abstractbaseDefinitioncopyrightdescriptionexperimentalfhirVersionjurisdiction
jurisdiction[0]kindnamepublisherpurposestatustitletypeurl| Left: | US Core Observation Clinical Result Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-clinical-result) |
| Right: | US Core Observation Clinical Result Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-clinical-result) |
| Name | Value | Comments | |
|---|---|---|---|
| abstract | false | ||
| baseDefinition | http://hl7.org/fhir/StructureDefinition/Observation | ||
| copyright | |||
| description | The US Core Observation Clinical Result Profile is based upon the core FHIR Observation Resource and, along with the US Core DiagnosticReport Profile, meets the US Core Data for Interoperability (USCDI) requirements for *Diagnostic Imaging* and *Clinical Tests* Data Classes. This profile sets minimum expectations for the Observation resource to record and search non-laboratory clinical test results (e.g., radiology and other clinical observations generated from procedures). An example would be when a gastroenterologist reports the size of a polyp observed during a colonoscopy. This profile is the basis for the US Core Laboratory Result Observation Profile, which defines additional data elements to record and search laboratory test results. The US Core Observation Clinical Result Profile sets minimum expectations to promote interoperability and adoption through common implementation. It identifies which core elements, extensions, vocabularies, and value sets **SHALL** be present in the resource and constrains the way the elements are used when using this profile. It provides the floor for standards development for specific use cases. | ||
| experimental | |||
| fhirVersion | 4.0.1 | ||
| jurisdiction | |||
| jurisdiction[0] | urn:iso:std:iso:3166#US | ||
| kind | resource | ||
| name | USCoreObservationClinicalResultProfile | ||
| publisher | HL7 International / Cross-Group Projects | ||
| purpose | |||
| status | active | ||
| title | US Core Observation Clinical Result Profile | ||
| type | Observation | ||
| url | http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-clinical-result | ||
| Name | L Flags | L Card. | L Type | L Description & Constraints | R Flags | R Card. | R Type | R Description & Constraints | Comments | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
 Observation | C | 0..* | Observation | Measurements and simple assertions Constraints: us-core-2 | C | 0..* | Observation | Measurements and simple assertions Constraints: us-core-2 | |||||||||
 id | 0..1 | id | Logical id of this artifact | 0..1 | id | Logical id of this artifact | |||||||||||
| meta | 0..1 | Meta | Metadata about the resource | 0..1 | Meta | Metadata about the resource | |||||||||||
| implicitRules | 0..1 | uri | A set of rules under which this content was created | 0..1 | uri | A set of rules under which this content was created | |||||||||||
| language | 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language.
| 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language.
| |||||||||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||||||||
| contained | 0..* | Resource | Contained, inline Resources | 0..* | Resource | Contained, inline Resources | |||||||||||
 extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
 modifierExtension | 0..* | Extension | Extensions that cannot be ignored | 0..* | Extension | Extensions that cannot be ignored | |||||||||||
| identifier | 0..* | Identifier | Business Identifier for observation | 0..* | Identifier | Business Identifier for observation | |||||||||||
| basedOn | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | |||||||||||
| partOf | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | |||||||||||
| status | 1..1 | code | registered | preliminary | final | amended + Binding: ?? (required): Codes providing the status of an observation. | 1..1 | code | registered | preliminary | final | amended + Binding: ?? (required): Codes providing the status of an observation. | |||||||||||
| Slices for category | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this Binding: ?? (preferred): Codes for high level observation categories. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this Binding: ?? (preferred): Codes for high level observation categories. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||||||||
| code | 1..1 | CodeableConcept | Clinical Test or Procedure Name Binding: ?? (extensible) | 1..1 | CodeableConcept | Clinical Test or Procedure Name Binding: ?? (extensible) | |||||||||||
| subject | 1..1 | Reference(US Core Patient Profile | Group | US Core Device Profile | US Core Location Profile) | Who and/or what the observation is about | 1..1 | Reference(US Core Patient Profile | Group | US Core Device Profile | US Core Location Profile) | Who and/or what the observation is about | |||||||||||
| focus | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | |||||||||||
| encounter | 0..1 | Reference(US Core Encounter Profile) | Encounter associated with Observation | 0..1 | Reference(US Core Encounter Profile) | Encounter associated with Observation | |||||||||||
| effective[x] | C | 0..1 | dateTime , Period, Timing, instant | Clinically relevant time/time-period for observation Constraints: us-core-1 | C | 0..1 | dateTime , Period, Timing, instant | Clinically relevant time/time-period for observation Constraints: us-core-1 | |||||||||
| issued | 0..1 | instant | Date/Time this version was made available | 0..1 | instant | Date/Time this version was made available | |||||||||||
| performer | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) | Who is responsible for the observation | 0..* | Reference(US Core Practitioner Profile | 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] | C | 0..1 | Quantity , CodeableConcept , string , boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Result Value Constraints: us-core-3 | C | 0..1 | Quantity , CodeableConcept , string , boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Result Value Constraints: us-core-3 | |||||||||
| dataAbsentReason | C | 0..1 | CodeableConcept | Why the result is missing Binding: ?? (extensible): Codes specifying why the result (Observation.value[x]) is missing. | C | 0..1 | CodeableConcept | Why the result is missing Binding: ?? (extensible): Codes specifying why the result (Observation.value[x]) is missing. | |||||||||
| interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ?? (extensible): Codes identifying interpretations of observations. | 0..* | CodeableConcept | High, low, normal, etc. Binding: ?? (extensible): Codes identifying interpretations of observations. | |||||||||||
| note | 0..* | Annotation | Comments about the observation | 0..* | Annotation | Comments about the observation | |||||||||||
| bodySite | 0..1 | CodeableConcept | Observed body part Binding: ?? (example): Codes describing anatomical locations. May include laterality. | 0..1 | CodeableConcept | Observed body part Binding: ?? (example): Codes describing anatomical locations. May include laterality. | |||||||||||
| method | 0..1 | CodeableConcept | How it was done Binding: ?? (example): Methods for simple observations. | 0..1 | CodeableConcept | How it was done Binding: ?? (example): Methods for simple observations. | |||||||||||
| specimen | 0..1 | Reference(Specimen) | Specimen used for this observation | 0..1 | Reference(Specimen) | Specimen used for this observation | |||||||||||
| device | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||||||||
| referenceRange | C | 0..* | BackboneElement | Provides guide for interpretation | C | 0..* | BackboneElement | Provides guide for interpretation | |||||||||
 id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||||
| low | C | 0..1 | ?? | Low Range, if relevant | C | 0..1 | ?? | Low Range, if relevant | |||||||||
| high | C | 0..1 | ?? | High Range, if relevant | C | 0..1 | ?? | High Range, if relevant | |||||||||
| type | 0..1 | CodeableConcept | Reference range qualifier Binding: ?? (preferred): Code for the meaning of a reference range. | 0..1 | CodeableConcept | Reference range qualifier Binding: ?? (preferred): Code for the meaning of a reference range. | |||||||||||
| appliesTo | 0..* | CodeableConcept | Reference range population Binding: ?? (example): Codes identifying the population the reference range applies to. | 0..* | CodeableConcept | Reference range population Binding: ?? (example): Codes identifying the population the reference range applies to. | |||||||||||
| age | 0..1 | Range | Applicable age range, if relevant | 0..1 | Range | Applicable age range, if relevant | |||||||||||
| text | 0..1 | string | Text based reference range in an observation | 0..1 | string | Text based reference range in an observation | |||||||||||
| hasMember | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | |||||||||||
| derivedFrom | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | |||||||||||
| component | 0..* | BackboneElement | Component results | 0..* | BackboneElement | Component results | |||||||||||
 id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||||
| code | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: ?? (example): Codes identifying names of simple observations. | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: ?? (example): Codes identifying names of simple observations. | |||||||||||
| value[x] | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual component result | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual component result | |||||||||||
| dataAbsentReason | C | 0..1 | CodeableConcept | Why the component result is missing Binding: ?? (extensible): Codes specifying why the result (Observation.value[x]) is missing. | C | 0..1 | CodeableConcept | Why the component result is missing Binding: ?? (extensible): Codes specifying why the result (Observation.value[x]) is missing. | |||||||||
| interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ?? (extensible): Codes identifying interpretations of observations. | 0..* | CodeableConcept | High, low, normal, etc. Binding: ?? (extensible): Codes identifying interpretations of observations. | |||||||||||
 referenceRange | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |||||||||||
| Documentation for this format | |||||||||||||||||