QI-Core Implementation Guide
6.0.0 - STU6 United States of America flag

QI-Core Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 6.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-qi-core/ and changes regularly. See the Directory of published versions

Resource Profile: QICore Observation Screening Assessment

Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation-screening-assessment Version: 6.0.0
Active as of 2022-04-20 Computable Name: QICoreObservationScreeningAssessment

The QI-Core Observation Screening Assessment Profile is based upon the US Core Observation Screening Assessment Profile which can be used to represent individual responses, panels of multi-question surveys, and multi-select responses to “check all that apply” questions. The QI-Core Observation Survey Profile sets minimum expectations for the Observation Resource to record, search, and fetch retrieve observations that represent the questions and responses to form/survey and defines the core set of elements and extensions for quality rule and measure authors.

Guidance

Reference Guidance for use of the Observation Screening Assessment profile can be found here.

  • See the Social Determinants of Health (SDOH) Guidance Page for how this profile along with other Observation Profiles or alternatively QuestionnaireResponse to is used represent SDOH assessments.

Usage

See the patterns page for implementation and usage patterns.

Examples

10 minute Apgar Heart Rate Example

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreObservationScreeningAssessmentProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*USCoreObservationScreeningAssessmentProfileSurvey Observation
... status 1..1code(QI-Core)(USCDI) registered | prliminary | final | amended | corrected | entered-in-error | unknown
Binding: Non-Negative Observation Status (required)
... Slices for category 1..*CodeableConcept(QI-Core)(USCDI) Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (required): Codes for high level observation categories.


.... category:survey 1..1CodeableConcept(QI-Core)(USCDI) Classification of type of observation
Binding: ObservationCategoryCodes (required): Codes for high level observation categories.



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: survey
.... category:screening-assessment 0..*CodeableConcept(QI-Core)(USCDI) Classification of type of observation
Binding: US Core Screening Assessment Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code Σ1..1CodeableConcept(QI-Core)(USCDI) Type of observation (code / type)
Binding: US Core Survey Codes (preferred)
... effective[x] Σ0..1(QI-Core)(USCDI) Clinically relevant time/time-period for observation
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
.... effectiveTimingTiming
.... effectiveInstantinstant
... performer 0..*Reference(QICore Practitioner | QICore Organization | QICore Patient | QICore PractitionerRole | QICore CareTeam | QICore RelatedPerson)(QI-Core)(USCDI) Who is responsible for the observation
... value[x] 0..1(QI-Core)(USCDI) Actual result
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
... dataAbsentReason 0..1CodeableConcept(QI-Core)(USCDI) Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConcept(QI-Core) High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... hasMember 0..*Reference(QICore Observation Screening Assessment | QICore QuestionnaireResponse)(QI-Core)(USCDI) Reference to panel or multi-select responses
... derivedFrom 0..*Reference(QICore Observation Screening Assessment | QICore QuestionnaireResponse)(QI-Core)(USCDI) Related Observations or QuestionnaireResponses that the observation is made from

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / CodeURI
Observation.statusrequiredNonNegativeObservationStatus
http://hl7.org/fhir/us/qicore/ValueSet/qicore-non-negative-observation-status
from this IG
Observation.categoryrequiredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:surveyrequiredPattern: survey
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:screening-assessmentrequiredUSCoreScreeningAssessmentObservationCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-category
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
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*USCoreObservationScreeningAssessmentProfileSurvey 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 ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣ1..1code(QI-Core)(USCDI) registered | prliminary | final | amended | corrected | entered-in-error | unknown
Binding: Non-Negative Observation Status (required)
.... category:survey S1..1CodeableConcept(QI-Core)(USCDI) Classification of type of observation
Binding: ObservationCategoryCodes (required): Codes for high level observation categories.



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: survey
.... category:screening-assessment S0..*CodeableConcept(QI-Core)(USCDI) Classification of type of observation
Binding: US Core Screening Assessment Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code SΣ1..1CodeableConcept(QI-Core)(USCDI) Type of observation (code / type)
Binding: US Core Survey Codes (preferred)
... subject SΣ1..1Reference(QICore Patient)(QI-Core)(USCDI) Who and/or what the observation is about
... effective[x] SΣC0..1(QI-Core)(USCDI) Clinically relevant time/time-period for observation
us-core-1: Datetime must be at least to day.
.... effectiveDateTimedateTime
... performer SΣ0..*Reference(QICore Practitioner | QICore Organization | QICore Patient | QICore PractitionerRole | QICore CareTeam | QICore RelatedPerson)(QI-Core)(USCDI) Who is responsible for the observation
... value[x] SΣC0..1(QI-Core)(USCDI) Actual result
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
... dataAbsentReason SC0..1CodeableConcept(QI-Core)(USCDI) Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConcept(QI-Core) High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... hasMember SΣ0..*Reference(QICore Observation Screening Assessment | QICore QuestionnaireResponse)(QI-Core)(USCDI) Reference to panel or multi-select responses
... derivedFrom SΣ0..*Reference(QICore Observation Screening Assessment | QICore QuestionnaireResponse)(QI-Core)(USCDI) Related Observations or QuestionnaireResponses that the observation is made from

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Observation.statusrequiredNonNegativeObservationStatus
http://hl7.org/fhir/us/qicore/ValueSet/qicore-non-negative-observation-status
from this IG
Observation.categoryrequiredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:surveyrequiredPattern: survey
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:screening-assessmentrequiredUSCoreScreeningAssessmentObservationCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-category
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

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorObservationIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorObservationIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorObservationIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorObservationIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceObservationA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
obs-6errorObservationdataAbsentReason SHALL only be present if Observation.value[x] is not present
: dataAbsentReason.empty() or value.empty()
obs-7errorObservationIf Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
: value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
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-3errorObservationSHALL use UCUM for coded quantity units.
: value.ofType(Quantity).system.empty() or value.ofType(Quantity).system = 'http://unitsofmeasure.org'
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*USCoreObservationScreeningAssessmentProfileSurvey 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 Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!SΣ1..1code(QI-Core)(USCDI) registered | prliminary | final | amended | corrected | entered-in-error | unknown
Binding: Non-Negative Observation Status (required)
... Slices for category S1..*CodeableConcept(QI-Core)(USCDI) Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (required): Codes for high level observation categories.


.... category:survey S1..1CodeableConcept(QI-Core)(USCDI) Classification of type of observation
Binding: ObservationCategoryCodes (required): Codes for high level observation categories.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: survey
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
.... category:screening-assessment S0..*CodeableConcept(QI-Core)(USCDI) Classification of type of observation
Binding: US Core Screening Assessment Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code SΣ1..1CodeableConcept(QI-Core)(USCDI) Type of observation (code / type)
Binding: US Core Survey Codes (preferred)
... subject SΣ1..1Reference(QICore Patient)(QI-Core)(USCDI) Who and/or what the observation is about
... focus Σ0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter Σ0..1Reference(Encounter)Healthcare event during which this observation is made
... effective[x] SΣC0..1(QI-Core)(USCDI) Clinically relevant time/time-period for observation
us-core-1: Datetime must be at least to day.
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod
.... effectiveTimingTiming
.... effectiveInstantinstant
... issued Σ0..1instantDate/Time this version was made available
... performer SΣ0..*Reference(QICore Practitioner | QICore Organization | QICore Patient | QICore PractitionerRole | QICore CareTeam | QICore RelatedPerson)(QI-Core)(USCDI) Who is responsible for the observation
... value[x] SΣC0..1(QI-Core)(USCDI) Actual result
.... valueQuantityQuantity S
.... valueCodeableConceptCodeableConcept S
.... valueStringstring S
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
... dataAbsentReason SC0..1CodeableConcept(QI-Core)(USCDI) Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConcept(QI-Core) High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..*AnnotationComments about the observation
... bodySite 0..1CodeableConceptObserved body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1CodeableConceptHow it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange C0..*BackboneElementProvides guide for interpretation
obs-3: Must have at least a low or a high or text
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low C0..1SimpleQuantityLow Range, if relevant
.... high C0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember SΣ0..*Reference(QICore Observation Screening Assessment | QICore QuestionnaireResponse)(QI-Core)(USCDI) Reference to panel or multi-select responses
... derivedFrom SΣ0..*Reference(QICore Observation Screening Assessment | QICore QuestionnaireResponse)(QI-Core)(USCDI) Related Observations or QuestionnaireResponses that the observation is made from
... component Σ0..*BackboneElementComponent results
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason C0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..*CodeableConceptHigh, 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.statusrequiredNonNegativeObservationStatus
http://hl7.org/fhir/us/qicore/ValueSet/qicore-non-negative-observation-status
from this IG
Observation.categoryrequiredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:surveyrequiredPattern: survey
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:screening-assessmentrequiredUSCoreScreeningAssessmentObservationCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-category
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

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorObservationIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorObservationIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorObservationIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorObservationIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceObservationA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
obs-3errorObservation.referenceRangeMust have at least a low or a high or text
: low.exists() or high.exists() or text.exists()
obs-6errorObservationdataAbsentReason SHALL only be present if Observation.value[x] is not present
: dataAbsentReason.empty() or value.empty()
obs-7errorObservationIf Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
: value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
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-3errorObservationSHALL use UCUM for coded quantity units.
: value.ofType(Quantity).system.empty() or value.ofType(Quantity).system = 'http://unitsofmeasure.org'

Differential View

This structure is derived from USCoreObservationScreeningAssessmentProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*USCoreObservationScreeningAssessmentProfileSurvey Observation
... status 1..1code(QI-Core)(USCDI) registered | prliminary | final | amended | corrected | entered-in-error | unknown
Binding: Non-Negative Observation Status (required)
... Slices for category 1..*CodeableConcept(QI-Core)(USCDI) Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (required): Codes for high level observation categories.


.... category:survey 1..1CodeableConcept(QI-Core)(USCDI) Classification of type of observation
Binding: ObservationCategoryCodes (required): Codes for high level observation categories.



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: survey
.... category:screening-assessment 0..*CodeableConcept(QI-Core)(USCDI) Classification of type of observation
Binding: US Core Screening Assessment Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code Σ1..1CodeableConcept(QI-Core)(USCDI) Type of observation (code / type)
Binding: US Core Survey Codes (preferred)
... effective[x] Σ0..1(QI-Core)(USCDI) Clinically relevant time/time-period for observation
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
.... effectiveTimingTiming
.... effectiveInstantinstant
... performer 0..*Reference(QICore Practitioner | QICore Organization | QICore Patient | QICore PractitionerRole | QICore CareTeam | QICore RelatedPerson)(QI-Core)(USCDI) Who is responsible for the observation
... value[x] 0..1(QI-Core)(USCDI) Actual result
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
... dataAbsentReason 0..1CodeableConcept(QI-Core)(USCDI) Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConcept(QI-Core) High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... hasMember 0..*Reference(QICore Observation Screening Assessment | QICore QuestionnaireResponse)(QI-Core)(USCDI) Reference to panel or multi-select responses
... derivedFrom 0..*Reference(QICore Observation Screening Assessment | QICore QuestionnaireResponse)(QI-Core)(USCDI) Related Observations or QuestionnaireResponses that the observation is made from

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / CodeURI
Observation.statusrequiredNonNegativeObservationStatus
http://hl7.org/fhir/us/qicore/ValueSet/qicore-non-negative-observation-status
from this IG
Observation.categoryrequiredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:surveyrequiredPattern: survey
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:screening-assessmentrequiredUSCoreScreeningAssessmentObservationCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-category
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

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*USCoreObservationScreeningAssessmentProfileSurvey 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 ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣ1..1code(QI-Core)(USCDI) registered | prliminary | final | amended | corrected | entered-in-error | unknown
Binding: Non-Negative Observation Status (required)
.... category:survey S1..1CodeableConcept(QI-Core)(USCDI) Classification of type of observation
Binding: ObservationCategoryCodes (required): Codes for high level observation categories.



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: survey
.... category:screening-assessment S0..*CodeableConcept(QI-Core)(USCDI) Classification of type of observation
Binding: US Core Screening Assessment Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code SΣ1..1CodeableConcept(QI-Core)(USCDI) Type of observation (code / type)
Binding: US Core Survey Codes (preferred)
... subject SΣ1..1Reference(QICore Patient)(QI-Core)(USCDI) Who and/or what the observation is about
... effective[x] SΣC0..1(QI-Core)(USCDI) Clinically relevant time/time-period for observation
us-core-1: Datetime must be at least to day.
.... effectiveDateTimedateTime
... performer SΣ0..*Reference(QICore Practitioner | QICore Organization | QICore Patient | QICore PractitionerRole | QICore CareTeam | QICore RelatedPerson)(QI-Core)(USCDI) Who is responsible for the observation
... value[x] SΣC0..1(QI-Core)(USCDI) Actual result
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
... dataAbsentReason SC0..1CodeableConcept(QI-Core)(USCDI) Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConcept(QI-Core) High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... hasMember SΣ0..*Reference(QICore Observation Screening Assessment | QICore QuestionnaireResponse)(QI-Core)(USCDI) Reference to panel or multi-select responses
... derivedFrom SΣ0..*Reference(QICore Observation Screening Assessment | QICore QuestionnaireResponse)(QI-Core)(USCDI) Related Observations or QuestionnaireResponses that the observation is made from

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Observation.statusrequiredNonNegativeObservationStatus
http://hl7.org/fhir/us/qicore/ValueSet/qicore-non-negative-observation-status
from this IG
Observation.categoryrequiredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:surveyrequiredPattern: survey
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:screening-assessmentrequiredUSCoreScreeningAssessmentObservationCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-category
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

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorObservationIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorObservationIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorObservationIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorObservationIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceObservationA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
obs-6errorObservationdataAbsentReason SHALL only be present if Observation.value[x] is not present
: dataAbsentReason.empty() or value.empty()
obs-7errorObservationIf Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
: value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
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-3errorObservationSHALL use UCUM for coded quantity units.
: value.ofType(Quantity).system.empty() or value.ofType(Quantity).system = 'http://unitsofmeasure.org'

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*USCoreObservationScreeningAssessmentProfileSurvey 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 Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!SΣ1..1code(QI-Core)(USCDI) registered | prliminary | final | amended | corrected | entered-in-error | unknown
Binding: Non-Negative Observation Status (required)
... Slices for category S1..*CodeableConcept(QI-Core)(USCDI) Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (required): Codes for high level observation categories.


.... category:survey S1..1CodeableConcept(QI-Core)(USCDI) Classification of type of observation
Binding: ObservationCategoryCodes (required): Codes for high level observation categories.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: survey
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
.... category:screening-assessment S0..*CodeableConcept(QI-Core)(USCDI) Classification of type of observation
Binding: US Core Screening Assessment Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code SΣ1..1CodeableConcept(QI-Core)(USCDI) Type of observation (code / type)
Binding: US Core Survey Codes (preferred)
... subject SΣ1..1Reference(QICore Patient)(QI-Core)(USCDI) Who and/or what the observation is about
... focus Σ0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter Σ0..1Reference(Encounter)Healthcare event during which this observation is made
... effective[x] SΣC0..1(QI-Core)(USCDI) Clinically relevant time/time-period for observation
us-core-1: Datetime must be at least to day.
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod
.... effectiveTimingTiming
.... effectiveInstantinstant
... issued Σ0..1instantDate/Time this version was made available
... performer SΣ0..*Reference(QICore Practitioner | QICore Organization | QICore Patient | QICore PractitionerRole | QICore CareTeam | QICore RelatedPerson)(QI-Core)(USCDI) Who is responsible for the observation
... value[x] SΣC0..1(QI-Core)(USCDI) Actual result
.... valueQuantityQuantity S
.... valueCodeableConceptCodeableConcept S
.... valueStringstring S
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
... dataAbsentReason SC0..1CodeableConcept(QI-Core)(USCDI) Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConcept(QI-Core) High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..*AnnotationComments about the observation
... bodySite 0..1CodeableConceptObserved body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1CodeableConceptHow it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange C0..*BackboneElementProvides guide for interpretation
obs-3: Must have at least a low or a high or text
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low C0..1SimpleQuantityLow Range, if relevant
.... high C0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember SΣ0..*Reference(QICore Observation Screening Assessment | QICore QuestionnaireResponse)(QI-Core)(USCDI) Reference to panel or multi-select responses
... derivedFrom SΣ0..*Reference(QICore Observation Screening Assessment | QICore QuestionnaireResponse)(QI-Core)(USCDI) Related Observations or QuestionnaireResponses that the observation is made from
... component Σ0..*BackboneElementComponent results
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason C0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..*CodeableConceptHigh, 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.statusrequiredNonNegativeObservationStatus
http://hl7.org/fhir/us/qicore/ValueSet/qicore-non-negative-observation-status
from this IG
Observation.categoryrequiredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:surveyrequiredPattern: survey
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:screening-assessmentrequiredUSCoreScreeningAssessmentObservationCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-category
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

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorObservationIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorObservationIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorObservationIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorObservationIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceObservationA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
obs-3errorObservation.referenceRangeMust have at least a low or a high or text
: low.exists() or high.exists() or text.exists()
obs-6errorObservationdataAbsentReason SHALL only be present if Observation.value[x] is not present
: dataAbsentReason.empty() or value.empty()
obs-7errorObservationIf Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
: value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
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-3errorObservationSHALL use UCUM for coded quantity units.
: value.ofType(Quantity).system.empty() or value.ofType(Quantity).system = 'http://unitsofmeasure.org'

 

Other representations of profile: CSV, Excel, Schematron