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 Simple Observation

Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-simple-observation Version: 6.0.0
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.

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..*USCoreSimpleObservationProfileassessment observation
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status 1..1code(QI-Core)(USCDI) registered | prliminary | final | amended | corrected | entered-in-error | unknown
Binding: Non-Negative Observation Status (required)
... code 1..1CodeableConcept(QI-Core)(USCDI) Type of observation (code / type)
Binding: LOINCCodes (preferred): This value set specifies the type of observation

... subject Σ1..1Reference(QICore Patient)(QI-Core)(USCDI) Who and/or what the observation is about
... 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
... Slices for value[x] Σ0..1(QI-Core)(USCDI) Actual result
Slice: Unordered, Open by type:$this
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
.... value[x]:valueCodeableConcept 0..1CodeableConcept(QI-Core) actual | potential
Binding: US Core Observation Value Codes (SNOMED-CT) (preferred): SNOMED CT for coded results

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


... derivedFrom Σ0..*Reference(QICore Simple Observation | QICore QuestionnaireResponse | QICore ImagingStudy | US Core DocumentReference Profile | Media | MolecularSequence)(QI-Core)(USCDI) US Core Profiles or other resource the observation is made from

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.statusrequiredNonNegativeObservationStatus
http://hl7.org/fhir/us/qicore/ValueSet/qicore-non-negative-observation-status
from this IG
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 C0..*USCoreSimpleObservationProfileassessment observation
... 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:us-core S0..*CodeableConcept(USCDI) 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 SΣ1..1CodeableConcept(QI-Core)(USCDI) Type of observation (code / type)
Binding: LOINCCodes (preferred): This value set specifies the type of observation

... subject SΣ1..1Reference(QICore Patient)(QI-Core)(USCDI) Who and/or what the observation is about
... effective[x] SΣ0..1(QI-Core)(USCDI) Clinically relevant time/time-period for observation
.... 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
... Slices for value[x] SΣC0..1(QI-Core)(USCDI) Actual result
Slice: Unordered, Open by type:$this
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... value[x]:valueCodeableConcept SΣC0..1CodeableConcept(QI-Core) actual | potential
Binding: US Core Observation Value Codes (SNOMED-CT) (preferred): SNOMED CT for coded results

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


... derivedFrom Σ0..*Reference(QICore Simple Observation | QICore QuestionnaireResponse | QICore ImagingStudy | US Core DocumentReference Profile | Media | MolecularSequence)(QI-Core)(USCDI) US Core Profiles or other resource the observation is made from

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.statusrequiredNonNegativeObservationStatus
http://hl7.org/fhir/us/qicore/ValueSet/qicore-non-negative-observation-status
from this IG
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 C0..*USCoreSimpleObservationProfileassessment observation
... 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 (preferred): Codes for high level observation categories.


.... category:us-core S0..*CodeableConcept(USCDI) 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 SΣ1..1CodeableConcept(QI-Core)(USCDI) Type of observation (code / type)
Binding: LOINCCodes (preferred): This value set specifies the type of observation

... 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] SΣ0..1(QI-Core)(USCDI) Clinically relevant time/time-period for observation
.... 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
... Slices for value[x] SΣC0..1(QI-Core)(USCDI) Actual result
Slice: Unordered, Open by type:$this
.... valueQuantityQuantity S
.... valueCodeableConceptCodeableConcept S
.... valueStringstring S
.... valueBooleanboolean S
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
.... value[x]:valueCodeableConcept SΣC0..1CodeableConcept S(QI-Core) actual | potential
Binding: US Core Observation Value Codes (SNOMED-CT) (preferred): SNOMED CT for coded results

... dataAbsentReason C0..1CodeableConceptWhy 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
.... 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 Σ0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)Related resource that belongs to the Observation group
... derivedFrom Σ0..*Reference(QICore Simple Observation | QICore QuestionnaireResponse | QICore ImagingStudy | US Core DocumentReference Profile | Media | MolecularSequence)(QI-Core)(USCDI) US Core Profiles or other resource 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

PathConformanceValueSetURI
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.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..*USCoreSimpleObservationProfileassessment observation
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status 1..1code(QI-Core)(USCDI) registered | prliminary | final | amended | corrected | entered-in-error | unknown
Binding: Non-Negative Observation Status (required)
... code 1..1CodeableConcept(QI-Core)(USCDI) Type of observation (code / type)
Binding: LOINCCodes (preferred): This value set specifies the type of observation

... subject Σ1..1Reference(QICore Patient)(QI-Core)(USCDI) Who and/or what the observation is about
... 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
... Slices for value[x] Σ0..1(QI-Core)(USCDI) Actual result
Slice: Unordered, Open by type:$this
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
.... value[x]:valueCodeableConcept 0..1CodeableConcept(QI-Core) actual | potential
Binding: US Core Observation Value Codes (SNOMED-CT) (preferred): SNOMED CT for coded results

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


... derivedFrom Σ0..*Reference(QICore Simple Observation | QICore QuestionnaireResponse | QICore ImagingStudy | US Core DocumentReference Profile | Media | MolecularSequence)(QI-Core)(USCDI) US Core Profiles or other resource the observation is made from

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.statusrequiredNonNegativeObservationStatus
http://hl7.org/fhir/us/qicore/ValueSet/qicore-non-negative-observation-status
from this IG
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 C0..*USCoreSimpleObservationProfileassessment observation
... 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:us-core S0..*CodeableConcept(USCDI) 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 SΣ1..1CodeableConcept(QI-Core)(USCDI) Type of observation (code / type)
Binding: LOINCCodes (preferred): This value set specifies the type of observation

... subject SΣ1..1Reference(QICore Patient)(QI-Core)(USCDI) Who and/or what the observation is about
... effective[x] SΣ0..1(QI-Core)(USCDI) Clinically relevant time/time-period for observation
.... 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
... Slices for value[x] SΣC0..1(QI-Core)(USCDI) Actual result
Slice: Unordered, Open by type:$this
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... value[x]:valueCodeableConcept SΣC0..1CodeableConcept(QI-Core) actual | potential
Binding: US Core Observation Value Codes (SNOMED-CT) (preferred): SNOMED CT for coded results

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


... derivedFrom Σ0..*Reference(QICore Simple Observation | QICore QuestionnaireResponse | QICore ImagingStudy | US Core DocumentReference Profile | Media | MolecularSequence)(QI-Core)(USCDI) US Core Profiles or other resource the observation is made from

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.statusrequiredNonNegativeObservationStatus
http://hl7.org/fhir/us/qicore/ValueSet/qicore-non-negative-observation-status
from this IG
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 C0..*USCoreSimpleObservationProfileassessment observation
... 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 (preferred): Codes for high level observation categories.


.... category:us-core S0..*CodeableConcept(USCDI) 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 SΣ1..1CodeableConcept(QI-Core)(USCDI) Type of observation (code / type)
Binding: LOINCCodes (preferred): This value set specifies the type of observation

... 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] SΣ0..1(QI-Core)(USCDI) Clinically relevant time/time-period for observation
.... 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
... Slices for value[x] SΣC0..1(QI-Core)(USCDI) Actual result
Slice: Unordered, Open by type:$this
.... valueQuantityQuantity S
.... valueCodeableConceptCodeableConcept S
.... valueStringstring S
.... valueBooleanboolean S
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
.... value[x]:valueCodeableConcept SΣC0..1CodeableConcept S(QI-Core) actual | potential
Binding: US Core Observation Value Codes (SNOMED-CT) (preferred): SNOMED CT for coded results

... dataAbsentReason C0..1CodeableConceptWhy 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
.... 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 Σ0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)Related resource that belongs to the Observation group
... derivedFrom Σ0..*Reference(QICore Simple Observation | QICore QuestionnaireResponse | QICore ImagingStudy | US Core DocumentReference Profile | Media | MolecularSequence)(QI-Core)(USCDI) US Core Profiles or other resource 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

PathConformanceValueSetURI
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.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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