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: Reason

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/Reason Version: 3.0.0
Draft as of 2024-05-18 Computable Name: Reason
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.24.3.88:2023-05-01

This template describes the thought process or justification for an action or for not performing an action. Examples include patient, system, or non-problem/diagnosis medical-related reasons for declining to perform specific actions, or any reason for performing an action. Note that the parent template that calls this template can be asserted to have occurred or to not have occurred. Therefore, this template simply adds a reason to some other (possibly negated) act. As such, there is nothing in this template that says whether the parent act did or did not occur. It is expected that the primary use of this template within C-CDA is to provide the rationale for why something was not done. If this template is called by a template that is not negated, the Reason template should contain something other than a problem or a diagnosis, such as a patient preference. The Indication observation: 2.16.840.1.113883.10.20.22.4.19 should be used to represent a diagnosis or problem to indicate the diagnosis or problem is the rationale for an action. Immunization Refusal Reason: 2.16.840.1.113883.10.20.22.4.53 should be used to represent the rationale for the patient declining an immunization as the value set is crafted for the immunization use case.

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 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:reason 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.24.3.88
..... @extension 1..1 st Required Pattern: 2023-05-01
... @classCode 1..1 cs Fixed Value: OBS
... @moodCode 1..1 cs Fixed Value: EVN
... code 1..1 CD
.... @code 1..1 cs Required Pattern: 77301-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... 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
.... low 1..1 IVXB_TS
.... high 0..1 IVXB_TS
... value 1..1 CD

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningObservationSHOULD contain text/reference/@value
: text.reference.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('#')
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:reason 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.24.3.88
..... @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 1..1 CD Binding: ObservationType (example)
.... @code 1..1 cs Required Pattern: 77301-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... 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
.... low 1..1 IVXB_TS
.... high 0..1 IVXB_TS
... value 1..1 CD

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

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningObservationSHOULD contain text/reference/@value
: text.reference.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('#')
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:reason 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: 2.16.840.1.113883.10.20.24.3.88
..... @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 1..1 CD Binding: ObservationType (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 77301-0
.... @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
.... @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)
... value 1..1 CD
... 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..* Author
... informant 0..* Informant
... participant 0..* Participant2
... entryRelationship 0..* EntryRelationship
... 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:reason.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.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.interpretationCoderequiredCDAObservationInterpretation
http://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation
Observation.methodCodeexampleObservationMethod
http://terminology.hl7.org/ValueSet/v3-ObservationMethod
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
should-text-ref-valuewarningObservationSHOULD contain text/reference/@value
: text.reference.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 Observation

Summary

Mandatory: 12 elements
Fixed: 3 elements

Slices

This structure defines the following Slices:

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

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:reason 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.24.3.88
..... @extension 1..1 st Required Pattern: 2023-05-01
... @classCode 1..1 cs Fixed Value: OBS
... @moodCode 1..1 cs Fixed Value: EVN
... code 1..1 CD
.... @code 1..1 cs Required Pattern: 77301-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... 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
.... low 1..1 IVXB_TS
.... high 0..1 IVXB_TS
... value 1..1 CD

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningObservationSHOULD contain text/reference/@value
: text.reference.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('#')

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:reason 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.24.3.88
..... @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 1..1 CD Binding: ObservationType (example)
.... @code 1..1 cs Required Pattern: 77301-0
.... @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1
... 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
.... low 1..1 IVXB_TS
.... high 0..1 IVXB_TS
... value 1..1 CD

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

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningObservationSHOULD contain text/reference/@value
: text.reference.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('#')

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:reason 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: 2.16.840.1.113883.10.20.24.3.88
..... @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 1..1 CD Binding: ObservationType (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 77301-0
.... @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
.... @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)
... value 1..1 CD
... 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..* Author
... informant 0..* Informant
... participant 0..* Participant2
... entryRelationship 0..* EntryRelationship
... 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:reason.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.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.interpretationCoderequiredCDAObservationInterpretation
http://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation
Observation.methodCodeexampleObservationMethod
http://terminology.hl7.org/ValueSet/v3-ObservationMethod
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
should-text-ref-valuewarningObservationSHOULD contain text/reference/@value
: text.reference.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 Observation

Summary

Mandatory: 12 elements
Fixed: 3 elements

Slices

This structure defines the following Slices:

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

 

Other representations of profile: CSV, Excel