exists()
should-bmiwarningAct.entryRelationship:vitalSignObservation.observationBMI should be represented in kg/m2
: (code.code = '39156-5') implies value.unit = 'kg/m2'
should-bpwarningAct.entryRelationship:vitalSignObservation.observationBlood pressure should be represented in mm[Hg]
: (code.code in ('8480-6' | '8462-4' | '8478-0' | '96608-5' | '96609-3')) implies value.unit = 'mm[Hg]'
should-bsawarningAct.entryRelationship:vitalSignObservation.observationBSA should be represented in m2
: (code.code = '3140-1') implies value.unit = 'm2'
should-celwarningAct.entryRelationship:vitalSignObservation.observationTemperature should be represented in Celcius (Cel)
: (code.code = '8310-5') implies value.unit = 'Cel'
should-cmwarningAct.entryRelationship:vitalSignObservation.observationHeight & Head Circumference should be represented in cm
: (code.code in ('8287-5' | '8302-2' | '8306-3' | '9843-4')) implies value.unit = 'cm'
should-codewarningAct.entryRelationship:vitalSignObservation.observationSHOULD contain code
: code.exists()
should-effectiveTimewarningAct.entryRelationship:pregnancyObservation.observation, Act.entryRelationship:reactionObservation.observation, Act.entryRelationship:priorityPreference1.observation, Act.entryRelationship:priorityPreference2.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-interpretationCodewarningAct.entryRelationship:resultObservation.observationSHOULD contain interpretationCode
: interpretationCode.exists()
should-kgwarningAct.entryRelationship:vitalSignObservation.observationWeight should be represented in kg
: (code.code = '29463-7') implies value.unit = 'kg'
should-not-severitywarningAct.entryRelationship:allergy-IntoleranceObservation.observation, Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.observationAllergy SHOULD NOT include severity. Severity belongs at reaction level, while Criticality is used at the allergy level.
: entryRelationship.observation.where(code.code = 'SEV' and code.codeSystem = '2.16.840.1.113883.5.4').empty()
should-percentwarningAct.entryRelationship:vitalSignObservation.observationPercentage codes (PulseOx, O2 Concentration, Percentiles) should be represented with %
: (code.code in ('2708-6' | '3150-0' | '59408-5' | '8289-1' | '59575-1' | '59576-9')) implies value.unit = '%'
should-rateswarningAct.entryRelationship:vitalSignObservation.observationRates should be represented in /min
: (code.code in ('8867-4' | '9279-1')) implies value.unit = '/min'
should-referenceRangewarningAct.entryRelationship:resultObservation.observationSHOULD contain referenceRange
: referenceRange.exists()
should-sdtctext-ref-valuewarningAct.entryRelationship:entryRelationship11.organizer, Act.entryRelationship:resultOrganizer.organizerSHOULD contain text/reference/@value
: sdtcText.reference.value.exists()
should-setIdwarningAct.reference.externalDocumentSHOULD contain setId
: setId.exists()
should-sh-authorwarningAct.entryRelationship:socialHistoryObservation.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningActSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningAct.entryRelationship:problemObservation1.observation, Act.entryRelationship:allergy-IntoleranceObservation.observation, Act.entryRelationship:entryReferenceRefr.act, Act.entryRelationship:entryReferenceComp.act, Act.entryRelationship:assessmentScaleObservation.observation, Act.entryRelationship:mentalStatusObservation1.observation, Act.entryRelationship:self-CareActivitiesADLandIADL.observation, Act.entryRelationship:mentalStatusObservation2.observation, Act.entryRelationship:smokingStatus.observation, Act.entryRelationship:encounterDiagnosis.act, Act.entryRelationship:functionalStatusObservation.observation, Act.entryRelationship:hospitalAdmissionDiagnosis.act, Act.entryRelationship:nutritionAssessment.observation, Act.entryRelationship:postprocedureDiagnosis.act, Act.entryRelationship:pregnancyObservation.observation, Act.entryRelationship:preoperativeDiagnosis.act, Act.entryRelationship:reactionObservation.observation, Act.entryRelationship:resultObservation.observation, Act.entryRelationship:sensoryStatus.observation, Act.entryRelationship:socialHistoryObservation.observation, Act.entryRelationship:substanceorDeviceAllergy-IntoleranceObservation.observation, Act.entryRelationship:vitalSignObservation.observation, Act.entryRelationship:longitudinalCareWoundObservation.observation, Act.entryRelationship:problemObservation2.observation, Act.entryRelationship:caregiverCharacteristics.observation, Act.entryRelationship:culturalandReligiousObservation.observation, Act.entryRelationship:characteristicsofHomeEnvironment.observation, Act.entryRelationship:nutritionalStatusObservation.observation, Act.entryRelationship:priorityPreference1.observation, Act.entryRelationship:priorityPreference2.observation, Act.entryRelationship:problemConcernAct.actSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningAct.entryRelationship:socialHistoryObservation.observationSHOULD contain value
: value.exists()
should-versionNumberwarningAct.reference.externalDocumentSHOULD contain versionNumber
: versionNumber.exists()
value-starts-octothorpeerrorAct.text.referenceIf 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 Act

Summary

Mandatory: 9 elements(34 nested mandatory elements)
Fixed: 36 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of Act.templateId
  • The element 4 is sliced based on the values of Act.entryRelationship

 

Other representations of profile: CSV, Excel