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FR Document Core (CDA)
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FR Document Core (CDA) - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Logical Model: CDA - FR Evaluation Composant

Official URL: https://interop.esante.gouv.fr/ig/cda/document-core/StructureDefinition/fr-cda-evaluation-composant Version: 0.1.0
Draft as of 2026-08-28 Computable Name: FRCDAEvaluationComposant

Entrée FR-Evaluation-Composant: Cette entrée permet de porter un résultat élémentaire (ex : score unitaire) répondant à une question faisant partie d’une évaluation.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation 1..1 Observation(2.0.3-sd) XML Namespace: urn:hl7-org:v3
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 3..3 II Slice: Unordered, Open by value:root
.... templateId:ccdResultObservation 1..1 II Conformité Simple Observation (CCD)
..... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Required Pattern: 2.16.840.1.113883.10.20.1.31
.... templateId:iheSimpleObservation 1..1 II Conformité Simple Observation (IHE PCC)
..... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.4.13
.... templateId:frEvaluationComposant 1..1 II Conformité FR-Evaluation-Composant(CI-SIS)
..... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Required Pattern: 1.2.250.1.213.1.1.3.214
... @classCode S 1..1 cs(2.0.3-sd) Required Pattern: OBS
... @moodCode S 1..1 cs(2.0.3-sd) Required Pattern: EVN
... code S 1..1 CD Code de l'évaluation : dépend du volet utilisant cette entrée (les précisions sont alors fournies dans le volet correspondant). Utiliser de préférence un code LOINC (2.16.840.1.113883.6.1) ou ICF (2.16.840.1.113883.6.254) ou autre.Si le type d'évaluation n'est pas trouvé dans les terminologies proposées, utiliser le code='54522-8' displayName='Statut fonctionnel' codeSystem=' 2.16.840.1.113883.6.1' codeSystemName='LOINC' et décrire le type d'évaluation sous forme de texte libre dans la partie narrative avec une référence vers l'entrée correspondante.
.... @code S 1..1 cs(2.0.3-sd)
.... @codeSystem S 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd)
.... @displayName S 0..1 st(2.0.3-sd)
... text S 1..1 ED Partie narrative
.... reference 1..1 TEL
... statusCode S 1..1 CS Statut de l'entrée - Fixé à la valeur 'completed'
.... @code 0..1 cs(2.0.3-sd) Required Pattern: completed
... effectiveTime S 1..1 IVL_TS Horodatage de l'entrée
... value S 1..1 CD Résultat de l'évaluation - Le type et la valeur du résultat de l'évaluation (value) dépendent du volet utilisant cette entrée (les précisions sont alors fournies dans le volet correspondant).
.... originalText S 0..1 ED
..... reference 1..1 TEL
... interpretationCode S 0..1 CE Interprétation
... Slices for entryRelationship S 0..* EntryRelationship Slice: Unordered, Open by value:$this
.... entryRelationship:frEvaluationComposantN2 0..* EntryRelationship Sous-composant de l'évaluation
..... @typeCode 1..1 cs(2.0.3-sd) Required Pattern: COMP
..... @inversionInd 0..1 bl(2.0.3-sd) Required Pattern: false
..... observation 0..1 FRCDAEvaluationComposantN2(0.1.0)
.... entryRelationship:frCommentaireER 0..* EntryRelationship Commentaire
..... @typeCode 1..1 cs(2.0.3-sd) Required Pattern: SUBJ
..... @inversionInd 0..1 bl(2.0.3-sd) Required Pattern: true
..... act 0..1 FRCDACommentaireER(0.1.0)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation 1..1 Observation(2.0.3-sd) XML Namespace: urn:hl7-org:v3
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
... realmCode 0..* CS
... typeId C 0..1 II Constraints: II-1
.... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
.... @assigningAuthorityName 0..1 st(2.0.3-sd)
.... @displayable 0..1 bl(2.0.3-sd)
.... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st(2.0.3-sd)
... Slices for templateId 3..3 II Slice: Unordered, Open by value:root
.... templateId:ccdResultObservation 1..1 II Conformité Simple Observation (CCD)
..... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
..... @assigningAuthorityName 0..1 st(2.0.3-sd)
..... @displayable 0..1 bl(2.0.3-sd)
..... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Required Pattern: 2.16.840.1.113883.10.20.1.31
..... @extension 0..1 st(2.0.3-sd)
.... templateId:iheSimpleObservation 1..1 II Conformité Simple Observation (IHE PCC)
..... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
..... @assigningAuthorityName 0..1 st(2.0.3-sd)
..... @displayable 0..1 bl(2.0.3-sd)
..... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.4.13
..... @extension 0..1 st(2.0.3-sd)
.... templateId:frEvaluationComposant 1..1 II Conformité FR-Evaluation-Composant(CI-SIS)
..... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
..... @assigningAuthorityName 0..1 st(2.0.3-sd)
..... @displayable 0..1 bl(2.0.3-sd)
..... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Required Pattern: 1.2.250.1.213.1.1.3.214
..... @extension 0..1 st(2.0.3-sd)
... @classCode S 1..1 cs(2.0.3-sd) Binding: CDAActClassObservation (2.0.3-sd) (required)
Required Pattern: OBS
... @moodCode S 1..1 cs(2.0.3-sd) Binding: XActMoodDocumentObservation (2.0.0) (required)
Required Pattern: EVN
... @negationInd 0..1 bl(2.0.3-sd)
... id S 1..1 II Identifiant de l'entrée
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code S 1..1 CD Code de l'évaluation : dépend du volet utilisant cette entrée (les précisions sont alors fournies dans le volet correspondant). Utiliser de préférence un code LOINC (2.16.840.1.113883.6.1) ou ICF (2.16.840.1.113883.6.254) ou autre.Si le type d'évaluation n'est pas trouvé dans les terminologies proposées, utiliser le code='54522-8' displayName='Statut fonctionnel' codeSystem=' 2.16.840.1.113883.6.1' codeSystemName='LOINC' et décrire le type d'évaluation sous forme de texte libre dans la partie narrative avec une référence vers l'entrée correspondante.
Binding: ObservationType (3.0.0) (example)
.... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
.... @code S 1..1 cs(2.0.3-sd)
.... @codeSystem S 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd)
.... @codeSystemName 0..1 st(2.0.3-sd)
.... @codeSystemVersion 0..1 st(2.0.3-sd)
.... @displayName S 0..1 st(2.0.3-sd)
.... @sdtcValueSet 0..1 oid(2.0.3-sd) XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st(2.0.3-sd) XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... qualifier 0..* CR
.... translation 0..* CD
... derivationExpr 0..1 ST
... text S 1..1 ED Partie narrative
.... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
.... @compression 0..1 cs(2.0.3-sd) Binding: CDACompressionAlgorithm (2.0.3-sd) (required)
.... @integrityCheck 0..1 bin(2.0.3-sd)
.... @integrityCheckAlgorithm 0..1 cs(2.0.3-sd) Binding: IntegrityCheckAlgorithm (2.0.0) (required)
.... @language 0..1 cs(2.0.3-sd)
.... @mediaType 0..1 cs(2.0.3-sd) Binding: MediaType (3.0.0) (example)
.... @representation 0..1 cs(2.0.3-sd) Binding: BinaryDataEncoding (2.0.3-sd) (required)
.... xmlText 0..1 st(2.0.3-sd) Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
.... reference 1..1 TEL
.... thumbnail C 0..1 ED Constraints: ED-1
... statusCode S 1..1 CS Statut de l'entrée - Fixé à la valeur 'completed'
Binding: ActStatus (3.0.0) (required)
.... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
.... @code 0..1 cs(2.0.3-sd) Required Pattern: completed
.... @sdtcValueSet 0..1 oid(2.0.3-sd) XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st(2.0.3-sd) XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime S 1..1 IVL_TS Horodatage de l'entrée
... priorityCode 0..1 CE Binding: ActPriority (3.0.0) (example)
... repeatNumber 0..1 IVL_INT
... languageCode 0..1 CS Binding: AllLanguages (required)
... value S 1..1 CD Résultat de l'évaluation - Le type et la valeur du résultat de l'évaluation (value) dépendent du volet utilisant cette entrée (les précisions sont alors fournies dans le volet correspondant).
.... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
.... @code 0..1 cs(2.0.3-sd)
.... @codeSystem 0..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd)
.... @codeSystemName 0..1 st(2.0.3-sd)
.... @codeSystemVersion 0..1 st(2.0.3-sd)
.... @displayName 0..1 st(2.0.3-sd)
.... @sdtcValueSet 0..1 oid(2.0.3-sd) XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st(2.0.3-sd) XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText S 0..1 ED
..... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
..... @compression 0..1 cs(2.0.3-sd) Binding: CDACompressionAlgorithm (2.0.3-sd) (required)
..... @integrityCheck 0..1 bin(2.0.3-sd)
..... @integrityCheckAlgorithm 0..1 cs(2.0.3-sd) Binding: IntegrityCheckAlgorithm (2.0.0) (required)
..... @language 0..1 cs(2.0.3-sd)
..... @mediaType 0..1 cs(2.0.3-sd) Binding: MediaType (3.0.0) (example)
..... @representation 0..1 cs(2.0.3-sd) Binding: BinaryDataEncoding (2.0.3-sd) (required)
..... xmlText 0..1 st(2.0.3-sd) Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
..... reference 1..1 TEL
..... thumbnail C 0..1 ED Constraints: ED-1
.... qualifier 0..* CR
.... translation 0..* CD
... interpretationCode S 0..1 CE Interprétation
Binding: CDAObservationInterpretation (2.0.3-sd) (required)
... methodCode 0..* CE Binding: ObservationMethod (3.0.0) (example)
... targetSiteCode 0..* CD
... subject 0..1 Subject
... specimen 0..* Specimen
... performer 0..* Performer2
... author 0..* Author
... informant 0..* Informant
... participant 0..* Participant2
... Slices for entryRelationship S 0..* EntryRelationship Slice: Unordered, Open by value:$this
.... entryRelationship:frEvaluationComposantN2 0..* EntryRelationship Sous-composant de l'évaluation
..... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
..... realmCode 0..* CS
..... typeId C 0..1 II Constraints: II-1
...... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
...... @assigningAuthorityName 0..1 st(2.0.3-sd)
...... @displayable 0..1 bl(2.0.3-sd)
...... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st(2.0.3-sd)
..... templateId 0..* II
..... @typeCode 1..1 cs(2.0.3-sd) Binding: XActRelationshipEntryRelationship (3.0.0) (required)
Required Pattern: COMP
..... @inversionInd 0..1 bl(2.0.3-sd) Required Pattern: false
..... @contextConductionInd 0..1 bl(2.0.3-sd)
..... @negationInd 0..1 bl(2.0.3-sd)
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation 0..1 FRCDAEvaluationComposantN2(0.1.0)
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:frCommentaireER 0..* EntryRelationship Commentaire
..... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
..... realmCode 0..* CS
..... typeId C 0..1 II Constraints: II-1
...... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
...... @assigningAuthorityName 0..1 st(2.0.3-sd)
...... @displayable 0..1 bl(2.0.3-sd)
...... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st(2.0.3-sd)
..... templateId 0..* II
..... @typeCode 1..1 cs(2.0.3-sd) Binding: XActRelationshipEntryRelationship (3.0.0) (required)
Required Pattern: SUBJ
..... @inversionInd 0..1 bl(2.0.3-sd) Required Pattern: true
..... @contextConductionInd 0..1 bl(2.0.3-sd)
..... @negationInd 0..1 bl(2.0.3-sd)
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act 0..1 FRCDACommentaireER(0.1.0)
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
... reference 0..* Reference
... precondition 0..* Precondition
... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... referenceRange 0..* InfrastructureRoot
.... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
.... realmCode 0..* CS
.... typeId C 0..1 II Constraints: II-1
..... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
..... @assigningAuthorityName 0..1 st(2.0.3-sd)
..... @displayable 0..1 bl(2.0.3-sd)
..... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st(2.0.3-sd)
.... templateId 0..* II
.... @typeCode 0..1 cs(2.0.3-sd) Binding: CDAActRelationshipType (2.0.3-sd) (required)
Fixed Value: REFV
.... observationRange 1..1 ObservationRange
... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Observation.nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.typeId.nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.templateId:ccdResultObservation.​nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.templateId:iheSimpleObservation.​nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.templateId:frEvaluationComposant.​nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.classCode Base required CDAActClassObservation 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.moodCode Base required x_ActMoodDocumentObservation 📍2.0.0 THO v5.2
Observation.code Base example ObservationType 📍3.0.0 THO v7.3
Observation.code.nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.text.nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.text.compression Base required CDACompressionAlgorithm 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
Observation.text.mediaType Base example MediaType 📍3.0.0 THO v7.3
Observation.text.representation Base required CDABinaryDataEncoding 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.statusCode Base required ActStatus 📍3.0.0 THO v7.3
Observation.statusCode.​nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.priorityCode Base example ActPriority 📍3.0.0 THO v7.3
Observation.languageCode Base required All Languages 📍5.0.0 FHIR Std.
Observation.value.nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.value.originalText.​nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.value.originalText.​compression Base required CDACompressionAlgorithm 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.value.originalText.​integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
Observation.value.originalText.​mediaType Base example MediaType 📍3.0.0 THO v7.3
Observation.value.originalText.​representation Base required CDABinaryDataEncoding 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.interpretationCode Base required CDAObservationInterpretation 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.methodCode Base example ObservationMethod 📍3.0.0 THO v7.3
Observation.entryRelationship:frEvaluationComposantN2.​nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.entryRelationship:frEvaluationComposantN2.​typeId.nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.entryRelationship:frEvaluationComposantN2.​typeCode Base required x_ActRelationshipEntryRelationship 📍3.0.0 THO v7.3
Observation.entryRelationship:frCommentaireER.​nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.entryRelationship:frCommentaireER.​typeId.nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.entryRelationship:frCommentaireER.​typeCode Base required x_ActRelationshipEntryRelationship 📍3.0.0 THO v7.3
Observation.referenceRange.​nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.referenceRange.​typeId.nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.referenceRange.​typeCode Base required CDAActRelationshipType 📍2.0.3-sd Clinical Document Architecture v2.0

Constraints

Id Grade Path(s) Description Expression
ED-1 error Observation.text.thumbnail, Observation.value.originalText.thumbnail Thumbnails cannot contain their own thumbnails thumbnail.empty()
II-1 error Observation.typeId, Observation.entryRelationship:frEvaluationComposantN2.typeId, Observation.entryRelationship:frCommentaireER.typeId, Observation.referenceRange.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()

Summary

Mandatory: 14 elements(1 nested mandatory element)
Must-Support: 14 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Observation.templateId
  • The element 1 is sliced based on the value of Observation.entryRelationship

Differential View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation 1..1 Observation(2.0.3-sd) XML Namespace: urn:hl7-org:v3
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 3..3 II Slice: Unordered, Open by value:root
.... templateId:ccdResultObservation 1..1 II Conformité Simple Observation (CCD)
..... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Required Pattern: 2.16.840.1.113883.10.20.1.31
.... templateId:iheSimpleObservation 1..1 II Conformité Simple Observation (IHE PCC)
..... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.4.13
.... templateId:frEvaluationComposant 1..1 II Conformité FR-Evaluation-Composant(CI-SIS)
..... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Required Pattern: 1.2.250.1.213.1.1.3.214
... @classCode S 1..1 cs(2.0.3-sd) Required Pattern: OBS
... @moodCode S 1..1 cs(2.0.3-sd) Required Pattern: EVN
... code S 1..1 CD Code de l'évaluation : dépend du volet utilisant cette entrée (les précisions sont alors fournies dans le volet correspondant). Utiliser de préférence un code LOINC (2.16.840.1.113883.6.1) ou ICF (2.16.840.1.113883.6.254) ou autre.Si le type d'évaluation n'est pas trouvé dans les terminologies proposées, utiliser le code='54522-8' displayName='Statut fonctionnel' codeSystem=' 2.16.840.1.113883.6.1' codeSystemName='LOINC' et décrire le type d'évaluation sous forme de texte libre dans la partie narrative avec une référence vers l'entrée correspondante.
.... @code S 1..1 cs(2.0.3-sd)
.... @codeSystem S 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd)
.... @displayName S 0..1 st(2.0.3-sd)
... text S 1..1 ED Partie narrative
.... reference 1..1 TEL
... statusCode S 1..1 CS Statut de l'entrée - Fixé à la valeur 'completed'
.... @code 0..1 cs(2.0.3-sd) Required Pattern: completed
... effectiveTime S 1..1 IVL_TS Horodatage de l'entrée
... value S 1..1 CD Résultat de l'évaluation - Le type et la valeur du résultat de l'évaluation (value) dépendent du volet utilisant cette entrée (les précisions sont alors fournies dans le volet correspondant).
.... originalText S 0..1 ED
..... reference 1..1 TEL
... interpretationCode S 0..1 CE Interprétation
... Slices for entryRelationship S 0..* EntryRelationship Slice: Unordered, Open by value:$this
.... entryRelationship:frEvaluationComposantN2 0..* EntryRelationship Sous-composant de l'évaluation
..... @typeCode 1..1 cs(2.0.3-sd) Required Pattern: COMP
..... @inversionInd 0..1 bl(2.0.3-sd) Required Pattern: false
..... observation 0..1 FRCDAEvaluationComposantN2(0.1.0)
.... entryRelationship:frCommentaireER 0..* EntryRelationship Commentaire
..... @typeCode 1..1 cs(2.0.3-sd) Required Pattern: SUBJ
..... @inversionInd 0..1 bl(2.0.3-sd) Required Pattern: true
..... act 0..1 FRCDACommentaireER(0.1.0)

doco Documentation for this format

Snapshot ViewView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation 1..1 Observation(2.0.3-sd) XML Namespace: urn:hl7-org:v3
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
... realmCode 0..* CS
... typeId C 0..1 II Constraints: II-1
.... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
.... @assigningAuthorityName 0..1 st(2.0.3-sd)
.... @displayable 0..1 bl(2.0.3-sd)
.... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st(2.0.3-sd)
... Slices for templateId 3..3 II Slice: Unordered, Open by value:root
.... templateId:ccdResultObservation 1..1 II Conformité Simple Observation (CCD)
..... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
..... @assigningAuthorityName 0..1 st(2.0.3-sd)
..... @displayable 0..1 bl(2.0.3-sd)
..... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Required Pattern: 2.16.840.1.113883.10.20.1.31
..... @extension 0..1 st(2.0.3-sd)
.... templateId:iheSimpleObservation 1..1 II Conformité Simple Observation (IHE PCC)
..... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
..... @assigningAuthorityName 0..1 st(2.0.3-sd)
..... @displayable 0..1 bl(2.0.3-sd)
..... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.4.13
..... @extension 0..1 st(2.0.3-sd)
.... templateId:frEvaluationComposant 1..1 II Conformité FR-Evaluation-Composant(CI-SIS)
..... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
..... @assigningAuthorityName 0..1 st(2.0.3-sd)
..... @displayable 0..1 bl(2.0.3-sd)
..... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Required Pattern: 1.2.250.1.213.1.1.3.214
..... @extension 0..1 st(2.0.3-sd)
... @classCode S 1..1 cs(2.0.3-sd) Binding: CDAActClassObservation (2.0.3-sd) (required)
Required Pattern: OBS
... @moodCode S 1..1 cs(2.0.3-sd) Binding: XActMoodDocumentObservation (2.0.0) (required)
Required Pattern: EVN
... @negationInd 0..1 bl(2.0.3-sd)
... id S 1..1 II Identifiant de l'entrée
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code S 1..1 CD Code de l'évaluation : dépend du volet utilisant cette entrée (les précisions sont alors fournies dans le volet correspondant). Utiliser de préférence un code LOINC (2.16.840.1.113883.6.1) ou ICF (2.16.840.1.113883.6.254) ou autre.Si le type d'évaluation n'est pas trouvé dans les terminologies proposées, utiliser le code='54522-8' displayName='Statut fonctionnel' codeSystem=' 2.16.840.1.113883.6.1' codeSystemName='LOINC' et décrire le type d'évaluation sous forme de texte libre dans la partie narrative avec une référence vers l'entrée correspondante.
Binding: ObservationType (3.0.0) (example)
.... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
.... @code S 1..1 cs(2.0.3-sd)
.... @codeSystem S 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd)
.... @codeSystemName 0..1 st(2.0.3-sd)
.... @codeSystemVersion 0..1 st(2.0.3-sd)
.... @displayName S 0..1 st(2.0.3-sd)
.... @sdtcValueSet 0..1 oid(2.0.3-sd) XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st(2.0.3-sd) XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... qualifier 0..* CR
.... translation 0..* CD
... derivationExpr 0..1 ST
... text S 1..1 ED Partie narrative
.... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
.... @compression 0..1 cs(2.0.3-sd) Binding: CDACompressionAlgorithm (2.0.3-sd) (required)
.... @integrityCheck 0..1 bin(2.0.3-sd)
.... @integrityCheckAlgorithm 0..1 cs(2.0.3-sd) Binding: IntegrityCheckAlgorithm (2.0.0) (required)
.... @language 0..1 cs(2.0.3-sd)
.... @mediaType 0..1 cs(2.0.3-sd) Binding: MediaType (3.0.0) (example)
.... @representation 0..1 cs(2.0.3-sd) Binding: BinaryDataEncoding (2.0.3-sd) (required)
.... xmlText 0..1 st(2.0.3-sd) Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
.... reference 1..1 TEL
.... thumbnail C 0..1 ED Constraints: ED-1
... statusCode S 1..1 CS Statut de l'entrée - Fixé à la valeur 'completed'
Binding: ActStatus (3.0.0) (required)
.... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
.... @code 0..1 cs(2.0.3-sd) Required Pattern: completed
.... @sdtcValueSet 0..1 oid(2.0.3-sd) XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st(2.0.3-sd) XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime S 1..1 IVL_TS Horodatage de l'entrée
... priorityCode 0..1 CE Binding: ActPriority (3.0.0) (example)
... repeatNumber 0..1 IVL_INT
... languageCode 0..1 CS Binding: AllLanguages (required)
... value S 1..1 CD Résultat de l'évaluation - Le type et la valeur du résultat de l'évaluation (value) dépendent du volet utilisant cette entrée (les précisions sont alors fournies dans le volet correspondant).
.... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
.... @code 0..1 cs(2.0.3-sd)
.... @codeSystem 0..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd)
.... @codeSystemName 0..1 st(2.0.3-sd)
.... @codeSystemVersion 0..1 st(2.0.3-sd)
.... @displayName 0..1 st(2.0.3-sd)
.... @sdtcValueSet 0..1 oid(2.0.3-sd) XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st(2.0.3-sd) XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText S 0..1 ED
..... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
..... @compression 0..1 cs(2.0.3-sd) Binding: CDACompressionAlgorithm (2.0.3-sd) (required)
..... @integrityCheck 0..1 bin(2.0.3-sd)
..... @integrityCheckAlgorithm 0..1 cs(2.0.3-sd) Binding: IntegrityCheckAlgorithm (2.0.0) (required)
..... @language 0..1 cs(2.0.3-sd)
..... @mediaType 0..1 cs(2.0.3-sd) Binding: MediaType (3.0.0) (example)
..... @representation 0..1 cs(2.0.3-sd) Binding: BinaryDataEncoding (2.0.3-sd) (required)
..... xmlText 0..1 st(2.0.3-sd) Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
..... reference 1..1 TEL
..... thumbnail C 0..1 ED Constraints: ED-1
.... qualifier 0..* CR
.... translation 0..* CD
... interpretationCode S 0..1 CE Interprétation
Binding: CDAObservationInterpretation (2.0.3-sd) (required)
... methodCode 0..* CE Binding: ObservationMethod (3.0.0) (example)
... targetSiteCode 0..* CD
... subject 0..1 Subject
... specimen 0..* Specimen
... performer 0..* Performer2
... author 0..* Author
... informant 0..* Informant
... participant 0..* Participant2
... Slices for entryRelationship S 0..* EntryRelationship Slice: Unordered, Open by value:$this
.... entryRelationship:frEvaluationComposantN2 0..* EntryRelationship Sous-composant de l'évaluation
..... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
..... realmCode 0..* CS
..... typeId C 0..1 II Constraints: II-1
...... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
...... @assigningAuthorityName 0..1 st(2.0.3-sd)
...... @displayable 0..1 bl(2.0.3-sd)
...... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st(2.0.3-sd)
..... templateId 0..* II
..... @typeCode 1..1 cs(2.0.3-sd) Binding: XActRelationshipEntryRelationship (3.0.0) (required)
Required Pattern: COMP
..... @inversionInd 0..1 bl(2.0.3-sd) Required Pattern: false
..... @contextConductionInd 0..1 bl(2.0.3-sd)
..... @negationInd 0..1 bl(2.0.3-sd)
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation 0..1 FRCDAEvaluationComposantN2(0.1.0)
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:frCommentaireER 0..* EntryRelationship Commentaire
..... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
..... realmCode 0..* CS
..... typeId C 0..1 II Constraints: II-1
...... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
...... @assigningAuthorityName 0..1 st(2.0.3-sd)
...... @displayable 0..1 bl(2.0.3-sd)
...... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st(2.0.3-sd)
..... templateId 0..* II
..... @typeCode 1..1 cs(2.0.3-sd) Binding: XActRelationshipEntryRelationship (3.0.0) (required)
Required Pattern: SUBJ
..... @inversionInd 0..1 bl(2.0.3-sd) Required Pattern: true
..... @contextConductionInd 0..1 bl(2.0.3-sd)
..... @negationInd 0..1 bl(2.0.3-sd)
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act 0..1 FRCDACommentaireER(0.1.0)
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
... reference 0..* Reference
... precondition 0..* Precondition
... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... referenceRange 0..* InfrastructureRoot
.... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
.... realmCode 0..* CS
.... typeId C 0..1 II Constraints: II-1
..... @nullFlavor 0..1 cs(2.0.3-sd) Binding: CDANullFlavor (2.0.3-sd) (required)
..... @assigningAuthorityName 0..1 st(2.0.3-sd)
..... @displayable 0..1 bl(2.0.3-sd)
..... @root 1..1 oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st(2.0.3-sd)
.... templateId 0..* II
.... @typeCode 0..1 cs(2.0.3-sd) Binding: CDAActRelationshipType (2.0.3-sd) (required)
Fixed Value: REFV
.... observationRange 1..1 ObservationRange
... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Observation.nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.typeId.nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.templateId:ccdResultObservation.​nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.templateId:iheSimpleObservation.​nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.templateId:frEvaluationComposant.​nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.classCode Base required CDAActClassObservation 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.moodCode Base required x_ActMoodDocumentObservation 📍2.0.0 THO v5.2
Observation.code Base example ObservationType 📍3.0.0 THO v7.3
Observation.code.nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.text.nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.text.compression Base required CDACompressionAlgorithm 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
Observation.text.mediaType Base example MediaType 📍3.0.0 THO v7.3
Observation.text.representation Base required CDABinaryDataEncoding 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.statusCode Base required ActStatus 📍3.0.0 THO v7.3
Observation.statusCode.​nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.priorityCode Base example ActPriority 📍3.0.0 THO v7.3
Observation.languageCode Base required All Languages 📍5.0.0 FHIR Std.
Observation.value.nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.value.originalText.​nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.value.originalText.​compression Base required CDACompressionAlgorithm 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.value.originalText.​integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
Observation.value.originalText.​mediaType Base example MediaType 📍3.0.0 THO v7.3
Observation.value.originalText.​representation Base required CDABinaryDataEncoding 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.interpretationCode Base required CDAObservationInterpretation 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.methodCode Base example ObservationMethod 📍3.0.0 THO v7.3
Observation.entryRelationship:frEvaluationComposantN2.​nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.entryRelationship:frEvaluationComposantN2.​typeId.nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.entryRelationship:frEvaluationComposantN2.​typeCode Base required x_ActRelationshipEntryRelationship 📍3.0.0 THO v7.3
Observation.entryRelationship:frCommentaireER.​nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.entryRelationship:frCommentaireER.​typeId.nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.entryRelationship:frCommentaireER.​typeCode Base required x_ActRelationshipEntryRelationship 📍3.0.0 THO v7.3
Observation.referenceRange.​nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.referenceRange.​typeId.nullFlavor Base required CDANullFlavor 📍2.0.3-sd Clinical Document Architecture v2.0
Observation.referenceRange.​typeCode Base required CDAActRelationshipType 📍2.0.3-sd Clinical Document Architecture v2.0

Constraints

Id Grade Path(s) Description Expression
ED-1 error Observation.text.thumbnail, Observation.value.originalText.thumbnail Thumbnails cannot contain their own thumbnails thumbnail.empty()
II-1 error Observation.typeId, Observation.entryRelationship:frEvaluationComposantN2.typeId, Observation.entryRelationship:frCommentaireER.typeId, Observation.referenceRange.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()

Summary

Mandatory: 14 elements(1 nested mandatory element)
Must-Support: 14 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Observation.templateId
  • The element 1 is sliced based on the value of Observation.entryRelationship

 

Other representations of profile: CSV, Excel