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. For a full list of available versions, see the Directory of published versions

Logical Model: Assessment Scale Observation

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentScaleObservation Version: 3.0.0
Draft as of 2024-05-18 Computable Name: AssessmentScaleObservation
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.69:2022-06-01

An assessment scale is a collection of observations that together can yield a calculated or non-calculated summary evaluation of a one or more conditions. Examples include the Braden Scale (assesses pressure ulcer risk), APACHE Score (estimates mortality in critically ill patients), Mini-Mental Status Exam (assesses cognitive function), APGAR Score (assesses the health of a newborn), Glasgow Coma Scale (assesses coma and impaired consciousness), and WE CARE (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education - a clinic-based screening and referral system developed for pediatric settings).

When an Assessment Scale Observation is contained in a Problem Observation, a Social History Observation or a Procedure instance that is Social Determinant of Health focused, that Assessment scale MAY contain assessment scale observations that represent question and answer pairs from SDOH screening instruments that are represented in LOINC. Note that guidance on the use of LOINC in assessment scales already exists in Assessment Scale Observation constraints and Assessment Scale Supporting Observations constraints.

Usage:

Formal Views of Template Content

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

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:assessment-scale-obs 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.69
..... @extension 1..1 st Required Pattern: 2022-06-01
... @classCode 1..1 cs Fixed Value: OBS
... @moodCode 1..1 cs Fixed Value: EVN
... code 1..1 CD Binding: ObservationType (example)
Additional BindingsPurposeDocumentation
http://cts.nlm.nih.gov/fhir/ValueAet/2.16.840.1.113762.1.4.1247.206 Preferred Binding
For Social Determinant of Health Assessments
... derivationExpr 0..1 ST Such derivation expression can contain a text calculation of how the components total up to the summed score
... 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 Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards)
... value 1..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) Functional Status, Mental/Cognitive Status, Alcohol Use, Substance Use, Physical Activity, SDOH Assessment
... interpretationCode 0..* CE
.... translation 0..* CD
... author 0..* Author
... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:observation, value:typeCode
.... entryRelationship:supportingObs 0..* EntryRelationship entryRelationship
..... @typeCode 1..1 cs Fixed Value: COMP
..... observation 1..1 AssessmentScaleSupportingObservation Base for all types and resources
... referenceRange 0..* InfrastructureRoot The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7 = moderate pain, 8 to 10 = severe pain)
.... observationRange C 1..1 ObservationRange should-text: SHOULD contain text
should-text-ref-value: SHOULD contain text/reference/@value
..... text 0..1 ED The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain)
...... 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

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.codeexampleObservationType
http://terminology.hl7.org/ValueSet/v3-ObservationType

Constraints

IdGradePath(s)DetailsRequirements
should-textwarningObservation.referenceRange.observationRangeSHOULD contain text
: text.exists()
should-text-ref-valuewarningObservation, Observation.referenceRange.observationRangeSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorObservation.text.reference, Observation.referenceRange.observationRange.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
.. 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
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:assessment-scale-obs 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.69
..... @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
... code 1..1 CD Binding: ObservationType (example)
Additional BindingsPurposeDocumentation
http://cts.nlm.nih.gov/fhir/ValueAet/2.16.840.1.113762.1.4.1247.206 Preferred Binding
For Social Determinant of Health Assessments
... derivationExpr 0..1 ST Such derivation expression can contain a text calculation of how the components total up to the summed score
... 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 Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards)
... value 1..1 (USCDI) Functional Status, Mental/Cognitive Status, Alcohol Use, Substance Use, Physical Activity, SDOH Assessment
.... 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
... interpretationCode 0..* CE Binding: CDAObservationInterpretation (required)
.... translation 0..* CD
... author 0..* Author
... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:observation, value:typeCode
.... entryRelationship:supportingObs 0..* EntryRelationship entryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... observation C 1..1 AssessmentScaleSupportingObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
... referenceRange 0..* InfrastructureRoot The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7 = moderate pain, 8 to 10 = severe pain)
.... observationRange C 1..1 ObservationRange should-text: SHOULD contain text
should-text-ref-value: SHOULD contain text/reference/@value
..... text 0..1 ED The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain)
...... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Observation.classCoderequiredFixed Value: OBS
http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation
Observation.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Observation.codeexampleObservationType
http://terminology.hl7.org/ValueSet/v3-ObservationType
Observation.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Observation.interpretationCoderequiredCDAObservationInterpretation
http://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation
Observation.entryRelationship:supportingObs.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
should-textwarningObservation.referenceRange.observationRangeSHOULD contain text
: text.exists()
should-text-ref-valuewarningObservation, Observation.referenceRange.observationRangeSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningObservation.entryRelationship:supportingObs.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorObservation.text.reference, Observation.referenceRange.observationRange.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
.. 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
... @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:assessment-scale-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: 2.16.840.1.113883.10.20.22.4.69
..... @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 1..1 CD Binding: ObservationType (example)
Additional BindingsPurposeDocumentation
http://cts.nlm.nih.gov/fhir/ValueAet/2.16.840.1.113762.1.4.1247.206 Preferred Binding
For Social Determinant of Health Assessments
... derivationExpr 0..1 ST Such derivation expression can contain a text calculation of how the components total up to the summed score
... 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 Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards)
... priorityCode 0..1 CE Binding: ActPriority (example)
... repeatNumber 0..1 IVL_INT
... languageCode 0..1 CS Binding: AllLanguages (required)
... value 1..1 (USCDI) Functional Status, Mental/Cognitive Status, Alcohol Use, Substance Use, Physical Activity, SDOH Assessment
.... 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
... interpretationCode 0..* CE Binding: CDAObservationInterpretation (required)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 0..1 cs
.... @codeSystem 0..1 oid, uuid, ruid
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... translation 0..* CD
... methodCode 0..* CE Binding: ObservationMethod (example)
... targetSiteCode 0..* CD
... subject 0..1 Subject
... specimen 0..* Specimen
... performer 0..* Performer2
... author 0..* Author
... informant 0..* Informant
... participant 0..* Participant2
... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:observation, value:typeCode
.... entryRelationship:supportingObs 0..* EntryRelationship 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: COMP
..... @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 AssessmentScaleSupportingObservation 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
... reference 0..* Reference
... precondition 0..* Precondition
... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... referenceRange 0..* InfrastructureRoot The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7 = moderate pain, 8 to 10 = severe pain)
.... @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 C 1..1 ObservationRange should-text: SHOULD contain text
should-text-ref-value: SHOULD contain text/reference/@value
..... @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
..... @classCode 0..1 cs Binding: CDAActClassObservation (required)
..... @moodCode 0..1 cs Binding: ActMoodPredicate (required)
Fixed Value: EVN.CRT
..... code 0..1 CD Binding: v3 Code System ActCode (example)
..... text 0..1 ED The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain)
...... @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
..... value 0..1
...... 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
..... interpretationCode 0..1 CE Binding: CDAObservationInterpretation (required)
..... sdtcPrecondition1 0..* InfrastructureRoot XML Namespace: urn:hl7-org:sdtc
XML: precondition1 (urn:hl7-org:sdtc)
...... @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: PRCN
...... conjunctionCode 1..1 CS XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
Binding: RelationshipConjunction (2.0.0) (required)
...... criterion1 1..1 Criterion XML Namespace: urn:hl7-org:sdtc
XML Namespace: 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
Observation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.templateId:assessment-scale-obs.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.classCoderequiredFixed Value: OBS
http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation
Observation.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Observation.codeexampleObservationType
http://terminology.hl7.org/ValueSet/v3-ObservationType
Observation.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Observation.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Observation.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Observation.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Observation.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Observation.statusCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Observation.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Observation.interpretationCoderequiredCDAObservationInterpretation
http://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation
Observation.interpretationCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.methodCodeexampleObservationMethod
http://terminology.hl7.org/ValueSet/v3-ObservationMethod
Observation.entryRelationship:supportingObs.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.entryRelationship:supportingObs.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.entryRelationship:supportingObs.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Observation.referenceRange.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.typeCoderequiredFixed Value: REFV
http://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType
Observation.referenceRange.observationRange.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.classCoderequiredCDAActClassObservation
http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation
Observation.referenceRange.observationRange.moodCoderequiredFixed Value: EVN.CRT
http://terminology.hl7.org/ValueSet/v3-ActMoodPredicate
Observation.referenceRange.observationRange.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Observation.referenceRange.observationRange.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Observation.referenceRange.observationRange.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Observation.referenceRange.observationRange.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Observation.referenceRange.observationRange.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Observation.referenceRange.observationRange.interpretationCoderequiredCDAObservationInterpretation
http://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation
Observation.referenceRange.observationRange.sdtcPrecondition1.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.sdtcPrecondition1.typeCoderequiredFixed Value: PRCN
http://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType
Observation.referenceRange.observationRange.sdtcPrecondition1.conjunctionCoderequiredRelationshipConjunction
http://terminology.hl7.org/ValueSet/v3-RelationshipConjunction|2.0.0

Constraints

IdGradePath(s)DetailsRequirements
should-textwarningObservation.referenceRange.observationRangeSHOULD contain text
: text.exists()
should-text-ref-valuewarningObservation, Observation.referenceRange.observationRangeSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningObservation.entryRelationship:supportingObs.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorObservation.text.reference, Observation.referenceRange.observationRange.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 Observation

Summary

Mandatory: 9 elements(1 nested mandatory element)
Fixed: 4 elements

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

Differential View

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:assessment-scale-obs 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.69
..... @extension 1..1 st Required Pattern: 2022-06-01
... @classCode 1..1 cs Fixed Value: OBS
... @moodCode 1..1 cs Fixed Value: EVN
... code 1..1 CD Binding: ObservationType (example)
Additional BindingsPurposeDocumentation
http://cts.nlm.nih.gov/fhir/ValueAet/2.16.840.1.113762.1.4.1247.206 Preferred Binding
For Social Determinant of Health Assessments
... derivationExpr 0..1 ST Such derivation expression can contain a text calculation of how the components total up to the summed score
... 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 Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards)
... value 1..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) Functional Status, Mental/Cognitive Status, Alcohol Use, Substance Use, Physical Activity, SDOH Assessment
... interpretationCode 0..* CE
.... translation 0..* CD
... author 0..* Author
... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:observation, value:typeCode
.... entryRelationship:supportingObs 0..* EntryRelationship entryRelationship
..... @typeCode 1..1 cs Fixed Value: COMP
..... observation 1..1 AssessmentScaleSupportingObservation Base for all types and resources
... referenceRange 0..* InfrastructureRoot The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7 = moderate pain, 8 to 10 = severe pain)
.... observationRange C 1..1 ObservationRange should-text: SHOULD contain text
should-text-ref-value: SHOULD contain text/reference/@value
..... text 0..1 ED The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain)
...... 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

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.codeexampleObservationType
http://terminology.hl7.org/ValueSet/v3-ObservationType

Constraints

IdGradePath(s)DetailsRequirements
should-textwarningObservation.referenceRange.observationRangeSHOULD contain text
: text.exists()
should-text-ref-valuewarningObservation, Observation.referenceRange.observationRangeSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorObservation.text.reference, Observation.referenceRange.observationRange.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
.. 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
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:assessment-scale-obs 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.69
..... @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
... code 1..1 CD Binding: ObservationType (example)
Additional BindingsPurposeDocumentation
http://cts.nlm.nih.gov/fhir/ValueAet/2.16.840.1.113762.1.4.1247.206 Preferred Binding
For Social Determinant of Health Assessments
... derivationExpr 0..1 ST Such derivation expression can contain a text calculation of how the components total up to the summed score
... 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 Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards)
... value 1..1 (USCDI) Functional Status, Mental/Cognitive Status, Alcohol Use, Substance Use, Physical Activity, SDOH Assessment
.... 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
... interpretationCode 0..* CE Binding: CDAObservationInterpretation (required)
.... translation 0..* CD
... author 0..* Author
... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:observation, value:typeCode
.... entryRelationship:supportingObs 0..* EntryRelationship entryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... observation C 1..1 AssessmentScaleSupportingObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
... referenceRange 0..* InfrastructureRoot The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7 = moderate pain, 8 to 10 = severe pain)
.... observationRange C 1..1 ObservationRange should-text: SHOULD contain text
should-text-ref-value: SHOULD contain text/reference/@value
..... text 0..1 ED The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain)
...... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Observation.classCoderequiredFixed Value: OBS
http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation
Observation.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Observation.codeexampleObservationType
http://terminology.hl7.org/ValueSet/v3-ObservationType
Observation.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Observation.interpretationCoderequiredCDAObservationInterpretation
http://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation
Observation.entryRelationship:supportingObs.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
should-textwarningObservation.referenceRange.observationRangeSHOULD contain text
: text.exists()
should-text-ref-valuewarningObservation, Observation.referenceRange.observationRangeSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningObservation.entryRelationship:supportingObs.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorObservation.text.reference, Observation.referenceRange.observationRange.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
.. 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
... @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:assessment-scale-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: 2.16.840.1.113883.10.20.22.4.69
..... @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 1..1 CD Binding: ObservationType (example)
Additional BindingsPurposeDocumentation
http://cts.nlm.nih.gov/fhir/ValueAet/2.16.840.1.113762.1.4.1247.206 Preferred Binding
For Social Determinant of Health Assessments
... derivationExpr 0..1 ST Such derivation expression can contain a text calculation of how the components total up to the summed score
... 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 Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards)
... priorityCode 0..1 CE Binding: ActPriority (example)
... repeatNumber 0..1 IVL_INT
... languageCode 0..1 CS Binding: AllLanguages (required)
... value 1..1 (USCDI) Functional Status, Mental/Cognitive Status, Alcohol Use, Substance Use, Physical Activity, SDOH Assessment
.... 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
... interpretationCode 0..* CE Binding: CDAObservationInterpretation (required)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 0..1 cs
.... @codeSystem 0..1 oid, uuid, ruid
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... translation 0..* CD
... methodCode 0..* CE Binding: ObservationMethod (example)
... targetSiteCode 0..* CD
... subject 0..1 Subject
... specimen 0..* Specimen
... performer 0..* Performer2
... author 0..* Author
... informant 0..* Informant
... participant 0..* Participant2
... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:observation, value:typeCode
.... entryRelationship:supportingObs 0..* EntryRelationship 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: COMP
..... @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 AssessmentScaleSupportingObservation 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
... reference 0..* Reference
... precondition 0..* Precondition
... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... referenceRange 0..* InfrastructureRoot The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7 = moderate pain, 8 to 10 = severe pain)
.... @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 C 1..1 ObservationRange should-text: SHOULD contain text
should-text-ref-value: SHOULD contain text/reference/@value
..... @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
..... @classCode 0..1 cs Binding: CDAActClassObservation (required)
..... @moodCode 0..1 cs Binding: ActMoodPredicate (required)
Fixed Value: EVN.CRT
..... code 0..1 CD Binding: v3 Code System ActCode (example)
..... text 0..1 ED The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain)
...... @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
..... value 0..1
...... 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
..... interpretationCode 0..1 CE Binding: CDAObservationInterpretation (required)
..... sdtcPrecondition1 0..* InfrastructureRoot XML Namespace: urn:hl7-org:sdtc
XML: precondition1 (urn:hl7-org:sdtc)
...... @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: PRCN
...... conjunctionCode 1..1 CS XML Namespace: urn:hl7-org:sdtc
XML Namespace: urn:hl7-org:sdtc
Binding: RelationshipConjunction (2.0.0) (required)
...... criterion1 1..1 Criterion XML Namespace: urn:hl7-org:sdtc
XML Namespace: 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
Observation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.templateId:assessment-scale-obs.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.classCoderequiredFixed Value: OBS
http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation
Observation.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
Observation.codeexampleObservationType
http://terminology.hl7.org/ValueSet/v3-ObservationType
Observation.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Observation.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Observation.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Observation.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Observation.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Observation.statusCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Observation.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Observation.interpretationCoderequiredCDAObservationInterpretation
http://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation
Observation.interpretationCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.methodCodeexampleObservationMethod
http://terminology.hl7.org/ValueSet/v3-ObservationMethod
Observation.entryRelationship:supportingObs.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.entryRelationship:supportingObs.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.entryRelationship:supportingObs.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Observation.referenceRange.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.typeCoderequiredFixed Value: REFV
http://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType
Observation.referenceRange.observationRange.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.classCoderequiredCDAActClassObservation
http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation
Observation.referenceRange.observationRange.moodCoderequiredFixed Value: EVN.CRT
http://terminology.hl7.org/ValueSet/v3-ActMoodPredicate
Observation.referenceRange.observationRange.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Observation.referenceRange.observationRange.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Observation.referenceRange.observationRange.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Observation.referenceRange.observationRange.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Observation.referenceRange.observationRange.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Observation.referenceRange.observationRange.interpretationCoderequiredCDAObservationInterpretation
http://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation
Observation.referenceRange.observationRange.sdtcPrecondition1.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.sdtcPrecondition1.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.referenceRange.observationRange.sdtcPrecondition1.typeCoderequiredFixed Value: PRCN
http://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType
Observation.referenceRange.observationRange.sdtcPrecondition1.conjunctionCoderequiredRelationshipConjunction
http://terminology.hl7.org/ValueSet/v3-RelationshipConjunction|2.0.0

Constraints

IdGradePath(s)DetailsRequirements
should-textwarningObservation.referenceRange.observationRangeSHOULD contain text
: text.exists()
should-text-ref-valuewarningObservation, Observation.referenceRange.observationRangeSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningObservation.entryRelationship:supportingObs.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorObservation.text.reference, Observation.referenceRange.observationRange.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 Observation

Summary

Mandatory: 9 elements(1 nested mandatory element)
Fixed: 4 elements

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

 

Other representations of profile: CSV, Excel