Consolidated CDA (C-CDA)
3.0.0 - STU3
Consolidated CDA (C-CDA)
3.0.0 - STU3
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
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/SocialHistoryObservation | Version: 3.0.0 | |||
| Draft as of 2024-05-18 | Computable Name: SocialHistoryObservation | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.38:2022-06-01 | ||||
This template represents a patient’s job (occupation and industry), lifestyle, and environmental health risk factors. Demographic data (e.g., marital status, race, ethnicity, religious affiliation) are captured in the header. Though tobacco use and exposure may be represented with a Social History Observation, it is recommended to use the Current Smoking Status template or the Tobacco Use template instead, to represent smoking or tobacco habits. There are supplemental templates and guidance for observations of Occupational Data for Health, nutrition and pregnancy that could be captured in the Social History Observation, and implementers may want to consider using those more specific templates in the Social History section.
Usage:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
  Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) 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 | ||||||
  Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
   templateId:social-history-obs |
1..1 | II | ||||||||
  @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.38 | |||||||
  @extension |
1..1 | st | Required Pattern: 2022-06-01 | |||||||
 @classCode |
1..1 | cs | Fixed Value: OBS | |||||||
| @moodCode |
1..1 | cs | Fixed Value: EVN | |||||||
| id |
1..* | II | ||||||||
| code |
C | 1..1 | CD | Binding: Social History Type  (preferred)4515-32956: If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). | ||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
 reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| statusCode |
1..1 | CS | ||||||||
| @code |
1..1 | cs | Fixed Value: completed | |||||||
| effectiveTime |
1..1 | IVL_TS | ||||||||
| Slices for value |
0..1 | ANY, BL, ED, ST, CD, CV, CE, CO, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | (USCDI) Alcohol Use, Substance Use, SDOH Problems/Health Concerns Slice: Unordered, Open by type:$this | |||||||
 value:physical-quantity |
0..1 | PQ | ||||||||
 @unit |
1..1 | cs | Binding: UnitsOfMeasureCaseSensitive (preferred) | |||||||
 value:coded |
0..1 | CD | Binding: (unbound) (example): See additional binding
| |||||||
 author |
0..* | AuthorParticipation | Base for all types and resources | |||||||
 Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |||||||
| entryRelationship:supportingObs |
0..* | EntryRelationship | When an Assessment Scale Observation is contained in a Social History Observation instance that is a Social Determinant of Health Social History Observation, that Assessment Scale Observation MAY contain Assessment Scale Supporting Observations that contain LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @typeCode |
1..1 | cs | Fixed Value: SPRT | |||||||
| observation |
1..1 | AssessmentScaleObservation | Base for all types and resources | |||||||
| entryRelationship:entryReference |
0..* | EntryRelationship | When an Entry Reference is contained in a Social History Template instance that is a Social Determinant of Health Social History, that Entry Reference **MAY** reference an Assessment Scale Observation elsewhere in the document that represent LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @typeCode |
1..1 | cs | Fixed Value: SPRT | |||||||
| act |
1..1 | EntryReference | Base for all types and resources | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet | URI |
| Observation.code | preferred | SocialHistoryType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.60 | |
| Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| Observation.value:coded | example | |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-8555 | error | Observation | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4515-32956 | warning | Observation.code | If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). : codeSystem = '2.16.840.1.113883.6.1' or translation.where(codeSystem = '2.16.840.1.113883.6.1').exists() | |
| should-sh-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-value | warning | Observation | SHOULD contain value : value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) 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 | ||||||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:social-history-obs |
1..1 | II | ||||||||
 @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.38 | |||||||
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |||||||
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |||||||
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||
| id |
1..* | II | ||||||||
| code |
C | 1..1 | CD | Binding: Social History Type (preferred) 4515-32956: If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). | ||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |||||||
| @code |
1..1 | cs | Fixed Value: completed | |||||||
| effectiveTime |
1..1 | IVL_TS | ||||||||
| Slices for value |
0..1 | (USCDI) Alcohol Use, Substance Use, SDOH Problems/Health Concerns Slice: Unordered, Open by type:$this | ||||||||
  value |
ANY | |||||||||
| value |
BL | |||||||||
| value |
ED | |||||||||
| value |
ST | |||||||||
| value |
CD | |||||||||
| value |
CV | |||||||||
| value |
CE | |||||||||
| value |
CO | |||||||||
| value |
SC | |||||||||
| value |
II | |||||||||
| value |
TEL | |||||||||
| value |
AD | |||||||||
| value |
EN | |||||||||
| value |
INT | |||||||||
| value |
REAL | |||||||||
| value |
PQ | |||||||||
| value |
MO | |||||||||
| value |
TS | |||||||||
| value |
IVL_PQ | |||||||||
| value |
IVL_TS | |||||||||
| value |
PIVL_TS | |||||||||
| value |
EIVL_TS | |||||||||
| value |
SXPR_TS | |||||||||
| value |
RTO_PQ_PQ | |||||||||
| value:physical-quantity |
0..1 | PQ | ||||||||
| @unit |
1..1 | cs | Binding: UnitsOfMeasureCaseSensitive (preferred) | |||||||
| value:coded |
0..1 | CD | Binding: (unbound) (example): See additional binding
| |||||||
| author |
0..* | AuthorParticipation | Base for all types and resources | |||||||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |||||||
| entryRelationship:supportingObs |
0..* | EntryRelationship | When an Assessment Scale Observation is contained in a Social History Observation instance that is a Social Determinant of Health Social History Observation, that Assessment Scale Observation MAY contain Assessment Scale Supporting Observations that contain LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| observation |
C | 1..1 | AssessmentScaleObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| entryRelationship:entryReference |
0..* | EntryRelationship | When an Entry Reference is contained in a Social History Template instance that is a Social Determinant of Health Social History, that Entry Reference **MAY** reference an Assessment Scale Observation elsewhere in the document that represent LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| act |
C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Observation.code | preferred | SocialHistoryType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.60 | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| Observation.value:coded | example | ||
| Observation.entryRelationship:supportingObs.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.entryRelationship:entryReference.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-8555 | error | Observation | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4515-32956 | warning | Observation.code | If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). : codeSystem = '2.16.840.1.113883.6.1' or translation.where(codeSystem = '2.16.840.1.113883.6.1').exists() | |
| should-sh-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Observation.entryRelationship:supportingObs.observation, Observation.entryRelationship:entryReference.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-value | warning | Observation | SHOULD contain value : value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) 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 | ||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:social-history-obs |
1..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.38 | |||||||
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |||||||
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |||||||
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||
| @negationInd |
0..1 | bl | ||||||||
| id |
1..* | II | ||||||||
| code |
C | 1..1 | CD | Binding: Social History Type (preferred) 4515-32956: If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). | ||||||
| derivationExpr |
0..1 | ST | ||||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @compression |
0..1 | cs | Binding: 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) | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code |
1..1 | cs | Fixed Value: completed | |||||||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |||||||
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |||||||
| effectiveTime |
1..1 | IVL_TS | ||||||||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |||||||
| repeatNumber |
0..1 | IVL_INT | ||||||||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |||||||
| Slices for value |
0..1 | (USCDI) Alcohol Use, Substance Use, SDOH Problems/Health Concerns Slice: Unordered, Open by type:$this | ||||||||
| value |
ANY | |||||||||
| value |
BL | |||||||||
| value |
ED | |||||||||
| value |
ST | |||||||||
| value |
CD | |||||||||
| value |
CV | |||||||||
| value |
CE | |||||||||
| value |
CO | |||||||||
| value |
SC | |||||||||
| value |
II | |||||||||
| value |
TEL | |||||||||
| value |
AD | |||||||||
| value |
EN | |||||||||
| value |
INT | |||||||||
| value |
REAL | |||||||||
| value |
PQ | |||||||||
| value |
MO | |||||||||
| value |
TS | |||||||||
| value |
IVL_PQ | |||||||||
| value |
IVL_TS | |||||||||
| value |
PIVL_TS | |||||||||
| value |
EIVL_TS | |||||||||
| value |
SXPR_TS | |||||||||
| value |
RTO_PQ_PQ | |||||||||
| value:physical-quantity |
0..1 | PQ | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @unit |
1..1 | cs | Binding: UnitsOfMeasureCaseSensitive (preferred) | |||||||
| @value |
0..1 | real | ||||||||
| translation |
0..* | PQR | ||||||||
| value:coded |
0..1 | CD | Binding: (unbound) (example): See additional binding
| |||||||
| interpretationCode |
0..* | CE | Binding: CDAObservationInterpretation (required) | |||||||
| methodCode |
0..* | CE | Binding: ObservationMethod (example) | |||||||
| targetSiteCode |
0..* | CD | ||||||||
| subject |
0..1 | Subject | ||||||||
| specimen |
0..* | Specimen | ||||||||
| performer |
0..* | Performer2 | ||||||||
| author |
0..* | AuthorParticipation | Base for all types and resources | |||||||
| informant |
0..* | Informant | ||||||||
| participant |
0..* | Participant2 | ||||||||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |||||||
| entryRelationship:supportingObs |
0..* | EntryRelationship | When an Assessment Scale Observation is contained in a Social History Observation instance that is a Social Determinant of Health Social History Observation, that Assessment Scale Observation MAY contain Assessment Scale Supporting Observations that contain LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
 typeId |
0..1 | II | ||||||||
 @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | AssessmentScaleObservation | Base for all types and resources 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:entryReference |
0..* | EntryRelationship | When an Entry Reference is contained in a Social History Template instance that is a Social Determinant of Health Social History, that Entry Reference **MAY** reference an Assessment Scale Observation elsewhere in the document that represent LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
C | 1..1 | EntryReference | Base for all types and resources 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 | ||||||||
| reference |
0..* | Reference | ||||||||
| precondition |
0..* | Precondition | ||||||||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |||||||
| referenceRange |
0..* | InfrastructureRoot | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: REFV | |||||||
| observationRange |
1..1 | ObservationRange | ||||||||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.templateId:social-history-obs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Observation.code | preferred | SocialHistoryType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.60 | |
| Observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Observation.value:physical-quantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| Observation.value:coded | example | ||
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
| Observation.entryRelationship:supportingObs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:supportingObs.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:supportingObs.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.entryRelationship:entryReference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:entryReference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:entryReference.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.referenceRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.typeCode | required | Fixed Value: REFVhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-8555 | error | Observation | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4515-32956 | warning | Observation.code | If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). : codeSystem = '2.16.840.1.113883.6.1' or translation.where(codeSystem = '2.16.840.1.113883.6.1').exists() | |
| should-sh-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Observation.entryRelationship:supportingObs.observation, Observation.entryRelationship:entryReference.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-value | warning | Observation | SHOULD contain value : value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from Observation
Summary
Mandatory: 8 elements(3 nested mandatory elements)
Fixed: 5 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Observation
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) 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 | ||||||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:social-history-obs |
1..1 | II | ||||||||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.38 | |||||||
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |||||||
| @classCode |
1..1 | cs | Fixed Value: OBS | |||||||
| @moodCode |
1..1 | cs | Fixed Value: EVN | |||||||
| id |
1..* | II | ||||||||
| code |
C | 1..1 | CD | Binding: Social History Type (preferred) 4515-32956: If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). | ||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| statusCode |
1..1 | CS | ||||||||
| @code |
1..1 | cs | Fixed Value: completed | |||||||
| effectiveTime |
1..1 | IVL_TS | ||||||||
| Slices for value |
0..1 | ANY, BL, ED, ST, CD, CV, CE, CO, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | (USCDI) Alcohol Use, Substance Use, SDOH Problems/Health Concerns Slice: Unordered, Open by type:$this | |||||||
| value:physical-quantity |
0..1 | PQ | ||||||||
| @unit |
1..1 | cs | Binding: UnitsOfMeasureCaseSensitive (preferred) | |||||||
| value:coded |
0..1 | CD | Binding: (unbound) (example): See additional binding
| |||||||
| author |
0..* | AuthorParticipation | Base for all types and resources | |||||||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |||||||
| entryRelationship:supportingObs |
0..* | EntryRelationship | When an Assessment Scale Observation is contained in a Social History Observation instance that is a Social Determinant of Health Social History Observation, that Assessment Scale Observation MAY contain Assessment Scale Supporting Observations that contain LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @typeCode |
1..1 | cs | Fixed Value: SPRT | |||||||
| observation |
1..1 | AssessmentScaleObservation | Base for all types and resources | |||||||
| entryRelationship:entryReference |
0..* | EntryRelationship | When an Entry Reference is contained in a Social History Template instance that is a Social Determinant of Health Social History, that Entry Reference **MAY** reference an Assessment Scale Observation elsewhere in the document that represent LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @typeCode |
1..1 | cs | Fixed Value: SPRT | |||||||
| act |
1..1 | EntryReference | Base for all types and resources | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet | URI |
| Observation.code | preferred | SocialHistoryType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.60 | |
| Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| Observation.value:coded | example | |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-8555 | error | Observation | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4515-32956 | warning | Observation.code | If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). : codeSystem = '2.16.840.1.113883.6.1' or translation.where(codeSystem = '2.16.840.1.113883.6.1').exists() | |
| should-sh-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-value | warning | Observation | SHOULD contain value : value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) 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 | ||||||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:social-history-obs |
1..1 | II | ||||||||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.38 | |||||||
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |||||||
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |||||||
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||
| id |
1..* | II | ||||||||
| code |
C | 1..1 | CD | Binding: Social History Type (preferred) 4515-32956: If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). | ||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |||||||
| @code |
1..1 | cs | Fixed Value: completed | |||||||
| effectiveTime |
1..1 | IVL_TS | ||||||||
| Slices for value |
0..1 | (USCDI) Alcohol Use, Substance Use, SDOH Problems/Health Concerns Slice: Unordered, Open by type:$this | ||||||||
| value |
ANY | |||||||||
| value |
BL | |||||||||
| value |
ED | |||||||||
| value |
ST | |||||||||
| value |
CD | |||||||||
| value |
CV | |||||||||
| value |
CE | |||||||||
| value |
CO | |||||||||
| value |
SC | |||||||||
| value |
II | |||||||||
| value |
TEL | |||||||||
| value |
AD | |||||||||
| value |
EN | |||||||||
| value |
INT | |||||||||
| value |
REAL | |||||||||
| value |
PQ | |||||||||
| value |
MO | |||||||||
| value |
TS | |||||||||
| value |
IVL_PQ | |||||||||
| value |
IVL_TS | |||||||||
| value |
PIVL_TS | |||||||||
| value |
EIVL_TS | |||||||||
| value |
SXPR_TS | |||||||||
| value |
RTO_PQ_PQ | |||||||||
| value:physical-quantity |
0..1 | PQ | ||||||||
| @unit |
1..1 | cs | Binding: UnitsOfMeasureCaseSensitive (preferred) | |||||||
| value:coded |
0..1 | CD | Binding: (unbound) (example): See additional binding
| |||||||
| author |
0..* | AuthorParticipation | Base for all types and resources | |||||||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |||||||
| entryRelationship:supportingObs |
0..* | EntryRelationship | When an Assessment Scale Observation is contained in a Social History Observation instance that is a Social Determinant of Health Social History Observation, that Assessment Scale Observation MAY contain Assessment Scale Supporting Observations that contain LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| observation |
C | 1..1 | AssessmentScaleObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| entryRelationship:entryReference |
0..* | EntryRelationship | When an Entry Reference is contained in a Social History Template instance that is a Social Determinant of Health Social History, that Entry Reference **MAY** reference an Assessment Scale Observation elsewhere in the document that represent LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| act |
C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Observation.code | preferred | SocialHistoryType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.60 | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| Observation.value:coded | example | ||
| Observation.entryRelationship:supportingObs.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.entryRelationship:entryReference.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-8555 | error | Observation | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4515-32956 | warning | Observation.code | If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). : codeSystem = '2.16.840.1.113883.6.1' or translation.where(codeSystem = '2.16.840.1.113883.6.1').exists() | |
| should-sh-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Observation.entryRelationship:supportingObs.observation, Observation.entryRelationship:entryReference.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-value | warning | Observation | SHOULD contain value : value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observation |
C | 1..1 | Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, referenceRange, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) 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 | ||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:social-history-obs |
1..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.38 | |||||||
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |||||||
| @classCode |
1..1 | cs | Binding: CDAActClassObservation (required) Fixed Value: OBS | |||||||
| @moodCode |
1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: EVN | |||||||
| @negationInd |
0..1 | bl | ||||||||
| id |
1..* | II | ||||||||
| code |
C | 1..1 | CD | Binding: Social History Type (preferred) 4515-32956: If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). | ||||||
| derivationExpr |
0..1 | ST | ||||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @compression |
0..1 | cs | Binding: 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) | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code |
1..1 | cs | Fixed Value: completed | |||||||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |||||||
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |||||||
| effectiveTime |
1..1 | IVL_TS | ||||||||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |||||||
| repeatNumber |
0..1 | IVL_INT | ||||||||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |||||||
| Slices for value |
0..1 | (USCDI) Alcohol Use, Substance Use, SDOH Problems/Health Concerns Slice: Unordered, Open by type:$this | ||||||||
| value |
ANY | |||||||||
| value |
BL | |||||||||
| value |
ED | |||||||||
| value |
ST | |||||||||
| value |
CD | |||||||||
| value |
CV | |||||||||
| value |
CE | |||||||||
| value |
CO | |||||||||
| value |
SC | |||||||||
| value |
II | |||||||||
| value |
TEL | |||||||||
| value |
AD | |||||||||
| value |
EN | |||||||||
| value |
INT | |||||||||
| value |
REAL | |||||||||
| value |
PQ | |||||||||
| value |
MO | |||||||||
| value |
TS | |||||||||
| value |
IVL_PQ | |||||||||
| value |
IVL_TS | |||||||||
| value |
PIVL_TS | |||||||||
| value |
EIVL_TS | |||||||||
| value |
SXPR_TS | |||||||||
| value |
RTO_PQ_PQ | |||||||||
| value:physical-quantity |
0..1 | PQ | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @unit |
1..1 | cs | Binding: UnitsOfMeasureCaseSensitive (preferred) | |||||||
| @value |
0..1 | real | ||||||||
| translation |
0..* | PQR | ||||||||
| value:coded |
0..1 | CD | Binding: (unbound) (example): See additional binding
| |||||||
| interpretationCode |
0..* | CE | Binding: CDAObservationInterpretation (required) | |||||||
| methodCode |
0..* | CE | Binding: ObservationMethod (example) | |||||||
| targetSiteCode |
0..* | CD | ||||||||
| subject |
0..1 | Subject | ||||||||
| specimen |
0..* | Specimen | ||||||||
| performer |
0..* | Performer2 | ||||||||
| author |
0..* | AuthorParticipation | Base for all types and resources | |||||||
| informant |
0..* | Informant | ||||||||
| participant |
0..* | Participant2 | ||||||||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |||||||
| entryRelationship:supportingObs |
0..* | EntryRelationship | When an Assessment Scale Observation is contained in a Social History Observation instance that is a Social Determinant of Health Social History Observation, that Assessment Scale Observation MAY contain Assessment Scale Supporting Observations that contain LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | AssessmentScaleObservation | Base for all types and resources 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:entryReference |
0..* | EntryRelationship | When an Entry Reference is contained in a Social History Template instance that is a Social Determinant of Health Social History, that Entry Reference **MAY** reference an Assessment Scale Observation elsewhere in the document that represent LOINC question and answer pairs from SDOH screening instruments. | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SPRT | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
C | 1..1 | EntryReference | Base for all types and resources 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 | ||||||||
| reference |
0..* | Reference | ||||||||
| precondition |
0..* | Precondition | ||||||||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |||||||
| referenceRange |
0..* | InfrastructureRoot | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
0..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: REFV | |||||||
| observationRange |
1..1 | ObservationRange | ||||||||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.templateId:social-history-obs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.classCode | required | Fixed Value: OBShttp://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation | |
| Observation.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0 | |
| Observation.code | preferred | SocialHistoryType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.60 | |
| Observation.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Observation.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Observation.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Observation.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Observation.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Observation.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Observation.value:physical-quantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.value:physical-quantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| Observation.value:coded | example | ||
| Observation.interpretationCode | required | CDAObservationInterpretationhttp://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation | |
| Observation.methodCode | example | ObservationMethodhttp://terminology.hl7.org/ValueSet/v3-ObservationMethod | |
| Observation.entryRelationship:supportingObs.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:supportingObs.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:supportingObs.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.entryRelationship:entryReference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:entryReference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.entryRelationship:entryReference.typeCode | required | Fixed Value: SPRThttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Observation.referenceRange.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Observation.referenceRange.typeCode | required | Fixed Value: REFVhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType |
| Id | Grade | Path(s) | Details | Requirements |
| 4515-8555 | error | Observation | If Observation/value is a physical quantity (xsi:type="PQ"): This value SHALL contain exactly one [1..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC. Note: Base CDA requires that all @unit values SHALL be drawn from UCUM. : | |
| 4515-32956 | warning | Observation.code | If @codeSystem is not LOINC, then this code **SHALL** contain at least one [1..*] translation, which **SHOULD** be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:4515-32956). : codeSystem = '2.16.840.1.113883.6.1' or translation.where(codeSystem = '2.16.840.1.113883.6.1').exists() | |
| should-sh-author | warning | Observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Observation.entryRelationship:supportingObs.observation, Observation.entryRelationship:entryReference.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-value | warning | Observation | SHOULD contain value : value.exists() | |
| value-starts-octothorpe | error | Observation.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from Observation
Summary
Mandatory: 8 elements(3 nested mandatory elements)
Fixed: 5 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#3.0.0 based on FHIR 5.0.0. Generated 2024-05-18
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