Id2.16.840.1.113883.10.20.22.4.144Effective Date2015‑08‑13
Statusdraft DraftVersion Label2.1
NameOutcomeObservationDisplay NameOutcome Observation
Description
This template represents the outcome of care resulting from the interventions used to treat the patient. In the Care Planning workflow, the judgment about how well the person is progressing towards the goal is based on the observations made about the status of the patient with respect to interventions performed in the pursuit of achieving that goal. Often thought of as an "actual outcome", the Outcome Observation may be related to goals, progression toward goals, and the associated interventions. For example, an observation outcome of a blood oxygen saturation level of 95% is related to the goal of "Maintain Pulse Ox greater than 92", which in turn is related to the health concern of respiratory insufficiency and the problem of pneumonia. The template makes use of the Entry Reference (templateId:2.16.840.1.113883.10.20.22.4.122) to reference the interventions and goals defined elsewhere in the Care Plan CDA instance.
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.4.144
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 2 templates, Uses 4 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.21Transactionfinal Care Plan (V2)2015‑08‑01
2.16.840.1.113883.10.20.22.1.15linkdraft Care Plan (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.61Containmentdraft Health Status Evaluations and Outcomes Section (2.1)2015‑08‑13
Uses as NameVersion
2.16.840.1.113883.10.20.22.4.110Containmentdraft Progress Toward Goal Observation (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.115Containmentdraft External Document Reference (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.119Containmentdraft Author Participation (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.122Containmentdraft Entry Reference (2.1)2015‑08‑13
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
ItemDTCardConfDescriptionLabel
cda:observation
Outcdotstion
@classCode
cs1 … 1FOBSCONFdots1219
 SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1098-31219).
@moodCode
cs1 … 1FEVNCONFdots1220
 SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1098-31220).
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:1098-31221) such that itCONFdots1221
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.144CONFdots1222
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.144" (CONF:1098-31222).
cda:id
II1 … *SHALL contain at least one [1..*] id (CONF:1098-31223).CONFdots1223
cda:code
CD1 … 1MSHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:1098-32746).CONFdots2746
@codeSystem
CONF1 … 1F2.16.840.1.113883.6.1
cda:value
0 … 1RSHOULD contain zero or one [0..1] value (CONF:1098-32747).CONFdots2747
cda:author
0 … *RSHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31553).
Contains 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13)
CONFdots1553
Choice1 … Elements to choose from:
cda:entryRelationship
0 … *RThe following entryRelationship represents the relationship between an Outcome Observation and a Goal Observation. Because the Goal Observation is already described in the CDA document instance's Goals section, rather than repeating the full content of the Goal Observation, the Entry Reference template can be used to reference this entry.
Contains 2.16.840.1.113883.10.20.22.4.122 Entry Reference (2015‑08‑13)
CONFdots1224
where [@typeCode='GEVL']
@typeCode
cs1 … 1FGEVLCONFdots1225
 SHALL contain exactly one [1..1] @typeCode="GEVL" Evaluates goal (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-31225).
 ConstraintThis entryReference template *SHALL* reference an instance of a Goal Observation template
cda:entryRelationship
0 … 1RThe following entryRelationship represents the relationship between an Outcome Observation and a Progress Toward Goal Observation (Outcome Observation SUPPORTS Progress Toward Goal Observation). In the Care Planning workflow, the judgment about how well the person is progressing towards the goal is based on the observations made about the status of the patient with respect to interventions performed in the pursuit of achieving that goal.
Contains 2.16.840.1.113883.10.20.22.4.110 Progress Toward Goal Observation (2015‑08‑13)
CONFdots1427
@typeCode
cs1 … 1FSPRTCONFdots1428
 SHALL contain exactly one [1..1] @typeCode="SPRT" Has support (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-31428).
@inversionInd
bl1 … 1FtrueCONFdots1429
 SHALL contain exactly one [1..1] @inversionInd="true" (CONF:1098-31429).
cda:entryRelationship
0 … *Where an Outcome Observation needs to reference an Intervention Act already described in the CDA document instance, rather than repeating the full content of the Intervention Act, the Entry Reference template may be used to reference this entry.
Contains 2.16.840.1.113883.10.20.22.4.122 Entry Reference (2015‑08‑13)
CONFdots1688
where [@typeCode='RSON']
@typeCode
cs1 … 1FRSONCONFdots1689
 SHALL contain exactly one [1..1] @typeCode="RSON" Has reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-31689).
 ConstraintThis entryReference template *SHALL* reference an instance of a Intervention Act template
cda:reference
0 … *Contains 2.16.840.1.113883.10.20.22.4.115 External Document Reference (2014‑06‑09)CONFdots2763
@typeCode
cs1 … 1FREFRCONFdots2764
 The reference, if present, SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32764).