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 8.0.0-ballot 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
Official URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-adi-documentation | Version: 8.0.0-ballot | |||
Standards status: Trial-use | Maturity Level: 3 | Computable Name: USCoreObservationADIDocumentationProfile | ||
Other Identifiers: OID:2.16.840.1.113883.4.642.40.2.42.40 | ||||
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License |
The US Core Observation ADI Documentation Profile inherits from the FHIR Observation resource; refer to it for scope and usage definitions. This profile and the US Core Observation ADI DocumentationReference Profile meet the U.S. Core Data for Interoperability (USCDI) Advance Directive Observation Data Element requirements. It is used to communicate whether a person has advance directive information and, if one or more documents exist, their location. Examples of advance healthcare directive documents include physician order for life sustaining treatment (POLST), do not resuscitate order (DNR), and medical power of attorney. To communicate the type of advance directive document, the author, the verifier, and other properties, see the US Core Observation ADI Documentation Profile. This profile sets minimum expectations for the Observation resource to record, search, and fetch findings about the presence of a patient's advance directives. It specifies which core elements, extensions, vocabularies, and value sets SHALL be present in the resource and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption.
This page has new content for US Core Version 8.0.0
Example Usage Scenarios:
The following are example usage scenarios for this profile:
The following data elements must always be present (Mandatory definition) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Views below provides the formal summary, definitions, and terminology requirements.
Each Observation Must Have:
Each Observation Must Support:
*See guidance below
Profile Specific Implementation Guidance:
Observation.performer
of type Practitioner or Organization typically makes the observation, and an Observation.performer
of Patient or RelatedPerson usually supplies the information (for example, a next of kin who answers questions about the patient's advance directives). Systems may use the standard Performer function Extension to distinguish the type of involvement of the performer in the Observation resource.Usage:
Changes since version 7.0.0:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | Observation | US Core Observation ADI Presence Profile | |
Slices for extension | Content/Rules for all slices | |||
supporting-info | S | 0..* | (Complex) | Relevant ADI documents and information URL: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo |
value[x] | S | 1..1 | Reference(US Core ADI DocumentReference Profile S | Resource) | Reference to patient or provider authored ADI documents |
status | S | 1..1 | code | registered | preliminary | final | amended + |
Slices for category | S | 0..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this |
category:us-core | S | 0..1 | CodeableConcept | Classification of type of observation 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://hl7.org/fhir/us/core/CodeSystem/us-core-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: observation-adi-documentation | |
code | S | 1..1 | CodeableConcept | Observation ADI Documentation code 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 45473-6 | |
subject | S | 1..1 | Reference(US Core Patient Profile) | Who and/or what the observation is about |
issued | S | 0..1 | instant | Date/Time this observation was made available |
performer | S | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) | Who is responsible for the observation |
value[x] | S | 0..1 | CodeableConcept | Actual result Binding: Answer Set with Yes No and Unknowns (required): Answer Set with Yes No and Unknowns |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.value[x] | required | AnswerSetWithYesNoAndUnknowns http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.16 |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Observation | US Core Observation ADI Presence 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 |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | Content/Rules for all slices | |||
supporting-info | S | 0..* | (Complex) | Relevant ADI documents and information URL: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo" | |
value[x] | S | 1..1 | Reference(US Core ADI DocumentReference Profile) | Reference to patient or provider authored ADI documents |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
Slices for category | S | 0..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
category:us-core | S | 0..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. 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://hl7.org/fhir/us/core/CodeSystem/us-core-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: observation-adi-documentation | |
code | SΣ | 1..1 | CodeableConcept | Observation ADI Documentation code Binding: LOINCCodes (example): Codes identifying names of simple observations. 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 45473-6 | |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who and/or what the observation is about |
issued | SΣ | 0..1 | instant | Date/Time this observation was made available |
performer | SΣ | 0..* | Reference(US Core Practitioner Profile) | Who is responsible for the observation |
value[x] | SΣC | 0..1 | CodeableConcept | Actual result Binding: Answer Set with Yes No and Unknowns (required): Answer Set with Yes No and Unknowns |
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:us-core | preferred | Pattern: observation-adi-documentationhttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.code | example | Pattern: LOINC Code 45473-6http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | |
Observation.value[x] | required | AnswerSetWithYesNoAndUnknowns http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.16 |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | US Core Observation ADI Presence 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 | ||||
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 | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
supporting-info | S | 0..* | (Complex) | Relevant ADI documents and information URL: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo | ||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo" | |||||
value[x] | S | 1..1 | Reference(US Core ADI DocumentReference Profile S | Resource) | Reference to patient or provider authored ADI documents | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business Identifier for observation | ||||
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | ||||
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
Slices for category | S | 0..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
category:us-core | S | 0..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. 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://hl7.org/fhir/us/core/CodeSystem/us-core-category | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: observation-adi-documentation | |||||
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 | Observation ADI Documentation code Binding: LOINCCodes (example): Codes identifying names of simple observations. 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://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 45473-6 | |||||
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 | |||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | 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] | Σ | 0..1 | Clinically relevant time/time-period for observation | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
effectiveTiming | Timing | |||||||
effectiveInstant | instant | |||||||
issued | SΣ | 0..1 | instant | Date/Time this observation was made available | ||||
performer | SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) | Who is responsible for the observation | ||||
value[x] | SΣC | 0..1 | CodeableConcept | Actual result Binding: Answer Set with Yes No and Unknowns (required): Answer Set with Yes No and Unknowns | ||||
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 | Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
value[x] | Σ | 0..1 | Actual component result | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | 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:us-core | preferred | Pattern: observation-adi-documentationhttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.code | example | Pattern: LOINC Code 45473-6http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | ||||
Observation.value[x] | required | AnswerSetWithYesNoAndUnknowns http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.16 | ||||
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 | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes 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 |
This structure is derived from Observation
Summary
Mandatory: 1 element
Must-Support: 10 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 3
Differential View
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | Observation | US Core Observation ADI Presence Profile | |
Slices for extension | Content/Rules for all slices | |||
supporting-info | S | 0..* | (Complex) | Relevant ADI documents and information URL: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo |
value[x] | S | 1..1 | Reference(US Core ADI DocumentReference Profile S | Resource) | Reference to patient or provider authored ADI documents |
status | S | 1..1 | code | registered | preliminary | final | amended + |
Slices for category | S | 0..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this |
category:us-core | S | 0..1 | CodeableConcept | Classification of type of observation 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://hl7.org/fhir/us/core/CodeSystem/us-core-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: observation-adi-documentation | |
code | S | 1..1 | CodeableConcept | Observation ADI Documentation code 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 45473-6 | |
subject | S | 1..1 | Reference(US Core Patient Profile) | Who and/or what the observation is about |
issued | S | 0..1 | instant | Date/Time this observation was made available |
performer | S | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) | Who is responsible for the observation |
value[x] | S | 0..1 | CodeableConcept | Actual result Binding: Answer Set with Yes No and Unknowns (required): Answer Set with Yes No and Unknowns |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.value[x] | required | AnswerSetWithYesNoAndUnknowns http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.16 |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Observation | US Core Observation ADI Presence 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 |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | Content/Rules for all slices | |||
supporting-info | S | 0..* | (Complex) | Relevant ADI documents and information URL: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo" | |
value[x] | S | 1..1 | Reference(US Core ADI DocumentReference Profile) | Reference to patient or provider authored ADI documents |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
Slices for category | S | 0..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
category:us-core | S | 0..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. 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://hl7.org/fhir/us/core/CodeSystem/us-core-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: observation-adi-documentation | |
code | SΣ | 1..1 | CodeableConcept | Observation ADI Documentation code Binding: LOINCCodes (example): Codes identifying names of simple observations. 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 45473-6 | |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who and/or what the observation is about |
issued | SΣ | 0..1 | instant | Date/Time this observation was made available |
performer | SΣ | 0..* | Reference(US Core Practitioner Profile) | Who is responsible for the observation |
value[x] | SΣC | 0..1 | CodeableConcept | Actual result Binding: Answer Set with Yes No and Unknowns (required): Answer Set with Yes No and Unknowns |
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:us-core | preferred | Pattern: observation-adi-documentationhttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.code | example | Pattern: LOINC Code 45473-6http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | |
Observation.value[x] | required | AnswerSetWithYesNoAndUnknowns http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.16 |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | US Core Observation ADI Presence 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 | ||||
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 | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
supporting-info | S | 0..* | (Complex) | Relevant ADI documents and information URL: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo | ||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo" | |||||
value[x] | S | 1..1 | Reference(US Core ADI DocumentReference Profile S | Resource) | Reference to patient or provider authored ADI documents | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business Identifier for observation | ||||
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | ||||
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
Slices for category | S | 0..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
category:us-core | S | 0..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. 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://hl7.org/fhir/us/core/CodeSystem/us-core-category | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: observation-adi-documentation | |||||
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 | Observation ADI Documentation code Binding: LOINCCodes (example): Codes identifying names of simple observations. 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://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 45473-6 | |||||
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 | |||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | 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] | Σ | 0..1 | Clinically relevant time/time-period for observation | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
effectiveTiming | Timing | |||||||
effectiveInstant | instant | |||||||
issued | SΣ | 0..1 | instant | Date/Time this observation was made available | ||||
performer | SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) | Who is responsible for the observation | ||||
value[x] | SΣC | 0..1 | CodeableConcept | Actual result Binding: Answer Set with Yes No and Unknowns (required): Answer Set with Yes No and Unknowns | ||||
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 | Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
value[x] | Σ | 0..1 | Actual component result | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | 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:us-core | preferred | Pattern: observation-adi-documentationhttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.code | example | Pattern: LOINC Code 45473-6http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | ||||
Observation.value[x] | required | AnswerSetWithYesNoAndUnknowns http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.16 | ||||
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 | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes 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 |
This structure is derived from Observation
Summary
Mandatory: 1 element
Must-Support: 10 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 3
Other representations of profile: CSV, Excel, Schematron
Below is an overview of the required Server RESTful FHIR interactions for this profile - for example, search and read operations - when supporting the US Core interactions to access this profile's information (Profile Support + Interaction Support). Note that systems that support only US Core Profiles (Profile Only Support) are not required to support these interactions. See the US Core Server CapabilityStatement for a complete list of supported RESTful interactions for this IG.
The following search parameters and search parameter combinations SHALL be supported:
SHALL support searching using the combination of the patient
and category
search parameters:
GET [base]/Observation?patient={Type/}[id]&category=http://terminology.hl7.org/CodeSystem/observation-category|laboratory
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and a category code = laboratory
(how to search by reference and how to search by token)
patient
and code
search parameters:
code
(e.g.code={system|}[code],{system|}[code],...
)GET [base]/Observation?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and observation code(s). SHOULD support search by multiple report codes. The Observation code
parameter searches `Observation.code only. (how to search by reference and how to search by token)
patient
and category
and date
search parameters:
date
comparators: gt,lt,ge,le
date
(e.g.date=[date]&date=[date]]&...
)GET [base]/Observation?patient={Type/}[id]&category=http://terminology.hl7.org/CodeSystem/observation-category|laboratory&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and date and a category code = laboratory
(how to search by reference and how to search by token and how to search by date)
The following search parameter combinations SHOULD be supported:
patient
and category
and status
search parameters:
status
(e.g.status={system|}[code],{system|}[code],...
)GET [base]/Observation?patient={Type/}[id]&category=http://terminology.hl7.org/CodeSystem/observation-category|laboratory&status={system|}[code]{,{system|}[code],...}
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and category = laboratory
and status (how to search by reference and how to search by token)
patient
and category
and _lastUpdated
search parameters:
_lastUpdated
comparators: gt,lt,ge,le
_lastUpdated
(e.g._lastUpdated=[date]&_lastUpdated=[date]]&...
)GET [base]/Observation?patient={Type/}[id]&category={system|}[code]&_lastUpdated={gt|lt|ge|le}[date]{&_lastUpdated={gt|lt|ge|le}[date]&...}
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and category and _lastUpdated. See the US Core General Guidance page for Searching Using lastUpdated. (how to search by reference and how to search by token and how to search by date)
patient
and code
and date
search parameters:
code
(e.g.code={system|}[code],{system|}[code],...
)date
comparators: gt,lt,ge,le
date
(e.g.date=[date]&date=[date]]&...
)GET [base]/Observation?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and date and report code(s). SHOULD support search by multiple report codes. (how to search by reference and how to search by token and how to search by date)