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: Gender Identity Observation

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/GenderIdentityObservation Version: 3.0.0
Draft as of 2024-05-18 Computable Name: GenderIdentityObservation
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.34.3.45:2023-05-01

This observation represents the gender identity of the patient. Defined as:

“Ones basic sense of being male, female, or other gender (for example, transgender or gender queer). Gender identity can be congruent or incongruent with ones sex assigned at birth based on the appearance of external genitalia. (Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) CommunityA Field Guide, The Joint Commission (2011).)

This template follows the guidelines from the HL7 Gender Harmony project. This template is based on C-CDA Social History Observation template.

This observation is not appropriate for recording patient gender (administrativeGender) or birth sex.

Usage:

  • This Logical Model is not used by any profiles in this Implementation Guide

Formal Views of Template Content

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

This structure is derived from SocialHistoryObservation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1 SocialHistoryObservation 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, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, value, value, author, entryRelationship, entryRelationship, entryRelationship
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... templateId 2..* II
... Slices for templateId Content/Rules for all slices
.... templateId:gender-identity-obs 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.34.3.45
..... @extension 1..1 st Required Pattern: 2023-05-01
... @classCode 1..1 cs
... code 1..1 CD Gender Identity
.... @code 1..1 cs Required Pattern: 76691-5
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... statusCode 1..1 CS
.... @code 1..1 cs
... effectiveTime 1..1 IVL_TS The effectiveTime represents the relevant time of the observation. A patient's "gender identity" may change and using effectiveTime/low and effectiveTime/high defines the time during which the patient had identified as specified.
.... low 1..1 IVXB_TS
.... high 0..1 IVXB_TS
... 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) Alcohol Use, Substance Use, SDOH Problems/Health Concerns
... Slices for value Content/Rules for all slices
.... value:physical-quantity 0..0
.... value:coded 1..1 CD Binding: Gender Identity . (required)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.value:codedrequiredGenderIdentity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.32
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 1..1 SocialHistoryObservation 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, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, value, value, author, entryRelationship, entryRelationship, entryRelationship
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 2..* 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
.... templateId:gender-identity-obs 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.34.3.45
..... @extension 1..1 st Required Pattern: 2023-05-01
... @classCode 1..1 cs Binding: CDAActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1 cs Binding: XActMoodDocumentObservation (2.0.0) (required)
Fixed Value: EVN
... code C 1..1 CD Gender Identity
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).
.... @code 1..1 cs Required Pattern: 76691-5
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... statusCode 1..1 CS Binding: ActStatus (required)
.... @code 1..1 cs Fixed Value: completed
... effectiveTime 1..1 IVL_TS The effectiveTime represents the relevant time of the observation. A patient's "gender identity" may change and using effectiveTime/low and effectiveTime/high defines the time during which the patient had identified as specified.
.... low 1..1 IVXB_TS
.... high 0..1 IVXB_TS
... Slices for value 1..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:coded 1..1 CD Binding: Gender Identity . (required)
Additional BindingsPurposeDocumentation
Social Determinants of Health Conditions . Preferred Binding
Social Determinant of Health Observations

... 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

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.codepreferredSocialHistoryType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.60
Observation.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Observation.value:physical-quantity.unitpreferredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive
Observation.value:codedrequiredGenderIdentity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.32
Observation.entryRelationship:supportingObs.typeCoderequiredFixed Value: SPRT
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Observation.entryRelationship:entryReference.typeCoderequiredFixed Value: SPRT
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
4515-8555errorObservationIf 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.
:
4515-32956warningObservation.codeIf @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-authorwarningObservationSHOULD contain author
: author.exists()
should-text-ref-valuewarningObservation, Observation.entryRelationship:supportingObs.observation, Observation.entryRelationship:entryReference.actSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningObservationSHOULD contain value
: value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 1..1 SocialHistoryObservation 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, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, value, value, author, entryRelationship, entryRelationship, entryRelationship
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 2..* 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
.... templateId:gender-identity-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: 2.16.840.1.113883.10.20.34.3.45
..... @extension 1..1 st Required Pattern: 2023-05-01
... @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 Gender Identity
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).
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 76691-5
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... qualifier 0..* CR
.... translation 0..* CD
... derivationExpr 0..1 ST
... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @compression 0..1 cs Binding: 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 The effectiveTime represents the relevant time of the observation. A patient's "gender identity" may change and using effectiveTime/low and effectiveTime/high defines the time during which the patient had identified as specified.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @value 0..1 ts Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
.... @operator 0..1 cs Binding: CDASetOperator (required)
.... low 1..1 IVXB_TS
.... center 0..1 TS
.... width 0..1 PQ
.... high 0..1 IVXB_TS
... priorityCode 0..1 CE Binding: ActPriority (example)
... repeatNumber 0..1 IVL_INT
... languageCode 0..1 CS Binding: AllLanguages (required)
... Slices for value 1..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:coded 1..1 CD Binding: Gender Identity . (required)
Additional BindingsPurposeDocumentation
Social Determinants of Health Conditions . Preferred Binding
Social Determinant of Health Observations

... 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)

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:social-history-obs.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.templateId:gender-identity-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.codepreferredSocialHistoryType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.60
Observation.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
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.effectiveTime.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.effectiveTime.operatorrequiredCDASetOperator
http://hl7.org/cda/stds/core/ValueSet/CDASetOperator
Observation.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Observation.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Observation.value:physical-quantity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.value:physical-quantity.unitpreferredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive
Observation.value:codedrequiredGenderIdentity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.32
Observation.interpretationCoderequiredCDAObservationInterpretation
http://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation
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: SPRT
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Observation.entryRelationship:entryReference.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.entryRelationship:entryReference.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.entryRelationship:entryReference.typeCoderequiredFixed Value: SPRT
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

Constraints

IdGradePath(s)DetailsRequirements
4515-8555errorObservationIf 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.
:
4515-32956warningObservation.codeIf @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-authorwarningObservationSHOULD contain author
: author.exists()
should-text-ref-valuewarningObservation, Observation.entryRelationship:supportingObs.observation, Observation.entryRelationship:entryReference.actSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningObservationSHOULD contain value
: value.exists()
value-starts-octothorpeerrorObservation.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 SocialHistoryObservation

Summary

Mandatory: 8 elements
Prohibited: 1 element

Differential View

This structure is derived from SocialHistoryObservation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1 SocialHistoryObservation 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, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, value, value, author, entryRelationship, entryRelationship, entryRelationship
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... templateId 2..* II
... Slices for templateId Content/Rules for all slices
.... templateId:gender-identity-obs 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.34.3.45
..... @extension 1..1 st Required Pattern: 2023-05-01
... @classCode 1..1 cs
... code 1..1 CD Gender Identity
.... @code 1..1 cs Required Pattern: 76691-5
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... statusCode 1..1 CS
.... @code 1..1 cs
... effectiveTime 1..1 IVL_TS The effectiveTime represents the relevant time of the observation. A patient's "gender identity" may change and using effectiveTime/low and effectiveTime/high defines the time during which the patient had identified as specified.
.... low 1..1 IVXB_TS
.... high 0..1 IVXB_TS
... 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) Alcohol Use, Substance Use, SDOH Problems/Health Concerns
... Slices for value Content/Rules for all slices
.... value:physical-quantity 0..0
.... value:coded 1..1 CD Binding: Gender Identity . (required)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.value:codedrequiredGenderIdentity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.32

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 1..1 SocialHistoryObservation 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, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, value, value, author, entryRelationship, entryRelationship, entryRelationship
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 2..* 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
.... templateId:gender-identity-obs 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.34.3.45
..... @extension 1..1 st Required Pattern: 2023-05-01
... @classCode 1..1 cs Binding: CDAActClassObservation (required)
Fixed Value: OBS
... @moodCode 1..1 cs Binding: XActMoodDocumentObservation (2.0.0) (required)
Fixed Value: EVN
... code C 1..1 CD Gender Identity
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).
.... @code 1..1 cs Required Pattern: 76691-5
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... statusCode 1..1 CS Binding: ActStatus (required)
.... @code 1..1 cs Fixed Value: completed
... effectiveTime 1..1 IVL_TS The effectiveTime represents the relevant time of the observation. A patient's "gender identity" may change and using effectiveTime/low and effectiveTime/high defines the time during which the patient had identified as specified.
.... low 1..1 IVXB_TS
.... high 0..1 IVXB_TS
... Slices for value 1..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:coded 1..1 CD Binding: Gender Identity . (required)
Additional BindingsPurposeDocumentation
Social Determinants of Health Conditions . Preferred Binding
Social Determinant of Health Observations

... 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

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.codepreferredSocialHistoryType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.60
Observation.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Observation.value:physical-quantity.unitpreferredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive
Observation.value:codedrequiredGenderIdentity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.32
Observation.entryRelationship:supportingObs.typeCoderequiredFixed Value: SPRT
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Observation.entryRelationship:entryReference.typeCoderequiredFixed Value: SPRT
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
4515-8555errorObservationIf 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.
:
4515-32956warningObservation.codeIf @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-authorwarningObservationSHOULD contain author
: author.exists()
should-text-ref-valuewarningObservation, Observation.entryRelationship:supportingObs.observation, Observation.entryRelationship:entryReference.actSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningObservationSHOULD contain value
: value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 1..1 SocialHistoryObservation 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, templateId, templateId, classCode, moodCode, id, code, text, statusCode, effectiveTime, value, value, value, author, entryRelationship, entryRelationship, entryRelationship
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 2..* 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
.... templateId:gender-identity-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: 2.16.840.1.113883.10.20.34.3.45
..... @extension 1..1 st Required Pattern: 2023-05-01
... @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 Gender Identity
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).
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 76691-5
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... qualifier 0..* CR
.... translation 0..* CD
... derivationExpr 0..1 ST
... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @compression 0..1 cs Binding: 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 The effectiveTime represents the relevant time of the observation. A patient's "gender identity" may change and using effectiveTime/low and effectiveTime/high defines the time during which the patient had identified as specified.
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @value 0..1 ts Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
.... @operator 0..1 cs Binding: CDASetOperator (required)
.... low 1..1 IVXB_TS
.... center 0..1 TS
.... width 0..1 PQ
.... high 0..1 IVXB_TS
... priorityCode 0..1 CE Binding: ActPriority (example)
... repeatNumber 0..1 IVL_INT
... languageCode 0..1 CS Binding: AllLanguages (required)
... Slices for value 1..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:coded 1..1 CD Binding: Gender Identity . (required)
Additional BindingsPurposeDocumentation
Social Determinants of Health Conditions . Preferred Binding
Social Determinant of Health Observations

... 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)

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:social-history-obs.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.templateId:gender-identity-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.codepreferredSocialHistoryType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.60
Observation.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
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.effectiveTime.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.effectiveTime.operatorrequiredCDASetOperator
http://hl7.org/cda/stds/core/ValueSet/CDASetOperator
Observation.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Observation.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Observation.value:physical-quantity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.value:physical-quantity.unitpreferredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive
Observation.value:codedrequiredGenderIdentity .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.32
Observation.interpretationCoderequiredCDAObservationInterpretation
http://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation
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: SPRT
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Observation.entryRelationship:entryReference.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.entryRelationship:entryReference.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Observation.entryRelationship:entryReference.typeCoderequiredFixed Value: SPRT
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

Constraints

IdGradePath(s)DetailsRequirements
4515-8555errorObservationIf 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.
:
4515-32956warningObservation.codeIf @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-authorwarningObservationSHOULD contain author
: author.exists()
should-text-ref-valuewarningObservation, Observation.entryRelationship:supportingObs.observation, Observation.entryRelationship:entryReference.actSHOULD contain text/reference/@value
: text.reference.value.exists()
should-valuewarningObservationSHOULD contain value
: value.exists()
value-starts-octothorpeerrorObservation.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 SocialHistoryObservation

Summary

Mandatory: 8 elements
Prohibited: 1 element

 

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