Details
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Change Request
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Resolution: Persuasive
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Highest
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C-CDA Templates Clinical Notes (CDA)
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2.1.0 [deprecated]
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Structured Documents
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Templates [deprecated]
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Jean Duteau / Benjamin Flessner : 19-0-1
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Correction
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Compatible, substantive
Description
Specification - Extended HL7 CDA® R2 IG: C-CDA Templates for Clinical Notes DSTU Release 2.1 - US Realm
Document Description extended per extended per TSC tracker 12437, again with 14128 and jira.hl7.org/browse/TSC-38
Existing WordingThis is from Volume 2, section 3.92 Result Observation (V3).
5. SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:1198-7133).
a. This code SHOULD be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result SHALL be sent (CONF:1198-19212).
Proposed WordingWe have seen cases where in Result Observation entries the element contains both an @code attribute and an @nullFlavor attribute.
While this doesn't appear to be explicitly invalid I think it is contrary to the intent of the specification and should be disallowed. If you put a valid code on an observation then it shouldn't also have a nullFlavor. It's unclear which attribute should take precedence. The element should contain only one or the other. So I propose we add an additional conformance statement like this.
5. SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:1198-7133).a. This code SHOULD be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result SHALL be sent (CONF:1198-19212).
b. SHALL contain either a @code attribute or a @nullFlavor attribute, but not both (CONF:1198-XXXXX).
Existing WordingThis is from Volume 2, section 3.92 Result Observation (V3).
5. SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:1198-7133).
a. This code SHOULD be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result SHALL be sent (CONF:1198-19212).
Proposed WordingWe have seen cases where in Result Observation entries the element contains both an @code attribute and an @nullFlavor attribute.
While this doesn't appear to be explicitly invalid I think it is contrary to the intent of the specification and should be disallowed. If you put a valid code on an observation then it shouldn't also have a nullFlavor. It's unclear which attribute should take precedence. The element should contain only one or the other. So I propose we add an additional conformance statement like this.
5. SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:1198-7133).a. This code SHOULD be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result SHALL be sent (CONF:1198-19212).
b. SHALL contain either a @code attribute or a @nullFlavor attribute, but not both (CONF:1198-XXXXX).
element contains both an @code attribute and an @nullFlavor attribute.
While this doesn't appear to be explicitly invalid I think it is contrary to the intent of the specification and should be disallowed. If you put a valid code on an observation then it shouldn't also have a nullFlavor. It's unclear which attribute should take precedence. The element should contain only one or the other. So I propose we add an additional conformance statement like this.
5. SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:1198-7133).a. This code SHOULD be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result SHALL be sent (CONF:1198-19212).
b. SHALL contain either a @code attribute or a @nullFlavor attribute, but not both (CONF:1198-XXXXX).
