Canadian Baseline
1.1.0 - CI Build
Canadian Baseline, published by HL7 Canada - FHIR Implementation Work Group. This guide is not an authorized publication; it is the continuous build for version 1.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7-Canada/ca-baseline/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/ca/baseline/StructureDefinition/profile-observation-results | Version: 1.1.0 | |||
Draft as of 2024-11-24 | Computable Name: ObservationProfileLaboratory |
Proposed constraints on the Observation Resource to represent results produced by laboratory tests or panels/studies
While this profile does not currently apply MS constraints on the hasMember, referenceRange, interpretation or component elements, this profile is seeking community and implementer feedback on how these elements are being used to assess whether consistent patterns can be identified for use in the Canadian landscape for certain types of test results (e.g., panel, antibody, blood tests, etc)
Feedback can be provided through the Simplifier issue log for this profile.</p>
This Observation (Laboratory Results) profile further constrains the Observation (General Use) profile to represent results of laboratory tests.
This profile may represent a single value from a specific laboratory test (e.g. hematocrit) or it may represent a grouped set of results from a multi- test study or panel (e.g. complete blood count, urinalysis, electrolytes).
The Observation (Laboratory Results) profile reflects localization concepts in the Canadian context.
All elements or attributes within the FHIR specification have cardinality as part of their definition - a minimum number of required appearances and a maximum number of allowable appearances.
Most elements in the FHIR specification have a minimum cardinality of 0, so most elements are not required and subsequently they may be missing from a resource when it is exchanged between systems.
Required elements:
Note: if Observation.component is provided then Observation.component.value is mandatory.
Some elements are marked as Must Support. This means that implementations generating, receiving, or otherwise using resources with Must Support elements SHALL provide support for those elements in some meaningful way (see Must Support definition).
The following elements are marked as Must Support in the Observation (Laboratory Results) profile:
Must Support elements:
If the minimum cardinality of an element or attribute is 1 AND information is missing AND the Responder knows the precise reason for the absence of data, then Responders SHOULD send the reason for the missing information using values from the valueset where it exists by using the DataAbsentReason extension.
An Observation without a value, SHOULD include a reason why the data is absent unless there are component observations, or references to other Observations that are grouped within it, i.e., unless there are component observations, or references to other Observations that are grouped within it then either ONE of Observation.value OR Observation.dataAbsentReason but NOT both should be present.
Note: The conformance language above was modified from SHALL to SHOULD to reflect the community decision to relax the invariant to account for Canadian implementations that have reason to not meet the rule given circumstances with R4 modeling for value expressions that is corrected in later versions of FHIR. At least one Canadian lab implementation uses an extension to communicate a result value in the form of a PDF (which R4 does not support under its existing value data types).
Observation (Laboratory Results) is intended to represent results of laboratory tests and studies. This profile constrains the Observation (General Use) resource to represent laboratory results in messages and patient summaries if no other, more specific profile is more appropriate.
The following list of examples is intended to represent some examples of typical use cases and is not exhaustive:
including the interpretations and reference ranges associated with the result(s).
Observation (Laboratory Results) should not be used if one of the following profiles is applicable: (to be completed later)
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ObservationProfile
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | ObservationProfile | Observation Profile ca-baseline-results-1: SHOULD use SNOMED CT for coded Results |
status | 1..1 | code | registered | preliminary | final | amended + | |
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this |
category:laboratory | SC | 1..* | CodeableConcept | FHIR standard classification of type of observation ca-baseline-category: SHALL have a category from 'http://terminology.hl7.org/CodeSystem/observation-category' Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory | |
code | S | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (preferred): LOINC codes identifying names of simple observations. |
subject | S | 1..1 | Reference(Patient Profile | Group | Device | Location) | Who and/or what the observation is about |
effective[x] | SC | 0..1 | Clinically relevant time/time-period for observation ca-baseline-datetime: Datetime SHALL be at least to day | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
issued | 0..1 | instant | Date/Time this version was made available | |
performer | S | 0..* | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile | Patient Profile) | Who is responsible for the observation |
Slices for value[x] | S | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual result Slice: Unordered, Open by type:$this |
value[x]:valueCodeableConcept | 0..1 | CodeableConcept | Actual result | |
coding | 0..* | Coding | Code defined by a terminology system | |
system | 1..1 | uri | FHIR standard classification of type of observation code system | |
code | 1..1 | code | A code difining laboratory result | |
value[x]:valueQuantity | 0..1 | Quantity | Actual result | |
value | 1..1 | decimal | Numerical value (with implicit precision) | |
system | 0..1 | uri | System that defines coded unit form | |
dataAbsentReason | 0..1 | CodeableConcept | Why the result is missing | |
interpretation | 0..* | CodeableConcept | High, low, normal, etc. | |
referenceRange | 0..* | BackboneElement | Provides guide for interpretation | |
hasMember | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | |
component | 0..* | BackboneElement | Component results | |
code | S | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (preferred): LOINC codes identifying names of simple observations. |
Slices for value[x] | S | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual component result Slice: Unordered, Open by type:$this |
value[x]:valueCodeableConcept | 0..1 | CodeableConcept | Actual component result | |
coding | 0..* | Coding | FHIR standard classification of type of observation code system | |
system | 1..1 | uri | FHIR standard classification of type of observation code system | |
code | 1..1 | code | A code defining laboratory result | |
value[x]:valueQuantity | 0..1 | Quantity | Actual component result | |
value | 1..1 | decimal | Numerical value (with implicit precision) | |
system | 0..1 | uri | System that defines coded unit form | |
dataAbsentReason | 0..1 | CodeableConcept | Why the component result is missing | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | |
Observation.component.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
ca-baseline-category | error | Observation.category:laboratory | SHALL have a category from 'http://terminology.hl7.org/CodeSystem/observation-category' : where(coding.system='http://terminology.hl7.org/CodeSystem/observation-category' and coding.code.exists()).exists() | |
ca-baseline-datetime | error | Observation.effective[x] | Datetime SHALL be at least to day : ($this as dateTime).toString().length() >= 8 | |
ca-baseline-results-1 | warning | Observation | SHOULD use SNOMED CT for coded Results : (component.value | value).ofType(Quantity).all(system = 'http://unitsofmeasure.org') |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | ObservationProfile | Observation Profile 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 ca-baseline-results-1: SHOULD use SNOMED CT for coded Results |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
category:laboratory | SC | 1..* | CodeableConcept | FHIR standard classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. ca-baseline-category: SHALL have a category from 'http://terminology.hl7.org/CodeSystem/observation-category' Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory | |
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (preferred): LOINC codes identifying names of simple observations. |
subject | SΣ | 1..1 | Reference(Patient Profile | Group | Device | Location) | Who and/or what the observation is about |
effective[x] | SΣC | 0..1 | Clinically relevant time/time-period for observation ca-baseline-datetime: Datetime SHALL be at least to day | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
issued | Σ | 0..1 | instant | Date/Time this version was made available |
performer | SΣ | 0..* | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile | Patient Profile) | Who is responsible for the observation |
Slices for value[x] | SΣC | 0..1 | Actual result Slice: Unordered, Open by type:$this | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
value[x]:valueCodeableConcept | SΣC | 0..1 | CodeableConcept | Actual result |
coding | Σ | 0..* | Coding | Code defined by a terminology system |
system | Σ | 1..1 | uri | FHIR standard classification of type of observation code system |
code | Σ | 1..1 | code | A code difining laboratory result |
value[x]:valueQuantity | SΣC | 0..1 | Quantity | Actual result |
value | Σ | 1..1 | decimal | Numerical value (with implicit precision) |
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. |
system | ΣC | 0..1 | uri | System that defines coded unit form |
dataAbsentReason | C | 0..1 | CodeableConcept | Why the 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 | C | 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 |
hasMember | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group |
component | Σ | 0..* | BackboneElement | Component results |
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 (preferred): LOINC codes identifying names of simple observations. |
Slices for value[x] | SΣ | 0..1 | Actual component result Slice: Unordered, Open by type:$this | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
value[x]:valueCodeableConcept | SΣ | 0..1 | CodeableConcept | Actual component result |
coding | Σ | 0..* | Coding | FHIR standard classification of type of observation code system |
system | Σ | 1..1 | uri | FHIR standard classification of type of observation code system |
code | Σ | 1..1 | code | A code defining laboratory result |
value[x]:valueQuantity | SΣ | 0..1 | Quantity | Actual component result |
value | Σ | 1..1 | decimal | Numerical value (with implicit precision) |
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. |
system | ΣC | 0..1 | uri | System that defines coded unit form |
dataAbsentReason | C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | |
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.category:laboratory | preferred | Pattern: laboratoryhttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | |
Observation.value[x]:valueQuantity.comparator | required | QuantityComparatorhttp://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard | |
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | |
Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard | |
Observation.component.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | |
Observation.component.value[x]:valueQuantity.comparator | required | QuantityComparatorhttp://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard | |
Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
ca-baseline-category | error | Observation.category:laboratory | SHALL have a category from 'http://terminology.hl7.org/CodeSystem/observation-category' : where(coding.system='http://terminology.hl7.org/CodeSystem/observation-category' and coding.code.exists()).exists() | |
ca-baseline-datetime | error | Observation.effective[x] | Datetime SHALL be at least to day : ($this as dateTime).toString().length() >= 8 | |
ca-baseline-results-1 | warning | Observation | SHOULD use SNOMED CT for coded Results : (component.value | value).ofType(Quantity).all(system = 'http://unitsofmeasure.org') | |
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() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | ObservationProfile | Observation Profile 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 ca-baseline-results-1: SHOULD use SNOMED CT for coded Results | ||||
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.
| |||||
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 | 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 | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
category:laboratory | SC | 1..* | CodeableConcept | FHIR standard classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. ca-baseline-category: SHALL have a category from 'http://terminology.hl7.org/CodeSystem/observation-category' 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 | Type of observation (code / type) Binding: LOINCCodes (preferred): LOINC codes identifying names of simple observations. | ||||
subject | SΣ | 1..1 | Reference(Patient Profile | Group | Device | Location) | Who and/or what the observation is about | ||||
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 | 0..1 | Clinically relevant time/time-period for observation ca-baseline-datetime: Datetime SHALL be at least to day | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | SΣ | 0..* | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile | Patient Profile) | Who is responsible for the observation | ||||
Slices for value[x] | SΣC | 0..1 | Actual result Slice: Unordered, Open by type:$this | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
value[x]:valueCodeableConcept | SΣC | 0..1 | CodeableConcept | Actual result | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | FHIR standard classification of type of observation code system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | A code difining laboratory result | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
value[x]:valueQuantity | SΣC | 0..1 | Quantity | Actual result | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
value | Σ | 1..1 | decimal | Numerical value (with implicit precision) | ||||
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. | ||||
unit | Σ | 0..1 | string | Unit representation | ||||
system | ΣC | 0..1 | uri | System that defines coded unit form | ||||
code | Σ | 0..1 | code | Coded form of the unit | ||||
dataAbsentReason | C | 0..1 | CodeableConcept | Why the 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. | |||||
note | 0..* | Annotation | Comments about the observation | |||||
bodySite | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
method | 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 | C | 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 | 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 | Σ | 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 | SΣ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (preferred): LOINC codes identifying names of simple observations. | ||||
Slices for value[x] | SΣ | 0..1 | Actual component result Slice: Unordered, Open by type:$this | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
value[x]:valueCodeableConcept | SΣ | 0..1 | CodeableConcept | Actual component result | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | FHIR standard classification of type of observation code system | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | FHIR standard classification of type of observation code system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | A code defining laboratory result | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
value[x]:valueQuantity | SΣ | 0..1 | Quantity | Actual component result | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
value | Σ | 1..1 | decimal | Numerical value (with implicit precision) | ||||
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. | ||||
unit | Σ | 0..1 | string | Unit representation | ||||
system | ΣC | 0..1 | uri | System that defines coded unit form | ||||
code | Σ | 0..1 | code | Coded form of the unit | ||||
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 | 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.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | ||||
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.category:laboratory | preferred | Pattern: laboratoryhttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | ||||
Observation.value[x]:valueQuantity.comparator | required | QuantityComparatorhttp://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard | ||||
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard | ||||
Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methods from the FHIR Standard | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaning from the FHIR Standard | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliesto from the FHIR Standard | ||||
Observation.component.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | ||||
Observation.component.value[x]:valueQuantity.comparator | required | QuantityComparatorhttp://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
ca-baseline-category | error | Observation.category:laboratory | SHALL have a category from 'http://terminology.hl7.org/CodeSystem/observation-category' : where(coding.system='http://terminology.hl7.org/CodeSystem/observation-category' and coding.code.exists()).exists() | |
ca-baseline-datetime | error | Observation.effective[x] | Datetime SHALL be at least to day : ($this as dateTime).toString().length() >= 8 | |
ca-baseline-results-1 | warning | Observation | SHOULD use SNOMED CT for coded Results : (component.value | value).ofType(Quantity).all(system = 'http://unitsofmeasure.org') | |
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() |
This structure is derived from ObservationProfile
Summary
Mandatory: 3 elements(6 nested mandatory elements)
Must-Support: 9 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from ObservationProfile
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | ObservationProfile | Observation Profile ca-baseline-results-1: SHOULD use SNOMED CT for coded Results |
status | 1..1 | code | registered | preliminary | final | amended + | |
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this |
category:laboratory | SC | 1..* | CodeableConcept | FHIR standard classification of type of observation ca-baseline-category: SHALL have a category from 'http://terminology.hl7.org/CodeSystem/observation-category' Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory | |
code | S | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (preferred): LOINC codes identifying names of simple observations. |
subject | S | 1..1 | Reference(Patient Profile | Group | Device | Location) | Who and/or what the observation is about |
effective[x] | SC | 0..1 | Clinically relevant time/time-period for observation ca-baseline-datetime: Datetime SHALL be at least to day | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
issued | 0..1 | instant | Date/Time this version was made available | |
performer | S | 0..* | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile | Patient Profile) | Who is responsible for the observation |
Slices for value[x] | S | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual result Slice: Unordered, Open by type:$this |
value[x]:valueCodeableConcept | 0..1 | CodeableConcept | Actual result | |
coding | 0..* | Coding | Code defined by a terminology system | |
system | 1..1 | uri | FHIR standard classification of type of observation code system | |
code | 1..1 | code | A code difining laboratory result | |
value[x]:valueQuantity | 0..1 | Quantity | Actual result | |
value | 1..1 | decimal | Numerical value (with implicit precision) | |
system | 0..1 | uri | System that defines coded unit form | |
dataAbsentReason | 0..1 | CodeableConcept | Why the result is missing | |
interpretation | 0..* | CodeableConcept | High, low, normal, etc. | |
referenceRange | 0..* | BackboneElement | Provides guide for interpretation | |
hasMember | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | |
component | 0..* | BackboneElement | Component results | |
code | S | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (preferred): LOINC codes identifying names of simple observations. |
Slices for value[x] | S | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual component result Slice: Unordered, Open by type:$this |
value[x]:valueCodeableConcept | 0..1 | CodeableConcept | Actual component result | |
coding | 0..* | Coding | FHIR standard classification of type of observation code system | |
system | 1..1 | uri | FHIR standard classification of type of observation code system | |
code | 1..1 | code | A code defining laboratory result | |
value[x]:valueQuantity | 0..1 | Quantity | Actual component result | |
value | 1..1 | decimal | Numerical value (with implicit precision) | |
system | 0..1 | uri | System that defines coded unit form | |
dataAbsentReason | 0..1 | CodeableConcept | Why the component result is missing | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | |
Observation.component.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
ca-baseline-category | error | Observation.category:laboratory | SHALL have a category from 'http://terminology.hl7.org/CodeSystem/observation-category' : where(coding.system='http://terminology.hl7.org/CodeSystem/observation-category' and coding.code.exists()).exists() | |
ca-baseline-datetime | error | Observation.effective[x] | Datetime SHALL be at least to day : ($this as dateTime).toString().length() >= 8 | |
ca-baseline-results-1 | warning | Observation | SHOULD use SNOMED CT for coded Results : (component.value | value).ofType(Quantity).all(system = 'http://unitsofmeasure.org') |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | ObservationProfile | Observation Profile 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 ca-baseline-results-1: SHOULD use SNOMED CT for coded Results |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
category:laboratory | SC | 1..* | CodeableConcept | FHIR standard classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. ca-baseline-category: SHALL have a category from 'http://terminology.hl7.org/CodeSystem/observation-category' Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory | |
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (preferred): LOINC codes identifying names of simple observations. |
subject | SΣ | 1..1 | Reference(Patient Profile | Group | Device | Location) | Who and/or what the observation is about |
effective[x] | SΣC | 0..1 | Clinically relevant time/time-period for observation ca-baseline-datetime: Datetime SHALL be at least to day | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
issued | Σ | 0..1 | instant | Date/Time this version was made available |
performer | SΣ | 0..* | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile | Patient Profile) | Who is responsible for the observation |
Slices for value[x] | SΣC | 0..1 | Actual result Slice: Unordered, Open by type:$this | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
value[x]:valueCodeableConcept | SΣC | 0..1 | CodeableConcept | Actual result |
coding | Σ | 0..* | Coding | Code defined by a terminology system |
system | Σ | 1..1 | uri | FHIR standard classification of type of observation code system |
code | Σ | 1..1 | code | A code difining laboratory result |
value[x]:valueQuantity | SΣC | 0..1 | Quantity | Actual result |
value | Σ | 1..1 | decimal | Numerical value (with implicit precision) |
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. |
system | ΣC | 0..1 | uri | System that defines coded unit form |
dataAbsentReason | C | 0..1 | CodeableConcept | Why the 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 | C | 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 |
hasMember | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group |
component | Σ | 0..* | BackboneElement | Component results |
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 (preferred): LOINC codes identifying names of simple observations. |
Slices for value[x] | SΣ | 0..1 | Actual component result Slice: Unordered, Open by type:$this | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
value[x]:valueCodeableConcept | SΣ | 0..1 | CodeableConcept | Actual component result |
coding | Σ | 0..* | Coding | FHIR standard classification of type of observation code system |
system | Σ | 1..1 | uri | FHIR standard classification of type of observation code system |
code | Σ | 1..1 | code | A code defining laboratory result |
value[x]:valueQuantity | SΣ | 0..1 | Quantity | Actual component result |
value | Σ | 1..1 | decimal | Numerical value (with implicit precision) |
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. |
system | ΣC | 0..1 | uri | System that defines coded unit form |
dataAbsentReason | C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | |
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.category:laboratory | preferred | Pattern: laboratoryhttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | |
Observation.value[x]:valueQuantity.comparator | required | QuantityComparatorhttp://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard | |
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | |
Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard | |
Observation.component.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | |
Observation.component.value[x]:valueQuantity.comparator | required | QuantityComparatorhttp://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard | |
Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
ca-baseline-category | error | Observation.category:laboratory | SHALL have a category from 'http://terminology.hl7.org/CodeSystem/observation-category' : where(coding.system='http://terminology.hl7.org/CodeSystem/observation-category' and coding.code.exists()).exists() | |
ca-baseline-datetime | error | Observation.effective[x] | Datetime SHALL be at least to day : ($this as dateTime).toString().length() >= 8 | |
ca-baseline-results-1 | warning | Observation | SHOULD use SNOMED CT for coded Results : (component.value | value).ofType(Quantity).all(system = 'http://unitsofmeasure.org') | |
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() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | ObservationProfile | Observation Profile 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 ca-baseline-results-1: SHOULD use SNOMED CT for coded Results | ||||
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.
| |||||
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 | 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 | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
category:laboratory | SC | 1..* | CodeableConcept | FHIR standard classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. ca-baseline-category: SHALL have a category from 'http://terminology.hl7.org/CodeSystem/observation-category' 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 | Type of observation (code / type) Binding: LOINCCodes (preferred): LOINC codes identifying names of simple observations. | ||||
subject | SΣ | 1..1 | Reference(Patient Profile | Group | Device | Location) | Who and/or what the observation is about | ||||
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 | 0..1 | Clinically relevant time/time-period for observation ca-baseline-datetime: Datetime SHALL be at least to day | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | SΣ | 0..* | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile | Patient Profile) | Who is responsible for the observation | ||||
Slices for value[x] | SΣC | 0..1 | Actual result Slice: Unordered, Open by type:$this | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
value[x]:valueCodeableConcept | SΣC | 0..1 | CodeableConcept | Actual result | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | FHIR standard classification of type of observation code system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | A code difining laboratory result | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
value[x]:valueQuantity | SΣC | 0..1 | Quantity | Actual result | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
value | Σ | 1..1 | decimal | Numerical value (with implicit precision) | ||||
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. | ||||
unit | Σ | 0..1 | string | Unit representation | ||||
system | ΣC | 0..1 | uri | System that defines coded unit form | ||||
code | Σ | 0..1 | code | Coded form of the unit | ||||
dataAbsentReason | C | 0..1 | CodeableConcept | Why the 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. | |||||
note | 0..* | Annotation | Comments about the observation | |||||
bodySite | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
method | 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 | C | 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 | 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 | Σ | 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 | SΣ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (preferred): LOINC codes identifying names of simple observations. | ||||
Slices for value[x] | SΣ | 0..1 | Actual component result Slice: Unordered, Open by type:$this | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
value[x]:valueCodeableConcept | SΣ | 0..1 | CodeableConcept | Actual component result | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | FHIR standard classification of type of observation code system | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | FHIR standard classification of type of observation code system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | A code defining laboratory result | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
value[x]:valueQuantity | SΣ | 0..1 | Quantity | Actual component result | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
value | Σ | 1..1 | decimal | Numerical value (with implicit precision) | ||||
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. | ||||
unit | Σ | 0..1 | string | Unit representation | ||||
system | ΣC | 0..1 | uri | System that defines coded unit form | ||||
code | Σ | 0..1 | code | Coded form of the unit | ||||
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 | 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.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | ||||
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.category:laboratory | preferred | Pattern: laboratoryhttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | ||||
Observation.value[x]:valueQuantity.comparator | required | QuantityComparatorhttp://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard | ||||
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard | ||||
Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methods from the FHIR Standard | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaning from the FHIR Standard | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliesto from the FHIR Standard | ||||
Observation.component.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | ||||
Observation.component.value[x]:valueQuantity.comparator | required | QuantityComparatorhttp://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
ca-baseline-category | error | Observation.category:laboratory | SHALL have a category from 'http://terminology.hl7.org/CodeSystem/observation-category' : where(coding.system='http://terminology.hl7.org/CodeSystem/observation-category' and coding.code.exists()).exists() | |
ca-baseline-datetime | error | Observation.effective[x] | Datetime SHALL be at least to day : ($this as dateTime).toString().length() >= 8 | |
ca-baseline-results-1 | warning | Observation | SHOULD use SNOMED CT for coded Results : (component.value | value).ofType(Quantity).all(system = 'http://unitsofmeasure.org') | |
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() |
This structure is derived from ObservationProfile
Summary
Mandatory: 3 elements(6 nested mandatory elements)
Must-Support: 9 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
Additional codes that translate or map to the Observation code or category codes are allowed (see CodeableConcept data type). For example: providing both a local code and LOINC code providing a more specific category codes, SNOMED CT concept, or system specific codes.
The Observation.category specifies a code that classifies the general type of observation being made. The Observation.category element is CodeableConcept data type and more than one code is allowed. For interoperability reason one of the codes SHOULD be from the FHIR standard defined Observation Category Codes. Local codes are allowed as well. In case of using local codes to better classify the type both category.coding.system and category.coding.code SHOULD be provided.
The Observation.code element describes what was observed. Sometimes this is called the observation "name".
The pan-Canadian LOINC Observation Code Database (pCLOCD) is recommended for use in a Canadian context. Code System URI is https://fhir.infoway-inforoute.ca/CodeSystem/pCLOCD
If the result value is a code:
If the result value is a numeric quantity: