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: Specimen Collection Procedure

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/SpecimenCollectionProcedure Version: 3.0.0
Draft as of 2024-05-18 Computable Name: SpecimenCollectionProcedure
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.415:2018-09-01

This template represents clinical information about the specimen including when it was collected, the type and source of specimen, as well as related observations regarding the specimen.

Usage:

Formal Views of Template Content

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

This structure is derived from Procedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C 1..1 Procedure XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-targetSiteCode: SHOULD contain targetSiteCode
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:specimen-collection-proc 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.415
..... @extension 1..1 st Required Pattern: 2018-09-01
... @moodCode 1..1 cs Fixed Value: EVN
... code 1..1 CD Specimen collection (procedure)
.... @code 1..1 cs Required Pattern: 17636008
.... @codeSystem 1..1 oid, uuid, ruid SNOMED CT
Required Pattern: 2.16.840.1.113883.6.96
.... 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
... targetSiteCode 0..* CD (USCDI) Specimen Source Site
Binding: Body Site Value Set . (required)
... Slices for entryRelationship 1..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:specimenRef 1..1 EntryRelationship References the specimen that is the subject of this procedure
..... @typeCode 1..1 cs Fixed Value: SUBJ
..... act 1..1 EntryReference Base for all types and resources
.... entryRelationship:condition 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: COMP
..... observation 0..1 SpecimenConditionObservation (USCDI) Specimen Condition Acceptability

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Procedure.targetSiteCoderequiredBodySiteValueSet .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9

Constraints

IdGradePath(s)DetailsRequirements
should-effectiveTimewarningProcedureSHOULD contain effectiveTime
: effectiveTime.exists()
should-targetSiteCodewarningProcedureSHOULD contain targetSiteCode
: targetSiteCode.exists()
should-text-ref-valuewarningProcedureSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorProcedure.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
.. Procedure C 1..1 Procedure XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-targetSiteCode: SHOULD contain targetSiteCode
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:specimen-collection-proc 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.415
..... @extension 1..1 st Required Pattern: 2018-09-01
... @classCode 1..1 cs Binding: ActClassProcedure (required)
Fixed Value: PROC
... @moodCode 1..1 cs Binding: x_DocumentProcedureMood (required)
Fixed Value: EVN
.... @code 1..1 cs Required Pattern: 17636008
.... @codeSystem 1..1 oid, uuid, ruid SNOMED CT
Required Pattern: 2.16.840.1.113883.6.96
... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... targetSiteCode 0..* CD (USCDI) Specimen Source Site
Binding: Body Site Value Set . (required)
... Slices for entryRelationship 1..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:specimenRef 1..1 EntryRelationship References the specimen that is the subject of this procedure
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... act C 1..1 EntryReference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:condition 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... observation C 0..1 SpecimenConditionObservation (USCDI) Specimen Condition Acceptability
should-text-ref-value: SHOULD contain text/reference/@value

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.classCoderequiredFixed Value: PROC
http://terminology.hl7.org/ValueSet/v3-ActClassProcedure
Procedure.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xDocumentProcedureMood
Procedure.targetSiteCoderequiredBodySiteValueSet .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9
Procedure.entryRelationship:specimenRef.typeCoderequiredFixed Value: SUBJ
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Procedure.entryRelationship:condition.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
should-effectiveTimewarningProcedureSHOULD contain effectiveTime
: effectiveTime.exists()
should-targetSiteCodewarningProcedureSHOULD contain targetSiteCode
: targetSiteCode.exists()
should-text-ref-valuewarningProcedureSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningProcedure.entryRelationship:specimenRef.act, Procedure.entryRelationship:condition.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorProcedure.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
.. Procedure C 1..1 Procedure XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-targetSiteCode: SHOULD contain targetSiteCode
... @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:specimen-collection-proc 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: 2.16.840.1.113883.10.20.22.4.415
..... @extension 1..1 st Required Pattern: 2018-09-01
... @classCode 1..1 cs Binding: ActClassProcedure (required)
Fixed Value: PROC
... @moodCode 1..1 cs Binding: x_DocumentProcedureMood (required)
Fixed Value: EVN
... id 0..* II
... code 1..1 CD Specimen collection (procedure)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 17636008
.... @codeSystem 1..1 oid, uuid, ruid SNOMED CT
Required Pattern: 2.16.840.1.113883.6.96
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... qualifier 0..* CR
.... translation 0..* CD
... @negationInd 0..1 bl
... 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 0..1 CS Binding: ActStatus (required)
... effectiveTime 0..1 IVL_TS
... priorityCode 0..1 CE Binding: ActPriority (example)
... languageCode 0..1 CS Binding: AllLanguages (required)
... methodCode 0..* CE
... approachSiteCode 0..* CD
... targetSiteCode 0..* CD (USCDI) Specimen Source Site
Binding: Body Site Value Set . (required)
... subject 0..1 Subject
... specimen 0..* Specimen
... performer 0..* Performer2
... author 0..* Author
... informant 0..* Informant
... participant 0..* Participant2
... Slices for entryRelationship 1..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:specimenRef 1..1 EntryRelationship References the specimen that is the subject of this procedure
..... @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: SUBJ
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act C 1..1 EntryReference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:condition 0..* EntryRelationship
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: 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 0..1 SpecimenConditionObservation (USCDI) Specimen Condition Acceptability
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)
... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Procedure.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Procedure.templateId:specimen-collection-proc.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Procedure.classCoderequiredFixed Value: PROC
http://terminology.hl7.org/ValueSet/v3-ActClassProcedure
Procedure.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xDocumentProcedureMood
Procedure.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Procedure.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Procedure.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Procedure.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Procedure.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Procedure.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Procedure.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Procedure.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Procedure.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Procedure.targetSiteCoderequiredBodySiteValueSet .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9
Procedure.entryRelationship:specimenRef.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Procedure.entryRelationship:specimenRef.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Procedure.entryRelationship:specimenRef.typeCoderequiredFixed Value: SUBJ
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Procedure.entryRelationship:condition.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Procedure.entryRelationship:condition.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Procedure.entryRelationship:condition.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
should-effectiveTimewarningProcedureSHOULD contain effectiveTime
: effectiveTime.exists()
should-targetSiteCodewarningProcedureSHOULD contain targetSiteCode
: targetSiteCode.exists()
should-text-ref-valuewarningProcedureSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningProcedure.entryRelationship:specimenRef.act, Procedure.entryRelationship:condition.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorProcedure.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 Procedure

Summary

Mandatory: 10 elements
Fixed: 3 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 Procedure.templateId
  • The element 2 is sliced based on the values of Procedure.entryRelationship

Differential View

This structure is derived from Procedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C 1..1 Procedure XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-targetSiteCode: SHOULD contain targetSiteCode
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:specimen-collection-proc 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.415
..... @extension 1..1 st Required Pattern: 2018-09-01
... @moodCode 1..1 cs Fixed Value: EVN
... code 1..1 CD Specimen collection (procedure)
.... @code 1..1 cs Required Pattern: 17636008
.... @codeSystem 1..1 oid, uuid, ruid SNOMED CT
Required Pattern: 2.16.840.1.113883.6.96
.... 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
... targetSiteCode 0..* CD (USCDI) Specimen Source Site
Binding: Body Site Value Set . (required)
... Slices for entryRelationship 1..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:specimenRef 1..1 EntryRelationship References the specimen that is the subject of this procedure
..... @typeCode 1..1 cs Fixed Value: SUBJ
..... act 1..1 EntryReference Base for all types and resources
.... entryRelationship:condition 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: COMP
..... observation 0..1 SpecimenConditionObservation (USCDI) Specimen Condition Acceptability

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Procedure.targetSiteCoderequiredBodySiteValueSet .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9

Constraints

IdGradePath(s)DetailsRequirements
should-effectiveTimewarningProcedureSHOULD contain effectiveTime
: effectiveTime.exists()
should-targetSiteCodewarningProcedureSHOULD contain targetSiteCode
: targetSiteCode.exists()
should-text-ref-valuewarningProcedureSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorProcedure.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
.. Procedure C 1..1 Procedure XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-targetSiteCode: SHOULD contain targetSiteCode
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:specimen-collection-proc 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.415
..... @extension 1..1 st Required Pattern: 2018-09-01
... @classCode 1..1 cs Binding: ActClassProcedure (required)
Fixed Value: PROC
... @moodCode 1..1 cs Binding: x_DocumentProcedureMood (required)
Fixed Value: EVN
.... @code 1..1 cs Required Pattern: 17636008
.... @codeSystem 1..1 oid, uuid, ruid SNOMED CT
Required Pattern: 2.16.840.1.113883.6.96
... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... targetSiteCode 0..* CD (USCDI) Specimen Source Site
Binding: Body Site Value Set . (required)
... Slices for entryRelationship 1..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:specimenRef 1..1 EntryRelationship References the specimen that is the subject of this procedure
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... act C 1..1 EntryReference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:condition 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... observation C 0..1 SpecimenConditionObservation (USCDI) Specimen Condition Acceptability
should-text-ref-value: SHOULD contain text/reference/@value

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.classCoderequiredFixed Value: PROC
http://terminology.hl7.org/ValueSet/v3-ActClassProcedure
Procedure.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xDocumentProcedureMood
Procedure.targetSiteCoderequiredBodySiteValueSet .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9
Procedure.entryRelationship:specimenRef.typeCoderequiredFixed Value: SUBJ
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Procedure.entryRelationship:condition.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
should-effectiveTimewarningProcedureSHOULD contain effectiveTime
: effectiveTime.exists()
should-targetSiteCodewarningProcedureSHOULD contain targetSiteCode
: targetSiteCode.exists()
should-text-ref-valuewarningProcedureSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningProcedure.entryRelationship:specimenRef.act, Procedure.entryRelationship:condition.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorProcedure.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
.. Procedure C 1..1 Procedure XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-targetSiteCode: SHOULD contain targetSiteCode
... @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:specimen-collection-proc 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: 2.16.840.1.113883.10.20.22.4.415
..... @extension 1..1 st Required Pattern: 2018-09-01
... @classCode 1..1 cs Binding: ActClassProcedure (required)
Fixed Value: PROC
... @moodCode 1..1 cs Binding: x_DocumentProcedureMood (required)
Fixed Value: EVN
... id 0..* II
... code 1..1 CD Specimen collection (procedure)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 17636008
.... @codeSystem 1..1 oid, uuid, ruid SNOMED CT
Required Pattern: 2.16.840.1.113883.6.96
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... qualifier 0..* CR
.... translation 0..* CD
... @negationInd 0..1 bl
... 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 0..1 CS Binding: ActStatus (required)
... effectiveTime 0..1 IVL_TS
... priorityCode 0..1 CE Binding: ActPriority (example)
... languageCode 0..1 CS Binding: AllLanguages (required)
... methodCode 0..* CE
... approachSiteCode 0..* CD
... targetSiteCode 0..* CD (USCDI) Specimen Source Site
Binding: Body Site Value Set . (required)
... subject 0..1 Subject
... specimen 0..* Specimen
... performer 0..* Performer2
... author 0..* Author
... informant 0..* Informant
... participant 0..* Participant2
... Slices for entryRelationship 1..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:specimenRef 1..1 EntryRelationship References the specimen that is the subject of this procedure
..... @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: SUBJ
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act C 1..1 EntryReference Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:condition 0..* EntryRelationship
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: 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 0..1 SpecimenConditionObservation (USCDI) Specimen Condition Acceptability
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)
... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Procedure.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Procedure.templateId:specimen-collection-proc.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Procedure.classCoderequiredFixed Value: PROC
http://terminology.hl7.org/ValueSet/v3-ActClassProcedure
Procedure.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xDocumentProcedureMood
Procedure.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Procedure.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Procedure.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
Procedure.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
Procedure.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
Procedure.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
Procedure.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Procedure.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Procedure.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
Procedure.targetSiteCoderequiredBodySiteValueSet .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9
Procedure.entryRelationship:specimenRef.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Procedure.entryRelationship:specimenRef.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Procedure.entryRelationship:specimenRef.typeCoderequiredFixed Value: SUBJ
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
Procedure.entryRelationship:condition.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Procedure.entryRelationship:condition.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
Procedure.entryRelationship:condition.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship

Constraints

IdGradePath(s)DetailsRequirements
should-effectiveTimewarningProcedureSHOULD contain effectiveTime
: effectiveTime.exists()
should-targetSiteCodewarningProcedureSHOULD contain targetSiteCode
: targetSiteCode.exists()
should-text-ref-valuewarningProcedureSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningProcedure.entryRelationship:specimenRef.act, Procedure.entryRelationship:condition.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorProcedure.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 Procedure

Summary

Mandatory: 10 elements
Fixed: 3 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 Procedure.templateId
  • The element 2 is sliced based on the values of Procedure.entryRelationship

 

Other representations of profile: CSV, Excel