Australian Digital Health Agency FHIR Implementation Guide
1.2.0-ci-build - draft Australia flag

Australian Digital Health Agency FHIR Implementation Guide, published by Australian Digital Health Agency. This guide is not an authorized publication; it is the continuous build for version 1.2.0-ci-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/AuDigitalHealth/ci-fhir-r4/ and changes regularly. See the Directory of published versions

Resource Profile: ADHA Diagnostic Result Observation

Official URL: http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-observation-diagnosticresult-1 Version: 0.1.7
Draft as of 2024-06-11 Computable Name: ADHAObservationDiagnosticResult

Copyright/Legal: Copyright © 2022 Australian Digital Health Agency - All rights reserved. This content is licensed under a Creative Commons Attribution 4.0 International License. See https://creativecommons.org/licenses/by/4.0/.

The purpose of this profile is to represent a diagnostic result observation made during a diagnostic investigation for the electronic exchange of health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia.

This profile identifies the additional constraints, extensions, and value sets that build on and extend Observation that are supported.

Where a more specific Observation profile is applicable, e.g. pathology result observation or imaging result observation, an implementation SHALL ensure the resource conforms to that specific profile.

This profile is designed to set an Observation standard for:

  • Query for diagnostic examination results for a patient
  • Record or update diagnostic examination results belonging to a patient

This profile may be referred to by APIs, which will be listed here when available.

Profile specific guidance

  • Observation.category provides an efficient way of supporting system interactions, e.g. restricting searches. Implementers need to understand that data categorisation is somewhat subjective. The categorisation applied by the source may not align with a receiver’s expectations.
  • The Observation resource can represent a result using one or both of a single value with Observation.value, or set of results using either Observation.component.value or Observation.hasMember.
    • Although all are marked as must support, sending systems are not required to support all choices, but they SHALL support at least one of these elements.
    • A receiving or persisting system SHALL support both elements.
  • Observation.identifier may contain the same identifier as in the order or report connecting the resources that are related to a single request fulfilment workflow.

Boundaries and relationships

These profiles build on this profile (ADHA Diagnostic Result Observation) to define specific diagnostic results:

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
inv-dh-obs-05: If there is no component or hasMember element then at least value or data absent reason shall be present
... identifier S 0..* Identifier Business Identifier for observation
... status S 1..1 code preliminary | final | amended +
Binding: ObservationStatus Result Available . (required)
... category S 1..* CodeableConcept Classification of type of observation
... subject SC 1..1 Reference(ADHA Core Patient) Who and/or what the observation is about
inv-dh-obs-01: At least reference or a valid identifier shall be present
... effective[x] SC 1..1 dateTime, Period, Timing, instant Clinically relevant time/time-period for observation
inv-dh-obs-07: Date shall be at least to day
... performer SC 1..* Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA Core Patient | ADHA Authoring RelatedPerson) Who is responsible for the observation
inv-dh-obs-03: At least reference or display or a valid identifier shall be present
... value[x] SC 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Actual result
... dataAbsentReason SC 0..1 CodeableConcept Why the result is missing
... interpretation S 0..* CodeableConcept High, low, normal, etc.
... note S 0..* Annotation Comments about the observation
... bodySite SC 0..1 CodeableConcept Observed body part
Binding: Body Site . (extensible)
inv-dh-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT
... method S 0..1 CodeableConcept How it was done
... referenceRange S 0..* BackboneElement Provides guide for interpretation
.... low S 0..1 SimpleQuantity Low Range, if relevant
.... high S 0..1 SimpleQuantity High Range, if relevant
.... type S 0..1 CodeableConcept Reference range qualifier
.... text S 0..1 string Text based reference range in an observation
... hasMember S 0..* Reference(ADHA Diagnostic Result Observation | ADHA Imaging Result Observation | ADHA Pathology Result Observation) Individual observations in a group, study, or panel
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
... component SC 0..* BackboneElement Component results
inv-dh-obs-06: The component shall at least have a value or a data absent reason
.... code S 1..1 CodeableConcept Type of component observation (code / type)
.... value[x] SC 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Actual component result
.... dataAbsentReason SC 0..1 CodeableConcept Why the component result is missing

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.statusrequiredObservationStatusResultAvailable .
https://healthterminologies.gov.au/fhir/ValueSet/observationstatus-result-available-1
Observation.bodySiteextensibleBodySite .
https://healthterminologies.gov.au/fhir/ValueSet/body-site-1

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-obs-01errorObservation.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-obs-03errorObservation.performerAt least reference or display or a valid identifier shall be present
: reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-obs-04errorObservation.bodySiteIf a coded body site is provided, at least one code shall be from SNOMED CT
: coding.exists() implies coding.where(system='http://snomed.info/sct').exists()
inv-dh-obs-05errorObservationIf there is no component or hasMember element then at least value or data absent reason shall be present
: (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists())
inv-dh-obs-06errorObservation.componentThe component shall at least have a value or a data absent reason
: value.exists() or dataAbsentReason.exists()
inv-dh-obs-07errorObservation.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
inv-dh-obs-05: If there is no component or hasMember element then at least value or data absent reason shall be present
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 0..* Identifier Business Identifier for observation
... category S 1..* CodeableConcept Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


... code SΣ 1..1 CodeableConcept Type of observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

... subject SΣC 1..1 Reference(ADHA Core Patient) Who and/or what the observation is about
inv-dh-obs-01: At least reference or a valid identifier shall be present
... effective[x] SΣC 1..1 Clinically relevant time/time-period for observation
inv-dh-obs-07: Date shall be at least to day
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... performer SΣC 1..* Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA Core Patient | ADHA Authoring RelatedPerson) Who is responsible for the observation
inv-dh-obs-03: At least reference or display or a valid identifier shall be present
... value[x] SΣC 0..1 Actual result
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
... dataAbsentReason SC 0..1 CodeableConcept 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 S 0..* Annotation Comments about the observation
... bodySite SC 0..1 CodeableConcept Observed body part
Binding: Body Site . (extensible)
inv-dh-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT
... method S 0..1 CodeableConcept How it was done
Binding: ObservationMethods (example): Methods for simple observations.

... referenceRange SC 0..* BackboneElement Provides guide for interpretation
obs-3: Must have at least a low or a high or text
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... low SC 0..1 SimpleQuantity Low Range, if relevant
.... high SC 0..1 SimpleQuantity High Range, if relevant
.... type S 0..1 CodeableConcept Reference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... text S 0..1 string Text based reference range in an observation
... hasMember SΣ 0..* Reference(ADHA Diagnostic Result Observation | ADHA Imaging Result Observation | ADHA Pathology Result Observation) Individual observations in a group, study, or panel
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... component SΣC 0..* BackboneElement Component results
inv-dh-obs-06: The component shall at least have a value or a data absent reason
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code SΣ 1..1 CodeableConcept Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] SΣC 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 SC 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.statusrequiredObservationStatusResultAvailable .
https://healthterminologies.gov.au/fhir/ValueSet/observationstatus-result-available-1
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.bodySiteextensibleBodySite .
https://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Observation.methodexampleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
http://hl7.org/fhir/ValueSet/referencerange-meaning
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-obs-01errorObservation.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-obs-03errorObservation.performerAt least reference or display or a valid identifier shall be present
: reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-obs-04errorObservation.bodySiteIf a coded body site is provided, at least one code shall be from SNOMED CT
: coding.exists() implies coding.where(system='http://snomed.info/sct').exists()
inv-dh-obs-05errorObservationIf there is no component or hasMember element then at least value or data absent reason shall be present
: (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists())
inv-dh-obs-06errorObservation.componentThe component shall at least have a value or a data absent reason
: value.exists() or dataAbsentReason.exists()
inv-dh-obs-07errorObservation.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
inv-dh-obs-05: If there is no component or hasMember element then at least value or data absent reason shall be present
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... 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.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 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 preliminary | final | amended +
Binding: ObservationStatus Result Available . (required)
... category S 1..* CodeableConcept Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


... code SΣ 1..1 CodeableConcept Type of observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

... subject SΣC 1..1 Reference(ADHA Core Patient) Who and/or what the observation is about
inv-dh-obs-01: At least reference or a valid identifier shall be present
... focus Σ 0..* Reference(Resource) What the observation is about, when it is not about the subject of record
... encounter Σ 0..1 Reference(Encounter) Healthcare event during which this observation is made
... effective[x] SΣC 1..1 Clinically relevant time/time-period for observation
inv-dh-obs-07: Date shall be at least to day
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... issued Σ 0..1 instant Date/Time this version was made available
... performer SΣC 1..* Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA Core Patient | ADHA Authoring RelatedPerson) Who is responsible for the observation
inv-dh-obs-03: At least reference or display or a valid identifier shall be present
... value[x] SΣC 0..1 Actual result
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
... dataAbsentReason SC 0..1 CodeableConcept 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 S 0..* Annotation Comments about the observation
... bodySite SC 0..1 CodeableConcept Observed body part
Binding: Body Site . (extensible)
inv-dh-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT
... method S 0..1 CodeableConcept How it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1 Reference(Specimen) Specimen used for this observation
... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... referenceRange SC 0..* BackboneElement Provides guide for interpretation
obs-3: Must have at least a low or a high or text
.... 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 SC 0..1 SimpleQuantity Low Range, if relevant
.... high SC 0..1 SimpleQuantity High Range, if relevant
.... type S 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 S 0..1 string Text based reference range in an observation
... hasMember SΣ 0..* Reference(ADHA Diagnostic Result Observation | ADHA Imaging Result Observation | ADHA Pathology Result Observation) Individual observations in a group, study, or panel
.... 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 ΣC 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
... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
... component SΣC 0..* BackboneElement Component results
inv-dh-obs-06: The component shall at least have a value or a data absent reason
.... 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 SΣ 1..1 CodeableConcept Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] SΣC 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 SC 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Observation.statusrequiredObservationStatusResultAvailable .
https://healthterminologies.gov.au/fhir/ValueSet/observationstatus-result-available-1
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.bodySiteextensibleBodySite .
https://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Observation.methodexampleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
http://hl7.org/fhir/ValueSet/referencerange-meaning
from the FHIR Standard
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
http://hl7.org/fhir/ValueSet/referencerange-appliesto
from the FHIR Standard
Observation.hasMember.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-obs-01errorObservation.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-obs-03errorObservation.performerAt least reference or display or a valid identifier shall be present
: reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-obs-04errorObservation.bodySiteIf a coded body site is provided, at least one code shall be from SNOMED CT
: coding.exists() implies coding.where(system='http://snomed.info/sct').exists()
inv-dh-obs-05errorObservationIf there is no component or hasMember element then at least value or data absent reason shall be present
: (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists())
inv-dh-obs-06errorObservation.componentThe component shall at least have a value or a data absent reason
: value.exists() or dataAbsentReason.exists()
inv-dh-obs-07errorObservation.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10

Differential View

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
inv-dh-obs-05: If there is no component or hasMember element then at least value or data absent reason shall be present
... identifier S 0..* Identifier Business Identifier for observation
... status S 1..1 code preliminary | final | amended +
Binding: ObservationStatus Result Available . (required)
... category S 1..* CodeableConcept Classification of type of observation
... subject SC 1..1 Reference(ADHA Core Patient) Who and/or what the observation is about
inv-dh-obs-01: At least reference or a valid identifier shall be present
... effective[x] SC 1..1 dateTime, Period, Timing, instant Clinically relevant time/time-period for observation
inv-dh-obs-07: Date shall be at least to day
... performer SC 1..* Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA Core Patient | ADHA Authoring RelatedPerson) Who is responsible for the observation
inv-dh-obs-03: At least reference or display or a valid identifier shall be present
... value[x] SC 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Actual result
... dataAbsentReason SC 0..1 CodeableConcept Why the result is missing
... interpretation S 0..* CodeableConcept High, low, normal, etc.
... note S 0..* Annotation Comments about the observation
... bodySite SC 0..1 CodeableConcept Observed body part
Binding: Body Site . (extensible)
inv-dh-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT
... method S 0..1 CodeableConcept How it was done
... referenceRange S 0..* BackboneElement Provides guide for interpretation
.... low S 0..1 SimpleQuantity Low Range, if relevant
.... high S 0..1 SimpleQuantity High Range, if relevant
.... type S 0..1 CodeableConcept Reference range qualifier
.... text S 0..1 string Text based reference range in an observation
... hasMember S 0..* Reference(ADHA Diagnostic Result Observation | ADHA Imaging Result Observation | ADHA Pathology Result Observation) Individual observations in a group, study, or panel
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
... component SC 0..* BackboneElement Component results
inv-dh-obs-06: The component shall at least have a value or a data absent reason
.... code S 1..1 CodeableConcept Type of component observation (code / type)
.... value[x] SC 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Actual component result
.... dataAbsentReason SC 0..1 CodeableConcept Why the component result is missing

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.statusrequiredObservationStatusResultAvailable .
https://healthterminologies.gov.au/fhir/ValueSet/observationstatus-result-available-1
Observation.bodySiteextensibleBodySite .
https://healthterminologies.gov.au/fhir/ValueSet/body-site-1

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-obs-01errorObservation.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-obs-03errorObservation.performerAt least reference or display or a valid identifier shall be present
: reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-obs-04errorObservation.bodySiteIf a coded body site is provided, at least one code shall be from SNOMED CT
: coding.exists() implies coding.where(system='http://snomed.info/sct').exists()
inv-dh-obs-05errorObservationIf there is no component or hasMember element then at least value or data absent reason shall be present
: (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists())
inv-dh-obs-06errorObservation.componentThe component shall at least have a value or a data absent reason
: value.exists() or dataAbsentReason.exists()
inv-dh-obs-07errorObservation.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
inv-dh-obs-05: If there is no component or hasMember element then at least value or data absent reason shall be present
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 0..* Identifier Business Identifier for observation
... category S 1..* CodeableConcept Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


... code SΣ 1..1 CodeableConcept Type of observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

... subject SΣC 1..1 Reference(ADHA Core Patient) Who and/or what the observation is about
inv-dh-obs-01: At least reference or a valid identifier shall be present
... effective[x] SΣC 1..1 Clinically relevant time/time-period for observation
inv-dh-obs-07: Date shall be at least to day
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... performer SΣC 1..* Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA Core Patient | ADHA Authoring RelatedPerson) Who is responsible for the observation
inv-dh-obs-03: At least reference or display or a valid identifier shall be present
... value[x] SΣC 0..1 Actual result
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
... dataAbsentReason SC 0..1 CodeableConcept 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 S 0..* Annotation Comments about the observation
... bodySite SC 0..1 CodeableConcept Observed body part
Binding: Body Site . (extensible)
inv-dh-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT
... method S 0..1 CodeableConcept How it was done
Binding: ObservationMethods (example): Methods for simple observations.

... referenceRange SC 0..* BackboneElement Provides guide for interpretation
obs-3: Must have at least a low or a high or text
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... low SC 0..1 SimpleQuantity Low Range, if relevant
.... high SC 0..1 SimpleQuantity High Range, if relevant
.... type S 0..1 CodeableConcept Reference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... text S 0..1 string Text based reference range in an observation
... hasMember SΣ 0..* Reference(ADHA Diagnostic Result Observation | ADHA Imaging Result Observation | ADHA Pathology Result Observation) Individual observations in a group, study, or panel
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... component SΣC 0..* BackboneElement Component results
inv-dh-obs-06: The component shall at least have a value or a data absent reason
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code SΣ 1..1 CodeableConcept Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] SΣC 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 SC 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.statusrequiredObservationStatusResultAvailable .
https://healthterminologies.gov.au/fhir/ValueSet/observationstatus-result-available-1
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.bodySiteextensibleBodySite .
https://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Observation.methodexampleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
http://hl7.org/fhir/ValueSet/referencerange-meaning
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-obs-01errorObservation.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-obs-03errorObservation.performerAt least reference or display or a valid identifier shall be present
: reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-obs-04errorObservation.bodySiteIf a coded body site is provided, at least one code shall be from SNOMED CT
: coding.exists() implies coding.where(system='http://snomed.info/sct').exists()
inv-dh-obs-05errorObservationIf there is no component or hasMember element then at least value or data absent reason shall be present
: (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists())
inv-dh-obs-06errorObservation.componentThe component shall at least have a value or a data absent reason
: value.exists() or dataAbsentReason.exists()
inv-dh-obs-07errorObservation.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
inv-dh-obs-05: If there is no component or hasMember element then at least value or data absent reason shall be present
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... 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.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 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 preliminary | final | amended +
Binding: ObservationStatus Result Available . (required)
... category S 1..* CodeableConcept Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


... code SΣ 1..1 CodeableConcept Type of observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

... subject SΣC 1..1 Reference(ADHA Core Patient) Who and/or what the observation is about
inv-dh-obs-01: At least reference or a valid identifier shall be present
... focus Σ 0..* Reference(Resource) What the observation is about, when it is not about the subject of record
... encounter Σ 0..1 Reference(Encounter) Healthcare event during which this observation is made
... effective[x] SΣC 1..1 Clinically relevant time/time-period for observation
inv-dh-obs-07: Date shall be at least to day
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... issued Σ 0..1 instant Date/Time this version was made available
... performer SΣC 1..* Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA Core Patient | ADHA Authoring RelatedPerson) Who is responsible for the observation
inv-dh-obs-03: At least reference or display or a valid identifier shall be present
... value[x] SΣC 0..1 Actual result
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
... dataAbsentReason SC 0..1 CodeableConcept 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 S 0..* Annotation Comments about the observation
... bodySite SC 0..1 CodeableConcept Observed body part
Binding: Body Site . (extensible)
inv-dh-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT
... method S 0..1 CodeableConcept How it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1 Reference(Specimen) Specimen used for this observation
... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... referenceRange SC 0..* BackboneElement Provides guide for interpretation
obs-3: Must have at least a low or a high or text
.... 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 SC 0..1 SimpleQuantity Low Range, if relevant
.... high SC 0..1 SimpleQuantity High Range, if relevant
.... type S 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 S 0..1 string Text based reference range in an observation
... hasMember SΣ 0..* Reference(ADHA Diagnostic Result Observation | ADHA Imaging Result Observation | ADHA Pathology Result Observation) Individual observations in a group, study, or panel
.... 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 ΣC 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
... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
... component SΣC 0..* BackboneElement Component results
inv-dh-obs-06: The component shall at least have a value or a data absent reason
.... 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 SΣ 1..1 CodeableConcept Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] SΣC 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 SC 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Observation.statusrequiredObservationStatusResultAvailable .
https://healthterminologies.gov.au/fhir/ValueSet/observationstatus-result-available-1
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.bodySiteextensibleBodySite .
https://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Observation.methodexampleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
http://hl7.org/fhir/ValueSet/referencerange-meaning
from the FHIR Standard
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
http://hl7.org/fhir/ValueSet/referencerange-appliesto
from the FHIR Standard
Observation.hasMember.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-obs-01errorObservation.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-obs-03errorObservation.performerAt least reference or display or a valid identifier shall be present
: reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-obs-04errorObservation.bodySiteIf a coded body site is provided, at least one code shall be from SNOMED CT
: coding.exists() implies coding.where(system='http://snomed.info/sct').exists()
inv-dh-obs-05errorObservationIf there is no component or hasMember element then at least value or data absent reason shall be present
: (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists())
inv-dh-obs-06errorObservation.componentThe component shall at least have a value or a data absent reason
: value.exists() or dataAbsentReason.exists()
inv-dh-obs-07errorObservation.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Below is an overview of the mandatory and optional search parameters. FHIR search operations and the syntax used to describe the interactions is described here.

Name Type Description Conformance Path
category token The classification of the type of observation SHALL Observation.category
subject:identifier token The subject that the observation is about SHALL Observation.subject.identifier
code token The code of the observation type SHALL Observation.code
date date Obtained date/time. If the obtained element is a period, a date that falls in the period SHALL Observation.effective

Mandatory Search Parameters

The following search parameters and search parameter combinations SHALL be supported:

  1. SHALL support searching for all allergies for a patient using the subject:identifier search parameter:

    GET [base]/Observation?subject:identifier={system|}[code]

    Example:

    1. GET [base]/Observation?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0 8003608000228437

    Implementation Notes: Fetches a bundle of all Observation resources for the specified patient (how to search by :identifier)

  2. SHALL support searching using the combination subject:identifier and category search parameter:

    GET [base]/Observation?subject:identifier={system|}[code]&category[code]

    Example:

    1. GET [base]/Observation?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0 8003608000228437&category=http://terminology.hl7.org/CodeSystem/observation-category procedure

    Implementation Notes: Fetches a bundle of all Observation resources with the category of “procedure” for the specified patient (how to search by :identifier and how to search by token)

  3. SHALL support searching using the combination subject:identifier and code search parameter:

    GET [base]/Observation?subject:identifier={system|}[code]&code={system|}[code]

    Example:

    1. GET [base]/Observation?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0 8003608000228437&code=http://loinc.org 90568-7

    Implementation Notes: Fetches a bundle of all Observation resources with the code of an 90568-7 (Polysomnography panel) for the specified patient (how to search by :identifier and how to search by token)

  4. SHOULD support searching using the combination of the subject:identifier and date search parameters:

    GET [base]/Observation?subject:identifier={system|}[code]&date=[date]

    Example:

    1. GET [base]/Observation?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0 8003608000228437&date=ge2010-01-01&date=le2011-12-31

    Implementation Notes: Fetches a bundle of all Observation resources for the specified patient that have a date greater than or equal to 1st Jan 2010, a date less than or equal to 31st Dec 2011. (how to search by :identifier and how to search by date)