MCC eCare Plan Implementation Guide
1.0.0 - STU1
MCC eCare Plan Implementation Guide
1.0.0 - STU1
MCC eCare Plan Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-us-mcc/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/us/mcc/StructureDefinition/MCCPatientCaregiverConditionStatus | Version: 1.0.0 | |||
| Active as of 2022-09-27 | Computable Name: MCCPatientCaregiverConditionStatus | |||
This profile constrains US Core Simple Observation for use in the MCC FHIR Care Plan or other FHIR Care Plans. It is using Observation resource to record, search, and fetch Observations of the Patient or Caregivers feelings towards the status of patient conditions. The focus is on the conditions of interest and the performer element indicates weather this is the Patient or Caregiver's feelings. This is similar to a clinical impression but is being made by a non-clinican.
The US Core Simple Observation sets minimum expectations for the Observation resource to record, search, and fetch Observations of the Patient or Caregivers feelings towards the status of patient conditions. This is similar to a clinical impression but is being made by a non-clinician. It is a self or non-professional assessment of the status of the condition/observation and intentionally has different values than Condition.status value set. The profile identifies which core elements, extensions, vocabularies and value sets SHALL be present in the resource when using this profile. In addition to the requirements set forth in US Core Simple Observation this derived profile is designed to add requirements to the following elements:
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreSimpleObservationProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Observation |
C | 0..* | USCoreSimpleObservationProfile | assessment observation us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present |
  Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
   resource-pertainesToGoal |
S | 0..* | Reference(Goal) | The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal |
  status |
S | 1..1 | code | (USCDI) registered | preliminary | final | amended + |
| category |
S | 1..* | CodeableConcept | (USCDI) Classification of type of observation |
| code |
S | 1..1 | CodeableConcept | Observation on patient/caregiver feelings on the condition status (what is the trend of the condition status?) Required Pattern: At least the following |
  coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
 system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
 code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 89253-9 | |
 subject |
S | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who and/or what the observation is about |
 focus |
S | 1..* | Reference(US Core Condition Problems and Health Concerns Profile | US Core Condition Encounter Diagnosis Profile) | What the observation is about, when it is not about the subject of record Slice: Unordered, Open by value:url |
| effective[x] |
S | 0..1 | dateTime S, Period, Timing, instant | (USCDI) Clinically relevant time/time-period for observation |
| performer |
S | 1..* | Reference(US Core Patient Profile | US Core RelatedPerson Profile) | Represents the caregiver or patient who is making the observation on the condition’s trend |
 value[x] |
S | 0..1 | Coded or narrative feeling about condition | |
 valueCodeableConcept |
CodeableConcept | |||
 valueString |
string | |||
| valueCodeableConcept |
S | 0..1 | CodeableConcept | Response for feeling about the condition Binding: LOINC Answer List LL4938-8 (example): Use CodeableConcept.text for the exact words of the patient/caregiver, or when not using a coding. valueString is also available as an alternative to valueCodeableConcept. |
| text |
0..1 | string | can be used with or in place of code to provide a string representation | |
| dataAbsentReason |
S | 0..1 | CodeableConcept | Why the result is missing |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Observation.valueCodeableConcept | example | LOINC LL4938-8http://loinc.org/vs/LL4938-8 |
| Id | Grade | Path(s) | Details | Requirements |
| us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| 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 us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| resource-pertainesToGoal |
S | 0..* | Reference(Goal) | The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣ | 1..1 | code | (USCDI) registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
| Slices for category |
S | 1..* | CodeableConcept | (USCDI) Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
| category:us-core |
S | 0..* | CodeableConcept | (USCDI) Classification of type of observation Binding: US Core Simple Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets |
| code |
SΣ | 1..1 | CodeableConcept | Observation on patient/caregiver feelings on the condition status (what is the trend of the condition status?) Binding: LOINCCodes (preferred) Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 89253-9 | |
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who and/or what the observation is about |
| focus |
SΣ | 1..* | Reference(US Core Condition Problems and Health Concerns Profile | US Core Condition Encounter Diagnosis Profile) | What the observation is about, when it is not about the subject of record Slice: Unordered, Open by value:url |
| effective[x] |
SΣ | 0..1 | (USCDI) Clinically relevant time/time-period for observation | |
| effectiveDateTime |
dateTime | |||
| performer |
SΣ | 1..* | Reference(US Core Patient Profile | US Core RelatedPerson Profile) | Represents the caregiver or patient who is making the observation on the condition’s trend |
| Slices for value[x] |
SΣC | 0..1 | Coded or narrative feeling about condition Slice: Unordered, Open by type:$this | |
 valueCodeableConcept |
CodeableConcept | |||
| valueString |
string | |||
| value[x]:valueCodeableConcept |
SΣC | 0..1 | CodeableConcept | Response for feeling about the condition Binding: LOINC Answer List LL4938-8 (example): Use CodeableConcept.text for the exact words of the patient/caregiver, or when not using a coding. valueString is also available as an alternative to valueCodeableConcept. |
| dataAbsentReason |
SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1from the FHIR Standard | |
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | |
| Observation.category:us-core | required | USCoreSimpleObservationCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-simple-observation-category | |
| Observation.code | preferred | Pattern: LOINC Code 89253-9http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | |
| Observation.value[x]:valueCodeableConcept | example | LOINC LL4938-8http://loinc.org/vs/LL4938-8 | |
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Observation | If 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-4 | error | Observation | If 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-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
| us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| 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 us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must 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.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| resource-pertainesToGoal |
S | 0..* | Reference(Goal) | The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | Business Identifier for observation | ||||
| basedOn |
Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | ||||
| partOf |
Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
| status |
?!SΣ | 1..1 | code | (USCDI) registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
| Slices for category |
S | 1..* | CodeableConcept | (USCDI) 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 | (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 |
SΣ | 1..1 | CodeableConcept | Observation on patient/caregiver feelings on the condition status (what is the trend of the condition status?) Binding: LOINCCodes (preferred) Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 89253-9 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who and/or what the observation is about | ||||
| focus |
SΣ | 1..* | Reference(US Core Condition Problems and Health Concerns Profile | US Core Condition Encounter Diagnosis Profile) | What the observation is about, when it is not about the subject of record Slice: Unordered, Open by value:url | ||||
| encounter |
Σ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made | ||||
| effective[x] |
SΣ | 0..1 | (USCDI) 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 | 1..* | Reference(US Core Patient Profile | US Core RelatedPerson Profile) | Represents the caregiver or patient who is making the observation on the condition’s trend | ||||
| Slices for value[x] |
SΣC | 0..1 | Coded or narrative feeling about condition Slice: Unordered, Open by type:$this | |||||
| valueCodeableConcept |
CodeableConcept S | |||||||
| valueString |
string S | |||||||
 value[x]:valueCodeableConcept |
SΣC | 0..1 | CodeableConcept S | Response for feeling about the condition Binding: LOINC Answer List LL4938-8 (example): Use CodeableConcept.text for the exact words of the patient/caregiver, or when not using a coding. valueString is also available as an alternative to valueCodeableConcept. | ||||
 id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
Σ | 0..* | Coding | Code defined by a terminology system | ||||
 text |
Σ | 0..1 | string | can be used with or in place of code to provide a string representation | ||||
| dataAbsentReason |
SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
| interpretation |
0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
| note |
0..* | Annotation | Comments about the observation | |||||
| bodySite |
0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
| method |
0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |||||
| specimen |
0..1 | Reference(Specimen) | Specimen used for this observation | |||||
| device |
0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
| referenceRange |
C | 0..* | BackboneElement | Provides guide for interpretation obs-3: Must have at least a low or a high or text | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| low |
C | 0..1 | SimpleQuantity | Low Range, if relevant | ||||
| high |
C | 0..1 | SimpleQuantity | High Range, if relevant | ||||
| type |
0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range. | |||||
| appliesTo |
0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to. | |||||
| age |
0..1 | Range | Applicable age range, if relevant | |||||
| text |
0..1 | string | Text based reference range in an observation | |||||
| hasMember |
Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
| derivedFrom |
Σ | 0..* | Reference(Observation | US Core DocumentReference Profile | US Core QuestionnaireResponse Profile | ImagingStudy | Media | MolecularSequence) | (USCDI) 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 | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Observation.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1from the FHIR Standard | ||||
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | ||||
| Observation.category:us-core | required | USCoreSimpleObservationCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-simple-observation-category | ||||
| Observation.code | preferred | Pattern: LOINC Code 89253-9http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.value[x]:valueCodeableConcept | example | LOINC LL4938-8http://loinc.org/vs/LL4938-8 | ||||
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard | ||||
| Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methodsfrom the FHIR Standard | ||||
| Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaningfrom the FHIR Standard | ||||
| Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliestofrom the FHIR Standard | ||||
| Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Observation | If 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-4 | error | Observation | If 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-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
| us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
This structure is derived from USCoreSimpleObservationProfile
Summary
Mandatory: 3 elements
Must-Support: 11 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from USCoreSimpleObservationProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation |
C | 0..* | USCoreSimpleObservationProfile | assessment observation us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| resource-pertainesToGoal |
S | 0..* | Reference(Goal) | The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal |
| status |
S | 1..1 | code | (USCDI) registered | preliminary | final | amended + |
| category |
S | 1..* | CodeableConcept | (USCDI) Classification of type of observation |
| code |
S | 1..1 | CodeableConcept | Observation on patient/caregiver feelings on the condition status (what is the trend of the condition status?) Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 89253-9 | |
| subject |
S | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who and/or what the observation is about |
| focus |
S | 1..* | Reference(US Core Condition Problems and Health Concerns Profile | US Core Condition Encounter Diagnosis Profile) | What the observation is about, when it is not about the subject of record Slice: Unordered, Open by value:url |
| effective[x] |
S | 0..1 | dateTime S, Period, Timing, instant | (USCDI) Clinically relevant time/time-period for observation |
| performer |
S | 1..* | Reference(US Core Patient Profile | US Core RelatedPerson Profile) | Represents the caregiver or patient who is making the observation on the condition’s trend |
| value[x] |
S | 0..1 | Coded or narrative feeling about condition | |
| valueCodeableConcept |
CodeableConcept | |||
| valueString |
string | |||
| valueCodeableConcept |
S | 0..1 | CodeableConcept | Response for feeling about the condition Binding: LOINC Answer List LL4938-8 (example): Use CodeableConcept.text for the exact words of the patient/caregiver, or when not using a coding. valueString is also available as an alternative to valueCodeableConcept. |
| text |
0..1 | string | can be used with or in place of code to provide a string representation | |
| dataAbsentReason |
S | 0..1 | CodeableConcept | Why the result is missing |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Observation.valueCodeableConcept | example | LOINC LL4938-8http://loinc.org/vs/LL4938-8 |
| Id | Grade | Path(s) | Details | Requirements |
| us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| 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 us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| resource-pertainesToGoal |
S | 0..* | Reference(Goal) | The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣ | 1..1 | code | (USCDI) registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
| Slices for category |
S | 1..* | CodeableConcept | (USCDI) Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
| category:us-core |
S | 0..* | CodeableConcept | (USCDI) Classification of type of observation Binding: US Core Simple Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets |
| code |
SΣ | 1..1 | CodeableConcept | Observation on patient/caregiver feelings on the condition status (what is the trend of the condition status?) Binding: LOINCCodes (preferred) Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 89253-9 | |
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who and/or what the observation is about |
| focus |
SΣ | 1..* | Reference(US Core Condition Problems and Health Concerns Profile | US Core Condition Encounter Diagnosis Profile) | What the observation is about, when it is not about the subject of record Slice: Unordered, Open by value:url |
| effective[x] |
SΣ | 0..1 | (USCDI) Clinically relevant time/time-period for observation | |
| effectiveDateTime |
dateTime | |||
| performer |
SΣ | 1..* | Reference(US Core Patient Profile | US Core RelatedPerson Profile) | Represents the caregiver or patient who is making the observation on the condition’s trend |
| Slices for value[x] |
SΣC | 0..1 | Coded or narrative feeling about condition Slice: Unordered, Open by type:$this | |
| valueCodeableConcept |
CodeableConcept | |||
| valueString |
string | |||
| value[x]:valueCodeableConcept |
SΣC | 0..1 | CodeableConcept | Response for feeling about the condition Binding: LOINC Answer List LL4938-8 (example): Use CodeableConcept.text for the exact words of the patient/caregiver, or when not using a coding. valueString is also available as an alternative to valueCodeableConcept. |
| dataAbsentReason |
SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1from the FHIR Standard | |
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | |
| Observation.category:us-core | required | USCoreSimpleObservationCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-simple-observation-category | |
| Observation.code | preferred | Pattern: LOINC Code 89253-9http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | |
| Observation.value[x]:valueCodeableConcept | example | LOINC LL4938-8http://loinc.org/vs/LL4938-8 | |
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Observation | If 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-4 | error | Observation | If 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-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
| us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| 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 us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must 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.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| resource-pertainesToGoal |
S | 0..* | Reference(Goal) | The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | Business Identifier for observation | ||||
| basedOn |
Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | ||||
| partOf |
Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
| status |
?!SΣ | 1..1 | code | (USCDI) registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
| Slices for category |
S | 1..* | CodeableConcept | (USCDI) 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 | (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 |
SΣ | 1..1 | CodeableConcept | Observation on patient/caregiver feelings on the condition status (what is the trend of the condition status?) Binding: LOINCCodes (preferred) Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 89253-9 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who and/or what the observation is about | ||||
| focus |
SΣ | 1..* | Reference(US Core Condition Problems and Health Concerns Profile | US Core Condition Encounter Diagnosis Profile) | What the observation is about, when it is not about the subject of record Slice: Unordered, Open by value:url | ||||
| encounter |
Σ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made | ||||
| effective[x] |
SΣ | 0..1 | (USCDI) 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 | 1..* | Reference(US Core Patient Profile | US Core RelatedPerson Profile) | Represents the caregiver or patient who is making the observation on the condition’s trend | ||||
| Slices for value[x] |
SΣC | 0..1 | Coded or narrative feeling about condition Slice: Unordered, Open by type:$this | |||||
| valueCodeableConcept |
CodeableConcept S | |||||||
| valueString |
string S | |||||||
| value[x]:valueCodeableConcept |
SΣC | 0..1 | CodeableConcept S | Response for feeling about the condition Binding: LOINC Answer List LL4938-8 (example): Use CodeableConcept.text for the exact words of the patient/caregiver, or when not using a coding. valueString is also available as an alternative to valueCodeableConcept. | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
Σ | 0..* | Coding | Code defined by a terminology system | ||||
| text |
Σ | 0..1 | string | can be used with or in place of code to provide a string representation | ||||
| dataAbsentReason |
SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
| interpretation |
0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
| note |
0..* | Annotation | Comments about the observation | |||||
| bodySite |
0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
| method |
0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |||||
| specimen |
0..1 | Reference(Specimen) | Specimen used for this observation | |||||
| device |
0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
| referenceRange |
C | 0..* | BackboneElement | Provides guide for interpretation obs-3: Must have at least a low or a high or text | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| low |
C | 0..1 | SimpleQuantity | Low Range, if relevant | ||||
| high |
C | 0..1 | SimpleQuantity | High Range, if relevant | ||||
| type |
0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range. | |||||
| appliesTo |
0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to. | |||||
| age |
0..1 | Range | Applicable age range, if relevant | |||||
| text |
0..1 | string | Text based reference range in an observation | |||||
| hasMember |
Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
| derivedFrom |
Σ | 0..* | Reference(Observation | US Core DocumentReference Profile | US Core QuestionnaireResponse Profile | ImagingStudy | Media | MolecularSequence) | (USCDI) 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 | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Observation.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1from the FHIR Standard | ||||
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | ||||
| Observation.category:us-core | required | USCoreSimpleObservationCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-simple-observation-category | ||||
| Observation.code | preferred | Pattern: LOINC Code 89253-9http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.value[x]:valueCodeableConcept | example | LOINC LL4938-8http://loinc.org/vs/LL4938-8 | ||||
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard | ||||
| Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methodsfrom the FHIR Standard | ||||
| Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaningfrom the FHIR Standard | ||||
| Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliestofrom the FHIR Standard | ||||
| Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Observation | If 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-4 | error | Observation | If 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-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
| us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
This structure is derived from USCoreSimpleObservationProfile
Summary
Mandatory: 3 elements
Must-Support: 11 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2020+ HL7 International / Patient Care. Package hl7.fhir.us.mcc#1.0.0 based on FHIR 4.0.1. Generated 2024-08-13
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