QI-Core Implementation Guide
7.0.0 - STU7 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 7.0.0 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: QICoreSimpleObservation - Detailed Descriptions

Active as of 2018-08-22

Definitions for the qicore-simple-observation resource profile.

Guidance on how to interpret the contents of this table can be found here

0. Observation
Must Supportfalse
Alternate NamesVital Signs, Measurement, Results, Tests
2. Observation.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

ShortA set of rules under which this content was created
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
4. Observation.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
6. Observation.partOf
Short(QI) Part of referenced event
8. Observation.status
Short(QI) registered | prliminary | final | amended | corrected | cancelled | entered-in-error | unknown
10. Observation.category
Short(QI) Classification of type of observation
Control1..*
12. Observation.code
Short(QI) Type of observation (code / type)
BindingThe codes SHOULD be taken from LOINCCodes
(preferred to http://hl7.org/fhir/ValueSet/observation-codes)

This value set specifies the type of observation

14. Observation.subject
Definition

The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the focus element or the code itself specifies the actual focus of the observation.

Short(QI) Who and/or what the observation is about
Comments

One would expect this element to be a cardinality of 1..1. The only circumstance in which the subject can be missing is when the observation is made by a device that does not know the patient. In this case, the observation SHALL be matched to a patient through some context/channel matching technique, and at this point, the observation should be updated.

Control1..1
TypeReference(QICore Patient)
Is Modifierfalse
Requirements

Observations have no value if you don't know who or what they're about.

16. Observation.effective[x]
Definition

The time or time-period the observed value is asserted as being true. For biological subjects - e.g. human patients - this is usually called the "physiologically relevant time". This is usually either the time of the procedure or of specimen collection, but very often the source of the date/time is not known, only the date/time itself.

Short(QI) Clinically relevant time/time-period for observation
Comments

At least a date should be present unless this observation is a historical report. For recording imprecise or "fuzzy" times (For example, a blood glucose measurement taken "after breakfast") use the Timing datatype which allow the measurement to be tied to regular life events.

Control0..1
TypeChoice of: dateTime, Period, Timing, instant
[x] NoteSeeChoice of Data Typesfor further information about how to use [x]
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Requirements

Knowing when an observation was deemed true is important to its relevance as well as determining trends.

Alternate NamesOccurrence
18. Observation.performer
Short(QI) Who is responsible for the observation
TypeReference(QICore Practitioner, QICore Organization, QICore Patient, QICore PractitionerRole, QICore CareTeam, QICore RelatedPerson)
20. Observation.value[x]
Definition

The information determined as a result of making the observation, if the information has a simple value.

Short(QI) Actual result
Comments

An observation may have; 1) a single value here, 2) both a value and a set of related or component values, or 3) only a set of related or component values. If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the Notes section below.

Control0..1
TypeChoice of: Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period
[x] NoteSeeChoice of Data Typesfor further information about how to use [x]
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Requirements

An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations.

SlicingThis element introduces a set of slices on Observation.value[x]. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • type @ $this
  • 22. Observation.value[x]:valueCodeableConcept
    Slice NamevalueCodeableConcept
    Short(QI) actual | potential
    BindingThe codes SHOULD be taken from US Core Observation Value Codes (SNOMED-CT) .
    (preferred to http://hl7.org/fhir/us/core/ValueSet/us-core-observation-value-codes)

    SNOMED CT for coded results

    TypeCodeableConcept
    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
    Is Modifierfalse
    24. Observation.interpretation
    Definition

    A categorical assessment of an observation value. For example, high, low, normal.

    Short(QI) High, low, normal, etc.
    Comments

    Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result.

    Control0..*
    BindingUnless not suitable, these codes SHALL be taken from ObservationInterpretationCodes
    (extensible to http://hl7.org/fhir/ValueSet/observation-interpretation)

    Codes identifying interpretations of observations.

    TypeCodeableConcept
    Is Modifierfalse
    Requirements

    For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result.

    Alternate NamesAbnormal Flag
    26. Observation.derivedFrom
    Definition

    US Core Observations, DocumentReference, QuestionnaireResponse or other resource from which this observation value is derived.

    Short(QI) US Core Profiles or other resource the observation is made from
    Comments

    All the reference choices that are listed in this element can represent clinical observations and other measurements that may be the source for a derived value. The most common reference will be another Observation. For a discussion on the ways Observations can assembled in groups together, see Notes below.

    Control0..*
    TypeReference(QICore Simple Observation, QICore QuestionnaireResponse, QICore ImagingStudy, US Core DocumentReference Profile, Media, MolecularSequence)
    Is Modifierfalse
    Must Supportfalse