CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG
1.0.0 - Release 1
CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG
1.0.0 - Release 1
CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG - Local Development build (v1.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/ach-monthly-observation-lab | Version: 1.0.0 | |||
| Standards status: Trial-use | Maturity Level: 1 | Computable Name: AcuteCareHospitalMonthlyReportingLabObservation | ||
This profile contains Required and Must Support data elements for reporting laboratory result information to the NHSN Acute Care Hospital (ACH) Monthly Digital Quality Measure. This profile is based on the HL7 FHIR® US Core Lab Observation Profile v3.1.1.
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  Observation |
C | 0..* | USCoreLaboratoryResultObservationProfile(6.1.0) | Measurements and simple assertions Constraints: obs-6, obs-7, us-core-2 |
  id |
Σ | 1..1 | id | Logical id of this artifact |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣ | 1..1 | code | (USCDI) registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
  Slices for category |
S | 1..* | CodeableConcept | (USCDI) Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
   category:us-core |
S | 1..1 | CodeableConcept | (USCDI) Classification of type of observation Binding: US Core Clinical Result Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets Required Pattern: At least the following |
  id |
0..1 | string | Unique id for inter-element referencing | |
 extension |
0..* | Extension | Additional content defined by implementations | |
  coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
 id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory | |
| display |
0..1 | string | Representation defined by the system | |
 userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
 text |
0..1 | string | Plain text representation of the concept | |
| code |
SΣ | 1..1 | CodeableConcept | (USCDI) Laboratory Test Name Binding: US Core Laboratory Test Codes (extensible): Laboratory LOINC Codes |
 subject |
SΣ | 1..1 | Reference(US Core Patient Profile(6.1.0)) | (USCDI) Who and/or what the observation is about |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
SΣ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
 effective[x] |
SΣC | 1..1 | (USCDI) Clinically relevant time/time-period for observation Constraints: us-core-1 | |
| effectiveDateTime |
dateTime S | |||
| effectivePeriod |
Period | |||
| effectiveTiming |
Timing | |||
| effectiveInstant |
instant | |||
| issued |
SΣ | 0..1 | instant | Date/Time this version was made available |
| value[x] |
SΣC | 0..1 | (USCDI) Result Value Constraints: us-core-3, us-core-4 | |
| valueQuantity |
Quantity S | |||
| valueCodeableConcept |
CodeableConcept S | |||
| valueString |
string S | |||
| valueBoolean |
boolean | |||
| valueInteger |
integer | |||
| valueRange |
Range | |||
| valueRatio |
Ratio | |||
| valueSampledData |
SampledData | |||
| valueTime |
time | |||
| valueDateTime |
dateTime | |||
| valuePeriod |
Period | |||
| dataAbsentReason |
SC | 0..1 | CodeableConcept | (USCDI) Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
| interpretation |
S | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. |
| bodySite |
S | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
| method |
S | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (extensible) |
| specimen |
S | 0..1 | Reference(US Core Specimen Profile) | (USCDI) Specimen used for this observation |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
 component |
SΣ | 0..* | BackboneElement | Component results |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (extensible) |
| value[x] |
SΣ | 0..1 | Actual component result | |
| valueQuantity |
Quantity | |||
| valueCodeableConcept |
CodeableConcept | |||
| valueString |
string | |||
| valueBoolean |
boolean | |||
| valueInteger |
integer | |||
| valueRange |
Range | |||
| valueRatio |
Ratio | |||
| valueSampledData |
SampledData | |||
| valueTime |
time | |||
| valueDateTime |
dateTime | |||
| valuePeriod |
Period | |||
| interpretation |
S | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1From the FHIR Standard | |
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryFrom the FHIR Standard | |
| Observation.category:us-core | required | Pattern Value: laboratoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-clinical-result-observation-category | |
| Observation.code | extensible | USCoreLaboratoryTestCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-laboratory-test-codes | |
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonFrom the FHIR Standard | |
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationFrom the FHIR Standard | |
| Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-siteFrom the FHIR Standard | |
| Observation.method | extensible | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methodsFrom the FHIR Standard | |
| Observation.component.code | extensible | LOINCCodes(a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesFrom the FHIR Standard | |
| Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationFrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
| us-core-1 | error | Observation.effective[x] | Datetime must be at least to day. : $this is DateTime implies $this.toString().length() >= 10 | |
| us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
| us-core-3 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : value.ofType(Quantity).system.empty() or value.ofType(Quantity).system = 'http://unitsofmeasure.org' | |
| us-core-4 | best practice | Observation.value[x] | SHOULD use Snomed CT for coded Results : value.ofType(CodeableConcept).coding.system.empty() or value.ofType(CodeableConcept).coding.system = 'http://snomed.info/sct' |
This structure is derived from USCoreLaboratoryResultObservationProfile
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Observation |
0..* | USCoreLaboratoryResultObservationProfile(6.1.0) | Measurements and simple assertions | |
 id |
1..1 | id | Logical id of this artifact | |
| meta |
||||
| Slices for extension |
Content/Rules for all slices | |||
 extension:link-received-date-extension |
0..1 | dateTime | Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension | |
| subject |
||||
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
S | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made |
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| effective[x] |
1..1 | dateTime, Period, Timing, instant | (USCDI) Clinically relevant time/time-period for observation | |
| issued |
S | 0..1 | instant | Date/Time this version was made available |
| interpretation |
S | 0..* | CodeableConcept | High, low, normal, etc. |
| bodySite |
S | 0..1 | CodeableConcept | Observed body part |
| method |
S | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (extensible) |
| specimen |
||||
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| component |
S | 0..* | BackboneElement | Component results |
| code |
1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (extensible) | |
| value[x] |
S | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual component result |
| interpretation |
S | 0..* | CodeableConcept | High, low, normal, etc. |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Observation.method | extensible | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methodsFrom the FHIR Standard | |
| Observation.component.code | extensible | LOINCCodes(a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesFrom the FHIR Standard |
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| Observation |
C | 0..* | USCoreLaboratoryResultObservationProfile(6.1.0) | Measurements and simple assertions Constraints: obs-6, obs-7, us-core-2 | ||||
| id |
Σ | 1..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
 Slices for extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| extension:link-received-date-extension |
0..1 | dateTime | Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension | |||||
| versionId |
Σ | 0..1 | id | Version specific identifier | ||||
| lastUpdated |
Σ | 0..1 | instant | When the resource version last changed | ||||
| source |
Σ | 0..1 | uri | Identifies where the resource comes from | ||||
| profile |
Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
| security |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| tag |
Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | Business Identifier for observation | ||||
| basedOn |
Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | ||||
| partOf |
Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
| status |
?!SΣ | 1..1 | code | (USCDI) registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
| Slices for category |
S | 1..* | CodeableConcept | (USCDI) Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
| category:us-core |
S | 1..1 | CodeableConcept | (USCDI) Classification of type of observation Binding: US Core Clinical Result Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| code |
SΣ | 1..1 | CodeableConcept | (USCDI) Laboratory Test Name Binding: US Core Laboratory Test Codes (extensible): Laboratory LOINC Codes | ||||
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile(6.1.0)) | (USCDI) Who and/or what the observation is about | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| focus |
Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
| encounter |
SΣ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| effective[x] |
SΣC | 1..1 | (USCDI) Clinically relevant time/time-period for observation Constraints: us-core-1 | |||||
| effectiveDateTime |
dateTime S | |||||||
| effectivePeriod |
Period | |||||||
| effectiveTiming |
Timing | |||||||
| effectiveInstant |
instant | |||||||
| issued |
SΣ | 0..1 | instant | Date/Time this version was made available | ||||
| performer |
Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation | ||||
| value[x] |
SΣC | 0..1 | (USCDI) Result Value Constraints: us-core-3, us-core-4 | |||||
| valueQuantity |
Quantity S | |||||||
| valueCodeableConcept |
CodeableConcept S | |||||||
| valueString |
string S | |||||||
| valueBoolean |
boolean | |||||||
| valueInteger |
integer | |||||||
| valueRange |
Range | |||||||
| valueRatio |
Ratio | |||||||
| valueSampledData |
SampledData | |||||||
| valueTime |
time | |||||||
| valueDateTime |
dateTime | |||||||
| valuePeriod |
Period | |||||||
| dataAbsentReason |
SC | 0..1 | CodeableConcept | (USCDI) Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
| interpretation |
S | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | ||||
| note |
0..* | Annotation | Comments about the observation | |||||
| bodySite |
S | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
| method |
S | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (extensible) | ||||
| specimen |
S | 0..1 | Reference(US Core Specimen Profile) | (USCDI) Specimen used for this observation | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| device |
0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
| referenceRange |
C | 0..* | BackboneElement | Provides guide for interpretation Constraints: obs-3 | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| low |
C | 0..1 | SimpleQuantity | Low Range, if relevant | ||||
| high |
C | 0..1 | SimpleQuantity | High Range, if relevant | ||||
| type |
0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range. | |||||
| appliesTo |
0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to. | |||||
| age |
0..1 | Range | Applicable age range, if relevant | |||||
| text |
0..1 | string | Text based reference range in an observation | |||||
| hasMember |
Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
| derivedFrom |
Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
| component |
SΣ | 0..* | BackboneElement | Component results | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (extensible) | ||||
| value[x] |
SΣ | 0..1 | Actual component result | |||||
| valueQuantity |
Quantity | |||||||
| valueCodeableConcept |
CodeableConcept | |||||||
| valueString |
string | |||||||
| valueBoolean |
boolean | |||||||
| valueInteger |
integer | |||||||
| valueRange |
Range | |||||||
| valueRatio |
Ratio | |||||||
| valueSampledData |
SampledData | |||||||
| valueTime |
time | |||||||
| valueDateTime |
dateTime | |||||||
| valuePeriod |
Period | |||||||
| dataAbsentReason |
C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
| interpretation |
S | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | ||||
| referenceRange |
0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Observation.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels|4.0.1From the FHIR Standard | ||||
| Observation.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags|4.0.1From the FHIR Standard | ||||
| Observation.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesFrom the FHIR Standard
| ||||
| Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1From the FHIR Standard | ||||
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryFrom the FHIR Standard | ||||
| Observation.category:us-core | required | Pattern Value: laboratoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-clinical-result-observation-category | ||||
| Observation.code | extensible | USCoreLaboratoryTestCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-laboratory-test-codes | ||||
| Observation.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| Observation.encounter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonFrom the FHIR Standard | ||||
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationFrom the FHIR Standard | ||||
| Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-siteFrom the FHIR Standard | ||||
| Observation.method | extensible | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methodsFrom the FHIR Standard | ||||
| Observation.specimen.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaningFrom the FHIR Standard | ||||
| Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliestoFrom the FHIR Standard | ||||
| Observation.component.code | extensible | LOINCCodes(a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesFrom the FHIR Standard | ||||
| Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonFrom the FHIR Standard | ||||
| Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationFrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
| us-core-1 | error | Observation.effective[x] | Datetime must be at least to day. : $this is DateTime implies $this.toString().length() >= 10 | |
| us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
| us-core-3 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : value.ofType(Quantity).system.empty() or value.ofType(Quantity).system = 'http://unitsofmeasure.org' | |
| us-core-4 | best practice | Observation.value[x] | SHOULD use Snomed CT for coded Results : value.ofType(CodeableConcept).coding.system.empty() or value.ofType(CodeableConcept).coding.system = 'http://snomed.info/sct' |
This structure is derived from USCoreLaboratoryResultObservationProfile
Summary
Mandatory: 3 elements(2 nested mandatory elements)
Must-Support: 11 elements
Extensions
This structure refers to these extensions:
Maturity: 1
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Observation |
C | 0..* | USCoreLaboratoryResultObservationProfile(6.1.0) | Measurements and simple assertions Constraints: obs-6, obs-7, us-core-2 |
| id |
Σ | 1..1 | id | Logical id of this artifact |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣ | 1..1 | code | (USCDI) registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
| Slices for category |
S | 1..* | CodeableConcept | (USCDI) Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
| category:us-core |
S | 1..1 | CodeableConcept | (USCDI) Classification of type of observation Binding: US Core Clinical Result Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets Required Pattern: At least the following |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory | |
| display |
0..1 | string | Representation defined by the system | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| text |
0..1 | string | Plain text representation of the concept | |
| code |
SΣ | 1..1 | CodeableConcept | (USCDI) Laboratory Test Name Binding: US Core Laboratory Test Codes (extensible): Laboratory LOINC Codes |
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile(6.1.0)) | (USCDI) Who and/or what the observation is about |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
SΣ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| effective[x] |
SΣC | 1..1 | (USCDI) Clinically relevant time/time-period for observation Constraints: us-core-1 | |
| effectiveDateTime |
dateTime S | |||
| effectivePeriod |
Period | |||
| effectiveTiming |
Timing | |||
| effectiveInstant |
instant | |||
| issued |
SΣ | 0..1 | instant | Date/Time this version was made available |
| value[x] |
SΣC | 0..1 | (USCDI) Result Value Constraints: us-core-3, us-core-4 | |
| valueQuantity |
Quantity S | |||
| valueCodeableConcept |
CodeableConcept S | |||
| valueString |
string S | |||
| valueBoolean |
boolean | |||
| valueInteger |
integer | |||
| valueRange |
Range | |||
| valueRatio |
Ratio | |||
| valueSampledData |
SampledData | |||
| valueTime |
time | |||
| valueDateTime |
dateTime | |||
| valuePeriod |
Period | |||
| dataAbsentReason |
SC | 0..1 | CodeableConcept | (USCDI) Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
| interpretation |
S | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. |
| bodySite |
S | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
| method |
S | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (extensible) |
| specimen |
S | 0..1 | Reference(US Core Specimen Profile) | (USCDI) Specimen used for this observation |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| component |
SΣ | 0..* | BackboneElement | Component results |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (extensible) |
| value[x] |
SΣ | 0..1 | Actual component result | |
| valueQuantity |
Quantity | |||
| valueCodeableConcept |
CodeableConcept | |||
| valueString |
string | |||
| valueBoolean |
boolean | |||
| valueInteger |
integer | |||
| valueRange |
Range | |||
| valueRatio |
Ratio | |||
| valueSampledData |
SampledData | |||
| valueTime |
time | |||
| valueDateTime |
dateTime | |||
| valuePeriod |
Period | |||
| interpretation |
S | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1From the FHIR Standard | |
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryFrom the FHIR Standard | |
| Observation.category:us-core | required | Pattern Value: laboratoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-clinical-result-observation-category | |
| Observation.code | extensible | USCoreLaboratoryTestCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-laboratory-test-codes | |
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonFrom the FHIR Standard | |
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationFrom the FHIR Standard | |
| Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-siteFrom the FHIR Standard | |
| Observation.method | extensible | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methodsFrom the FHIR Standard | |
| Observation.component.code | extensible | LOINCCodes(a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesFrom the FHIR Standard | |
| Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationFrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
| us-core-1 | error | Observation.effective[x] | Datetime must be at least to day. : $this is DateTime implies $this.toString().length() >= 10 | |
| us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
| us-core-3 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : value.ofType(Quantity).system.empty() or value.ofType(Quantity).system = 'http://unitsofmeasure.org' | |
| us-core-4 | best practice | Observation.value[x] | SHOULD use Snomed CT for coded Results : value.ofType(CodeableConcept).coding.system.empty() or value.ofType(CodeableConcept).coding.system = 'http://snomed.info/sct' |
Differential View
This structure is derived from USCoreLaboratoryResultObservationProfile
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Observation |
0..* | USCoreLaboratoryResultObservationProfile(6.1.0) | Measurements and simple assertions | |
| id |
1..1 | id | Logical id of this artifact | |
| meta |
||||
| Slices for extension |
Content/Rules for all slices | |||
| extension:link-received-date-extension |
0..1 | dateTime | Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension | |
| subject |
||||
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
S | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made |
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| effective[x] |
1..1 | dateTime, Period, Timing, instant | (USCDI) Clinically relevant time/time-period for observation | |
| issued |
S | 0..1 | instant | Date/Time this version was made available |
| interpretation |
S | 0..* | CodeableConcept | High, low, normal, etc. |
| bodySite |
S | 0..1 | CodeableConcept | Observed body part |
| method |
S | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (extensible) |
| specimen |
||||
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| component |
S | 0..* | BackboneElement | Component results |
| code |
1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (extensible) | |
| value[x] |
S | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual component result |
| interpretation |
S | 0..* | CodeableConcept | High, low, normal, etc. |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Observation.method | extensible | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methodsFrom the FHIR Standard | |
| Observation.component.code | extensible | LOINCCodes(a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesFrom the FHIR Standard |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| Observation |
C | 0..* | USCoreLaboratoryResultObservationProfile(6.1.0) | Measurements and simple assertions Constraints: obs-6, obs-7, us-core-2 | ||||
| id |
Σ | 1..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| extension:link-received-date-extension |
0..1 | dateTime | Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension | |||||
| versionId |
Σ | 0..1 | id | Version specific identifier | ||||
| lastUpdated |
Σ | 0..1 | instant | When the resource version last changed | ||||
| source |
Σ | 0..1 | uri | Identifies where the resource comes from | ||||
| profile |
Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
| security |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| tag |
Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | Business Identifier for observation | ||||
| basedOn |
Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | ||||
| partOf |
Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
| status |
?!SΣ | 1..1 | code | (USCDI) registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
| Slices for category |
S | 1..* | CodeableConcept | (USCDI) Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
| category:us-core |
S | 1..1 | CodeableConcept | (USCDI) Classification of type of observation Binding: US Core Clinical Result Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| code |
SΣ | 1..1 | CodeableConcept | (USCDI) Laboratory Test Name Binding: US Core Laboratory Test Codes (extensible): Laboratory LOINC Codes | ||||
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile(6.1.0)) | (USCDI) Who and/or what the observation is about | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| focus |
Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
| encounter |
SΣ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| effective[x] |
SΣC | 1..1 | (USCDI) Clinically relevant time/time-period for observation Constraints: us-core-1 | |||||
| effectiveDateTime |
dateTime S | |||||||
| effectivePeriod |
Period | |||||||
| effectiveTiming |
Timing | |||||||
| effectiveInstant |
instant | |||||||
| issued |
SΣ | 0..1 | instant | Date/Time this version was made available | ||||
| performer |
Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation | ||||
| value[x] |
SΣC | 0..1 | (USCDI) Result Value Constraints: us-core-3, us-core-4 | |||||
| valueQuantity |
Quantity S | |||||||
| valueCodeableConcept |
CodeableConcept S | |||||||
| valueString |
string S | |||||||
| valueBoolean |
boolean | |||||||
| valueInteger |
integer | |||||||
| valueRange |
Range | |||||||
| valueRatio |
Ratio | |||||||
| valueSampledData |
SampledData | |||||||
| valueTime |
time | |||||||
| valueDateTime |
dateTime | |||||||
| valuePeriod |
Period | |||||||
| dataAbsentReason |
SC | 0..1 | CodeableConcept | (USCDI) Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
| interpretation |
S | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | ||||
| note |
0..* | Annotation | Comments about the observation | |||||
| bodySite |
S | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
| method |
S | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (extensible) | ||||
| specimen |
S | 0..1 | Reference(US Core Specimen Profile) | (USCDI) Specimen used for this observation | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| device |
0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
| referenceRange |
C | 0..* | BackboneElement | Provides guide for interpretation Constraints: obs-3 | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| low |
C | 0..1 | SimpleQuantity | Low Range, if relevant | ||||
| high |
C | 0..1 | SimpleQuantity | High Range, if relevant | ||||
| type |
0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range. | |||||
| appliesTo |
0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to. | |||||
| age |
0..1 | Range | Applicable age range, if relevant | |||||
| text |
0..1 | string | Text based reference range in an observation | |||||
| hasMember |
Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
| derivedFrom |
Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
| component |
SΣ | 0..* | BackboneElement | Component results | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (extensible) | ||||
| value[x] |
SΣ | 0..1 | Actual component result | |||||
| valueQuantity |
Quantity | |||||||
| valueCodeableConcept |
CodeableConcept | |||||||
| valueString |
string | |||||||
| valueBoolean |
boolean | |||||||
| valueInteger |
integer | |||||||
| valueRange |
Range | |||||||
| valueRatio |
Ratio | |||||||
| valueSampledData |
SampledData | |||||||
| valueTime |
time | |||||||
| valueDateTime |
dateTime | |||||||
| valuePeriod |
Period | |||||||
| dataAbsentReason |
C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
| interpretation |
S | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | ||||
| referenceRange |
0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Observation.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels|4.0.1From the FHIR Standard | ||||
| Observation.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags|4.0.1From the FHIR Standard | ||||
| Observation.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesFrom the FHIR Standard
| ||||
| Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1From the FHIR Standard | ||||
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryFrom the FHIR Standard | ||||
| Observation.category:us-core | required | Pattern Value: laboratoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-clinical-result-observation-category | ||||
| Observation.code | extensible | USCoreLaboratoryTestCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-laboratory-test-codes | ||||
| Observation.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| Observation.encounter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonFrom the FHIR Standard | ||||
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationFrom the FHIR Standard | ||||
| Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-siteFrom the FHIR Standard | ||||
| Observation.method | extensible | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methodsFrom the FHIR Standard | ||||
| Observation.specimen.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaningFrom the FHIR Standard | ||||
| Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliestoFrom the FHIR Standard | ||||
| Observation.component.code | extensible | LOINCCodes(a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesFrom the FHIR Standard | ||||
| Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonFrom the FHIR Standard | ||||
| Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationFrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
| us-core-1 | error | Observation.effective[x] | Datetime must be at least to day. : $this is DateTime implies $this.toString().length() >= 10 | |
| us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
| us-core-3 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : value.ofType(Quantity).system.empty() or value.ofType(Quantity).system = 'http://unitsofmeasure.org' | |
| us-core-4 | best practice | Observation.value[x] | SHOULD use Snomed CT for coded Results : value.ofType(CodeableConcept).coding.system.empty() or value.ofType(CodeableConcept).coding.system = 'http://snomed.info/sct' |
This structure is derived from USCoreLaboratoryResultObservationProfile
Summary
Mandatory: 3 elements(2 nested mandatory elements)
Must-Support: 11 elements
Extensions
This structure refers to these extensions:
Maturity: 1
Other representations of profile: CSV, Excel, Schematron
