Consolidated CDA (C-CDA)
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This page is part of the CCDA: Consolidated CDA Release (v4.0.0: CCDA 4.0) 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: MentalStatusObservation - Detailed Descriptions

Draft as of 2025-06-20

Definitions for the MentalStatusObservation logical model.

Guidance on how to interpret the contents of this table can be foundhere

0. Observation
Definition

Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type.


Base definition for all types defined in FHIR type system.

ShortBase for all types and resources
Control10..1*
Is Modifierfalse
Logical ContainerClinicalDocument (CDA Class)
ValidationInstance of this type are validated by templateId
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
Invariantsshould-text-ref-value: SHOULD contain text/reference/@value (text.reference.value.exists())
should-author: SHOULD contain author (author.exists())
2. Observation.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from CDANullFlavor
(required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
4. Observation.realmCode
Definition

When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question

Control0..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
6. Observation.typeId
Definition

When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.

Control0..1
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
InvariantsII-1: An II instance must have either a root or an nullFlavor. (root.exists() or nullFlavor.exists())
8. Observation.typeId.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from CDANullFlavor
(required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
Typecode(cs: Coded Simple Value)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExceptional Value Detail
10. Observation.typeId.assigningAuthorityName
Definition

A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

Control0..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelAssigning Authority Name
12. Observation.typeId.displayable
Definition

Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

Control0..1
Typeboolean(bl: Boolean)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelDisplayable
14. Observation.typeId.root
Definition

Identifies the type as an HL7 Registered model

Control1..1
Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelRoot
Fixed Value2.16.840.1.113883.1.3
16. Observation.typeId.extension
Definition

A character string as a unique identifier within the scope of the identifier root.

Control1..1
Typestring(st: Character String)
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
XML FormatIn the XML format, this property is represented as an attribute.
LabelExtension
18. Observation.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control1..*
Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
SlicingThis element introduces a set of slices on Observation.templateId. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ root
  • value @ extension
  • 20. Observation.templateId:mental-status-obs
    Slice Namemental-status-obs
    Definition

    When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

    Control1..1
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
    22. Observation.templateId:mental-status-obs.nullFlavor
    Definition

    If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

    Control0..1
    BindingThe codes SHALL be taken from CDANullFlavor
    (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
    Typecode(cs: Coded Simple Value)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelExceptional Value Detail
    24. Observation.templateId:mental-status-obs.assigningAuthorityName
    Definition

    A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

    Control0..1
    Typestring(st: Character String)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelAssigning Authority Name
    26. Observation.templateId:mental-status-obs.displayable
    Definition

    Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

    Control0..1
    Typeboolean(bl: Boolean)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelDisplayable
    28. Observation.templateId:mental-status-obs.root
    Definition

    A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.

    Control1..1
    Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelRoot
    Pattern Value2.16.840.1.113883.10.20.22.4.74
    30. Observation.templateId:mental-status-obs.extension
    Definition

    A character string as a unique identifier within the scope of the identifier root.

    Control1..1
    Typestring(st: Character String)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelExtension
    Pattern Value2024-05-01
    32. Observation.classCode
    Comments

    SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-14249).

    Control1..1
    BindingThe codes SHALL be taken from CDAActClassObservation
    (required to http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation)
    Typecode(cs: Coded Simple Value)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    Fixed ValueOBS
    34. Observation.moodCode
    Comments

    SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1198-14250).

    Control1..1
    BindingThe codes SHALL be taken from XActMoodDocumentObservation (2.0.0)
    (required to http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0)
    Typecode(cs: Coded Simple Value)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    Fixed ValueEVN
    36. Observation.negationInd
    Control0..1
    Typeboolean(bl: Boolean)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    38. Observation.id
    Definition

    The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

    ShortLogical id of this artifact
    Comments

    SHALL contain at least one [1..*] id (CONF:1198-14257).


    Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case.

    Control10..*1
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/IIid
    Is Modifierfalse
    40. Observation.sdtcCategory
    Control0..*
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
    XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namecategory.
    42. Observation.code
    Definition

    Describes what was observed. Sometimes this is called the observation "name".

    ShortMental StatusType of observation (code / type)
    Comments

    All code-value and, if present, component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.

    Control1..1
    This element is affected by the following invariants: obs-7
    BindingFor example codes, see ObservationTypehttp://hl7.org/fhir/ValueSet/observation-codes
    (example to http://terminology.hl7.org/ValueSet/v3-ObservationType)
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/CDCodeableConcept
    Is Modifierfalse
    XML FormatThe type of this property is determined using the xsi:typeattribute.
    Requirements

    Knowing what kind of observation is being made is essential to understanding the observation.

    Alternate NamesName
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    44. Observation.code.nullFlavor
    Definition

    If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

    Control0..1
    BindingThe codes SHALL be taken from CDANullFlavor
    (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
    Typecode(cs: Coded Simple Value)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelExceptional Value Detail
    46. Observation.code.code
    Definition

    The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

    Control1..1
    Typecode(cs: Coded Simple Value)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelCode
    Pattern Value8693-4
    48. Observation.code.codeSystem
    Definition

    Specifies the code system that defines the code.

    ShortLOINC
    Control1..1
    Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelCode System
    Pattern Value2.16.840.1.113883.6.1
    50. Observation.code.codeSystemName
    Definition

    The common name of the coding system.

    Control0..1
    Typestring(st: Character String)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelCode System Name
    52. Observation.code.codeSystemVersion
    Definition

    If applicable, a version descriptor defined specifically for the given code system.

    Control0..1
    Typestring(st: Character String)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelCode System Version
    54. Observation.code.displayName
    Definition

    A name or title for the code, under which the sending system shows the code value to its users.

    Control0..1
    Typestring(st: Character String)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelDisplay Name
    56. Observation.code.sdtcValueSet
    Definition

    The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.

    Control0..1
    Typestring(oid: ISO Object Identifier)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSet.
    58. Observation.code.sdtcValueSetVersion
    Definition

    The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.

    Control0..1
    Typestring(st: Character String)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSetVersion.
    60. Observation.code.originalText
    Definition

    The text or phrase used as the basis for the coding.

    Control0..1
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
    LabelOriginal Text
    62. Observation.code.qualifier
    Definition

    Specifies additional codes that increase the specificity of the the primary code.

    Control0..*
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/CR
    LabelQualifier
    64. Observation.code.translation
    Definition

    A set of other concept descriptors that translate this concept descriptor into other code systems.

    Control0..*
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
    XML FormatThe type of this property is determined using the xsi:typeattribute.
    LabelTranslation
    66. Observation.derivationExpr
    Control0..1
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/ST
    68. Observation.text
    Definition

    A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

    ShortSHOULD reference the portion of section narrative text corresponding to this entryText summary of the resource, for human interpretation
    Comments

    Contained resources do not have a narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

    Control0..1
    This element is affected by the following invariants: dom-6
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/EDNarrative
    Is Modifierfalse
    XML FormatThe type of this property is determined using the xsi:typeattribute.
    Alternate Namesnarrative, html, xhtml, display
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    70. Observation.text.nullFlavor
    Definition

    If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

    Control0..1
    BindingThe codes SHALL be taken from CDANullFlavor
    (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
    Typecode(cs: Coded Simple Value)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelExceptional Value Detail
    72. Observation.text.compression
    Definition

    Indicates whether the raw byte data is compressed, and what compression algorithm was used.

    Control0..1
    BindingThe codes SHALL be taken from CDACompressionAlgorithm
    (required to http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm)
    Typecode(cs: Coded Simple Value)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelCompression
    74. Observation.text.integrityCheck
    Definition

    The integrity check is a short binary value representing a cryptographically strong checksum that is calculated over the binary data. The purpose of this property, when communicated with a reference is for anyone to validate later whether the reference still resolved to the same data that the reference resolved to when the encapsulated data value with reference was created.

    Control0..1
    Typebase64Binary(bin: Binary Data)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelIntegrity Check
    76. Observation.text.integrityCheckAlgorithm
    Definition

    Specifies the algorithm used to compute the integrityCheck value. The cryptographically strong checksum algorithm Secure Hash Algorithm-1 (SHA-1) is currently the industry standard. It has superseded the MD5 algorithm only a couple of years ago, when certain flaws in the security of MD5 were discovered. Currently the SHA-1 hash algorithm is the default choice for the integrity check algorithm. Note that SHA-256 is also entering widespread usage.

    Control0..1
    BindingThe codes SHALL be taken from IntegrityCheckAlgorithm (2.0.0)
    (required to http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0)
    Typecode(cs: Coded Simple Value)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelIntegrity Check Algorithm
    78. Observation.text.language
    Definition

    For character based information the language property specifies the human language of the text.

    Control0..1
    Typecode(cs: Coded Simple Value)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelLanguage
    80. Observation.text.mediaType
    Definition

    Identifies the type of the encapsulated data and identifies a method to interpret or render the data.

    Control0..1
    BindingFor example codes, see MediaType
    (example to http://terminology.hl7.org/ValueSet/v3-MediaType)
    Typecode(cs: Coded Simple Value)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelMedia Type
    82. Observation.text.representation
    Control0..1
    BindingThe codes SHALL be taken from CDABinaryDataEncoding
    (required to http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding)
    Typecode(cs: Coded Simple Value)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    84. Observation.text.xmlText
    Definition

    Data that is primarily intended for human interpretation or for further machine processing is outside the scope of HL7. This includes unformatted or formatted written language, multimedia data, or structured information as defined by a different standard (e.g., XML-signatures.)

    ShortAllows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
    Comments

    This element is represented in XML as textual content. The actual name "xmlText" will not appear in a CDA instance.

    Control0..1
    Typestring(st: Character String)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as unadorned text.
    86. Observation.text.reference
    Definition

    A telecommunication address (TEL), such as a URL for HTTP or FTP, which will resolve to precisely the same binary data that could as well have been provided as inline data.

    Control0..1
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/TEL
    LabelReference
    Invariantsvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative (value.exists() implies value.startsWith('#'))
    88. Observation.text.thumbnail
    Definition

    An abbreviated rendition of the full data. A thumbnail requires significantly fewer resources than the full data, while still maintaining some distinctive similarity with the full data. A thumbnail is typically used with by-reference encapsulated data. It allows a user to select data more efficiently before actually downloading through the reference.

    Control0..1
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
    LabelThumbnail
    90. Observation.statusCode
    Comments

    SHALL contain exactly one [1..1] statusCode (CONF:1198-14254).

    Control1..1
    BindingThe codes SHALL be taken from ActStatus
    (required to http://terminology.hl7.org/ValueSet/v3-ActStatus)
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
    92. Observation.statusCode.nullFlavor
    Definition

    If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

    Control0..1
    BindingThe codes SHALL be taken from CDANullFlavor
    (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
    Typecode(cs: Coded Simple Value)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelExceptional Value Detail
    94. Observation.statusCode.code
    Definition

    The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

    Comments

    This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: HL7ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:1198-19092).

    Control1..1
    Typecode(cs: Coded Simple Value)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelCode
    Fixed Valuecompleted
    96. Observation.statusCode.codeSystem
    Definition

    Specifies the code system that defines the code.

    Control0..0
    Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelCode System
    98. Observation.statusCode.codeSystemName
    Definition

    The common name of the coding system.

    Control0..0
    Typestring(st: Character String)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelCode System Name
    100. Observation.statusCode.codeSystemVersion
    Definition

    If applicable, a version descriptor defined specifically for the given code system.

    Control0..0
    Typestring(st: Character String)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelCode System Version
    102. Observation.statusCode.displayName
    Definition

    A name or title for the code, under which the sending system shows the code value to its users.

    Control0..0
    Typestring(st: Character String)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.
    LabelDisplay Name
    104. Observation.statusCode.sdtcValueSet
    Definition

    The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.

    Control0..1
    Typestring(oid: ISO Object Identifier)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSet.
    106. Observation.statusCode.sdtcValueSetVersion
    Definition

    The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.

    Control0..1
    Typestring(st: Character String)
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSetVersion.
    108. Observation.statusCode.originalText
    Definition

    The text or phrase used as the basis for the coding.

    Control0..0
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
    LabelOriginal Text
    110. Observation.statusCode.qualifier
    Definition

    Specifies additional codes that increase the specificity of the the primary code.

    Control0..0
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/CR
    LabelQualifier
    112. Observation.statusCode.translation
    Definition

    A set of other concept descriptors that translate this concept descriptor into other code systems.

    Control0..0
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
    XML FormatThe type of this property is determined using the xsi:typeattribute.
    LabelTranslation
    114. Observation.effectiveTime
    Comments

    SHALL contain exactly one [1..1] effectiveTime (CONF:1198-14261).

    Control1..1
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/IVL-TS
    116. Observation.priorityCode
    Control0..1
    BindingFor example codes, see ActPriority
    (example to http://terminology.hl7.org/ValueSet/v3-ActPriority)
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
    118. Observation.repeatNumber
    Control0..1
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/IVL-INT
    120. Observation.languageCode
    Control0..1
    BindingThe codes SHALL be taken from AllLanguages
    (required to http://hl7.org/fhir/ValueSet/all-languages)
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
    122. Observation.value
    Comments

    SHALL contain exactly one [1..1] value (CONF:1198-14263).

    Control1..1
    TypeChoice of: http://hl7.org/cda/stds/core/StructureDefinition/ANY, http://hl7.org/cda/stds/core/StructureDefinition/BL, http://hl7.org/cda/stds/core/StructureDefinition/ED, http://hl7.org/cda/stds/core/StructureDefinition/ST, http://hl7.org/cda/stds/core/StructureDefinition/CD, http://hl7.org/cda/stds/core/StructureDefinition/CV, http://hl7.org/cda/stds/core/StructureDefinition/CE, http://hl7.org/cda/stds/core/StructureDefinition/CO, http://hl7.org/cda/stds/core/StructureDefinition/SC, http://hl7.org/cda/stds/core/StructureDefinition/II, http://hl7.org/cda/stds/core/StructureDefinition/TEL, http://hl7.org/cda/stds/core/StructureDefinition/AD, http://hl7.org/cda/stds/core/StructureDefinition/EN, http://hl7.org/cda/stds/core/StructureDefinition/INT, http://hl7.org/cda/stds/core/StructureDefinition/REAL, http://hl7.org/cda/stds/core/StructureDefinition/PQ, http://hl7.org/cda/stds/core/StructureDefinition/MO, http://hl7.org/cda/stds/core/StructureDefinition/TS, http://hl7.org/cda/stds/core/StructureDefinition/IVL-PQ, http://hl7.org/cda/stds/core/StructureDefinition/IVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/PIVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/EIVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/SXPR-TS, http://hl7.org/cda/stds/core/StructureDefinition/RTO-PQ-PQ
    XML FormatThe type of this property is determined using the xsi:typeattribute.
    SlicingThis element introduces a set of slices on Observation.value. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • type @ $this
    • 124. Observation.value:code
      Slice Namecode
      Control0..1
      BindingThe codes SHOULD be taken from Mental Status Observation .
      (preferred to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.1)
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
      XML FormatThe type of this property is determined using the xsi:typeattribute.
      126. Observation.interpretationCode
      Control0..*
      BindingThe codes SHALL be taken from CDAObservationInterpretation
      (required to http://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation)
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
      128. Observation.methodCode
      Control0..*
      BindingFor example codes, see ObservationMethod
      (example to http://terminology.hl7.org/ValueSet/v3-ObservationMethod)
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
      130. Observation.targetSiteCode
      Definition

      Drawn from concept domain ActSite

      Control0..*
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
      132. Observation.subject
      Definition

      The patient, or group of patients, location, device, organization, procedure or practitioner this observation is about and into whose or what record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the focus element or the code itself specifies the actual focus of the observation.

      ShortWho and/or what the observation is about
      Comments

      One would expect this element to be a cardinality of 1..1. The only circumstance in which the subject can be missing is when the observation is made by a device that does not know the patient. In this case, the observation SHALL be matched to a patient through some context/channel matching technique, and at this point, the observation should be updated. The subject of an Observation may in some cases be a procedure. This supports the regulatory inspection use case where observations are captured during inspections of a procedure that is being performed (independent of any particular patient or whether patient related at all).

      Control0..1
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/SubjectReference(Patient, Group, Device, Location, Organization, Procedure, Practitioner, Medication, Substance, BiologicallyDerivedProduct, NutritionProduct)
      Is Modifierfalse
      Requirements

      Observations have no value if you don't know who or what they're about.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      134. Observation.specimen
      Definition

      The specimen that was used when this observation was made.

      ShortSpecimen used for this observation
      Comments

      Should only be used if not implicit in code found in Observation.code. Observations are not made on specimens themselves; they are made on a subject, but in many cases by the means of a specimen. Note that although specimens are often involved, they are not always tracked and reported explicitly. Also note that observation resources may be used in contexts that track the specimen explicitly (e.g. Diagnostic Report).

      Control0..*1
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/SpecimenReference(Specimen, Group)
      Is Modifierfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      obs-9: If Observation.specimen is a reference to Group, the group can only have specimens ((reference.resolve().exists() and reference.resolve() is Group) implies reference.resolve().member.entity.resolve().all($this is Specimen))
      136. Observation.performer
      Definition

      Who was responsible for asserting the observed value as "true".

      ShortWho is responsible for the observation
      Control0..*
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Performer2Reference(Practitioner, PractitionerRole, Organization, CareTeam, Patient, RelatedPerson)
      Is Modifierfalse
      Requirements

      May give a degree of confidence in the observation and also indicates where follow-up questions should be directed.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      138. Observation.author
      Comments

      SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1198-14266).

      Control0..*
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Author(Author Participation)
      140. Observation.informant
      Control0..*
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Informant
      142. Observation.participant
      Control0..*
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Participant2
      144. Observation.entryRelationship
      Control0..*
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/EntryRelationship
      SlicingThis element introduces a set of slices on Observation.entryRelationship. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • profile @ observation
      • 146. Observation.entryRelationship:assessmentScale
        Slice NameassessmentScale
        Short𝗨𝗦𝗖𝗗𝗜: Mental/Cognitive Status
        Comments

        MAY contain zero or more [0..*] entryRelationship (CONF:1198-14469) such that it

        Control0..*
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/EntryRelationship
        148. Observation.entryRelationship:assessmentScale.nullFlavor
        Definition

        If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

        Control0..1
        BindingThe codes SHALL be taken from CDANullFlavor
        (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
        Typecode(cs: Coded Simple Value)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelExceptional Value Detail
        150. Observation.entryRelationship:assessmentScale.realmCode
        Definition

        When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question

        Control0..*
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
        152. Observation.entryRelationship:assessmentScale.typeId
        Definition

        When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.

        Control0..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
        InvariantsII-1: An II instance must have either a root or an nullFlavor. (root.exists() or nullFlavor.exists())
        154. Observation.entryRelationship:assessmentScale.typeId.nullFlavor
        Definition

        If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

        Control0..1
        BindingThe codes SHALL be taken from CDANullFlavor
        (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
        Typecode(cs: Coded Simple Value)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelExceptional Value Detail
        156. Observation.entryRelationship:assessmentScale.typeId.assigningAuthorityName
        Definition

        A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

        Control0..1
        Typestring(st: Character String)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelAssigning Authority Name
        158. Observation.entryRelationship:assessmentScale.typeId.displayable
        Definition

        Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

        Control0..1
        Typeboolean(bl: Boolean)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelDisplayable
        160. Observation.entryRelationship:assessmentScale.typeId.root
        Definition

        Identifies the type as an HL7 Registered model

        Control1..1
        Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelRoot
        Fixed Value2.16.840.1.113883.1.3
        162. Observation.entryRelationship:assessmentScale.typeId.extension
        Definition

        A character string as a unique identifier within the scope of the identifier root.

        Control1..1
        Typestring(st: Character String)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelExtension
        164. Observation.entryRelationship:assessmentScale.templateId
        Definition

        When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

        Control0..*
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
        166. Observation.entryRelationship:assessmentScale.typeCode
        Comments

        SHALL contain exactly one [1..1] @typeCode="SPRT" has support (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC).

        Control1..1
        BindingThe codes SHALL be taken from x_ActRelationshipEntryRelationship
        (required to http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship)
        Typecode(cs: Coded Simple Value)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        Fixed ValueSPRT
        168. Observation.entryRelationship:assessmentScale.inversionInd
        Definition

        The entryRelationship.inversionInd can be set to "true" to indicate that the relationship should be interpreted as if the roles of the source and target entries were reversed.

        Control0..1
        Typeboolean(bl: Boolean)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        170. Observation.entryRelationship:assessmentScale.contextConductionInd
        Definition

        The entryRelationship.contextConductionInd differs from the otherwise common use of this attribute in that in all other cases where this attribute is used, the value is fixed at "true", whereas here the value is defaulted to "true", and can be changed to "false" when referencing an entry in the same document. Setting the context conduction to false when referencing an entry in the same document keeps clear the fact that the referenced object retains its original context.

        Control0..1
        Typeboolean(bl: Boolean)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        Default Valuetrue
        172. Observation.entryRelationship:assessmentScale.negationInd
        Control0..1
        Typeboolean(bl: Boolean)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        174. Observation.entryRelationship:assessmentScale.sequenceNumber
        Control0..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/INT
        176. Observation.entryRelationship:assessmentScale.seperatableInd
        Control0..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/BL
        178. Observation.entryRelationship:assessmentScale.act
        Control0..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Act
        180. Observation.entryRelationship:assessmentScale.encounter
        Control0..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Encounter
        182. Observation.entryRelationship:assessmentScale.observation
        Comments

        SHALL contain exactly one [1..1] Assessment Scale Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.69) (CONF:1198-14470).

        Control1..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Assessment Scale Observation)
        184. Observation.entryRelationship:assessmentScale.observationMedia
        Control0..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/ObservationMedia
        186. Observation.entryRelationship:assessmentScale.organizer
        Control0..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Organizer
        188. Observation.entryRelationship:assessmentScale.procedure
        Control0..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Procedure
        190. Observation.entryRelationship:assessmentScale.regionOfInterest
        Control0..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/RegionOfInterest
        192. Observation.entryRelationship:assessmentScale.substanceAdministration
        Control0..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/SubstanceAdministration
        194. Observation.entryRelationship:assessmentScale.supply
        Control0..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Supply
        196. Observation.reference
        Control0..*
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Reference
        198. Observation.precondition
        Control0..*
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Precondition
        200. Observation.sdtcPrecondition2
        Control0..*
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Precondition2
        XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual nameprecondition2.
        202. Observation.referenceRange
        Definition

        Relates an Observation to the ObservationRange class, where the expected range of values for a particular observation can be specified.


        Guidance on how to interpret the value by comparison to a normal or recommended range. Multiple reference ranges are interpreted as an "OR". In other words, to represent two distinct target populations, two referenceRange elements would be used.

        ShortThe referenceRange could be used to represent normal or expected capability for the mental function being evaluated.Provides guide for interpretation
        Comments

        MAY contain zero or more [0..*] referenceRange (CONF:1198-14267).


        Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this might not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.

        Control0..*
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRootBackboneElement
        Is Modifierfalse
        Requirements

        Knowing what values are considered "normal" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        obs-3: Must have at least a low or a high or text (low.exists() or high.exists() or text.exists())
        204. Observation.referenceRange.nullFlavor
        Definition

        If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

        Control0..1
        BindingThe codes SHALL be taken from CDANullFlavor
        (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
        Typecode(cs: Coded Simple Value)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelExceptional Value Detail
        206. Observation.referenceRange.realmCode
        Definition

        When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question

        Control0..*
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
        208. Observation.referenceRange.typeId
        Definition

        When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.

        Control0..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
        InvariantsII-1: An II instance must have either a root or an nullFlavor. (root.exists() or nullFlavor.exists())
        210. Observation.referenceRange.typeId.nullFlavor
        Definition

        If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

        Control0..1
        BindingThe codes SHALL be taken from CDANullFlavor
        (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
        Typecode(cs: Coded Simple Value)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelExceptional Value Detail
        212. Observation.referenceRange.typeId.assigningAuthorityName
        Definition

        A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

        Control0..1
        Typestring(st: Character String)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelAssigning Authority Name
        214. Observation.referenceRange.typeId.displayable
        Definition

        Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

        Control0..1
        Typeboolean(bl: Boolean)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelDisplayable
        216. Observation.referenceRange.typeId.root
        Definition

        Identifies the type as an HL7 Registered model

        Control1..1
        Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelRoot
        Fixed Value2.16.840.1.113883.1.3
        218. Observation.referenceRange.typeId.extension
        Definition

        A character string as a unique identifier within the scope of the identifier root.

        Control1..1
        Typestring(st: Character String)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        LabelExtension
        220. Observation.referenceRange.templateId
        Definition

        When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

        Control0..*
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
        222. Observation.referenceRange.typeCode
        Control0..1
        BindingThe codes SHALL be taken from CDAActRelationshipType
        (required to http://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType)
        Typecode(cs: Coded Simple Value)
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        XML FormatIn the XML format, this property is represented as an attribute.
        Fixed ValueREFV
        224. Observation.referenceRange.observationRange
        Control1..1
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/ObservationRange
        226. Observation.sdtcInFulfillmentOf1
        Control0..*
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/InFulfillmentOf1
        XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual nameinFulfillmentOf1.

        Guidance on how to interpret the contents of this table can be foundhere

        0. Observation
        Logical ContainerClinicalDocument (CDA Class)
        ValidationInstance of this type are validated by templateId
        XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
        Invariantsshould-text-ref-value: SHOULD contain text/reference/@value (text.reference.value.exists())
        should-author: SHOULD contain author (author.exists())
        2. Observation.templateId
        Control1..?
        SlicingThis element introduces a set of slices on Observation.templateId. The slices areUnordered and Open, and can be differentiated using the following discriminators:
        • value @ root
        • value @ extension
        • 4. Observation.templateId:mental-status-obs
          Slice Namemental-status-obs
          Control1..1
          6. Observation.templateId:mental-status-obs.root
          Control1..?
          Pattern Value2.16.840.1.113883.10.20.22.4.74
          8. Observation.templateId:mental-status-obs.extension
          Control1..?
          Pattern Value2024-05-01
          10. Observation.classCode
          Comments

          SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-14249).

          Fixed ValueOBS
          12. Observation.moodCode
          Comments

          SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1198-14250).

          Fixed ValueEVN
          14. Observation.id
          Comments

          SHALL contain at least one [1..*] id (CONF:1198-14257).

          Control1..?
          16. Observation.code
          ShortMental Status
          18. Observation.code.code
          Control1..?
          Pattern Value8693-4
          20. Observation.code.codeSystem
          ShortLOINC
          Control1..?
          Pattern Value2.16.840.1.113883.6.1
          22. Observation.text
          ShortSHOULD reference the portion of section narrative text corresponding to this entry
          24. Observation.text.reference
          Invariantsvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative (value.exists() implies value.startsWith('#'))
          26. Observation.statusCode
          Comments

          SHALL contain exactly one [1..1] statusCode (CONF:1198-14254).

          Control1..?
          28. Observation.statusCode.code
          Comments

          This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: HL7ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:1198-19092).

          Control1..?
          Fixed Valuecompleted
          30. Observation.effectiveTime
          Comments

          SHALL contain exactly one [1..1] effectiveTime (CONF:1198-14261).

          Control1..?
          32. Observation.value
          Comments

          SHALL contain exactly one [1..1] value (CONF:1198-14263).

          Control1..1
          SlicingThis element introduces a set of slices on Observation.value. The slices areUnordered and Open, and can be differentiated using the following discriminators:
          • type @ $this
          • 34. Observation.value:code
            Slice Namecode
            Control0..1
            BindingThe codes SHOULD be taken from Mental Status Observation .
            (preferred to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.1)
            Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
            36. Observation.author
            Comments

            SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1198-14266).

            Typehttp://hl7.org/cda/stds/core/StructureDefinition/Author(Author Participation)
            38. Observation.entryRelationship
            SlicingThis element introduces a set of slices on Observation.entryRelationship. The slices areUnordered and Open, and can be differentiated using the following discriminators:
            • profile @ observation
            • 40. Observation.entryRelationship:assessmentScale
              Slice NameassessmentScale
              Short𝗨𝗦𝗖𝗗𝗜: Mental/Cognitive Status
              Comments

              MAY contain zero or more [0..*] entryRelationship (CONF:1198-14469) such that it

              Control0..*
              42. Observation.entryRelationship:assessmentScale.typeCode
              Comments

              SHALL contain exactly one [1..1] @typeCode="SPRT" has support (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC).

              Fixed ValueSPRT
              44. Observation.entryRelationship:assessmentScale.observation
              Comments

              SHALL contain exactly one [1..1] Assessment Scale Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.69) (CONF:1198-14470).

              Control1..?
              Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Assessment Scale Observation)
              46. Observation.referenceRange
              ShortThe referenceRange could be used to represent normal or expected capability for the mental function being evaluated.
              Comments

              MAY contain zero or more [0..*] referenceRange (CONF:1198-14267).

              Guidance on how to interpret the contents of this table can be foundhere

              0. Observation
              Definition

              Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type.

              ShortBase for all types and resources
              Control1..1
              Is Modifierfalse
              Logical ContainerClinicalDocument (CDA Class)
              ValidationInstance of this type are validated by templateId
              XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
              Invariantsshould-text-ref-value: SHOULD contain text/reference/@value (text.reference.value.exists())
              should-author: SHOULD contain author (author.exists())
              2. Observation.nullFlavor
              Definition

              If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

              Control0..1
              BindingThe codes SHALL be taken from CDANullFlavor
              (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
              Typecode(cs: Coded Simple Value)
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              XML FormatIn the XML format, this property is represented as an attribute.
              LabelExceptional Value Detail
              4. Observation.realmCode
              Definition

              When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question

              Control0..*
              Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
              6. Observation.typeId
              Definition

              When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.

              Control0..1
              Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
              InvariantsII-1: An II instance must have either a root or an nullFlavor. (root.exists() or nullFlavor.exists())
              8. Observation.typeId.nullFlavor
              Definition

              If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

              Control0..1
              BindingThe codes SHALL be taken from CDANullFlavor
              (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
              Typecode(cs: Coded Simple Value)
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              XML FormatIn the XML format, this property is represented as an attribute.
              LabelExceptional Value Detail
              10. Observation.typeId.assigningAuthorityName
              Definition

              A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

              Control0..1
              Typestring(st: Character String)
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              XML FormatIn the XML format, this property is represented as an attribute.
              LabelAssigning Authority Name
              12. Observation.typeId.displayable
              Definition

              Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

              Control0..1
              Typeboolean(bl: Boolean)
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              XML FormatIn the XML format, this property is represented as an attribute.
              LabelDisplayable
              14. Observation.typeId.root
              Definition

              Identifies the type as an HL7 Registered model

              Control1..1
              Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              XML FormatIn the XML format, this property is represented as an attribute.
              LabelRoot
              Fixed Value2.16.840.1.113883.1.3
              16. Observation.typeId.extension
              Definition

              A character string as a unique identifier within the scope of the identifier root.

              Control1..1
              Typestring(st: Character String)
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              XML FormatIn the XML format, this property is represented as an attribute.
              LabelExtension
              18. Observation.templateId
              Definition

              When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

              Control1..*
              Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
              SlicingThis element introduces a set of slices on Observation.templateId. The slices areUnordered and Open, and can be differentiated using the following discriminators:
              • value @ root
              • value @ extension
              • 20. Observation.templateId:mental-status-obs
                Slice Namemental-status-obs
                Definition

                When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

                Control1..1
                Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
                22. Observation.templateId:mental-status-obs.nullFlavor
                Definition

                If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

                Control0..1
                BindingThe codes SHALL be taken from CDANullFlavor
                (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
                Typecode(cs: Coded Simple Value)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelExceptional Value Detail
                24. Observation.templateId:mental-status-obs.assigningAuthorityName
                Definition

                A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

                Control0..1
                Typestring(st: Character String)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelAssigning Authority Name
                26. Observation.templateId:mental-status-obs.displayable
                Definition

                Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

                Control0..1
                Typeboolean(bl: Boolean)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelDisplayable
                28. Observation.templateId:mental-status-obs.root
                Definition

                A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.

                Control1..1
                Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelRoot
                Pattern Value2.16.840.1.113883.10.20.22.4.74
                30. Observation.templateId:mental-status-obs.extension
                Definition

                A character string as a unique identifier within the scope of the identifier root.

                Control1..1
                Typestring(st: Character String)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelExtension
                Pattern Value2024-05-01
                32. Observation.classCode
                Comments

                SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-14249).

                Control1..1
                BindingThe codes SHALL be taken from CDAActClassObservation
                (required to http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation)
                Typecode(cs: Coded Simple Value)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                Fixed ValueOBS
                34. Observation.moodCode
                Comments

                SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1198-14250).

                Control1..1
                BindingThe codes SHALL be taken from XActMoodDocumentObservation (2.0.0)
                (required to http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0)
                Typecode(cs: Coded Simple Value)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                Fixed ValueEVN
                36. Observation.negationInd
                Control0..1
                Typeboolean(bl: Boolean)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                38. Observation.id
                Comments

                SHALL contain at least one [1..*] id (CONF:1198-14257).

                Control1..*
                Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
                40. Observation.sdtcCategory
                Control0..*
                Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
                XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namecategory.
                42. Observation.code
                ShortMental Status
                Control1..1
                BindingFor example codes, see ObservationType
                (example to http://terminology.hl7.org/ValueSet/v3-ObservationType)
                Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
                XML FormatThe type of this property is determined using the xsi:typeattribute.
                44. Observation.code.nullFlavor
                Definition

                If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

                Control0..1
                BindingThe codes SHALL be taken from CDANullFlavor
                (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
                Typecode(cs: Coded Simple Value)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelExceptional Value Detail
                46. Observation.code.code
                Definition

                The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

                Control1..1
                Typecode(cs: Coded Simple Value)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelCode
                Pattern Value8693-4
                48. Observation.code.codeSystem
                Definition

                Specifies the code system that defines the code.

                ShortLOINC
                Control1..1
                Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelCode System
                Pattern Value2.16.840.1.113883.6.1
                50. Observation.code.codeSystemName
                Definition

                The common name of the coding system.

                Control0..1
                Typestring(st: Character String)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelCode System Name
                52. Observation.code.codeSystemVersion
                Definition

                If applicable, a version descriptor defined specifically for the given code system.

                Control0..1
                Typestring(st: Character String)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelCode System Version
                54. Observation.code.displayName
                Definition

                A name or title for the code, under which the sending system shows the code value to its users.

                Control0..1
                Typestring(st: Character String)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelDisplay Name
                56. Observation.code.sdtcValueSet
                Definition

                The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.

                Control0..1
                Typestring(oid: ISO Object Identifier)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSet.
                58. Observation.code.sdtcValueSetVersion
                Definition

                The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.

                Control0..1
                Typestring(st: Character String)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSetVersion.
                60. Observation.code.originalText
                Definition

                The text or phrase used as the basis for the coding.

                Control0..1
                Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
                LabelOriginal Text
                62. Observation.code.qualifier
                Definition

                Specifies additional codes that increase the specificity of the the primary code.

                Control0..*
                Typehttp://hl7.org/cda/stds/core/StructureDefinition/CR
                LabelQualifier
                64. Observation.code.translation
                Definition

                A set of other concept descriptors that translate this concept descriptor into other code systems.

                Control0..*
                Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
                XML FormatThe type of this property is determined using the xsi:typeattribute.
                LabelTranslation
                66. Observation.derivationExpr
                Control0..1
                Typehttp://hl7.org/cda/stds/core/StructureDefinition/ST
                68. Observation.text
                ShortSHOULD reference the portion of section narrative text corresponding to this entry
                Control0..1
                Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
                XML FormatThe type of this property is determined using the xsi:typeattribute.
                70. Observation.text.nullFlavor
                Definition

                If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

                Control0..1
                BindingThe codes SHALL be taken from CDANullFlavor
                (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
                Typecode(cs: Coded Simple Value)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelExceptional Value Detail
                72. Observation.text.compression
                Definition

                Indicates whether the raw byte data is compressed, and what compression algorithm was used.

                Control0..1
                BindingThe codes SHALL be taken from CDACompressionAlgorithm
                (required to http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm)
                Typecode(cs: Coded Simple Value)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelCompression
                74. Observation.text.integrityCheck
                Definition

                The integrity check is a short binary value representing a cryptographically strong checksum that is calculated over the binary data. The purpose of this property, when communicated with a reference is for anyone to validate later whether the reference still resolved to the same data that the reference resolved to when the encapsulated data value with reference was created.

                Control0..1
                Typebase64Binary(bin: Binary Data)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelIntegrity Check
                76. Observation.text.integrityCheckAlgorithm
                Definition

                Specifies the algorithm used to compute the integrityCheck value. The cryptographically strong checksum algorithm Secure Hash Algorithm-1 (SHA-1) is currently the industry standard. It has superseded the MD5 algorithm only a couple of years ago, when certain flaws in the security of MD5 were discovered. Currently the SHA-1 hash algorithm is the default choice for the integrity check algorithm. Note that SHA-256 is also entering widespread usage.

                Control0..1
                BindingThe codes SHALL be taken from IntegrityCheckAlgorithm (2.0.0)
                (required to http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0)
                Typecode(cs: Coded Simple Value)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelIntegrity Check Algorithm
                78. Observation.text.language
                Definition

                For character based information the language property specifies the human language of the text.

                Control0..1
                Typecode(cs: Coded Simple Value)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelLanguage
                80. Observation.text.mediaType
                Definition

                Identifies the type of the encapsulated data and identifies a method to interpret or render the data.

                Control0..1
                BindingFor example codes, see MediaType
                (example to http://terminology.hl7.org/ValueSet/v3-MediaType)
                Typecode(cs: Coded Simple Value)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelMedia Type
                82. Observation.text.representation
                Control0..1
                BindingThe codes SHALL be taken from CDABinaryDataEncoding
                (required to http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding)
                Typecode(cs: Coded Simple Value)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                84. Observation.text.xmlText
                Definition

                Data that is primarily intended for human interpretation or for further machine processing is outside the scope of HL7. This includes unformatted or formatted written language, multimedia data, or structured information as defined by a different standard (e.g., XML-signatures.)

                ShortAllows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
                Comments

                This element is represented in XML as textual content. The actual name "xmlText" will not appear in a CDA instance.

                Control0..1
                Typestring(st: Character String)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as unadorned text.
                86. Observation.text.reference
                Definition

                A telecommunication address (TEL), such as a URL for HTTP or FTP, which will resolve to precisely the same binary data that could as well have been provided as inline data.

                Control0..1
                Typehttp://hl7.org/cda/stds/core/StructureDefinition/TEL
                LabelReference
                Invariantsvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative (value.exists() implies value.startsWith('#'))
                88. Observation.text.thumbnail
                Definition

                An abbreviated rendition of the full data. A thumbnail requires significantly fewer resources than the full data, while still maintaining some distinctive similarity with the full data. A thumbnail is typically used with by-reference encapsulated data. It allows a user to select data more efficiently before actually downloading through the reference.

                Control0..1
                Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
                LabelThumbnail
                90. Observation.statusCode
                Comments

                SHALL contain exactly one [1..1] statusCode (CONF:1198-14254).

                Control1..1
                BindingThe codes SHALL be taken from ActStatus
                (required to http://terminology.hl7.org/ValueSet/v3-ActStatus)
                Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
                92. Observation.statusCode.nullFlavor
                Definition

                If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

                Control0..1
                BindingThe codes SHALL be taken from CDANullFlavor
                (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
                Typecode(cs: Coded Simple Value)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelExceptional Value Detail
                94. Observation.statusCode.code
                Definition

                The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

                Comments

                This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: HL7ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:1198-19092).

                Control1..1
                Typecode(cs: Coded Simple Value)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelCode
                Fixed Valuecompleted
                96. Observation.statusCode.codeSystem
                Definition

                Specifies the code system that defines the code.

                Control0..0
                Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelCode System
                98. Observation.statusCode.codeSystemName
                Definition

                The common name of the coding system.

                Control0..0
                Typestring(st: Character String)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelCode System Name
                100. Observation.statusCode.codeSystemVersion
                Definition

                If applicable, a version descriptor defined specifically for the given code system.

                Control0..0
                Typestring(st: Character String)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelCode System Version
                102. Observation.statusCode.displayName
                Definition

                A name or title for the code, under which the sending system shows the code value to its users.

                Control0..0
                Typestring(st: Character String)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.
                LabelDisplay Name
                104. Observation.statusCode.sdtcValueSet
                Definition

                The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.

                Control0..1
                Typestring(oid: ISO Object Identifier)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSet.
                106. Observation.statusCode.sdtcValueSetVersion
                Definition

                The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.

                Control0..1
                Typestring(st: Character String)
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                XML FormatIn the XML format, this property is represented as an attribute.In the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual namevalueSetVersion.
                108. Observation.statusCode.originalText
                Definition

                The text or phrase used as the basis for the coding.

                Control0..0
                Typehttp://hl7.org/cda/stds/core/StructureDefinition/ED
                LabelOriginal Text
                110. Observation.statusCode.qualifier
                Definition

                Specifies additional codes that increase the specificity of the the primary code.

                Control0..0
                Typehttp://hl7.org/cda/stds/core/StructureDefinition/CR
                LabelQualifier
                112. Observation.statusCode.translation
                Definition

                A set of other concept descriptors that translate this concept descriptor into other code systems.

                Control0..0
                Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
                XML FormatThe type of this property is determined using the xsi:typeattribute.
                LabelTranslation
                114. Observation.effectiveTime
                Comments

                SHALL contain exactly one [1..1] effectiveTime (CONF:1198-14261).

                Control1..1
                Typehttp://hl7.org/cda/stds/core/StructureDefinition/IVL-TS
                116. Observation.priorityCode
                Control0..1
                BindingFor example codes, see ActPriority
                (example to http://terminology.hl7.org/ValueSet/v3-ActPriority)
                Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
                118. Observation.repeatNumber
                Control0..1
                Typehttp://hl7.org/cda/stds/core/StructureDefinition/IVL-INT
                120. Observation.languageCode
                Control0..1
                BindingThe codes SHALL be taken from AllLanguages
                (required to http://hl7.org/fhir/ValueSet/all-languages)
                Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
                122. Observation.value
                Comments

                SHALL contain exactly one [1..1] value (CONF:1198-14263).

                Control1..1
                TypeChoice of: http://hl7.org/cda/stds/core/StructureDefinition/ANY, http://hl7.org/cda/stds/core/StructureDefinition/BL, http://hl7.org/cda/stds/core/StructureDefinition/ED, http://hl7.org/cda/stds/core/StructureDefinition/ST, http://hl7.org/cda/stds/core/StructureDefinition/CD, http://hl7.org/cda/stds/core/StructureDefinition/CV, http://hl7.org/cda/stds/core/StructureDefinition/CE, http://hl7.org/cda/stds/core/StructureDefinition/CO, http://hl7.org/cda/stds/core/StructureDefinition/SC, http://hl7.org/cda/stds/core/StructureDefinition/II, http://hl7.org/cda/stds/core/StructureDefinition/TEL, http://hl7.org/cda/stds/core/StructureDefinition/AD, http://hl7.org/cda/stds/core/StructureDefinition/EN, http://hl7.org/cda/stds/core/StructureDefinition/INT, http://hl7.org/cda/stds/core/StructureDefinition/REAL, http://hl7.org/cda/stds/core/StructureDefinition/PQ, http://hl7.org/cda/stds/core/StructureDefinition/MO, http://hl7.org/cda/stds/core/StructureDefinition/TS, http://hl7.org/cda/stds/core/StructureDefinition/IVL-PQ, http://hl7.org/cda/stds/core/StructureDefinition/IVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/PIVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/EIVL-TS, http://hl7.org/cda/stds/core/StructureDefinition/SXPR-TS, http://hl7.org/cda/stds/core/StructureDefinition/RTO-PQ-PQ
                XML FormatThe type of this property is determined using the xsi:typeattribute.
                SlicingThis element introduces a set of slices on Observation.value. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                • type @ $this
                • 124. Observation.value:code
                  Slice Namecode
                  Control0..1
                  BindingThe codes SHOULD be taken from Mental Status Observation .
                  (preferred to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.1)
                  Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
                  XML FormatThe type of this property is determined using the xsi:typeattribute.
                  126. Observation.interpretationCode
                  Control0..*
                  BindingThe codes SHALL be taken from CDAObservationInterpretation
                  (required to http://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation)
                  Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
                  128. Observation.methodCode
                  Control0..*
                  BindingFor example codes, see ObservationMethod
                  (example to http://terminology.hl7.org/ValueSet/v3-ObservationMethod)
                  Typehttp://hl7.org/cda/stds/core/StructureDefinition/CE
                  130. Observation.targetSiteCode
                  Definition

                  Drawn from concept domain ActSite

                  Control0..*
                  Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
                  132. Observation.subject
                  Control0..1
                  Typehttp://hl7.org/cda/stds/core/StructureDefinition/Subject
                  134. Observation.specimen
                  Control0..*
                  Typehttp://hl7.org/cda/stds/core/StructureDefinition/Specimen
                  136. Observation.performer
                  Control0..*
                  Typehttp://hl7.org/cda/stds/core/StructureDefinition/Performer2
                  138. Observation.author
                  Shorticon Removed:Base for all types and resources
                  Comments

                  SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1198-14266).

                  Control0..*
                  Typehttp://hl7.org/cda/stds/core/StructureDefinition/Author(Author Participation)
                  140. Observation.informant
                  Control0..*
                  Typehttp://hl7.org/cda/stds/core/StructureDefinition/Informant
                  142. Observation.participant
                  Control0..*
                  Typehttp://hl7.org/cda/stds/core/StructureDefinition/Participant2
                  144. Observation.entryRelationship
                  Control0..*
                  Typehttp://hl7.org/cda/stds/core/StructureDefinition/EntryRelationship
                  SlicingThis element introduces a set of slices on Observation.entryRelationship. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                  • profile @ observation
                  • 146. Observation.entryRelationship:assessmentScale
                    Slice NameassessmentScale
                    Short𝗨𝗦𝗖𝗗𝗜: Mental/Cognitive Status
                    Comments

                    MAY contain zero or more [0..*] entryRelationship (CONF:1198-14469) such that it

                    Control0..*
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/EntryRelationship
                    148. Observation.entryRelationship:assessmentScale.nullFlavor
                    Definition

                    If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

                    Control0..1
                    BindingThe codes SHALL be taken from CDANullFlavor
                    (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
                    Typecode(cs: Coded Simple Value)
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    XML FormatIn the XML format, this property is represented as an attribute.
                    LabelExceptional Value Detail
                    150. Observation.entryRelationship:assessmentScale.realmCode
                    Definition

                    When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question

                    Control0..*
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
                    152. Observation.entryRelationship:assessmentScale.typeId
                    Definition

                    When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.

                    Control0..1
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
                    InvariantsII-1: An II instance must have either a root or an nullFlavor. (root.exists() or nullFlavor.exists())
                    154. Observation.entryRelationship:assessmentScale.typeId.nullFlavor
                    Definition

                    If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

                    Control0..1
                    BindingThe codes SHALL be taken from CDANullFlavor
                    (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
                    Typecode(cs: Coded Simple Value)
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    XML FormatIn the XML format, this property is represented as an attribute.
                    LabelExceptional Value Detail
                    156. Observation.entryRelationship:assessmentScale.typeId.assigningAuthorityName
                    Definition

                    A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

                    Control0..1
                    Typestring(st: Character String)
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    XML FormatIn the XML format, this property is represented as an attribute.
                    LabelAssigning Authority Name
                    158. Observation.entryRelationship:assessmentScale.typeId.displayable
                    Definition

                    Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

                    Control0..1
                    Typeboolean(bl: Boolean)
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    XML FormatIn the XML format, this property is represented as an attribute.
                    LabelDisplayable
                    160. Observation.entryRelationship:assessmentScale.typeId.root
                    Definition

                    Identifies the type as an HL7 Registered model

                    Control1..1
                    Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    XML FormatIn the XML format, this property is represented as an attribute.
                    LabelRoot
                    Fixed Value2.16.840.1.113883.1.3
                    162. Observation.entryRelationship:assessmentScale.typeId.extension
                    Definition

                    A character string as a unique identifier within the scope of the identifier root.

                    Control1..1
                    Typestring(st: Character String)
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    XML FormatIn the XML format, this property is represented as an attribute.
                    LabelExtension
                    164. Observation.entryRelationship:assessmentScale.templateId
                    Definition

                    When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

                    Control0..*
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
                    166. Observation.entryRelationship:assessmentScale.typeCode
                    Comments

                    SHALL contain exactly one [1..1] @typeCode="SPRT" has support (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC).

                    Control1..1
                    BindingThe codes SHALL be taken from x_ActRelationshipEntryRelationship
                    (required to http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship)
                    Typecode(cs: Coded Simple Value)
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    XML FormatIn the XML format, this property is represented as an attribute.
                    Fixed ValueSPRT
                    168. Observation.entryRelationship:assessmentScale.inversionInd
                    Definition

                    The entryRelationship.inversionInd can be set to "true" to indicate that the relationship should be interpreted as if the roles of the source and target entries were reversed.

                    Control0..1
                    Typeboolean(bl: Boolean)
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    XML FormatIn the XML format, this property is represented as an attribute.
                    170. Observation.entryRelationship:assessmentScale.contextConductionInd
                    Definition

                    The entryRelationship.contextConductionInd differs from the otherwise common use of this attribute in that in all other cases where this attribute is used, the value is fixed at "true", whereas here the value is defaulted to "true", and can be changed to "false" when referencing an entry in the same document. Setting the context conduction to false when referencing an entry in the same document keeps clear the fact that the referenced object retains its original context.

                    Control0..1
                    Typeboolean(bl: Boolean)
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    XML FormatIn the XML format, this property is represented as an attribute.
                    Default Valuetrue
                    172. Observation.entryRelationship:assessmentScale.negationInd
                    Control0..1
                    Typeboolean(bl: Boolean)
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    XML FormatIn the XML format, this property is represented as an attribute.
                    174. Observation.entryRelationship:assessmentScale.sequenceNumber
                    Control0..1
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/INT
                    176. Observation.entryRelationship:assessmentScale.seperatableInd
                    Control0..1
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/BL
                    178. Observation.entryRelationship:assessmentScale.act
                    Control0..1
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/Act
                    180. Observation.entryRelationship:assessmentScale.encounter
                    Control0..1
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/Encounter
                    182. Observation.entryRelationship:assessmentScale.observation
                    Comments

                    SHALL contain exactly one [1..1] Assessment Scale Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.69) (CONF:1198-14470).

                    Control1..1
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Assessment Scale Observation)
                    184. Observation.entryRelationship:assessmentScale.observationMedia
                    Control0..1
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/ObservationMedia
                    186. Observation.entryRelationship:assessmentScale.organizer
                    Control0..1
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/Organizer
                    188. Observation.entryRelationship:assessmentScale.procedure
                    Control0..1
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/Procedure
                    190. Observation.entryRelationship:assessmentScale.regionOfInterest
                    Control0..1
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/RegionOfInterest
                    192. Observation.entryRelationship:assessmentScale.substanceAdministration
                    Control0..1
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/SubstanceAdministration
                    194. Observation.entryRelationship:assessmentScale.supply
                    Control0..1
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/Supply
                    196. Observation.reference
                    Control0..*
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/Reference
                    198. Observation.precondition
                    Control0..*
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/Precondition
                    200. Observation.sdtcPrecondition2
                    Control0..*
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/Precondition2
                    XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual nameprecondition2.
                    202. Observation.referenceRange
                    Definition

                    Relates an Observation to the ObservationRange class, where the expected range of values for a particular observation can be specified.

                    ShortThe referenceRange could be used to represent normal or expected capability for the mental function being evaluated.
                    Comments

                    MAY contain zero or more [0..*] referenceRange (CONF:1198-14267).

                    Control0..*
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/InfrastructureRoot
                    204. Observation.referenceRange.nullFlavor
                    Definition

                    If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

                    Control0..1
                    BindingThe codes SHALL be taken from CDANullFlavor
                    (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
                    Typecode(cs: Coded Simple Value)
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    XML FormatIn the XML format, this property is represented as an attribute.
                    LabelExceptional Value Detail
                    206. Observation.referenceRange.realmCode
                    Definition

                    When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question

                    Control0..*
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/CS
                    208. Observation.referenceRange.typeId
                    Definition

                    When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.

                    Control0..1
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
                    InvariantsII-1: An II instance must have either a root or an nullFlavor. (root.exists() or nullFlavor.exists())
                    210. Observation.referenceRange.typeId.nullFlavor
                    Definition

                    If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

                    Control0..1
                    BindingThe codes SHALL be taken from CDANullFlavor
                    (required to http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor)
                    Typecode(cs: Coded Simple Value)
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    XML FormatIn the XML format, this property is represented as an attribute.
                    LabelExceptional Value Detail
                    212. Observation.referenceRange.typeId.assigningAuthorityName
                    Definition

                    A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

                    Control0..1
                    Typestring(st: Character String)
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    XML FormatIn the XML format, this property is represented as an attribute.
                    LabelAssigning Authority Name
                    214. Observation.referenceRange.typeId.displayable
                    Definition

                    Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

                    Control0..1
                    Typeboolean(bl: Boolean)
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    XML FormatIn the XML format, this property is represented as an attribute.
                    LabelDisplayable
                    216. Observation.referenceRange.typeId.root
                    Definition

                    Identifies the type as an HL7 Registered model

                    Control1..1
                    Typestring(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    XML FormatIn the XML format, this property is represented as an attribute.
                    LabelRoot
                    Fixed Value2.16.840.1.113883.1.3
                    218. Observation.referenceRange.typeId.extension
                    Definition

                    A character string as a unique identifier within the scope of the identifier root.

                    Control1..1
                    Typestring(st: Character String)
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    XML FormatIn the XML format, this property is represented as an attribute.
                    LabelExtension
                    220. Observation.referenceRange.templateId
                    Definition

                    When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

                    Control0..*
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/II
                    222. Observation.referenceRange.typeCode
                    Control0..1
                    BindingThe codes SHALL be taken from CDAActRelationshipType
                    (required to http://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType)
                    Typecode(cs: Coded Simple Value)
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    XML FormatIn the XML format, this property is represented as an attribute.
                    Fixed ValueREFV
                    224. Observation.referenceRange.observationRange
                    Control1..1
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/ObservationRange
                    226. Observation.sdtcInFulfillmentOf1
                    Control0..*
                    Typehttp://hl7.org/cda/stds/core/StructureDefinition/InFulfillmentOf1
                    XML FormatIn the XML format, this property has the namespace urn:hl7-org:sdtc.In the XML format, this property has the actual nameinFulfillmentOf1.