US Core Implementation Guide
8.0.0-ballot - Ballot 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 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

Resource Profile: US Core Observation Screening Assessment Profile

Official URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-screening-assessment Version: 8.0.0-ballot
Standards status: Trial-use Maturity Level: 3 Computable Name: USCoreObservationScreeningAssessmentProfile
Other Identifiers: OID:2.16.840.1.113883.4.642.40.2.42.46

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

The US Core Observation Screening Assessment Profile inherits from the FHIR Observation resource; refer to it for scope and usage definitions. This profile meets the requirements of the U.S. Core Data for Interoperability (USCDI) Health Status Assessments Data Class. It sets the minimum expectations for the Observation Resource to record, search, and fetch observations representing the questions and responses to surveys and screening and assessment tools. For example, a social history status such as education or food insecurity or an assessment of cognitive, functional, or disability status. It can represent a single response, multiple responses, and multi-select "check all that apply" type questions. This profile 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. Before reviewing this profile, implementers are encouraged to read the Screening and Assessments guidance page, which documents the process of recording responses and capturing assertions/determinations resulting from surveys and questionnaires.

This page has new content for US Core Version 8.0.0

Example Usage Scenarios:

The following are example usage scenarios for this profile:

  • Query for screening or assessment results for a patient.
  • Record or update screening and assessment results belonging to a Patient

Mandatory and Must Support Data Elements

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.

  1. a status
  2. a category code of "survey"
  3. a LOINC code, if available, which tells you the survey question
  4. a patient

Each Observation Must Support:

  1. additional categories that further specify the assessment or screening*
  2. a time indicating when the survey was taken
  3. the answer or a reason why the data is absent*
    • if the result value is a numeric quantity and coded quantity units are used, UCUM is required.
  4. who answered the questions (in other words, a performer)*
  5. related questionnaire responses or observations that this observation is made from
  6. reference to observations that make up this observation*

* see guidance below

Profile Specific Implementation Guidance:

  • *See the Screening and Assessments guidance page for how this profile represents surveys, screenings, and assessments.
    • Each response to individual questions and each answer to a multi-select or "check all that apply" question is a separate US Core Screening and Assessments Observation. The question is communicated in Observation.code, and the answer is in Observation.value.
    • Multi-question screenings and assessments use the US Core Screening and Assessments Observation to represent a "panel" or grouping. The multi-question surveys or assessments Observation.code is an overarching assessment or screening code, and the Observation.value element SHOULD be empty. Observation.hasMember references US Core Screening and Assessments Observations that represent the responses to each question in the screening or assessment.
  • A practitioner's clinical observation or assertion about a patient's health status, which is not a response to a screening or assessment question, SHOULD use the US Core Simple Observation Profile instead.

  • *The category type "survey" is required, and, at a minimum, Servers SHALL support, the US Core Screening Assessment Observation Category codes, SHOULD support the other US Core Screening Assessment Observation Maximum Category codes, and MAY support other categories.

    • ​The Observation.category element provides an efficient way of restricting search on observations to a given context such as survey observations. Example searches are shown in the Quick Start section below. However, clients need to understand that data categorization is somewhat subjective. The categorization applied by the source may not align with the client's expectations. Clients may find it more useful to use queries based on a specific code or set of codes or to perform additional client-side filtering of query results.
  • *An Observation without a value, SHALL include a reason why the data is absent unless there are 1) component observations, or 2) reporting panel observations using Observation.hasMember.
    • For further guidance, see the Observation Grouping section in FHIR Specification.
    • 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 a component observation without a component value are not required to support Observation.component.dataAbsentReason.
  • *Although 'Observation.performer' target profiles US Core Practitioner Profile and US Core Patient Profile are labeled Must Support. Servers are not required to support both, but SHALL support at least one. Clients SHALL support both.
  • *Although 'Observation.derivedFrom' target profiles Observation and US Core QuestionnaireResponse Profile are labeled Must Support. The certifying server system is not required to support both, but SHALL support at least one. The client application SHALL support both.

Usage:

Changes since version 7.0.0:

  • The data elements list has changed
  • One or more text definitions, invariants or bindings have changed

    • Formal Views of Profile Content

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

    This structure is derived from Observation

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Observation C 0..* Observation Survey Observation
    us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present
    ... status S 1..1 code registered | preliminary | final | amended +
    ... Slices for category S 1..* CodeableConcept Classification of type of observation
    Slice: Unordered, Open by pattern:$this
    .... category:survey S 1..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://terminology.hl7.org/CodeSystem/observation-category
    ...... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: survey
    .... category:screening-assessment S 0..* CodeableConcept Classification of type of observation
    Binding: US Core Screening Assessment Observation Maximum Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets

    Additional BindingsPurpose
    US Core Screening Assessment Observation Category Min Binding
    ... code S 1..1 CodeableConcept Type of observation (code / type)
    Binding: US Core Survey Codes (preferred)
    ... subject S 1..1 Reference(US Core Patient Profile S | Group | Device | US Core Location Profile) Who and/or what the observation is about
    ... effective[x] SC 0..1 Clinically relevant time/time-period for observation
    us-core-1: Datetime must be at least to day.
    .... effectiveDateTime dateTime S
    .... effectivePeriod Period
    .... effectiveTiming Timing
    .... effectiveInstant instant
    ... performer S 0..* Reference(US Core Practitioner Profile S | US Core Patient Profile S | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) Who is responsible for the observation
    ... value[x] SC 0..1 Actual result
    us-core-3: SHALL use UCUM for coded quantity units.
    .... valueQuantity Quantity S
    .... valueCodeableConcept CodeableConcept S
    .... valueString string S
    .... valueBoolean boolean
    .... valueInteger integer
    .... valueRange Range
    .... valueRatio Ratio
    .... valueSampledData SampledData
    .... valueTime time
    .... valueDateTime dateTime
    .... valuePeriod Period
    ... dataAbsentReason SC 0..1 CodeableConcept Why the result is missing
    ... hasMember S 0..* Reference(US Core Observation Screening Assessment Profile S | QuestionnaireResponse | MolecularSequence) Reference to panel members or multi-select responses or multi-select responses
    ... derivedFrom S 0..* Reference(US Core Observation Screening Assessment Profile S | US Core QuestionnaireResponse Profile S | US Core DocumentReference Profile | ImagingStudy | Media | MolecularSequence) Related measurements the observation is made from

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Observation.category:screening-assessmentrequiredUSCoreScreeningAssessmentObservationMaximumCategory
    Additional Bindings Purpose
    US Core Screening Assessment Observation Category Min Binding
    http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-maximum-category
    from this IG
    Observation.codepreferredUSCoreSurveyCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-survey-codes
    from this IG

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-1errorObservation.effective[x]Datetime must be at least to day.
    : $this is dateTime implies $this.toString().length() >= 10
    us-core-2errorObservationIf there is no component or hasMember element then either a value[x] or a data absent reason must be present
    : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists())
    us-core-3errorObservation.value[x]SHALL use UCUM for coded quantity units.
    : ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org'
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Observation C 0..* Observation Survey Observation
    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
    us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... status ?!SΣ 1..1 code registered | preliminary | final | amended +
    Binding: ObservationStatus (required): Codes providing the status of an observation.

    ... Slices for category S 1..* CodeableConcept Classification of type of observation
    Slice: Unordered, Open by pattern:$this
    Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


    .... category:survey S 1..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://terminology.hl7.org/CodeSystem/observation-category
    ...... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: survey
    .... category:screening-assessment S 0..* CodeableConcept Classification of type of observation
    Binding: US Core Screening Assessment Observation Maximum Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets

    Additional BindingsPurpose
    US Core Screening Assessment Observation Category Min Binding

    ... code SΣ 1..1 CodeableConcept Type of observation (code / type)
    Binding: US Core Survey Codes (preferred)
    ... subject SΣ 1..1 Reference(US Core Patient Profile) Who and/or what the observation is about
    ... effective[x] SΣC 0..1 Clinically relevant time/time-period for observation
    us-core-1: Datetime must be at least to day.
    .... effectiveDateTime dateTime
    ... performer SΣ 0..* Reference(US Core Practitioner Profile | US Core Patient Profile) Who is responsible for the observation
    ... value[x] SΣC 0..1 Actual result
    us-core-3: SHALL use UCUM for coded quantity units.
    .... valueQuantity Quantity
    .... valueCodeableConcept CodeableConcept
    .... valueString string
    ... dataAbsentReason SC 0..1 CodeableConcept Why the result is missing
    Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

    ... hasMember SΣ 0..* Reference(US Core Observation Screening Assessment Profile) Reference to panel members or multi-select responses or multi-select responses
    ... derivedFrom SΣ 0..* Reference(US Core Observation Screening Assessment Profile | US Core QuestionnaireResponse Profile) Related measurements the observation is made from

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Observation.statusrequiredObservationStatus
    http://hl7.org/fhir/ValueSet/observation-status|4.0.1
    from the FHIR Standard
    Observation.categorypreferredObservationCategoryCodes
    http://hl7.org/fhir/ValueSet/observation-category
    from the FHIR Standard
    Observation.category:surveypreferredPattern: survey
    http://hl7.org/fhir/ValueSet/observation-category
    from the FHIR Standard
    Observation.category:screening-assessmentrequiredUSCoreScreeningAssessmentObservationMaximumCategory
    Additional Bindings Purpose
    US Core Screening Assessment Observation Category Min Binding
    http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-maximum-category
    from this IG
    Observation.codepreferredUSCoreSurveyCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-survey-codes
    from this IG
    Observation.dataAbsentReasonextensibleDataAbsentReason
    http://hl7.org/fhir/ValueSet/data-absent-reason
    from the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-1errorObservation.effective[x]Datetime must be at least to day.
    : $this is dateTime implies $this.toString().length() >= 10
    us-core-2errorObservationIf there is no component or hasMember element then either a value[x] or a data absent reason must be present
    : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists())
    us-core-3errorObservation.value[x]SHALL use UCUM for coded quantity units.
    : ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org'
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Observation C 0..* Observation Survey Observation
    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
    us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present
    ... id Σ 0..1 id Logical id of this artifact
    ... meta Σ 0..1 Meta Metadata about the resource
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... language 0..1 code Language of the resource content
    Binding: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguages Max Binding
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    ... contained 0..* Resource Contained, inline Resources
    ... extension 0..* Extension Additional content defined by implementations
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... identifier 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 1..* CodeableConcept Classification of type of observation
    Slice: Unordered, Open by pattern:$this
    Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


    .... category:survey S 1..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://terminology.hl7.org/CodeSystem/observation-category
    ...... version 0..1 string Version of the system - if relevant
    ...... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: survey
    ...... 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
    .... category:screening-assessment S 0..* CodeableConcept Classification of type of observation
    Binding: US Core Screening Assessment Observation Maximum Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets

    Additional BindingsPurpose
    US Core Screening Assessment Observation Category Min Binding

    ... code SΣ 1..1 CodeableConcept Type of observation (code / type)
    Binding: US Core Survey Codes (preferred)
    ... subject SΣ 1..1 Reference(US Core Patient Profile S | Group | Device | US Core Location 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] SΣC 0..1 Clinically relevant time/time-period for observation
    us-core-1: Datetime must be at least to day.
    .... effectiveDateTime dateTime S
    .... effectivePeriod Period
    .... effectiveTiming Timing
    .... effectiveInstant instant
    ... issued Σ 0..1 instant Date/Time this version was made available
    ... performer SΣ 0..* Reference(US Core Practitioner Profile S | US Core Patient Profile S | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) Who is responsible for the observation
    ... value[x] SΣC 0..1 Actual result
    us-core-3: SHALL use UCUM for coded quantity units.
    .... valueQuantity Quantity S
    .... valueCodeableConcept CodeableConcept S
    .... valueString string S
    .... valueBoolean boolean
    .... valueInteger integer
    .... valueRange Range
    .... valueRatio Ratio
    .... valueSampledData SampledData
    .... valueTime time
    .... valueDateTime dateTime
    .... valuePeriod Period
    ... dataAbsentReason SC 0..1 CodeableConcept 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 SΣ 0..* Reference(US Core Observation Screening Assessment Profile S | QuestionnaireResponse | MolecularSequence) Reference to panel members or multi-select responses or multi-select responses
    ... derivedFrom SΣ 0..* Reference(US Core Observation Screening Assessment Profile S | US Core QuestionnaireResponse Profile S | US Core DocumentReference Profile | ImagingStudy | Media | 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

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Observation.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Observation.statusrequiredObservationStatus
    http://hl7.org/fhir/ValueSet/observation-status|4.0.1
    from the FHIR Standard
    Observation.categorypreferredObservationCategoryCodes
    http://hl7.org/fhir/ValueSet/observation-category
    from the FHIR Standard
    Observation.category:surveypreferredPattern: survey
    http://hl7.org/fhir/ValueSet/observation-category
    from the FHIR Standard
    Observation.category:screening-assessmentrequiredUSCoreScreeningAssessmentObservationMaximumCategory
    Additional Bindings Purpose
    US Core Screening Assessment Observation Category Min Binding
    http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-maximum-category
    from this IG
    Observation.codepreferredUSCoreSurveyCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-survey-codes
    from this IG
    Observation.dataAbsentReasonextensibleDataAbsentReason
    http://hl7.org/fhir/ValueSet/data-absent-reason
    from the FHIR Standard
    Observation.interpretationextensibleObservationInterpretationCodes
    http://hl7.org/fhir/ValueSet/observation-interpretation
    from the FHIR Standard
    Observation.bodySiteexampleSNOMEDCTBodyStructures
    http://hl7.org/fhir/ValueSet/body-site
    from the FHIR Standard
    Observation.methodexampleObservationMethods
    http://hl7.org/fhir/ValueSet/observation-methods
    from the FHIR Standard
    Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
    http://hl7.org/fhir/ValueSet/referencerange-meaning
    from the FHIR Standard
    Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
    http://hl7.org/fhir/ValueSet/referencerange-appliesto
    from the FHIR Standard
    Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
    http://hl7.org/fhir/ValueSet/observation-codes
    from the FHIR Standard
    Observation.component.dataAbsentReasonextensibleDataAbsentReason
    http://hl7.org/fhir/ValueSet/data-absent-reason
    from the FHIR Standard
    Observation.component.interpretationextensibleObservationInterpretationCodes
    http://hl7.org/fhir/ValueSet/observation-interpretation
    from the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-1errorObservation.effective[x]Datetime must be at least to day.
    : $this is dateTime implies $this.toString().length() >= 10
    us-core-2errorObservationIf there is no component or hasMember element then either a value[x] or a data absent reason must be present
    : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists())
    us-core-3errorObservation.value[x]SHALL use UCUM for coded quantity units.
    : ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org'

    Differential View

    This structure is derived from Observation

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Observation C 0..* Observation Survey Observation
    us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present
    ... status S 1..1 code registered | preliminary | final | amended +
    ... Slices for category S 1..* CodeableConcept Classification of type of observation
    Slice: Unordered, Open by pattern:$this
    .... category:survey S 1..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://terminology.hl7.org/CodeSystem/observation-category
    ...... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: survey
    .... category:screening-assessment S 0..* CodeableConcept Classification of type of observation
    Binding: US Core Screening Assessment Observation Maximum Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets

    Additional BindingsPurpose
    US Core Screening Assessment Observation Category Min Binding
    ... code S 1..1 CodeableConcept Type of observation (code / type)
    Binding: US Core Survey Codes (preferred)
    ... subject S 1..1 Reference(US Core Patient Profile S | Group | Device | US Core Location Profile) Who and/or what the observation is about
    ... effective[x] SC 0..1 Clinically relevant time/time-period for observation
    us-core-1: Datetime must be at least to day.
    .... effectiveDateTime dateTime S
    .... effectivePeriod Period
    .... effectiveTiming Timing
    .... effectiveInstant instant
    ... performer S 0..* Reference(US Core Practitioner Profile S | US Core Patient Profile S | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) Who is responsible for the observation
    ... value[x] SC 0..1 Actual result
    us-core-3: SHALL use UCUM for coded quantity units.
    .... valueQuantity Quantity S
    .... valueCodeableConcept CodeableConcept S
    .... valueString string S
    .... valueBoolean boolean
    .... valueInteger integer
    .... valueRange Range
    .... valueRatio Ratio
    .... valueSampledData SampledData
    .... valueTime time
    .... valueDateTime dateTime
    .... valuePeriod Period
    ... dataAbsentReason SC 0..1 CodeableConcept Why the result is missing
    ... hasMember S 0..* Reference(US Core Observation Screening Assessment Profile S | QuestionnaireResponse | MolecularSequence) Reference to panel members or multi-select responses or multi-select responses
    ... derivedFrom S 0..* Reference(US Core Observation Screening Assessment Profile S | US Core QuestionnaireResponse Profile S | US Core DocumentReference Profile | ImagingStudy | Media | MolecularSequence) Related measurements the observation is made from

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Observation.category:screening-assessmentrequiredUSCoreScreeningAssessmentObservationMaximumCategory
    Additional Bindings Purpose
    US Core Screening Assessment Observation Category Min Binding
    http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-maximum-category
    from this IG
    Observation.codepreferredUSCoreSurveyCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-survey-codes
    from this IG

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-1errorObservation.effective[x]Datetime must be at least to day.
    : $this is dateTime implies $this.toString().length() >= 10
    us-core-2errorObservationIf there is no component or hasMember element then either a value[x] or a data absent reason must be present
    : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists())
    us-core-3errorObservation.value[x]SHALL use UCUM for coded quantity units.
    : ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org'

    Key Elements View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Observation C 0..* Observation Survey Observation
    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
    us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... status ?!SΣ 1..1 code registered | preliminary | final | amended +
    Binding: ObservationStatus (required): Codes providing the status of an observation.

    ... Slices for category S 1..* CodeableConcept Classification of type of observation
    Slice: Unordered, Open by pattern:$this
    Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


    .... category:survey S 1..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://terminology.hl7.org/CodeSystem/observation-category
    ...... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: survey
    .... category:screening-assessment S 0..* CodeableConcept Classification of type of observation
    Binding: US Core Screening Assessment Observation Maximum Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets

    Additional BindingsPurpose
    US Core Screening Assessment Observation Category Min Binding

    ... code SΣ 1..1 CodeableConcept Type of observation (code / type)
    Binding: US Core Survey Codes (preferred)
    ... subject SΣ 1..1 Reference(US Core Patient Profile) Who and/or what the observation is about
    ... effective[x] SΣC 0..1 Clinically relevant time/time-period for observation
    us-core-1: Datetime must be at least to day.
    .... effectiveDateTime dateTime
    ... performer SΣ 0..* Reference(US Core Practitioner Profile | US Core Patient Profile) Who is responsible for the observation
    ... value[x] SΣC 0..1 Actual result
    us-core-3: SHALL use UCUM for coded quantity units.
    .... valueQuantity Quantity
    .... valueCodeableConcept CodeableConcept
    .... valueString string
    ... dataAbsentReason SC 0..1 CodeableConcept Why the result is missing
    Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

    ... hasMember SΣ 0..* Reference(US Core Observation Screening Assessment Profile) Reference to panel members or multi-select responses or multi-select responses
    ... derivedFrom SΣ 0..* Reference(US Core Observation Screening Assessment Profile | US Core QuestionnaireResponse Profile) Related measurements the observation is made from

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Observation.statusrequiredObservationStatus
    http://hl7.org/fhir/ValueSet/observation-status|4.0.1
    from the FHIR Standard
    Observation.categorypreferredObservationCategoryCodes
    http://hl7.org/fhir/ValueSet/observation-category
    from the FHIR Standard
    Observation.category:surveypreferredPattern: survey
    http://hl7.org/fhir/ValueSet/observation-category
    from the FHIR Standard
    Observation.category:screening-assessmentrequiredUSCoreScreeningAssessmentObservationMaximumCategory
    Additional Bindings Purpose
    US Core Screening Assessment Observation Category Min Binding
    http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-maximum-category
    from this IG
    Observation.codepreferredUSCoreSurveyCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-survey-codes
    from this IG
    Observation.dataAbsentReasonextensibleDataAbsentReason
    http://hl7.org/fhir/ValueSet/data-absent-reason
    from the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-1errorObservation.effective[x]Datetime must be at least to day.
    : $this is dateTime implies $this.toString().length() >= 10
    us-core-2errorObservationIf there is no component or hasMember element then either a value[x] or a data absent reason must be present
    : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists())
    us-core-3errorObservation.value[x]SHALL use UCUM for coded quantity units.
    : ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org'

    Snapshot View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Observation C 0..* Observation Survey Observation
    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
    us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present
    ... id Σ 0..1 id Logical id of this artifact
    ... meta Σ 0..1 Meta Metadata about the resource
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... language 0..1 code Language of the resource content
    Binding: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguages Max Binding
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    ... contained 0..* Resource Contained, inline Resources
    ... extension 0..* Extension Additional content defined by implementations
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... identifier 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 1..* CodeableConcept Classification of type of observation
    Slice: Unordered, Open by pattern:$this
    Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


    .... category:survey S 1..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://terminology.hl7.org/CodeSystem/observation-category
    ...... version 0..1 string Version of the system - if relevant
    ...... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: survey
    ...... 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
    .... category:screening-assessment S 0..* CodeableConcept Classification of type of observation
    Binding: US Core Screening Assessment Observation Maximum Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets

    Additional BindingsPurpose
    US Core Screening Assessment Observation Category Min Binding

    ... code SΣ 1..1 CodeableConcept Type of observation (code / type)
    Binding: US Core Survey Codes (preferred)
    ... subject SΣ 1..1 Reference(US Core Patient Profile S | Group | Device | US Core Location 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] SΣC 0..1 Clinically relevant time/time-period for observation
    us-core-1: Datetime must be at least to day.
    .... effectiveDateTime dateTime S
    .... effectivePeriod Period
    .... effectiveTiming Timing
    .... effectiveInstant instant
    ... issued Σ 0..1 instant Date/Time this version was made available
    ... performer SΣ 0..* Reference(US Core Practitioner Profile S | US Core Patient Profile S | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) Who is responsible for the observation
    ... value[x] SΣC 0..1 Actual result
    us-core-3: SHALL use UCUM for coded quantity units.
    .... valueQuantity Quantity S
    .... valueCodeableConcept CodeableConcept S
    .... valueString string S
    .... valueBoolean boolean
    .... valueInteger integer
    .... valueRange Range
    .... valueRatio Ratio
    .... valueSampledData SampledData
    .... valueTime time
    .... valueDateTime dateTime
    .... valuePeriod Period
    ... dataAbsentReason SC 0..1 CodeableConcept 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 SΣ 0..* Reference(US Core Observation Screening Assessment Profile S | QuestionnaireResponse | MolecularSequence) Reference to panel members or multi-select responses or multi-select responses
    ... derivedFrom SΣ 0..* Reference(US Core Observation Screening Assessment Profile S | US Core QuestionnaireResponse Profile S | US Core DocumentReference Profile | ImagingStudy | Media | 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

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Observation.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Observation.statusrequiredObservationStatus
    http://hl7.org/fhir/ValueSet/observation-status|4.0.1
    from the FHIR Standard
    Observation.categorypreferredObservationCategoryCodes
    http://hl7.org/fhir/ValueSet/observation-category
    from the FHIR Standard
    Observation.category:surveypreferredPattern: survey
    http://hl7.org/fhir/ValueSet/observation-category
    from the FHIR Standard
    Observation.category:screening-assessmentrequiredUSCoreScreeningAssessmentObservationMaximumCategory
    Additional Bindings Purpose
    US Core Screening Assessment Observation Category Min Binding
    http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-maximum-category
    from this IG
    Observation.codepreferredUSCoreSurveyCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-survey-codes
    from this IG
    Observation.dataAbsentReasonextensibleDataAbsentReason
    http://hl7.org/fhir/ValueSet/data-absent-reason
    from the FHIR Standard
    Observation.interpretationextensibleObservationInterpretationCodes
    http://hl7.org/fhir/ValueSet/observation-interpretation
    from the FHIR Standard
    Observation.bodySiteexampleSNOMEDCTBodyStructures
    http://hl7.org/fhir/ValueSet/body-site
    from the FHIR Standard
    Observation.methodexampleObservationMethods
    http://hl7.org/fhir/ValueSet/observation-methods
    from the FHIR Standard
    Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
    http://hl7.org/fhir/ValueSet/referencerange-meaning
    from the FHIR Standard
    Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
    http://hl7.org/fhir/ValueSet/referencerange-appliesto
    from the FHIR Standard
    Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
    http://hl7.org/fhir/ValueSet/observation-codes
    from the FHIR Standard
    Observation.component.dataAbsentReasonextensibleDataAbsentReason
    http://hl7.org/fhir/ValueSet/data-absent-reason
    from the FHIR Standard
    Observation.component.interpretationextensibleObservationInterpretationCodes
    http://hl7.org/fhir/ValueSet/observation-interpretation
    from the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-1errorObservation.effective[x]Datetime must be at least to day.
    : $this is dateTime implies $this.toString().length() >= 10
    us-core-2errorObservationIf there is no component or hasMember element then either a value[x] or a data absent reason must be present
    : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists())
    us-core-3errorObservation.value[x]SHALL use UCUM for coded quantity units.
    : ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org'

     

    Other representations of profile: CSV, Excel, Schematron