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: QICore Simple Observation

Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-simple-observation Version: 7.0.0
Active as of 2018-08-22 Computable Name: QICoreSimpleObservation

Profile of Simple Observation for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Must Have:
  • status: (QI) registered | prliminary | final | amended | corrected | entered-in-error | unknown
  • category: (QI) Classification of type of observation
  • code: (QI) Type of observation (code / type)
  • subject: (QI) Who and/or what the observation is about
QI Elements:
  • partOf: (QI) Part of referenced event
  • effective[x]: (QI) Clinically relevant time/time-period for observation
  • performer: (QI) Who is responsible for the observation
  • value[x]: (QI) Actual result
  • value[x]: (QI) actual | potential
  • interpretation: (QI) High, low, normal, etc.
  • derivedFrom: (QI) US Core Profiles or other resource the observation is made from
Primary code path: code
(PCPath) This element is the primary code path for this resource CQL Retrieve


NOTE TO BALLOT REVIEWERS:
  • US Core 7.0, and thus QI-Core 7.0, has a new approach to USCDI requirements.
    • As noted in the US Core 7.0 Must Support section, US Core 7.0 no longer highlights mandatory (cardinality 1..* or 1..1) and Must Support elements with a (USCDI) indicator as such items must be supported for interoperability.
    • Those USCDI elements that are not mandatory or Must Support now include an indicator (ADDITIONAL USCDI) in US Core. QI-Core 7.0 does not reference USCDI elements; rather, users should access US Core 7.0 to understand its implementation of USCDI version 4.
  • We invite comments about the approach and suggestions for other options that would also avoid unnecessary noise or reading load to the QI-Core profile representation.
  • Further, QI-Core 7.0 does not discuss USCDI+Quality because at the time of ballot preparation, no published version of USCDI+Quality is available. We seek reviewer advice regarding how QI-Core might address future USCDI+Quality.

Usage

Note: US-Core and QI-Core define precise profiles for specific observations, as well as a general profile for LOINC-code laboratory result observations. QI-Core inherits these US Core specific profiles directly and individually profiles others. When creating expressions for eCQMs or CDS artifacts with QI-Core for the following clinical data, use the applicable profile directly rather than the generic QICore Observation profile:

As stated in the Home Page, QI-Core derives from US Core and so the requirements on “MustSupport” defined in US Core must be respected. QI-Core further describes and constrains the “MustSupport” functionality.

​To create an expression specifically requesting information that an observation intentionally did not occur for a medical, patient or system reason, use the profile QICore Observation Cancelled.

The following example illustrates the use of the observation profile.

define "Pap Test with Results":
  [Observation: "Pap Test"] PapTest
    where PapTest.value is not null
      and PapTest.status in { 'final', 'amended', 'corrected', 'preliminary' }

See the patterns page for implementation and usage patterns.

Examples

Example of a Frailty Observation
Example of a Gestation Age at Birth Observation
Example of a Date and time of obstetric delivery observation
Example of an estimated delivery date observation
Example of a number of preterm births observation
Example of a number of term births observation
Example of a number of parity observation
Example of a number of pregnancies observation

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreSimpleObservationProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..* USCoreSimpleObservationProfile assessment observation
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... partOf 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) (QI) Part of referenced event
... category 1..* CodeableConcept (QI) Classification of type of observation
... code 1..1 CodeableConcept (QI) Type of observation (code / type)
Binding: LOINCCodes (preferred): This value set specifies the type of observation

... subject Σ 1..1 Reference(QICore Patient) (QI) Who and/or what the observation is about
... effective[x] Σ 0..1 (QI) Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... performer 0..* Reference(QICore Practitioner | QICore Organization | QICore Patient | QICore PractitionerRole | QICore CareTeam | QICore RelatedPerson) (QI) Who is responsible for the observation
... Slices for value[x] Σ 0..1 (QI) Actual result
Slice: Unordered, Open by type:$this
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
.... value[x]:valueCodeableConcept 0..1 CodeableConcept (QI) actual | potential
Binding: US Core Observation Value Codes (SNOMED-CT) . (preferred): SNOMED CT for coded results

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


... derivedFrom Σ 0..* Reference(QICore Simple Observation | QICore QuestionnaireResponse | QICore ImagingStudy | US Core DocumentReference Profile | Media | MolecularSequence) (QI) US Core Profiles or other resource the observation is made from

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.codepreferredLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.value[x]:valueCodeableConceptpreferredUSCoreObservationValueCodes . (a valid code from SNOMED CT)
http://hl7.org/fhir/us/core/ValueSet/us-core-observation-value-codes
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* USCoreSimpleObservationProfile assessment 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
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) (QI) Part of referenced event
... Slices for category S 1..* CodeableConcept (QI) Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:us-core S 0..* CodeableConcept Classification of type of observation
Binding: US Core Simple Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code SΣ 1..1 CodeableConcept (QI) Type of observation (code / type)
Binding: LOINCCodes (preferred): This value set specifies the type of observation

... subject SΣ 1..1 Reference(QICore Patient) (QI) Who and/or what the observation is about
... effective[x] SΣ 0..1 (QI) Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
... performer SΣ 0..* Reference(QICore Practitioner | QICore Organization | QICore Patient | QICore PractitionerRole | QICore CareTeam | QICore RelatedPerson) (QI) Who is responsible for the observation
... Slices for value[x] SΣC 0..1 (QI) Actual result
Slice: Unordered, Open by type:$this
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... value[x]:valueCodeableConcept SΣC 0..1 CodeableConcept (QI) actual | potential
Binding: US Core Observation Value Codes (SNOMED-CT) . (preferred): SNOMED CT for coded results

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


... derivedFrom Σ 0..* Reference(QICore Simple Observation | QICore QuestionnaireResponse | QICore ImagingStudy | US Core DocumentReference Profile | Media | MolecularSequence) (QI) US Core Profiles or other resource the observation is made from

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
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:us-corerequiredUSCoreSimpleObservationCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-simple-observation-category
Observation.codepreferredLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.value[x]:valueCodeableConceptpreferredUSCoreObservationValueCodes . (a valid code from SNOMED CT)
http://hl7.org/fhir/us/core/ValueSet/us-core-observation-value-codes
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()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* USCoreSimpleObservationProfile assessment 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
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business Identifier for observation
... basedOn Σ 0..* Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Fulfills plan, proposal or order
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) (QI) Part of referenced event
... status ?!SΣ 1..1 code (QI) registered | prliminary | final | amended | corrected | cancelled | entered-in-error | unknown
Binding: ObservationStatus (required): Codes providing the status of an observation.

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


.... category:us-core S 0..* CodeableConcept Classification of type of observation
Binding: US Core Simple Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code SΣ 1..1 CodeableConcept (QI) Type of observation (code / type)
Binding: LOINCCodes (preferred): This value set specifies the type of observation

... subject SΣ 1..1 Reference(QICore Patient) (QI) 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] SΣ 0..1 (QI) Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime S
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... issued Σ 0..1 instant Date/Time this version was made available
... performer SΣ 0..* Reference(QICore Practitioner | QICore Organization | QICore Patient | QICore PractitionerRole | QICore CareTeam | QICore RelatedPerson) (QI) Who is responsible for the observation
... Slices for value[x] SΣC 0..1 (QI) Actual result
Slice: Unordered, Open by type:$this
.... valueQuantity Quantity S
.... valueCodeableConcept CodeableConcept S
.... valueString string S
.... valueBoolean boolean S
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
.... value[x]:valueCodeableConcept SΣC 0..1 CodeableConcept S (QI) actual | potential
Binding: US Core Observation Value Codes (SNOMED-CT) . (preferred): SNOMED CT for coded results

... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

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


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

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

... specimen 0..1 Reference(Specimen) Specimen used for this observation
... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... referenceRange C 0..* BackboneElement Provides guide for interpretation
obs-3: Must have at least a low or a high or text
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... low C 0..1 SimpleQuantity Low Range, if relevant
.... high C 0..1 SimpleQuantity High Range, if relevant
.... type 0..1 CodeableConcept Reference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

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


.... age 0..1 Range Applicable age range, if relevant
.... text 0..1 string Text based reference range in an observation
... hasMember Σ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom Σ 0..* Reference(QICore Simple Observation | QICore QuestionnaireResponse | QICore ImagingStudy | US Core DocumentReference Profile | Media | MolecularSequence) (QI) US Core Profiles or other resource the observation is made from
... component Σ 0..* BackboneElement Component results
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 CodeableConcept Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ 0..1 Actual component result
..... valueQuantity Quantity
..... valueCodeableConcept CodeableConcept
..... valueString string
..... valueBoolean boolean
..... valueInteger integer
..... valueRange Range
..... valueRatio Ratio
..... valueSampledData SampledData
..... valueTime time
..... valueDateTime dateTime
..... valuePeriod Period
.... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

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


.... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
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:us-corerequiredUSCoreSimpleObservationCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-simple-observation-category
Observation.codepreferredLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.value[x]:valueCodeableConceptpreferredUSCoreObservationValueCodes . (a valid code from SNOMED CT)
http://hl7.org/fhir/us/core/ValueSet/us-core-observation-value-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()

Differential View

This structure is derived from USCoreSimpleObservationProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..* USCoreSimpleObservationProfile assessment observation
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... partOf 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) (QI) Part of referenced event
... category 1..* CodeableConcept (QI) Classification of type of observation
... code 1..1 CodeableConcept (QI) Type of observation (code / type)
Binding: LOINCCodes (preferred): This value set specifies the type of observation

... subject Σ 1..1 Reference(QICore Patient) (QI) Who and/or what the observation is about
... effective[x] Σ 0..1 (QI) Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... performer 0..* Reference(QICore Practitioner | QICore Organization | QICore Patient | QICore PractitionerRole | QICore CareTeam | QICore RelatedPerson) (QI) Who is responsible for the observation
... Slices for value[x] Σ 0..1 (QI) Actual result
Slice: Unordered, Open by type:$this
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
.... value[x]:valueCodeableConcept 0..1 CodeableConcept (QI) actual | potential
Binding: US Core Observation Value Codes (SNOMED-CT) . (preferred): SNOMED CT for coded results

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


... derivedFrom Σ 0..* Reference(QICore Simple Observation | QICore QuestionnaireResponse | QICore ImagingStudy | US Core DocumentReference Profile | Media | MolecularSequence) (QI) US Core Profiles or other resource the observation is made from

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.codepreferredLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.value[x]:valueCodeableConceptpreferredUSCoreObservationValueCodes . (a valid code from SNOMED CT)
http://hl7.org/fhir/us/core/ValueSet/us-core-observation-value-codes
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* USCoreSimpleObservationProfile assessment 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
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) (QI) Part of referenced event
... Slices for category S 1..* CodeableConcept (QI) Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:us-core S 0..* CodeableConcept Classification of type of observation
Binding: US Core Simple Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code SΣ 1..1 CodeableConcept (QI) Type of observation (code / type)
Binding: LOINCCodes (preferred): This value set specifies the type of observation

... subject SΣ 1..1 Reference(QICore Patient) (QI) Who and/or what the observation is about
... effective[x] SΣ 0..1 (QI) Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
... performer SΣ 0..* Reference(QICore Practitioner | QICore Organization | QICore Patient | QICore PractitionerRole | QICore CareTeam | QICore RelatedPerson) (QI) Who is responsible for the observation
... Slices for value[x] SΣC 0..1 (QI) Actual result
Slice: Unordered, Open by type:$this
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... value[x]:valueCodeableConcept SΣC 0..1 CodeableConcept (QI) actual | potential
Binding: US Core Observation Value Codes (SNOMED-CT) . (preferred): SNOMED CT for coded results

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


... derivedFrom Σ 0..* Reference(QICore Simple Observation | QICore QuestionnaireResponse | QICore ImagingStudy | US Core DocumentReference Profile | Media | MolecularSequence) (QI) US Core Profiles or other resource the observation is made from

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
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:us-corerequiredUSCoreSimpleObservationCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-simple-observation-category
Observation.codepreferredLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.value[x]:valueCodeableConceptpreferredUSCoreObservationValueCodes . (a valid code from SNOMED CT)
http://hl7.org/fhir/us/core/ValueSet/us-core-observation-value-codes
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()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* USCoreSimpleObservationProfile assessment 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
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business Identifier for observation
... basedOn Σ 0..* Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Fulfills plan, proposal or order
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) (QI) Part of referenced event
... status ?!SΣ 1..1 code (QI) registered | prliminary | final | amended | corrected | cancelled | entered-in-error | unknown
Binding: ObservationStatus (required): Codes providing the status of an observation.

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


.... category:us-core S 0..* CodeableConcept Classification of type of observation
Binding: US Core Simple Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code SΣ 1..1 CodeableConcept (QI) Type of observation (code / type)
Binding: LOINCCodes (preferred): This value set specifies the type of observation

... subject SΣ 1..1 Reference(QICore Patient) (QI) 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] SΣ 0..1 (QI) Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime S
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... issued Σ 0..1 instant Date/Time this version was made available
... performer SΣ 0..* Reference(QICore Practitioner | QICore Organization | QICore Patient | QICore PractitionerRole | QICore CareTeam | QICore RelatedPerson) (QI) Who is responsible for the observation
... Slices for value[x] SΣC 0..1 (QI) Actual result
Slice: Unordered, Open by type:$this
.... valueQuantity Quantity S
.... valueCodeableConcept CodeableConcept S
.... valueString string S
.... valueBoolean boolean S
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
.... value[x]:valueCodeableConcept SΣC 0..1 CodeableConcept S (QI) actual | potential
Binding: US Core Observation Value Codes (SNOMED-CT) . (preferred): SNOMED CT for coded results

... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

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


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

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

... specimen 0..1 Reference(Specimen) Specimen used for this observation
... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... referenceRange C 0..* BackboneElement Provides guide for interpretation
obs-3: Must have at least a low or a high or text
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... low C 0..1 SimpleQuantity Low Range, if relevant
.... high C 0..1 SimpleQuantity High Range, if relevant
.... type 0..1 CodeableConcept Reference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

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


.... age 0..1 Range Applicable age range, if relevant
.... text 0..1 string Text based reference range in an observation
... hasMember Σ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom Σ 0..* Reference(QICore Simple Observation | QICore QuestionnaireResponse | QICore ImagingStudy | US Core DocumentReference Profile | Media | MolecularSequence) (QI) US Core Profiles or other resource the observation is made from
... component Σ 0..* BackboneElement Component results
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 CodeableConcept Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ 0..1 Actual component result
..... valueQuantity Quantity
..... valueCodeableConcept CodeableConcept
..... valueString string
..... valueBoolean boolean
..... valueInteger integer
..... valueRange Range
..... valueRatio Ratio
..... valueSampledData SampledData
..... valueTime time
..... valueDateTime dateTime
..... valuePeriod Period
.... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

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


.... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
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:us-corerequiredUSCoreSimpleObservationCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-simple-observation-category
Observation.codepreferredLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.value[x]:valueCodeableConceptpreferredUSCoreObservationValueCodes . (a valid code from SNOMED CT)
http://hl7.org/fhir/us/core/ValueSet/us-core-observation-value-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()

 

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