PACIO Personal Functioning and Engagement Implementation Guide
1.9.0 - STU1 United States of America flag

PACIO Personal Functioning and Engagement Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.9.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-pacio-pfe/ and changes regularly. See the Directory of published versions

Resource Profile: Personal Functioning and Engagement Single Observation

Official URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/pfe-observation-single Version: 1.9.0
Draft as of 2024-04-16 Computable Name: PFESingleObservation

An exchange of post-acute care observation for a patient. This profile is used for exchanging an observation for a single question generally included in a structured resource (e.g., assessment tool, instrument, or screen).

Example Usage Scenarios:

The following are example usage scenarios for this Profile:

  • Query for an observation representing a single question with a formal panel related to a patient’s functioning and engagement.
  • Record or update observations related to a single question for a Patient.

Mandatory and Must Support Data Elements

The following data elements must always be present or must be supported if the data is present in the sending system (Must Support definition). They are presented below with a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.

Each Personal Functioning and Engagement Observation must have:

  1. a status
  2. a category code of “survey” and “functioning”
  3. a code identifying the question asked or observation made
  4. a patient
  5. the point in time or period when the observation was made
  6. who made the observation

Each Personal Functioning and Engagement Observation must support:

  1. the location the observation was made
  2. any devices the patient used
  3. an additional category value or values specifying the specific health or health-related domain that this observation is related to***
  4. the answer* or a reason why the data is absent**
  5. related questionnaire responses that this observation is made from

* ** *** see guidance below

Profile specific implementation guidance:

  • *These observations represent a specific question or observation, so the Observation.value element SHOULD be populated and the hasMember list SHALL be empty.
  • **An Observation without a value, SHALL include a reason why the data is absent unless there are component observations. Systems that never provide an observation without a value are not required to support Observation.dataAbsentReason.
  • ***When a health or health-related domain is specified as an additional category value, Observation.code SHOULD be drawn from the corresponding domain-based value set as discussed below and on the domains page.

Usage

Rather than offer a separate Observation profile for each PFE category (also called domain – e.g., Mental Functions, Mobility, etc.), this profile can support any PFE category. The PFE Domain can be specified in a CodeableConcept in the Observation.category slice. Based on the code selected for the optional Observation.category slice, the Table below provides the PACIO-vetted, example value sets that contain the Assessment Observation codes to be placed in Observation.code for the selected domain. Where a preferred value set contains a code to describe a needed concept, servers SHOULD use that code. For more information regarding the ICF categorization process, and how to categorize new codes, see: domains

Body Functions PFE Domains

Observation.category Domain Element binding Assessment Observation Codes ValueSet
mental-functions Mental functions Observation.code PFE- Mental functions ValueSet
sensory_functions_and_pain Sensory functions and pain Observation.code PFE - Sensory functions and pain ValueSet
voice_and_speech_functions Voice and speech functions Observation.code PFE- Voice and speech functions ValueSet
functions_of_the_digestive_metabolic_and_endocrine_systems Functions of the digestive, metabolic and endocrine systems Observation.code PFE - Functions of the digestive, metabolic and endocrine systems ValueSet
genitourinary_and_reproductive_functions Genitourinary and reproductive functions Observation.code PFE- Genitourinary and reproductive functions ValueSet
neuromusculoskeletal_and_movement-related_functions Neuromusculoskeletal and movement-related functions Observation.code PFE- Neuromusculoskeletal and movement-related functions ValueSet
functions_of_the_skin_and_related_structures Functions of the skin and related structures Observation.code PFE- Functions of the skin and related structures ValueSet

Activities and Participation PFE Domains

Observation.category Domain Element binding Assessment Observation Codes ValueSet
learning_and_applying_knowledge Learning and applying knowledge Observation.code PFE - Learning and applying knowledge ValueSet
communication Communication Observation.code PFE - Communication ValueSet
mobility Mobility Observation.code PFE - Mobility ValueSet
self-care Self-care Observation.code PFE - Self-care ValueSet
domestic_life Domestic life Observation.code PFE - Domestic life ValueSet

Body Structures PFE Domains

Observation.category Domain Element binding Assessment Observation Codes ValueSet
body-structures Body structures Observation.code PFE - Body structures ValueSet
structures_involved_in_voice_and_speech Structures involved in voice and speech Observation.code PFE - Structures involved in voice and speech ValueSet

Environmental Factors PFE Domains

| Observation.category | Domain | Element binding | Assessment Observation Codes ValueSet | | —— | ——————– | ————————- | ———— | | products_and_technology | Products and technology | Observation.code | PFE - Products and Technology ValueSet |

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreObservationSurveyProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation USCoreObservationSurveyProfile
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
... device-use S 0..* Reference(Personal Functioning and Engagement Use of Device) An extension to indicate a record of assistive device usage by a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/device-patient-used
... category 2..* CodeableConcept Classification of type of observation
... category:functioning 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://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: functioning
..... display 1..1 string Representation defined by the system
Fixed Value: Functioning
... category:PFEDomain S 0..* CodeableConcept Classification of type of observation
Binding: Personal Functioning and Engagement Category Value Set (required)
... code 1..1 CodeableConcept For PFE Assessments, should include a LOINC code and text for the question or concept name.
... effective[x] 1..1 dateTime Clinically relevant time/time-period for observation
... performer 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... value[x] 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Whenever possible should use the CodeableConcept datatype to provide a suitable code to define the concept for the observation data. As for values like an assessment score or roll-up value, the datatype for this element should be determined by Observation.code. However, for values that are ordinal, may use the CodeableConcept datatype along with the Ordinal Value Extension.
... hasMember 0..0
... derivedFrom 0..* Reference(US Core QuestionnaireResponse Profile | US Core Observation Survey Profile) Should point back to the QuestionnaireResponse that this resource is derived from.

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* USCoreObservationSurveyProfile 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
us-core-3: SHALL use UCUM for coded quantity units.
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code Should have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category S 2..* 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:functioning 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://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: functioning
...... display 1..1 string Representation defined by the system
Fixed Value: Functioning
.... category:PFEDomain S 0..* CodeableConcept Classification of type of observation
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ 1..1 CodeableConcept For PFE Assessments, should include a LOINC code and text for the question or concept name.
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 1..1 dateTime Clinically relevant time/time-period for observation
us-core-1: Datetime must be at least to day.
... performer SΣ 1..* Reference(US Core Practitioner Profile) The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... value[x] SΣC 0..1 Whenever possible should use the CodeableConcept datatype to provide a suitable code to define the concept for the observation data. As for values like an assessment score or roll-up value, the datatype for this element should be determined by Observation.code. However, for values that are ordinal, may use the CodeableConcept datatype along with the Ordinal Value Extension.
.... 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.

... derivedFrom SΣ 0..* Reference(US Core QuestionnaireResponse Profile | US Core Observation Survey Profile) Should point back to the QuestionnaireResponse that this resource is derived 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:functioningpreferredPattern: functioning("Functioning")
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs
from this IG
Observation.codepreferredUSCoreSurveyCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-survey-codes
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* USCoreObservationSurveyProfile 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
us-core-3: SHALL use UCUM for coded quantity units.
... 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
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
... device-use S 0..* Reference(Personal Functioning and Engagement Use of Device) An extension to indicate a record of assistive device usage by a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/device-patient-used
... 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 Should have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category S 2..* 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:functioning 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://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: functioning
...... display 1..1 string Representation defined by the system
Fixed Value: Functioning
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
.... category:PFEDomain S 0..* CodeableConcept Classification of type of observation
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ 1..1 CodeableConcept For PFE Assessments, should include a LOINC code and text for the question or concept name.
Binding: US Core Survey Codes (preferred)
... 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] SΣC 1..1 dateTime S Clinically relevant time/time-period for observation
us-core-1: Datetime must be at least to day.
... issued Σ 0..1 instant Date/Time this version was made available
... performer SΣ 1..* Reference(US Core Practitioner Profile S | US Core PractitionerRole Profile | US Core Organization Profile) The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... value[x] SΣC 0..1 Whenever possible should use the CodeableConcept datatype to provide a suitable code to define the concept for the observation data. As for values like an assessment score or roll-up value, the datatype for this element should be determined by Observation.code. However, for values that are ordinal, may use the CodeableConcept datatype along with the Ordinal Value Extension.
.... 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
... derivedFrom SΣ 0..* Reference(US Core QuestionnaireResponse Profile S | US Core Observation Survey Profile S) Should point back to the QuestionnaireResponse that this resource is derived 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:functioningpreferredPattern: functioning("Functioning")
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs
from this IG
Observation.codepreferredUSCoreSurveyCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-survey-codes
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

Differential View

This structure is derived from USCoreObservationSurveyProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation USCoreObservationSurveyProfile
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
... device-use S 0..* Reference(Personal Functioning and Engagement Use of Device) An extension to indicate a record of assistive device usage by a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/device-patient-used
... category 2..* CodeableConcept Classification of type of observation
... category:functioning 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://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: functioning
..... display 1..1 string Representation defined by the system
Fixed Value: Functioning
... category:PFEDomain S 0..* CodeableConcept Classification of type of observation
Binding: Personal Functioning and Engagement Category Value Set (required)
... code 1..1 CodeableConcept For PFE Assessments, should include a LOINC code and text for the question or concept name.
... effective[x] 1..1 dateTime Clinically relevant time/time-period for observation
... performer 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... value[x] 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Whenever possible should use the CodeableConcept datatype to provide a suitable code to define the concept for the observation data. As for values like an assessment score or roll-up value, the datatype for this element should be determined by Observation.code. However, for values that are ordinal, may use the CodeableConcept datatype along with the Ordinal Value Extension.
... hasMember 0..0
... derivedFrom 0..* Reference(US Core QuestionnaireResponse Profile | US Core Observation Survey Profile) Should point back to the QuestionnaireResponse that this resource is derived from.

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs
from this IG

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* USCoreObservationSurveyProfile 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
us-core-3: SHALL use UCUM for coded quantity units.
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code Should have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category S 2..* 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:functioning 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://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: functioning
...... display 1..1 string Representation defined by the system
Fixed Value: Functioning
.... category:PFEDomain S 0..* CodeableConcept Classification of type of observation
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ 1..1 CodeableConcept For PFE Assessments, should include a LOINC code and text for the question or concept name.
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 1..1 dateTime Clinically relevant time/time-period for observation
us-core-1: Datetime must be at least to day.
... performer SΣ 1..* Reference(US Core Practitioner Profile) The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... value[x] SΣC 0..1 Whenever possible should use the CodeableConcept datatype to provide a suitable code to define the concept for the observation data. As for values like an assessment score or roll-up value, the datatype for this element should be determined by Observation.code. However, for values that are ordinal, may use the CodeableConcept datatype along with the Ordinal Value Extension.
.... 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.

... derivedFrom SΣ 0..* Reference(US Core QuestionnaireResponse Profile | US Core Observation Survey Profile) Should point back to the QuestionnaireResponse that this resource is derived 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:functioningpreferredPattern: functioning("Functioning")
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs
from this IG
Observation.codepreferredUSCoreSurveyCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-survey-codes
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* USCoreObservationSurveyProfile 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
us-core-3: SHALL use UCUM for coded quantity units.
... 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
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
... device-use S 0..* Reference(Personal Functioning and Engagement Use of Device) An extension to indicate a record of assistive device usage by a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/device-patient-used
... 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 Should have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category S 2..* 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:functioning 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://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: functioning
...... display 1..1 string Representation defined by the system
Fixed Value: Functioning
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
.... category:PFEDomain S 0..* CodeableConcept Classification of type of observation
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ 1..1 CodeableConcept For PFE Assessments, should include a LOINC code and text for the question or concept name.
Binding: US Core Survey Codes (preferred)
... 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] SΣC 1..1 dateTime S Clinically relevant time/time-period for observation
us-core-1: Datetime must be at least to day.
... issued Σ 0..1 instant Date/Time this version was made available
... performer SΣ 1..* Reference(US Core Practitioner Profile S | US Core PractitionerRole Profile | US Core Organization Profile) The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... value[x] SΣC 0..1 Whenever possible should use the CodeableConcept datatype to provide a suitable code to define the concept for the observation data. As for values like an assessment score or roll-up value, the datatype for this element should be determined by Observation.code. However, for values that are ordinal, may use the CodeableConcept datatype along with the Ordinal Value Extension.
.... 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
... derivedFrom SΣ 0..* Reference(US Core QuestionnaireResponse Profile S | US Core Observation Survey Profile S) Should point back to the QuestionnaireResponse that this resource is derived 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:functioningpreferredPattern: functioning("Functioning")
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs
from this IG
Observation.codepreferredUSCoreSurveyCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-survey-codes
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

 

Other representations of profile: CSV, Excel, Schematron

Notes:

The syntax used to describe the interactions below is described here.

Mandatory Search Parameters:

The following search parameters and search parameter combinations SHALL be supported:

  1. SHALL support searching using the combination of the patient and category search parameters:

    GET [base]/Observation?patient={Type/}[id]&category={system|}[code]

    Example:

    1. GET [base]/Observation?patient=1134281&category=http://terminology.hl7.org/CodeSystem/observation-category|survey
    2. GET [base]/Observation?patient=1134281&category=http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-category-cs|mental_functions

    Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and a category code = survey or mental_functions respectively (how to search by reference and how to search by token)

  2. SHALL support searching using the combination of the patient and code search parameters:
    • including optional support for OR search on code (e.g.code={system|}[code],{system|}[code],...)

    GET [base]/Observation?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}

    Example:

    1. GET [base]/Observation?patient=1134281&code=http://loinc.org|72133-2
    2. GET [base]/Observation?patient=1134281&code=http://loinc.org|72133-2,http://loinc.org|72107-6,http://loinc.org|54635-8

    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)

  3. SHALL support searching using the combination of the patient and category and date search parameters:
    • including support for these date comparators: gt,lt,ge,le
    • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)

    GET [base]/Observation?patient={Type/}[id]&category={system|}[code]&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]Observation?patient=555580&category=http://terminology.hl7.org/CodeSystem/observation-category|survey&date=ge2018-03-14T00:00:00Z
    2. GET [base]Observation?patient=555580&category=http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-category-cs|mental_functions&date=ge2018-03-14T00:00:00Z

    Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and date and a category code = survey or mental_functions respectively (how to search by reference and how to search by token and how to search by date)

Optional Search Parameters:

The following search parameter combinations SHOULD be supported:

  1. SHOULD support searching using the combination of the patient and category and status search parameters:
    • including support for OR search on status (e.g.status={system|}[code],{system|}[code],...)

    GET [base]/Observation?patient={Type/}[id]&category={system|}[code]&status={system|}[code]{,{system|}[code],...}

    Example:

    1. GET [base]/Observation?patient=1134281&category=http://terminology.hl7.org/CodeSystem/observation-category|survey&status=final
    2. GET [base]/Observation?patient=1134281&category=http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-category-cs|mental_functions&status=final

    Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and category = survey or mental_functions respectively and status final (how to search by reference and how to search by token)

  2. SHOULD support searching using the combination of the patient and code and date search parameters:
    • including optional support for OR search on code (e.g.code={system|}[code],{system|}[code],...)
    • including support for these date comparators: gt,lt,ge,le
    • including optional support for AND search on 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:

    1. GET [base]Observation?patient=555580&code=http://loinc.org|72133-2&date=ge2019-01-01T00:00:00Z

    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)