US Core Implementation Guide
7.0.0 - CI Build United States of America flag

US Core Implementation Guide, published by HL7 International / Cross-Group Projects. This guide is not an authorized publication; it is the continuous build for version 7.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/US-Core/ and changes regularly. See the Directory of published versions

CapabilityStatement: US Core Server CapabilityStatement

Official URL: http://hl7.org/fhir/us/core/CapabilityStatement/us-core-server Version: 7.0.0
Standards status: Trial-use Maturity Level: 3 Computable Name: UsCoreServerCapabilityStatement
Other Identifiers: OID:2.16.840.1.113883.4.642.40.13.2

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License

This Section describes the expected capabilities of the US Core Server actor which is responsible for providing responses to the queries submitted by the US Core Requestors. The complete list of FHIR profiles, RESTful operations, and search parameters supported by US Core Servers are defined. Systems implementing this capability statement should meet the ONC 2015 Common Clinical Data Set (CCDS) access requirement for Patient Selection 170.315(g)(7) and Application Access - Data Category Request 170.315(g)(8) and the ONC U.S. Core Data for Interoperability (USCDI) Version 4 July 2023.

Raw OpenAPI-Swagger Definition file | Download

SHOULD Support the Following Implementation Guides:

FHIR RESTful Capabilities

The US Core Server SHALL:

  1. Support the US Core Patient resource profile AND at least one additional resource profile from the list of US Core Profiles AND and all Must Support US Core Profiles and resources it references.
    • The Table below summarizes the Must Support references to other US Core Profiles and FHIR resources for each US Core Profile:
  2. Implement the RESTful behavior according to the FHIR specification.
  3. Follow the requirements documented in the General Requirements and Must Support pages
  4. Return the following response classes:
    • (Status 400): invalid parameter
    • (Status 401/4xx): unauthorized request
    • (Status 403): insufficient scopes
    • (Status 404): unknown resource
  5. Support JSON source formats for all US Core interactions.

The US Core Server SHOULD:

  1. Follow the guidance documented in the General Guidance page
  2. Support XML source formats for all US Core interactions.
  3. Identify the US Core profiles supported as part of the FHIR meta.profile attribute for each instance.

Security:

  1. See the General Security Considerations section for requirements and recommendations.
  2. A server SHALL reject any unauthorized requests by returning an HTTP 401 "Unauthorized", HTTP 403 "Forbidden", or HTTP 404 "Not Found"

Summary of System Wide Interactions

  • MAY support the transaction interaction.
  • MAY support the batch interaction.
  • MAY support the search-system interaction.
  • MAY support the history-system interaction.

RESTful Capabilities by Resource/Profile:

Summary

Resource Type Supported Profiles Supported Searches Supported _includes Supported _revincludes Supported Operations
AllergyIntolerance US Core AllergyIntolerance Profile clinical-status, patient patient+clinical-status - Provenance:target -
CarePlan US Core CarePlan Profile category, date, patient, status patient+category+status+date, patient+category+date, patient+category, patient+category+status - Provenance:target -
CareTeam US Core CareTeam Profile patient, role, status patient+status, patient+role CareTeam:participant:PractitionerRole, CareTeam:participant:Practitioner, CareTeam:participant:Patient, CareTeam:participant:RelatedPerson Provenance:target -
Condition US Core Condition Encounter Diagnosis Profile, US Core Condition Problems and Health Concerns Profile abatement-date, asserted-date, category, clinical-status, code, encounter, onset-date, patient, recorded-date, _lastUpdated patient+category+clinical-status, patient+onset-date, patient+abatement-date, patient+clinical-status, patient+asserted-date, patient+code, patient+category+encounter, patient+_lastUpdated, patient+recorded-date, patient+category - Provenance:target -
Coverage US Core Coverage Profile patient - Provenance:target -
Device US Core Implantable Device Profile patient, status, type patient+status, patient+type - Provenance:target -
DiagnosticReport US Core DiagnosticReport Profile for Report and Note exchange, US Core DiagnosticReport Profile for Laboratory Results Reporting category, code, date, _lastUpdated, patient, status patient+code, patient+category+date, patient+code+date, patient+status, patient+category+_lastUpdated, patient+category - Provenance:target -
DocumentReference US Core DocumentReference Profile _id, category, date, patient, period, status, type patient+type, patient+category+date, patient+type+period, patient+status, patient+category - Provenance:target docref
Encounter US Core Encounter Profile _id, class, date, _lastUpdated, discharge-disposition, identifier, location, patient, status, type date+patient, class+patient, patient+type, patient+_lastUpdated, patient+status, patient+location, patient+discharge-disposition - Provenance:target -
Endpoint - - - - -
Goal US Core Goal Profile description, lifecycle-status, patient, target-date patient+target-date, patient+lifecycle-status, patient+description - Provenance:target -
HealthcareService - - - - -
Immunization US Core Immunization Profile date, patient, status patient+date, patient+status - Provenance:target -
Location US Core Location Profile address, address-city, address-postalcode, address-state, name - - -
Media - - - - -
Medication US Core Medication Profile - - - -
MedicationDispense US Core MedicationDispense Profile patient, status, type patient+status+type, patient+status MedicationDispense:medication Provenance:target -
MedicationRequest US Core MedicationRequest Profile authoredon, encounter, intent, patient, status patient+intent+encounter, patient+intent+authoredon, patient+intent+status, patient+intent MedicationRequest:medication Provenance:target -
Observation US Core Laboratory Result Observation Profile, US Core Observation Pregnancy Status Profile, US Core Observation Pregnancy Intent Profile, US Core Observation Occupation Profile, US Core Respiratory Rate Profile, US Core Simple Observation Profile, US Core Treatment Intervention Preference Profile, US Core Care Experience Preference Profile, US Core Heart Rate Profile, US Core Body Temperature Profile, US Core Pediatric Weight for Height Observation Profile, US Core Pulse Oximetry Profile, US Core Smoking Status Observation Profile, US Core Observation Sexual Orientation Profile, US Core Head Circumference Profile, US Core Body Height Profile, US Core BMI Profile, US Core Observation Screening Assessment Profile, US Core Average Blood Pressure Profile, US Core Blood Pressure Profile, US Core Observation Clinical Result Profile, US Core Pediatric BMI for Age Observation Profile, US Core Pediatric Head Occipital Frontal Circumference Percentile Profile, US Core Body Weight Profile, US Core Vital Signs Profile category, code, date, _lastUpdated, patient, status patient+code, patient+category+date, patient+code+date, patient+category+status, patient+category+_lastUpdated, patient+category - Provenance:target -
Organization US Core Organization Profile address, name - - -
Patient US Core Patient Profile _id, birthdate, death-date, family, gender, given, identifier, name birthdate+name, family+gender, birthdate+family, gender+name, death-date+family - Provenance:target -
Practitioner US Core Practitioner Profile _id, identifier, name - - -
PractitionerRole US Core PractitionerRole Profile practitioner, specialty PractitionerRole:endpoint, PractitionerRole:practitioner - -
Procedure US Core Procedure Profile code, date, patient, status patient+code+date, patient+date, patient+status - Provenance:target -
Provenance US Core Provenance Profile - - - -
Questionnaire SDC Base Questionnaire Profile - - - -
QuestionnaireResponse US Core QuestionnaireResponse Profile _id, authored, patient, questionnaire, status patient+questionnaire, patient+authored, patient+status - Provenance:target -
RelatedPerson US Core RelatedPerson Profile _id, name, patient patient+name - Provenance:target -
ServiceRequest US Core ServiceRequest Profile _id, authored, category, code, patient, status patient+code, patient+category+authored, patient+code+authored, patient+status, patient+category - Provenance:target -
Specimen US Core Specimen Profile _id, patient - - -
ValueSet - - - - expand

Summary of Must Support and Additional USCDI References Between Profiles

  • US Core Profile: The profile that has a Must Support or Additional USCDI references to other profiles or resources (i.e., Target Profiles).
  • Resource Type: The FHIR resource type of the source profile.
  • Target Profile: The US Core Profile references these profiles and resources as a Must Support or Additional USCDI element. Additional USCDI-referenced profiles or resources are identified with the label "(ADDITIONAL USCDI)".
  • Target Resource Type: The FHIR resource type of the Target Profile.
US Core Profile Resource Type Target Profile Target Resource Type
US Core Pediatric Head Occipital Frontal Circumference Percentile Profile Observation US Core Patient Profile Patient
US Core Pediatric BMI for Age Observation Profile Observation US Core Patient Profile Patient
US Core Pediatric Weight for Height Observation Profile Observation US Core Patient Profile Patient
US Core AllergyIntolerance Profile AllergyIntolerance US Core Patient Profile Patient
US Core Average Blood Pressure Profile Observation US Core Patient Profile Patient
US Core Blood Pressure Profile Observation US Core Patient Profile Patient
US Core BMI Profile Observation US Core Patient Profile Patient
US Core Body Height Profile Observation US Core Patient Profile Patient
US Core Body Temperature Profile Observation US Core Patient Profile Patient
US Core Body Weight Profile Observation US Core Patient Profile Patient
US Core Care Experience Preference Profile Observation US Core Patient Profile Patient
US Core CarePlan Profile CarePlan US Core Patient Profile Patient
US Core CareTeam Profile CareTeam US Core RelatedPerson Profile
US Core PractitionerRole Profile
US Core Practitioner Profile
US Core Patient Profile
RelatedPerson
PractitionerRole
Practitioner
Patient
US Core Condition Encounter Diagnosis Profile Condition US Core Encounter Profile
US Core Patient Profile
Encounter
Patient
US Core Condition Problems and Health Concerns Profile Condition US Core Patient Profile Patient
US Core Coverage Profile Coverage US Core Organization Profile
US Core Patient Profile
Organization
Patient
US Core DiagnosticReport Profile for Laboratory Results Reporting DiagnosticReport US Core Encounter Profile
US Core Practitioner Profile
US Core Patient Profile
US Core Laboratory Result Observation Profile
Encounter
Practitioner
Patient
Observation
US Core DiagnosticReport Profile for Report and Note Exchange DiagnosticReport Media
US Core Practitioner Profile
US Core Observation Clinical Result Profile
US Core Laboratory Result Observation Profile
US Core Organization Profile
US Core Encounter Profile
US Core Patient Profile
Media
Practitioner
Observation
Observation
Organization
Encounter
Patient
US Core DocumentReference Profile DocumentReference US Core Encounter Profile
US Core Practitioner Profile
US Core Patient Profile
Encounter
Practitioner
Patient
US Core Encounter Profile Encounter US Core Practitioner Profile
US Core Condition Encounter Diagnosis Profile
US Core Organization Profile
US Core Location Profile
US Core Condition Problems and Health Concerns Profile
US Core Patient Profile
Practitioner
Condition
Organization
Location
Condition
Patient
US Core Goal Profile Goal US Core Patient Profile Patient
US Core Head Circumference Profile Observation US Core Patient Profile Patient
US Core Heart Rate Profile Observation US Core Patient Profile Patient
US Core Immunization Profile Immunization US Core Encounter Profile
US Core Location Profile
US Core Patient Profile
Encounter
Location
Patient
US Core Implantable Device Profile Device US Core Patient Profile Patient
US Core Location Profile Location US Core Organization Profile Organization
US Core Medication Profile Medication - -
US Core MedicationDispense Profile MedicationDispense US Core Practitioner Profile
US Core Medication Profile
US Core Organization Profile
US Core Encounter Profile
US Core MedicationRequest Profile
US Core Patient Profile
Practitioner
Medication
Organization
Encounter
MedicationRequest
Patient
US Core MedicationRequest Profile MedicationRequest US Core Encounter Profile
US Core Patient Profile
US Core Practitioner Profile
US Core Medication Profile
Observation(ADDITIONAL USCDI)
Condition(ADDITIONAL USCDI)
Encounter
Patient
Practitioner
Medication
Observation
Condition
US Core Observation Clinical Result Profile Observation US Core Encounter Profile
US Core Patient Profile
Encounter
Patient
US Core Laboratory Result Observation Profile Observation US Core Specimen Profile
US Core Encounter Profile
US Core Patient Profile
Specimen
Encounter
Patient
US Core Observation Occupation Profile Observation US Core Patient Profile Patient
US Core Observation Pregnancy Intent Profile Observation US Core Patient Profile Patient
US Core Observation Pregnancy Status Profile Observation US Core Patient Profile Patient
US Core Observation Screening Assessment Profile Observation US Core Observation Screening Assessment Profile
US Core QuestionnaireResponse Profile
US Core Patient Profile
Observation
QuestionnaireResponse
Patient
US Core Observation Sexual Orientation Profile Observation US Core Patient Profile Patient
US Core Organization Profile Organization - -
US Core Patient Profile Patient - -
US Core Practitioner Profile Practitioner - -
US Core PractitionerRole Profile PractitionerRole US Core Organization Profile
US Core Practitioner Profile
US Core Location Profile
Endpoint
HealthcareService(ADDITIONAL USCDI)
Organization
Practitioner
Location
Endpoint
HealthcareService
US Core Procedure Profile Procedure US Core Encounter Profile
US Core Patient Profile
Observation(ADDITIONAL USCDI)
Procedure(ADDITIONAL USCDI)
DocumentReference(ADDITIONAL USCDI)
Condition(ADDITIONAL USCDI)
DiagnosticReport(ADDITIONAL USCDI)
Encounter
Patient
Observation
Procedure
DocumentReference
Condition
DiagnosticReport
US Core Provenance Profile Provenance US Core Organization Profile
Any Resource
Organization
Any Resource
US Core Pulse Oximetry Profile Observation US Core Patient Profile Patient
US Core QuestionnaireResponse Profile QuestionnaireResponse Any Resource
US Core Practitioner Profile
US Core Patient Profile
Any Resource
Practitioner
Patient
US Core RelatedPerson Profile RelatedPerson US Core Patient Profile Patient
US Core Respiratory Rate Profile Observation US Core Patient Profile Patient
US Core ServiceRequest Profile ServiceRequest US Core Encounter Profile
US Core Practitioner Profile
US Core Patient Profile
Observation(ADDITIONAL USCDI)
Condition(ADDITIONAL USCDI)
DiagnosticReport(ADDITIONAL USCDI)
DocumentReference(ADDITIONAL USCDI)
Encounter
Practitioner
Patient
Observation
Condition
DiagnosticReport
DocumentReference
US Core Simple Observation Profile Observation US Core Patient Profile Patient
US Core Smoking Status Observation Profile Observation US Core Patient Profile Patient
US Core Specimen Profile Specimen US Core Patient Profile Patient
US Core Treatment Intervention Preference Profile Observation US Core Patient Profile Patient
US Core Vital Signs Profile Observation US Core Patient Profile Patient

AllergyIntolerance

Conformance Expectation: SHALL

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a AllergyIntolerance resource using: GET [base]/AllergyIntolerance/[id]
  • A Server SHALL be capable of supporting the following _revincludes: Provenance:target - GET [base]/AllergyIntolerance?[parameter=value]&_revinclude=Provenance:target

Search Parameter Summary:

Conformance Parameter Type
SHALL patient reference

Search Parameter Combination Summary:

Conformance Parameter Combination Types
SHOULD patient+ clinical-status reference+token

Search Parameter Requirements (When Used Alone or in Combination):

  • clinical-status (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • patient (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.


CarePlan

Conformance Expectation: SHALL

Resource Specific Documentation:

  • Additional considerations for systems aligning with HL7 Consolidated (C-CDA) Care Plan requirements:
    • US Core Goal SHOULD be present in CarePlan.goal
    • US Core Condition SHOULD be present in CarePlan.addresses
    • Assement and Plan MAY be included as narrative text

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a CarePlan resource using: GET [base]/CarePlan/[id]
  • A Server SHALL be capable of supporting the following _revincludes: Provenance:target - GET [base]/CarePlan?[parameter=value]&_revinclude=Provenance:target

Search Parameter Combination Summary:

Conformance Parameter Combination Types
SHOULD patient+ category+ status+ date reference+token+token+date
SHOULD patient+ category+ date reference+token+date
SHALL patient+ category reference+token
SHOULD patient+ category+ status reference+token+token

Search Parameter Requirements (When Used Alone or in Combination):

  • category (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • date (date):

    A client SHALL provide a value precise to the second + time offset.

    A server SHALL support a value precise to the second + time offset.

  • patient (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • status (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.


CareTeam

Conformance Expectation: SHALL

Resource Specific Documentation:

  • In order to access care team member's names, identifiers, locations, and contact information, the CareTeam profile supports several types of care team participants. They are represented as references to other profiles and include the following four profiles which are marked as must support:
    1. US Core Practitioner Profile
    2. US Core PractitionerRole Profile
    3. US Core Patient Profile
    4. US Core RelatedPerson Profile
  • Although both US Core Practitioner Profile and US Core PractitionerRole are must support, the server system is not required to support both types of references, but SHALL support at least one of them.
  • The client application SHALL support all four profile references.
  • Bacause the US Core PractitionerRole Profile supplies the provider's location and contact information and a reference to the Practitioner, server systems SHOULD reference it instead of the US Core Practitioner Profile.
  • Servers that support only US Core Practitioner Profile and do not support the US Core PractitionerRole Profile SHALL provide implementation specific guidance how to access a provider’s location and contact information using only the Practitioner resource.

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a CareTeam resource using: GET [base]/CareTeam/[id]
  • A Server SHOULD be capable of supporting the following _includes:
    • CareTeam:participant:PractitionerRole: GET [base]/CareTeam?[parameter=value]&_include=CareTeam:participant:PractitionerRole
    • CareTeam:participant:Practitioner: GET [base]/CareTeam?[parameter=value]&_include=CareTeam:participant:Practitioner
    • CareTeam:participant:Patient: GET [base]/CareTeam?[parameter=value]&_include=CareTeam:participant:Patient
    • CareTeam:participant:RelatedPerson: GET [base]/CareTeam?[parameter=value]&_include=CareTeam:participant:RelatedPerson
  • A Server SHALL be capable of supporting the following _revincludes: Provenance:target - GET [base]/CareTeam?[parameter=value]&_revinclude=Provenance:target

Search Parameter Summary:

Conformance Parameter Type
SHOULD role token

Search Parameter Combination Summary:

Conformance Parameter Combination Types
SHALL patient+ status reference+token
SHOULD patient+ role reference+token

Search Parameter Requirements (When Used Alone or in Combination):

  • patient (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • role (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • status (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.


Condition

Conformance Expectation: SHALL

Resource Specific Documentation:

  • For Encounter Diagnosis use the US Core Condition Encounter Diagnosis Profile.
    • When Condition.category is "encounter-diagnosis" the encounter, SHOULD be referenced in Condition.encounter.
  • For Problems and Health Concerns use the US Core Condition Problems and Health Concerns Profile.
    • When Condition.category is a "problems-list-item", the `Condition.clinicalStatus SHOULD NOT be unknown.
  • There is no single element in Condition that represents the date of diagnosis. It may be the assertedDate Extension, Condition.onsetDateTime, or Condition.recordedDate.
    • Although all three are marked as must support, the server is not required to support all.
    • A server SHALL support Condition.recordedDate.
    • A server SHALL support at least one of the assertedDate Extension and Condition.onsetDateTime. A server may support both, which means they support all three elements.
    • The client application SHALL support all three elements.

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a Condition resource using: GET [base]/Condition/[id]
  • A Server SHALL be capable of supporting the following _revincludes: Provenance:target - GET [base]/Condition?[parameter=value]&_revinclude=Provenance:target

Search Parameter Summary:

Conformance Parameter Type
SHALL patient reference

Search Parameter Combination Summary:

Conformance Parameter Combination Types
SHOULD patient+ category+ clinical-status reference+token+token
SHOULD patient+ onset-date reference+date
SHOULD patient+ abatement-date reference+date
SHOULD patient+ clinical-status reference+token
SHOULD patient+ asserted-date reference+date
SHOULD patient+ code reference+token
SHOULD patient+ category+ encounter reference+token+reference
SHOULD patient+ _lastUpdated reference+date
SHOULD patient+ recorded-date reference+date
SHALL patient+ category reference+token

Search Parameter Requirements (When Used Alone or in Combination):

  • abatement-date (date):

    A client SHALL provide a value precise to the second + time offset.

    A server SHALL support a value precise to the second + time offset.

  • asserted-date (date):

    A client SHALL provide a value precise to the second + time offset.

    A server SHALL support a value precise to the second + time offset.

  • category (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • clinical-status (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • code (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • encounter (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • onset-date (date):

    A client SHALL provide a value precise to the second + time offset.

    A server SHALL support a value precise to the second + time offset.

  • patient (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • recorded-date (date):

    A client SHALL provide a value precise to the second + time offset.

    A server SHALL support a value precise to the second + time offset.

  • _lastUpdated (date):

    A server SHALL document the types of changes that can be detected using this parameter.

    A client SHALL provide a value precise to the second + time offset.

    A server SHALL support a value precise to the second + time offset.


Coverage

Conformance Expectation: SHALL

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a Coverage resource using: GET [base]/Coverage/[id]
  • A Server SHALL be capable of supporting the following _revincludes: Provenance:target - GET [base]/Coverage?[parameter=value]&_revinclude=Provenance:target

Search Parameter Summary:

Conformance Parameter Type
SHALL patient reference

Search Parameter Requirements (When Used Alone or in Combination):

  • patient (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.


Device

Conformance Expectation: SHALL

Resource Specific Documentation:

  • Implantable medical devices that have UDI information SHALL represent the UDI code in Device.udiCarrier.carrierHRF.

    • All of the five UDI-PI elements that are present in the UDI code SHALL be represented in the corresponding US Core Implantable Device Profile element.

    UDI may not be present in all scenarios such as historical implantable devices, patient reported implant information, payer reported devices, or improperly documented implants. If UDI is not present and the manufacturer and/or model number information is available, they SHOULD be included to support historical reports of implantable medical devices as follows:

    manufacturer -> Device.manufacturer
    model -> Device.model

  • Servers SHOULD support query by Device.type to allow clients to request the patient's devices by a specific type. Note: The Device.type is too granular to differentiate implantable vs. non-implantable devices.

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a Device resource using: GET [base]/Device/[id]
  • A Server SHALL be capable of supporting the following _revincludes: Provenance:target - GET [base]/Device?[parameter=value]&_revinclude=Provenance:target

Search Parameter Summary:

Conformance Parameter Type
SHALL patient reference

Search Parameter Combination Summary:

Conformance Parameter Combination Types
SHOULD patient+ status reference+token
SHOULD patient+ type reference+token

Search Parameter Requirements (When Used Alone or in Combination):

  • patient (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • status (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • type (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.


DiagnosticReport

Conformance Expectation: SHALL

Resource Specific Documentation:

  • When DiagnosticReport.category is "LAB" the encounter, Updates to Meta.lastUpdated SHOULD reflect:
    • New laboratory reports
    • Changes in the status of laboratory reports including events that trigger the same status (e.g., amended → amended).

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support create, search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support update, patch, delete, history-type.
create

This conformance expectation applies only to the US Core DiagnosticReport Profile for Report and Note exchange profile. The conformance expectation for the US Core DiagnosticReport Profile for Laboratory Results Reporting is MAY.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a DiagnosticReport resource using: GET [base]/DiagnosticReport/[id]
  • A Server SHALL be capable of supporting the following _revincludes: Provenance:target - GET [base]/DiagnosticReport?[parameter=value]&_revinclude=Provenance:target

Search Parameter Summary:

Conformance Parameter Type
SHALL patient reference

Search Parameter Combination Summary:

Conformance Parameter Combination Types
SHALL patient+ code reference+token
SHALL patient+ category+ date reference+token+date
SHOULD patient+ code+ date reference+token+date
SHOULD patient+ status reference+token
SHOULD patient+ category+ _lastUpdated reference+token+date
SHALL patient+ category reference+token

Search Parameter Requirements (When Used Alone or in Combination):

  • category (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • code (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • date (date):

    A client SHALL provide a value precise to the second + time offset.

    A server SHALL support a value precise to the second + time offset.

  • _lastUpdated (date):

    A server SHALL document the types of changes that can be detected using this parameter.

    A client SHALL provide a value precise to the second + time offset.

    A server SHALL support a value precise to the second + time offset.

  • patient (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • status (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.


DocumentReference

Conformance Expectation: SHALL

Resource Specific Documentation:

  • The DocumentReference.type binding SHALL support at a minimum the 5 Common Clinical Notes and may extend to the full US Core DocumentReference Type Value Set
  • The DocumentReference resources can represent the referenced content using either an address where the document can be retrieved using DocumentReference.attachment.url or the content as inline base64 encoded data using DocumentReference.attachment.data.
    • Although both are marked as must support, the server system is not required to support an address, and inline base64 encoded data, but SHALL support at least one of these elements.
    • The client application SHALL support both elements.
    • The content.url may refer to a FHIR Binary Resource (i.e. [base]/Binary/[id]), FHIR Document Bundle (i.e [base]/Bundle/[id] or another endpoint.
      • If the endpoint is outside the FHIR base URL, it SHOULD NOT require additional authorization to access.
    • If there are multiple DocumentReference.content element repetitions, these SHALL all represent the same document in different format or attachment metadata. The content element SHALL NOT contain different versions of the same content. For version handling use multiple DocumentReferences with DocumentReference.relatesTo
  • Every DocumentReference must have a responsible Organization. The organization responsible for the DocumentReference SHALL be present either in DocumentReference.custodian or accessible in the Provenance resource targeting the DocumentReference using Provenance.agent.who or Provenance.agent.onBehalfOf.

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support create, search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support update, patch, delete, history-type.

Operation Summary:

  • SHALL support the $docref operation

    A server SHALL be capable of responding to a $docref operation and capable of returning at least a reference to a generated CCD document, if available. MAY provide references to other 'on-demand' and 'stable' documents (or 'delayed/deferred assembly') that meet the query parameters as well. If a context date range is supplied the server ** SHOULD** provide references to any document that falls within the date range. If no date range is supplied, then the server SHALL provide references to last or current document(s). SHOULD document what resources, if any, are returned as included resources

    GET [base]/DocumentReference/$docref?patient=[id]

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a DocumentReference resource using: GET [base]/DocumentReference/[id]
  • A Server SHALL be capable of supporting the following _revincludes: Provenance:target - GET [base]/DocumentReference?[parameter=value]&_revinclude=Provenance:target

Search Parameter Summary:

Conformance Parameter Type
SHALL _id token
SHALL patient reference

Search Parameter Combination Summary:

Conformance Parameter Combination Types
SHALL patient+ type reference+token
SHALL patient+ category+ date reference+token+date
SHOULD patient+ type+ period reference+token+date
SHOULD patient+ status reference+token
SHALL patient+ category reference+token

Search Parameter Requirements (When Used Alone or in Combination):

  • category (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • date (date):

    A client SHALL provide a value precise to the second + time offset.

    A server SHALL support a value precise to the second + time offset.

  • patient (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • period (date):

    A client SHALL provide a value precise to the second + time offset.

    A server SHALL support a value precise to the second + time offset.

  • status (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • type (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.


Encounter

Conformance Expectation: SHALL

Resource Specific Documentation:

  • The Encounter resource can represent a reason using either a code with Encounter.reasonCode, or a reference with Encounter.reasonReference to Condition or other resource.

    • Although both are marked as must support, the server systems are not required to support both a code and a reference, but they SHALL support at least one of these elements.
    • The client application SHALL support both elements.
    • if Encounter.reasonReference references an Observation, it SHOULD conform to a US Core Observation if applicable. (for example, a laboratory result should conform to the US Core Laboratory Result Observation Profile)
  • The location address can be represented by either by the Location referenced by Encounter.location.location or indirectly through the Organization referenced by Encounter.serviceProvider.

    • Although both are marked as must support, the server systems are not required to support both Encounter.location.location and Encounter.serviceProvider, but they SHALL support at least one of these elements.
    • The client application SHALL support both elements.
  • If the event facility/location differs from the Encounter.location, systems SHOULD reference it directly:

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a Encounter resource using: GET [base]/Encounter/[id]
  • A Server SHALL be capable of supporting the following _revincludes: Provenance:target - GET [base]/Encounter?[parameter=value]&_revinclude=Provenance:target

Search Parameter Summary:

Conformance Parameter Type
SHALL _id token
SHOULD identifier token
SHALL patient reference

Search Parameter Combination Summary:

Conformance Parameter Combination Types
SHALL date+ patient date+reference
SHOULD class+ patient token+reference
SHOULD patient+ type reference+token
SHOULD patient+ _lastUpdated reference+date
SHOULD patient+ status reference+token
SHOULD patient+ location reference+reference
SHOULD patient+ discharge-disposition reference+token

Search Parameter Requirements (When Used Alone or in Combination):

  • class (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • date (date):

    A client SHALL provide a value precise to the second + time offset.

    A server SHALL support a value precise to the second + time offset.

  • _lastUpdated (date):

    A server SHALL document the types of changes that can be detected using this parameter.

    A client SHALL provide a value precise to the second + time offset.

    A server SHALL support a value precise to the second + time offset.

  • discharge-disposition (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • identifier (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • location (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • patient (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • status (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • type (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.


Endpoint

Conformance Expectation: SHALL

Resource Specific Documentation:

The Media Resource is a Must Suppot referenced resource when using the US Core PracitionerRole Profile.

Reference Policy

Profile Interaction Summary:

  • SHOULD support read, vread.
  • MAY support create, search-type, update, patch, delete, history-instance, history-type.

Fetch and Search Criteria:

  • A Server SHOULD be capable of returning a Endpoint resource using: GET [base]/Endpoint/[id]

Goal

Conformance Expectation: SHALL

Resource Specific Documentation:

  • Although both Goal.startDate and Goal.target.dueDate are marked as must support, the server system is not required to support both, but SHALL support at least one of these elements. The client application SHALL support both elements.

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a Goal resource using: GET [base]/Goal/[id]
  • A Server SHALL be capable of supporting the following _revincludes: Provenance:target - GET [base]/Goal?[parameter=value]&_revinclude=Provenance:target

Search Parameter Summary:

Conformance Parameter Type
SHALL patient reference

Search Parameter Combination Summary:

Conformance Parameter Combination Types
SHOULD patient+ target-date reference+date
SHOULD patient+ lifecycle-status reference+token
SHOULD patient+ description reference+token

Search Parameter Requirements (When Used Alone or in Combination):

  • lifecycle-status (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • patient (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • target-date (date):

    A client SHALL provide a value precise to the day.

    A server SHALL support a value a value precise to the day.


HealthcareService

Conformance Expectation: MAY

Resource Specific Documentation:

The HealthcareService Resource is a referenced resource when using the US Core PracitionRole Profile and subject to constraint us-core-13: "SHALL have a practitioner, an organization, a healthcare service, or a location."

Reference Policy

Profile Interaction Summary:

  • SHOULD support read, vread.
  • MAY support create, search-type, update, patch, delete, history-instance, history-type.

Fetch and Search Criteria:

  • A Server SHOULD be capable of returning a HealthcareService resource using: GET [base]/HealthcareService/[id]

Immunization

Conformance Expectation: SHALL

Resource Specific Documentation:

  • Based upon the ONC U.S. Core Data for Interoperability (USCDI) requirements, CVX vaccine codes are required and the NDC vaccine codes SHOULD be supported as translations to them.

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a Immunization resource using: GET [base]/Immunization/[id]
  • A Server SHALL be capable of supporting the following _revincludes: Provenance:target - GET [base]/Immunization?[parameter=value]&_revinclude=Provenance:target

Search Parameter Summary:

Conformance Parameter Type
SHALL patient reference

Search Parameter Combination Summary:

Conformance Parameter Combination Types
SHOULD patient+ date reference+date
SHOULD patient+ status reference+token

Search Parameter Requirements (When Used Alone or in Combination):

  • date (date):

    A client SHALL provide a value precise to the second + time offset.

    A server SHALL support a value precise to the second + time offset.

  • patient (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • status (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.


Location

Conformance Expectation: SHALL

Resource Specific Documentation:

  • Systems SHOULD follow the Project US@ Technical Specification for Patient Addresses Final Version 1.0 as the standard style guide for Location.address.line and Location.address.city.

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a Location resource using: GET [base]/Location/[id]

Search Parameter Summary:

Conformance Parameter Type
SHALL address string
SHOULD address-city string
SHOULD address-postalcode string
SHOULD address-state string
SHALL name string

Media

Conformance Expectation: SHALL

Resource Specific Documentation:

The Media Resource is a Must Suppot referenced resource when using the US Core DiagnosticReport Profile for Report and Note Exchange.

Reference Policy

Profile Interaction Summary:

  • SHOULD support read, vread.
  • MAY support create, search-type, update, patch, delete, history-instance, history-type.

Fetch and Search Criteria:

  • A Server SHOULD be capable of returning a Media resource using: GET [base]/Media/[id]

Medication

Conformance Expectation: SHALL

Resource Specific Documentation:

  • The MedicationRequest resource can represent a medication, using an external reference to a Medication resource. If an external Medication Resource is used in a MedicationRequest, then the READ SHALL be supported.

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support read.
  • SHOULD support vread, history-instance.
  • MAY support create, search-type, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a Medication resource using: GET [base]/Medication/[id]

MedicationDispense

Conformance Expectation: SHALL

Resource Specific Documentation:

  • The MedicationDispense resources can represent a medication using either a code or refer to the Medication resource. When referencing Medication, the resource may be contained or an external resource. The server application MAY choose any one way or more than one method, but if an external reference to Medication is used, the server SHALL support the _include` parameter for searching this element. The client application must support all methods.
    • For example, A server SHALL be capable of returning dispense records for all medications for a patient using one of or both:
      • GET /MedicationDispense?patient=[id]
      • GET /MedicationDispense?patient=[id]&_include=MedicationDispense:medication

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a MedicationDispense resource using: GET [base]/MedicationDispense/[id]
  • A Server SHOULD be capable of supporting the following _includes:
    • MedicationDispense:medication: GET [base]/MedicationDispense?[parameter=value]&_include=MedicationDispense:medication
  • A Server SHALL be capable of supporting the following _revincludes: Provenance:target - GET [base]/MedicationDispense?[parameter=value]&_revinclude=Provenance:target

Search Parameter Summary:

Conformance Parameter Type
SHALL patient reference

Search Parameter Combination Summary:

Conformance Parameter Combination Types
SHOULD patient+ status+ type reference+token+token
SHOULD patient+ status reference+token

Search Parameter Requirements (When Used Alone or in Combination):

  • patient (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • status (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • type (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.


MedicationRequest

Conformance Expectation: SHALL

Resource Specific Documentation:

  • The MedicationRequest resources can represent a medication using either a code or refer to the Medication resource. When referencing Medication, the resource may be contained or an external resource. The server application MAY choose any one way or more than one method, but if an external reference to Medication is used, the server SHALL support the _include` parameter for searching this element. The client application must support all methods.

    • For example, A server SHALL be capable of returning all medications for a patient using one of or both:
      • GET /MedicationRequest?patient=[id]
      • GET /MedicationRequest?patient=[id]&_include=MedicationRequest:medication
  • The MedicationRequest resource can represent that information is from a secondary source using either a boolean flag or reference in MedicationRequest.reportedBoolean, or a reference using MedicationRequest.reportedReference to Practitioner or other resource.

    • Although both are marked as must support, the server systems are not required to support both a boolean and a reference, but SHALL choose to support at least one of these elements.
    • The client application SHALL support both elements.
  • When recording “self-prescribed” medication, requester SHOULD be used to indicate the Patient or RelatedPerson as the prescriber. (See the Medication List section for guidance on accessing a patient medications including over the counter (OTC) medication and other substances taken for medical and recreational use.)

  • The MedicationRequest resource can communicate the reason or indication for treatment using either a code in MedicationRequest.reasonCode or a reference using MedicationRequest.reasonReference.

  • Although both MedicationRequest.reasonCode and MedicationRequest.reasonReference are marked as Additional USCDI Requirements. The certifying server system is not required to support both but SHALL support at least one of these elements. The certifying client application SHALL support both elements.

    • when using MedicationRequest.reasonReference:
      • Servers SHALL support at least one target resource in MedicationRequest.reasonReference. Clients SHALL support all target resources.
      • The referenced resources SHOULD be a US Core Profile as documented in Referencing US Core Profiles.

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a MedicationRequest resource using: GET [base]/MedicationRequest/[id]
  • A Server SHOULD be capable of supporting the following _includes:
    • MedicationRequest:medication: GET [base]/MedicationRequest?[parameter=value]&_include=MedicationRequest:medication
  • A Server SHALL be capable of supporting the following _revincludes: Provenance:target - GET [base]/MedicationRequest?[parameter=value]&_revinclude=Provenance:target

Search Parameter Combination Summary:

Conformance Parameter Combination Types
SHOULD patient+ intent+ encounter reference+token+reference
SHOULD patient+ intent+ authoredon reference+token+date
SHALL patient+ intent+ status reference+token+token
SHALL patient+ intent reference+token

Search Parameter Requirements (When Used Alone or in Combination):

  • authoredon (date):

    A client SHALL provide a value precise to the second + time offset.

    A server SHALL support a value precise to the second + time offset.

  • encounter (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • intent (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • patient (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • status (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.


Observation

Conformance Expectation: SHALL

Resource Specific Documentation:

  • Systems SHOULD support Observation.effectivePeriod to accurately represent tests that are collected over a period of time (for example, a 24-Hour Urine Collection test).
  • An Observation without a value, SHALL include a reason why the data is absent unless there are component observations, or references to other Observations that are grouped within it
    • Systems that never provide an observation without a value are not required to support Observation.dataAbsentReason
  • An Observation.component without a value, SHALL include a reason why the data is absent.
    • Systems that never provide an component observation without a component value are not required to support Observation.component.dataAbsentReason.
  • When Observation.category is "laboratory" the encounter, Updates to Meta.lastUpdated SHOULD reflect:
    • New laboratory results
    • Changes in the status of laboratory results including events that trigger the same status (e.g., amended → amended).

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a Observation resource using: GET [base]/Observation/[id]
  • A Server SHALL be capable of supporting the following _revincludes: Provenance:target - GET [base]/Observation?[parameter=value]&_revinclude=Provenance:target

Search Parameter Combination Summary:

Conformance Parameter Combination Types
SHALL patient+ code reference+token
SHALL patient+ category+ date reference+token+date
SHOULD patient+ code+ date reference+token+date
SHOULD patient+ category+ status reference+token+token
SHOULD patient+ category+ _lastUpdated reference+token+date
SHALL patient+ category reference+token

Search Parameter Requirements (When Used Alone or in Combination):

  • category (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • code (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • date (date):

    A client SHALL provide a value precise to the second + time offset.

    A server SHALL support a value precise to the second + time offset.

  • _lastUpdated (date):

    A server SHALL document the types of changes that can be detected using this parameter.

    A client SHALL provide a value precise to the second + time offset.

    A server SHALL support a value precise to the second + time offset.

  • patient (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • status (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.


Organization

Conformance Expectation: SHALL

Resource Specific Documentation:

  • Systems SHALL support National Provider Identifier (NPI) for organizations and SHOULD support Clinical Laboratory Improvement Amendments (CLIA) identifiers for Organization.Identifier.
  • Systems SHOULD follow the Project US@ Technical Specification for Patient Addresses Final Version 1.0 as the standard style guide for Organization.address.line and Organization.address.city.

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a Organization resource using: GET [base]/Organization/[id]

Search Parameter Summary:

Conformance Parameter Type
SHALL address string
SHALL name string

Patient

Conformance Expectation: SHALL

Resource Specific Documentation:

  • For ONC's USCDI requirements, each Patient must support the following additional elements. These elements are included in the formal definition of the profile. The patient examples include all of these elements.

    1. contact detail (e.g. a telephone number or an email address)
    2. a communication language
    3. a race
    4. an ethnicity
    5. a birth sex*
    6. previous name
      • Previous name is represented by providing an end date in the Patient.name.period element for a previous name.
    7. suffix
      • Suffix is represented using the Patient.name.suffix element.
  • The Patient's Social Security Numbers SHOULD NOT be used as a patient identifier in Patient.identifier.value.

  • Although Patient.deceased[x] is marked as 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜, certifying systems are not required to support both choices, but SHALL support at least Patient.deceasedDateTime.

  • Certifying systems SHALL and non-certifying systems SHOULD follow the Project US@ Technical Specification for Patient Addresses Final Version 1.0 as the standard style guide for Patient.address.line and Patient.address.city for new and updated records.

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a Patient resource using: GET [base]/Patient/[id]
  • A Server SHALL be capable of supporting the following _revincludes: Provenance:target - GET [base]/Patient?[parameter=value]&_revinclude=Provenance:target

Search Parameter Summary:

Conformance Parameter Type
SHALL _id token
SHALL identifier token
SHALL name string

Search Parameter Combination Summary:

Conformance Parameter Combination Types
SHALL birthdate+ name date+string
SHOULD family+ gender string+token
SHOULD birthdate+ family date+string
SHALL gender+ name token+string
SHOULD death-date+ family date+string

Search Parameter Requirements (When Used Alone or in Combination):

  • birthdate (date):

    A client SHALL provide a value precise to the day.

    A server SHALL support a value a value precise to the day.

  • death-date (date):

    A client SHALL provide a value precise to the day.

    A server SHALL support a value a value precise to the day.

  • family (string):

    A server SHALL support a value precise to the day.

  • gender (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • identifier (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.


Practitioner

Conformance Expectation: SHALL

Resource Specific Documentation:

  • Servers that support only US Core Practitioner Profile SHALL provide implementation specific guidance how to access a provider’s location and contact information using only the Practitioner resource.
    • Although Practitioner.address is marked as Must Support, the server system is not required to support it if they support the US Core PractitionerRole Profile, but SHALL support it if they do not support the US Core PractitionerRole Profile. The client application SHALL support both.
  • Systems SHOULD follow the Project US@ Technical Specification for Patient Addresses Final Version 1.0 as the standard style guide for Practitioner.address.line and Practitioner.address.city.

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a Practitioner resource using: GET [base]/Practitioner/[id]

Search Parameter Summary:

Conformance Parameter Type
SHOULD _id token
SHALL identifier token
SHALL name string

Search Parameter Requirements (When Used Alone or in Combination):

  • identifier (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.


PractitionerRole

Conformance Expectation: SHALL

Resource Specific Documentation:

  • Due to implementer feedback, some US Core Profiles reference the PractitionerRole resource instead of the US Core PractitionerRole Profile. However the US Core PractitionerRole Profile SHOULD be used as the default profile if referenced by another US Core profile.

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a PractitionerRole resource using: GET [base]/PractitionerRole/[id]
  • A Server SHOULD be capable of supporting the following _includes:
    • PractitionerRole:endpoint: GET [base]/PractitionerRole?[parameter=value]&_include=PractitionerRole:endpoint
    • PractitionerRole:practitioner: GET [base]/PractitionerRole?[parameter=value]&_include=PractitionerRole:practitioner

Search Parameter Summary:

Conformance Parameter Type
SHALL practitioner reference
SHALL specialty token

Search Parameter Requirements (When Used Alone or in Combination):

  • practitioner (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • specialty (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.


Procedure

Conformance Expectation: SHALL

Resource Specific Documentation:

  • Procedure codes can be taken from SNOMED-CT, CPT, HCPCS II, ICD-10-PCS, CDT. LOINC.
    • Only LOINC concepts that reflect actual procedures SHOULD be used
  • A procedure including an implantable device SHOULD use Procedure.focalDevice with a reference to the US Core Implantable Device Profile.
  • Servers and Clients SHALL support both US Core ServiceRequest and US Core Procedure Profiles for communicating the reason or justification for a referral as Additional USCDI Requirements. Typically, the reason or justification for a referral or consultation is communicated through Procedure.basedOn linking the Procedure to the US Core ServiceRequest Profile that includes either ServiceRequest.reasonCode or ServiceRequest.reasonReference. When the Procedure does not have an associated ServiceRequest, it is communicated through the US Core Procedure Profile's Procedure.reasonCode or Procedure.reasonReference. Depending on the procedure being documented, a server will select the appropriate Profile to use.
    • Although both Procedure.reasonCode and Procedure.reasonReference are marked as Additional USCDI Requirements. The certifying server system is not required to support both but SHALL support at least one of these elements. The certifying client application SHALL support both elements.
      • when using Procedure.reasonReference:
        • Servers SHALL support at least one target resource in Procedure.reasonReference. Clients SHALL support all target resources .
        • The referenced resources SHOULD be a US Core Profile.

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a Procedure resource using: GET [base]/Procedure/[id]
  • A Server SHALL be capable of supporting the following _revincludes: Provenance:target - GET [base]/Procedure?[parameter=value]&_revinclude=Provenance:target

Search Parameter Summary:

Conformance Parameter Type
SHALL patient reference

Search Parameter Combination Summary:

Conformance Parameter Combination Types
SHOULD patient+ code+ date reference+token+date
SHALL patient+ date reference+date
SHOULD patient+ status reference+token

Search Parameter Requirements (When Used Alone or in Combination):

  • code (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • date (date):

    A client SHALL provide a value precise to the second + time offset.

    A server SHALL support a value precise to the second + time offset.

  • patient (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • status (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.


Provenance

Conformance Expectation: SHALL

Resource Specific Documentation:

  • The US Core Provenance resource SHALL be supported for these US Core resources:
    • AllergyIntolerance
    • CarePlan
    • CareTeam
    • Condition
    • Coverage
    • Device
    • DiagnosticReport
    • DocumentReference
    • Encounter
    • Goal
    • Immunization
    • MedicationDispense
    • MedicationRequest
    • Observation
    • Patient
    • Procedure
    • QuestionnaireResponse
    • RelatedPerson
    • ServiceRequest
  • If a system receives a provider in Provenance.agent.who as free text they must capture who sent them the information as the organization. On request they SHALL provide this organization as the source and MAY include the free text provider.
  • Systems that need to know the activity has occurred SHOULD populate the activity.

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support read.
  • SHOULD support vread, history-instance.
  • MAY support create, search-type, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a Provenance resource using: GET [base]/Provenance/[id]

Questionnaire

Conformance Expectation: SHOULD

Resource Specific Documentation:

  • US Core defines two ways to represent the questions and responses to screening and assessment instruments:

    • Observation: US Core Observation Screening Assessment Profile
    • Questionnaire/QuestionnaireResponse: SDC Base Questionnaire/US Core QuestionnaireResponse Profile
  • US Core Servers SHALL support US Core Observation Screening Assessment Profile and SHOULD support the SDC Base Questionnaire Profile/US Core QuestionnaireResponse Profile

Supported Profiles:

Profile Interaction Summary:

  • SHOULD support read, vread.
  • MAY support create, search-type, update, patch, delete, history-instance, history-type.

Fetch and Search Criteria:

  • A Server SHOULD be capable of returning a Questionnaire resource using: GET [base]/Questionnaire/[id]

QuestionnaireResponse

Conformance Expectation: SHOULD

Resource Specific Documentation:

  • US Core defines two ways to represent the questions and responses to screening and assessment instruments:

    • Observation: US Core Observation Screening Assessment Profile
    • Questionnaire/QuestionnaireResponse: SDC Base Questionnaire/US Core QuestionnaireResponse Profile
  • US Core Servers SHALL support US Core Observation Screening Assessment Profile and SHOULD support the SDC Base Questionnaire Profile/US Core QuestionnaireResponse Profile

Supported Profiles:

Profile Interaction Summary:

  • SHOULD support search-type, read, vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHOULD be capable of returning a QuestionnaireResponse resource using: GET [base]/QuestionnaireResponse/[id]
  • A Server SHALL be capable of supporting the following _revincludes: Provenance:target - GET [base]/QuestionnaireResponse?[parameter=value]&_revinclude=Provenance:target

Search Parameter Summary:

Conformance Parameter Type
SHALL _id token
SHALL patient reference

Search Parameter Combination Summary:

Conformance Parameter Combination Types
SHOULD patient+ questionnaire reference+reference
SHOULD patient+ authored reference+date
SHOULD patient+ status reference+token

Search Parameter Requirements (When Used Alone or in Combination):

  • authored (date):

    A client SHALL provide a value precise to the second + time offset.

    A server SHALL support a value precise to the second + time offset.

  • patient (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • questionnaire (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • status (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.


RelatedPerson

Conformance Expectation: SHALL

Resource Specific Documentation:

  • Systems SHOULD follow the Project US@ Technical Specification for Patient Addresses Final Version 1.0 as the standard style guide for RelatedPerson.address.line and RelatedPerson.address.city.

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support search-type, read.
  • SHOULD support vread, history-instance.
  • MAY support create, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a RelatedPerson resource using: GET [base]/RelatedPerson/[id]
  • A Server SHALL be capable of supporting the following _revincludes: Provenance:target - GET [base]/RelatedPerson?[parameter=value]&_revinclude=Provenance:target

Search Parameter Summary:

Conformance Parameter Type
SHALL _id token
SHOULD name string
SHOULD patient reference

Search Parameter Combination Summary:

Conformance Parameter Combination Types
SHOULD patient+ name reference+string

Search Parameter Requirements (When Used Alone or in Combination):

  • patient (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.


ServiceRequest

Conformance Expectation: SHALL

Resource Specific Documentation:

  • Servers and Clients SHALL support both US Core ServiceRequest and US Core Procedure Profiles for communicating the reason or justification for a referral as Additional USCDI Requirements. Typically, the reason or justification for a referral or consultation is communicated through Procedure.basedOn linking the Procedure to the US Core ServiceRequest Profile that includes either ServiceRequest.reasonCode or ServiceRequest.reasonReference. When the Procedure does not have an associated ServiceRequest, it is communicated through the US Core Procedure Profile's Procedure.reasonCode or Procedure.reasonReference. Depending on the procedure being documented, a server will select the appropriate Profile to use.
    • ServiceRequest.reasonCode and ServiceRequest.reasonReference are marked as Additional USCDI Requirements. The certifying server system is not required to support both but SHALL support at least one of these elements. The certifying client application SHALL support both elements.
      • when using ServiceRequest.reasonReference:
        • Servers SHALL support at least one target resource in ServiceRequest.reasonReference. Clients SHALL support all target resources.
        • The referenced resources SHOULD be a US Core Profile.

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support read.
  • SHOULD support vread, history-instance.
  • MAY support create, search-type, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a ServiceRequest resource using: GET [base]/ServiceRequest/[id]
  • A Server SHALL be capable of supporting the following _revincludes: Provenance:target - GET [base]/ServiceRequest?[parameter=value]&_revinclude=Provenance:target

Search Parameter Summary:

Conformance Parameter Type
SHALL _id token
SHALL patient reference

Search Parameter Combination Summary:

Conformance Parameter Combination Types
SHALL patient+ code reference+token
SHALL patient+ category+ authored reference+token+date
SHOULD patient+ code+ authored reference+token+date
SHOULD patient+ status reference+token
SHALL patient+ category reference+token

Search Parameter Requirements (When Used Alone or in Combination):

  • authored (date):

    A client SHALL provide a value precise to the second + time offset.

    A server SHALL support a value precise to the second + time offset.

  • category (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • code (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.

  • patient (reference):

    The client SHALL provide at least a id value and MAY provide both the Type and id values.

    The server SHALL support both.

  • status (token):

    The client SHALL provide at least a code value and MAY provide both the system and code values.

    The server SHALL support both.


Specimen

Conformance Expectation: SHALL

Resource Specific Documentation:

  • Although both Specimen.identifier and Specimen.accessionIdentifier are marked as Must Support, the server system is not required to support both, but SHALL support at least one of these elements. The client application SHALL support both.

Supported Profiles:

Reference Policy

Profile Interaction Summary:

  • SHALL support read.
  • SHOULD support vread, history-instance.
  • MAY support create, search-type, update, patch, delete, history-type.

Fetch and Search Criteria:

  • A Server SHALL be capable of returning a Specimen resource using: GET [base]/Specimen/[id]

Search Parameter Summary:

Conformance Parameter Type
SHALL _id token
SHOULD patient reference

ValueSet

Conformance Expectation: SHOULD

Operation Summary:

  • SHOULD support the $expand operation

    If a server supports DocumentReference for creating, using, and sharing clinical notes, it SHOULD also support the context and contextdirection parameters of the $expand operation to enable clients to determine the supported note and report types, as well as the supported read/write formats for notes on the server.