HRSA 2024 Uniform Data System (UDS) Patient Level Submission (PLS) (UDS+) FHIR IG
2.0.0 - STU2 Release 1 - Standard for Trial-Use
HRSA 2024 Uniform Data System (UDS) Patient Level Submission (PLS) (UDS+) FHIR IG
2.0.0 - STU2 Release 1 - Standard for Trial-Use
HRSA 2024 Uniform Data System (UDS) Patient Level Submission (PLS) (UDS+) FHIR IG, published by HRSA BPHC. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/drajer-health/uds-plus/ and changes regularly. See the Directory of published versions
| Official URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-observation | Version: 2.0.0 | |||
| Standards status: Trial-use | Maturity Level: 2 | Computable Name: UDSPlusObservation | ||
The UDS+ profile is based on the Observation resource and establishes the core elements, extensions, vocabularies and value sets for representing assessments, vitals and other social history observations for UDS+ program.
The following is new content for 1.1.0
This profile is used to represent de-identified Observation for Assessments, Physical Exams, Assessment and Social History information. The de-identification process has to remove all data elements not explicitly identified as "SUPPORTED" in the profile.
The HHS De-identification Guidance is to be followed to ensure appropriate level of de-identification is performed.
According to the HHS guidance, dates should not have a precision of more than the year. This means month and day cannot be included. This includes Observation for Lab Result.period.
In FHIR Resources, text elements and reference.display elements which provide human readable information to the providers may be generated using programs and tools from the data present within the resource. For e.g a Observation for Lab Result resource text element may contain information such as the Observation for Lab Result date, patient information. This type of information will enable identification of the individuals. In order to avoid inadvertent revealing of PII/PHI, text elements cannot be included in the De-identified FHIR resource and the submission will be rejected when text elements are present by the validation process.
Ids and References
The original Observation for Lab Result resource id should not be included in the De-identified Observation for Lab Result instance. Instead a new id should be created and provided as part of the FHIR resource. The Data Submitter should be capable of using the generated id to relink the data to the original Observation for Lab Result. All resource references to the Observation for Lab Result submitted as part of the UDS+ report should refer to newly generated id.
Resource references cannot contain text element as it may contain PHI/PII. The text element for following references are not allowed
Date Truncation
The Data Submitter has to truncate the following dates to only have a precision of year
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Observation |
0..* | Observation | De-Identified UDS Plus Observation | |
  id |
S | 0..1 | id | The de-identified Observation identifier created by the health center to send data to UDS+ Data Receiver |
| text |
0..0 | |||
| contained |
0..0 | |||
  Slices for extension |
Content/Rules for all slices | |||
   deidentifiedIssuedTime |
0..1 | dateTime | Indicates the time with a precision of only Year. URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-deidentified-instant-extension | |
| status |
S | 1..1 | code | registered | preliminary | final | amended + |
| category |
S | 1..* | CodeableConcept | Classification of type of observation |
| code |
S | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (preferred): The set of codes indicating the Observations |
 subject |
S | 1..1 | Reference(De-Identified UDS Plus Patient) | Who and/or what the observation is about |
 display |
0..0 | |||
| encounter |
S | 0..1 | Reference(De-Identified UDS Plus Encounter) | Healthcare event during which this observation is made |
| display |
0..0 | |||
 effective[x] |
SC | 0..1 | Clinically relevant time/time-period for observation uds-plus-obs-1: All dateTime data elements should be truncated to a year only for de-identified resources. uds-plus-obs-2: All Period.start data elements should be truncated to a year only for de-identified resources. uds-plus-obs-3: All Period.emd data elements should be truncated to a year only for de-identified resources. uds-plus-obs-4: All Timing.event data elements should be truncated to a year only for de-identified resources. uds-plus-obs-5: All Timing.event data elements should be truncated to a year only for de-identified resources. | |
 effectiveDateTime |
dateTime S | |||
 effectivePeriod |
Period | |||
| effectiveTiming |
Timing | |||
| issued |
0..0 | |||
| performer |
S | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation |
| display |
0..0 | |||
| value[x] |
SC | 0..1 | Actual result uds-plus-obs-6: All dateTime data elements should be truncated to a year only for de-identified resources. uds-plus-obs-7: All Period.start data elements should be truncated to a year only for de-identified resources. uds-plus-obs-8: All Period.end data elements should be truncated to a year only for de-identified resources. | |
| valueQuantity |
Quantity S | |||
| valueCodeableConcept |
CodeableConcept S | |||
| valueString |
string S | |||
| valueBoolean |
boolean | |||
| valueInteger |
integer | |||
| valueRange |
Range | |||
| valueRatio |
Ratio | |||
| valueSampledData |
SampledData | |||
| valueDateTime |
dateTime | |||
| valuePeriod |
Period | |||
| note |
0..0 | |||
| bodySite |
S | 0..1 | CodeableConcept | Observed body part |
 component |
S | 0..* | BackboneElement | Component results |
 code |
S | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (preferred): The set of codes indicating the Observations |
| value[x] |
SC | 0..1 | Actual component result uds-plus-obs-9: All dateTime data elements should be truncated to a year only for de-identified resources. uds-plus-obs-10: All Period.start data elements should be truncated to a year only for de-identified resources. uds-plus-obs-11: All Period.end data elements should be truncated to a year only for de-identified resources. | |
| valueQuantity |
Quantity S | |||
| valueCodeableConcept |
CodeableConcept S | |||
| valueString |
string S | |||
| valueBoolean |
boolean | |||
| valueInteger |
integer | |||
| valueRange |
Range | |||
| valueRatio |
Ratio | |||
| valueSampledData |
SampledData | |||
| valueDateTime |
dateTime | |||
| valuePeriod |
Period | |||
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Observation.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | |
| Observation.component.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| uds-plus-obs-1 | error | Observation.effective[x] | All dateTime data elements should be truncated to a year only for de-identified resources. : $this is DateTime implies $this.toString().length() = 4 | |
| uds-plus-obs-2 | error | Observation.effective[x] | All Period.start data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.start.exists() implies $this.start.toString().length() = 4 | |
| uds-plus-obs-3 | error | Observation.effective[x] | All Period.emd data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.end.exists() implies $this.end.toString().length() = 4 | |
| uds-plus-obs-4 | error | Observation.effective[x] | All Timing.event data elements should be truncated to a year only for de-identified resources. : $this is Timing and Timing.event.exists() implies $this.event.count() = 1 | |
| uds-plus-obs-5 | error | Observation.effective[x] | All Timing.event data elements should be truncated to a year only for de-identified resources. : $this is Timing and Timing.event.exists() implies $this.event.first().toString().length() = 4 | |
| uds-plus-obs-6 | error | Observation.value[x] | All dateTime data elements should be truncated to a year only for de-identified resources. : $this is dateTime implies $this.toString().length() = 4 | |
| uds-plus-obs-7 | error | Observation.value[x] | All Period.start data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.start.exists() implies $this.start.toString().length() = 4 | |
| uds-plus-obs-8 | error | Observation.value[x] | All Period.end data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.end.exists() implies $this.end.toString().length() = 4 | |
| uds-plus-obs-9 | error | Observation.component.value[x] | All dateTime data elements should be truncated to a year only for de-identified resources. : $this is dateTime implies $this.toString().length() = 4 | |
| uds-plus-obs-10 | error | Observation.component.value[x] | All Period.start data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.start.exists() implies $this.start.toString().length() = 4 | |
| uds-plus-obs-11 | error | Observation.component.value[x] | All Period.end data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.end.exists() implies $this.end.toString().length() = 4 |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation |
C | 0..* | Observation | De-Identified UDS Plus 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 |
SΣ | 0..1 | id | The de-identified Observation identifier created by the health center to send data to UDS+ Data Receiver |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
Content/Rules for all slices | |||
| deidentifiedIssuedTime |
0..1 | dateTime | Indicates the time with a precision of only Year. URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-deidentified-instant-extension | |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
| category |
S | 1..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
| code |
SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (preferred): The set of codes indicating the Observations |
| subject |
SΣ | 1..1 | Reference(De-Identified UDS Plus Patient) | Who and/or what the observation is about |
| encounter |
SΣ | 0..1 | Reference(De-Identified UDS Plus Encounter) | Healthcare event during which this observation is made |
| effective[x] |
SΣC | 0..1 | Clinically relevant time/time-period for observation uds-plus-obs-1: All dateTime data elements should be truncated to a year only for de-identified resources. uds-plus-obs-2: All Period.start data elements should be truncated to a year only for de-identified resources. uds-plus-obs-3: All Period.emd data elements should be truncated to a year only for de-identified resources. uds-plus-obs-4: All Timing.event data elements should be truncated to a year only for de-identified resources. uds-plus-obs-5: All Timing.event data elements should be truncated to a year only for de-identified resources. | |
| effectiveDateTime |
dateTime | |||
| performer |
SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation |
| value[x] |
SΣC | 0..1 | Actual result uds-plus-obs-6: All dateTime data elements should be truncated to a year only for de-identified resources. uds-plus-obs-7: All Period.start data elements should be truncated to a year only for de-identified resources. uds-plus-obs-8: All Period.end data elements should be truncated to a year only for de-identified resources. | |
| valueQuantity |
Quantity | |||
| valueCodeableConcept |
CodeableConcept | |||
| valueString |
string | |||
| bodySite |
S | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
| component |
SΣ | 0..* | BackboneElement | Component results |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
SΣ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (preferred): The set of codes indicating the Observations |
| value[x] |
SΣC | 0..1 | Actual component result uds-plus-obs-9: All dateTime data elements should be truncated to a year only for de-identified resources. uds-plus-obs-10: All Period.start data elements should be truncated to a year only for de-identified resources. uds-plus-obs-11: All Period.end data elements should be truncated to a year only for de-identified resources. | |
| valueQuantity |
Quantity | |||
| valueCodeableConcept |
CodeableConcept | |||
| valueString |
string | |||
| Documentation for this format | ||||
| Path | Conformance | ValueSet | 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.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | |
| Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | |
| Observation.component.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom 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() | |
| uds-plus-obs-1 | error | Observation.effective[x] | All dateTime data elements should be truncated to a year only for de-identified resources. : $this is DateTime implies $this.toString().length() = 4 | |
| uds-plus-obs-2 | error | Observation.effective[x] | All Period.start data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.start.exists() implies $this.start.toString().length() = 4 | |
| uds-plus-obs-3 | error | Observation.effective[x] | All Period.emd data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.end.exists() implies $this.end.toString().length() = 4 | |
| uds-plus-obs-4 | error | Observation.effective[x] | All Timing.event data elements should be truncated to a year only for de-identified resources. : $this is Timing and Timing.event.exists() implies $this.event.count() = 1 | |
| uds-plus-obs-5 | error | Observation.effective[x] | All Timing.event data elements should be truncated to a year only for de-identified resources. : $this is Timing and Timing.event.exists() implies $this.event.first().toString().length() = 4 | |
| uds-plus-obs-6 | error | Observation.value[x] | All dateTime data elements should be truncated to a year only for de-identified resources. : $this is dateTime implies $this.toString().length() = 4 | |
| uds-plus-obs-7 | error | Observation.value[x] | All Period.start data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.start.exists() implies $this.start.toString().length() = 4 | |
| uds-plus-obs-8 | error | Observation.value[x] | All Period.end data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.end.exists() implies $this.end.toString().length() = 4 | |
| uds-plus-obs-9 | error | Observation.component.value[x] | All dateTime data elements should be truncated to a year only for de-identified resources. : $this is dateTime implies $this.toString().length() = 4 | |
| uds-plus-obs-10 | error | Observation.component.value[x] | All Period.start data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.start.exists() implies $this.start.toString().length() = 4 | |
| uds-plus-obs-11 | error | Observation.component.value[x] | All Period.end data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.end.exists() implies $this.end.toString().length() = 4 |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Observation |
C | 0..* | Observation | De-Identified UDS Plus 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 |
SΣ | 0..1 | id | The de-identified Observation identifier created by the health center to send data to UDS+ Data Receiver | ||||
| 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.
| |||||
 Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| deidentifiedIssuedTime |
0..1 | dateTime | Indicates the time with a precision of only Year. URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-deidentified-instant-extension | |||||
| 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 | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
| category |
S | 1..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
| code |
SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (preferred): The set of codes indicating the Observations | ||||
| subject |
SΣ | 1..1 | Reference(De-Identified UDS Plus Patient) | Who and/or what the observation is about | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| focus |
Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
| encounter |
SΣ | 0..1 | Reference(De-Identified UDS Plus Encounter) | Healthcare event during which this observation is made | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| effective[x] |
SΣC | 0..1 | Clinically relevant time/time-period for observation uds-plus-obs-1: All dateTime data elements should be truncated to a year only for de-identified resources. uds-plus-obs-2: All Period.start data elements should be truncated to a year only for de-identified resources. uds-plus-obs-3: All Period.emd data elements should be truncated to a year only for de-identified resources. uds-plus-obs-4: All Timing.event data elements should be truncated to a year only for de-identified resources. uds-plus-obs-5: All Timing.event data elements should be truncated to a year only for de-identified resources. | |||||
| effectiveDateTime |
dateTime S | |||||||
| effectivePeriod |
Period | |||||||
| effectiveTiming |
Timing | |||||||
| performer |
SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| value[x] |
SΣC | 0..1 | Actual result uds-plus-obs-6: All dateTime data elements should be truncated to a year only for de-identified resources. uds-plus-obs-7: All Period.start data elements should be truncated to a year only for de-identified resources. uds-plus-obs-8: All Period.end data elements should be truncated to a year only for de-identified resources. | |||||
| valueQuantity |
Quantity S | |||||||
| valueCodeableConcept |
CodeableConcept S | |||||||
| valueString |
string S | |||||||
| valueBoolean |
boolean | |||||||
| valueInteger |
integer | |||||||
| valueRange |
Range | |||||||
| valueRatio |
Ratio | |||||||
| valueSampledData |
SampledData | |||||||
| valueDateTime |
dateTime | |||||||
| valuePeriod |
Period | |||||||
| 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 | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
| bodySite |
S | 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(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
| component |
SΣ | 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 |
SΣ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (preferred): The set of codes indicating the Observations | ||||
| value[x] |
SΣC | 0..1 | Actual component result uds-plus-obs-9: All dateTime data elements should be truncated to a year only for de-identified resources. uds-plus-obs-10: All Period.start data elements should be truncated to a year only for de-identified resources. uds-plus-obs-11: All Period.end data elements should be truncated to a year only for de-identified resources. | |||||
| valueQuantity |
Quantity S | |||||||
| valueCodeableConcept |
CodeableConcept S | |||||||
| valueString |
string S | |||||||
| valueBoolean |
boolean | |||||||
| valueInteger |
integer | |||||||
| valueRange |
Range | |||||||
| valueRatio |
Ratio | |||||||
| valueSampledData |
SampledData | |||||||
| 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 | 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.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Observation.encounter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Observation.performer.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| 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 | preferred | 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() | |
| uds-plus-obs-1 | error | Observation.effective[x] | All dateTime data elements should be truncated to a year only for de-identified resources. : $this is DateTime implies $this.toString().length() = 4 | |
| uds-plus-obs-2 | error | Observation.effective[x] | All Period.start data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.start.exists() implies $this.start.toString().length() = 4 | |
| uds-plus-obs-3 | error | Observation.effective[x] | All Period.emd data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.end.exists() implies $this.end.toString().length() = 4 | |
| uds-plus-obs-4 | error | Observation.effective[x] | All Timing.event data elements should be truncated to a year only for de-identified resources. : $this is Timing and Timing.event.exists() implies $this.event.count() = 1 | |
| uds-plus-obs-5 | error | Observation.effective[x] | All Timing.event data elements should be truncated to a year only for de-identified resources. : $this is Timing and Timing.event.exists() implies $this.event.first().toString().length() = 4 | |
| uds-plus-obs-6 | error | Observation.value[x] | All dateTime data elements should be truncated to a year only for de-identified resources. : $this is dateTime implies $this.toString().length() = 4 | |
| uds-plus-obs-7 | error | Observation.value[x] | All Period.start data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.start.exists() implies $this.start.toString().length() = 4 | |
| uds-plus-obs-8 | error | Observation.value[x] | All Period.end data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.end.exists() implies $this.end.toString().length() = 4 | |
| uds-plus-obs-9 | error | Observation.component.value[x] | All dateTime data elements should be truncated to a year only for de-identified resources. : $this is dateTime implies $this.toString().length() = 4 | |
| uds-plus-obs-10 | error | Observation.component.value[x] | All Period.start data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.start.exists() implies $this.start.toString().length() = 4 | |
| uds-plus-obs-11 | error | Observation.component.value[x] | All Period.end data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.end.exists() implies $this.end.toString().length() = 4 |
This structure is derived from Observation
Summary
Mandatory: 4 elements(1 nested mandatory element)
Must-Support: 13 elements
Prohibited: 7 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 2
Differential View
This structure is derived from Observation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation |
0..* | Observation | De-Identified UDS Plus Observation | |
| id |
S | 0..1 | id | The de-identified Observation identifier created by the health center to send data to UDS+ Data Receiver |
| text |
0..0 | |||
| contained |
0..0 | |||
| Slices for extension |
Content/Rules for all slices | |||
| deidentifiedIssuedTime |
0..1 | dateTime | Indicates the time with a precision of only Year. URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-deidentified-instant-extension | |
| status |
S | 1..1 | code | registered | preliminary | final | amended + |
| category |
S | 1..* | CodeableConcept | Classification of type of observation |
| code |
S | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (preferred): The set of codes indicating the Observations |
| subject |
S | 1..1 | Reference(De-Identified UDS Plus Patient) | Who and/or what the observation is about |
| display |
0..0 | |||
| encounter |
S | 0..1 | Reference(De-Identified UDS Plus Encounter) | Healthcare event during which this observation is made |
| display |
0..0 | |||
| effective[x] |
SC | 0..1 | Clinically relevant time/time-period for observation uds-plus-obs-1: All dateTime data elements should be truncated to a year only for de-identified resources. uds-plus-obs-2: All Period.start data elements should be truncated to a year only for de-identified resources. uds-plus-obs-3: All Period.emd data elements should be truncated to a year only for de-identified resources. uds-plus-obs-4: All Timing.event data elements should be truncated to a year only for de-identified resources. uds-plus-obs-5: All Timing.event data elements should be truncated to a year only for de-identified resources. | |
| effectiveDateTime |
dateTime S | |||
| effectivePeriod |
Period | |||
| effectiveTiming |
Timing | |||
| issued |
0..0 | |||
| performer |
S | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation |
| display |
0..0 | |||
| value[x] |
SC | 0..1 | Actual result uds-plus-obs-6: All dateTime data elements should be truncated to a year only for de-identified resources. uds-plus-obs-7: All Period.start data elements should be truncated to a year only for de-identified resources. uds-plus-obs-8: All Period.end data elements should be truncated to a year only for de-identified resources. | |
| valueQuantity |
Quantity S | |||
| valueCodeableConcept |
CodeableConcept S | |||
| valueString |
string S | |||
| valueBoolean |
boolean | |||
| valueInteger |
integer | |||
| valueRange |
Range | |||
| valueRatio |
Ratio | |||
| valueSampledData |
SampledData | |||
| valueDateTime |
dateTime | |||
| valuePeriod |
Period | |||
| note |
0..0 | |||
| bodySite |
S | 0..1 | CodeableConcept | Observed body part |
| component |
S | 0..* | BackboneElement | Component results |
| code |
S | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (preferred): The set of codes indicating the Observations |
| value[x] |
SC | 0..1 | Actual component result uds-plus-obs-9: All dateTime data elements should be truncated to a year only for de-identified resources. uds-plus-obs-10: All Period.start data elements should be truncated to a year only for de-identified resources. uds-plus-obs-11: All Period.end data elements should be truncated to a year only for de-identified resources. | |
| valueQuantity |
Quantity S | |||
| valueCodeableConcept |
CodeableConcept S | |||
| valueString |
string S | |||
| valueBoolean |
boolean | |||
| valueInteger |
integer | |||
| valueRange |
Range | |||
| valueRatio |
Ratio | |||
| valueSampledData |
SampledData | |||
| valueDateTime |
dateTime | |||
| valuePeriod |
Period | |||
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Observation.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | |
| Observation.component.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| uds-plus-obs-1 | error | Observation.effective[x] | All dateTime data elements should be truncated to a year only for de-identified resources. : $this is DateTime implies $this.toString().length() = 4 | |
| uds-plus-obs-2 | error | Observation.effective[x] | All Period.start data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.start.exists() implies $this.start.toString().length() = 4 | |
| uds-plus-obs-3 | error | Observation.effective[x] | All Period.emd data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.end.exists() implies $this.end.toString().length() = 4 | |
| uds-plus-obs-4 | error | Observation.effective[x] | All Timing.event data elements should be truncated to a year only for de-identified resources. : $this is Timing and Timing.event.exists() implies $this.event.count() = 1 | |
| uds-plus-obs-5 | error | Observation.effective[x] | All Timing.event data elements should be truncated to a year only for de-identified resources. : $this is Timing and Timing.event.exists() implies $this.event.first().toString().length() = 4 | |
| uds-plus-obs-6 | error | Observation.value[x] | All dateTime data elements should be truncated to a year only for de-identified resources. : $this is dateTime implies $this.toString().length() = 4 | |
| uds-plus-obs-7 | error | Observation.value[x] | All Period.start data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.start.exists() implies $this.start.toString().length() = 4 | |
| uds-plus-obs-8 | error | Observation.value[x] | All Period.end data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.end.exists() implies $this.end.toString().length() = 4 | |
| uds-plus-obs-9 | error | Observation.component.value[x] | All dateTime data elements should be truncated to a year only for de-identified resources. : $this is dateTime implies $this.toString().length() = 4 | |
| uds-plus-obs-10 | error | Observation.component.value[x] | All Period.start data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.start.exists() implies $this.start.toString().length() = 4 | |
| uds-plus-obs-11 | error | Observation.component.value[x] | All Period.end data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.end.exists() implies $this.end.toString().length() = 4 |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation |
C | 0..* | Observation | De-Identified UDS Plus 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 |
SΣ | 0..1 | id | The de-identified Observation identifier created by the health center to send data to UDS+ Data Receiver |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
Content/Rules for all slices | |||
| deidentifiedIssuedTime |
0..1 | dateTime | Indicates the time with a precision of only Year. URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-deidentified-instant-extension | |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
| category |
S | 1..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
| code |
SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (preferred): The set of codes indicating the Observations |
| subject |
SΣ | 1..1 | Reference(De-Identified UDS Plus Patient) | Who and/or what the observation is about |
| encounter |
SΣ | 0..1 | Reference(De-Identified UDS Plus Encounter) | Healthcare event during which this observation is made |
| effective[x] |
SΣC | 0..1 | Clinically relevant time/time-period for observation uds-plus-obs-1: All dateTime data elements should be truncated to a year only for de-identified resources. uds-plus-obs-2: All Period.start data elements should be truncated to a year only for de-identified resources. uds-plus-obs-3: All Period.emd data elements should be truncated to a year only for de-identified resources. uds-plus-obs-4: All Timing.event data elements should be truncated to a year only for de-identified resources. uds-plus-obs-5: All Timing.event data elements should be truncated to a year only for de-identified resources. | |
| effectiveDateTime |
dateTime | |||
| performer |
SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation |
| value[x] |
SΣC | 0..1 | Actual result uds-plus-obs-6: All dateTime data elements should be truncated to a year only for de-identified resources. uds-plus-obs-7: All Period.start data elements should be truncated to a year only for de-identified resources. uds-plus-obs-8: All Period.end data elements should be truncated to a year only for de-identified resources. | |
| valueQuantity |
Quantity | |||
| valueCodeableConcept |
CodeableConcept | |||
| valueString |
string | |||
| bodySite |
S | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
| component |
SΣ | 0..* | BackboneElement | Component results |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
SΣ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (preferred): The set of codes indicating the Observations |
| value[x] |
SΣC | 0..1 | Actual component result uds-plus-obs-9: All dateTime data elements should be truncated to a year only for de-identified resources. uds-plus-obs-10: All Period.start data elements should be truncated to a year only for de-identified resources. uds-plus-obs-11: All Period.end data elements should be truncated to a year only for de-identified resources. | |
| valueQuantity |
Quantity | |||
| valueCodeableConcept |
CodeableConcept | |||
| valueString |
string | |||
| Documentation for this format | ||||
| Path | Conformance | ValueSet | 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.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | |
| Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | |
| Observation.component.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom 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() | |
| uds-plus-obs-1 | error | Observation.effective[x] | All dateTime data elements should be truncated to a year only for de-identified resources. : $this is DateTime implies $this.toString().length() = 4 | |
| uds-plus-obs-2 | error | Observation.effective[x] | All Period.start data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.start.exists() implies $this.start.toString().length() = 4 | |
| uds-plus-obs-3 | error | Observation.effective[x] | All Period.emd data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.end.exists() implies $this.end.toString().length() = 4 | |
| uds-plus-obs-4 | error | Observation.effective[x] | All Timing.event data elements should be truncated to a year only for de-identified resources. : $this is Timing and Timing.event.exists() implies $this.event.count() = 1 | |
| uds-plus-obs-5 | error | Observation.effective[x] | All Timing.event data elements should be truncated to a year only for de-identified resources. : $this is Timing and Timing.event.exists() implies $this.event.first().toString().length() = 4 | |
| uds-plus-obs-6 | error | Observation.value[x] | All dateTime data elements should be truncated to a year only for de-identified resources. : $this is dateTime implies $this.toString().length() = 4 | |
| uds-plus-obs-7 | error | Observation.value[x] | All Period.start data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.start.exists() implies $this.start.toString().length() = 4 | |
| uds-plus-obs-8 | error | Observation.value[x] | All Period.end data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.end.exists() implies $this.end.toString().length() = 4 | |
| uds-plus-obs-9 | error | Observation.component.value[x] | All dateTime data elements should be truncated to a year only for de-identified resources. : $this is dateTime implies $this.toString().length() = 4 | |
| uds-plus-obs-10 | error | Observation.component.value[x] | All Period.start data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.start.exists() implies $this.start.toString().length() = 4 | |
| uds-plus-obs-11 | error | Observation.component.value[x] | All Period.end data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.end.exists() implies $this.end.toString().length() = 4 |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Observation |
C | 0..* | Observation | De-Identified UDS Plus 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 |
SΣ | 0..1 | id | The de-identified Observation identifier created by the health center to send data to UDS+ Data Receiver | ||||
| 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.
| |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| deidentifiedIssuedTime |
0..1 | dateTime | Indicates the time with a precision of only Year. URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-deidentified-instant-extension | |||||
| 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 | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
| category |
S | 1..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
| code |
SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (preferred): The set of codes indicating the Observations | ||||
| subject |
SΣ | 1..1 | Reference(De-Identified UDS Plus Patient) | Who and/or what the observation is about | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| focus |
Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
| encounter |
SΣ | 0..1 | Reference(De-Identified UDS Plus Encounter) | Healthcare event during which this observation is made | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| effective[x] |
SΣC | 0..1 | Clinically relevant time/time-period for observation uds-plus-obs-1: All dateTime data elements should be truncated to a year only for de-identified resources. uds-plus-obs-2: All Period.start data elements should be truncated to a year only for de-identified resources. uds-plus-obs-3: All Period.emd data elements should be truncated to a year only for de-identified resources. uds-plus-obs-4: All Timing.event data elements should be truncated to a year only for de-identified resources. uds-plus-obs-5: All Timing.event data elements should be truncated to a year only for de-identified resources. | |||||
| effectiveDateTime |
dateTime S | |||||||
| effectivePeriod |
Period | |||||||
| effectiveTiming |
Timing | |||||||
| performer |
SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| value[x] |
SΣC | 0..1 | Actual result uds-plus-obs-6: All dateTime data elements should be truncated to a year only for de-identified resources. uds-plus-obs-7: All Period.start data elements should be truncated to a year only for de-identified resources. uds-plus-obs-8: All Period.end data elements should be truncated to a year only for de-identified resources. | |||||
| valueQuantity |
Quantity S | |||||||
| valueCodeableConcept |
CodeableConcept S | |||||||
| valueString |
string S | |||||||
| valueBoolean |
boolean | |||||||
| valueInteger |
integer | |||||||
| valueRange |
Range | |||||||
| valueRatio |
Ratio | |||||||
| valueSampledData |
SampledData | |||||||
| valueDateTime |
dateTime | |||||||
| valuePeriod |
Period | |||||||
| 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 | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
| bodySite |
S | 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(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
| component |
SΣ | 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 |
SΣ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (preferred): The set of codes indicating the Observations | ||||
| value[x] |
SΣC | 0..1 | Actual component result uds-plus-obs-9: All dateTime data elements should be truncated to a year only for de-identified resources. uds-plus-obs-10: All Period.start data elements should be truncated to a year only for de-identified resources. uds-plus-obs-11: All Period.end data elements should be truncated to a year only for de-identified resources. | |||||
| valueQuantity |
Quantity S | |||||||
| valueCodeableConcept |
CodeableConcept S | |||||||
| valueString |
string S | |||||||
| valueBoolean |
boolean | |||||||
| valueInteger |
integer | |||||||
| valueRange |
Range | |||||||
| valueRatio |
Ratio | |||||||
| valueSampledData |
SampledData | |||||||
| 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 | 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.code | preferred | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Observation.encounter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Observation.performer.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| 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 | preferred | 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() | |
| uds-plus-obs-1 | error | Observation.effective[x] | All dateTime data elements should be truncated to a year only for de-identified resources. : $this is DateTime implies $this.toString().length() = 4 | |
| uds-plus-obs-2 | error | Observation.effective[x] | All Period.start data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.start.exists() implies $this.start.toString().length() = 4 | |
| uds-plus-obs-3 | error | Observation.effective[x] | All Period.emd data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.end.exists() implies $this.end.toString().length() = 4 | |
| uds-plus-obs-4 | error | Observation.effective[x] | All Timing.event data elements should be truncated to a year only for de-identified resources. : $this is Timing and Timing.event.exists() implies $this.event.count() = 1 | |
| uds-plus-obs-5 | error | Observation.effective[x] | All Timing.event data elements should be truncated to a year only for de-identified resources. : $this is Timing and Timing.event.exists() implies $this.event.first().toString().length() = 4 | |
| uds-plus-obs-6 | error | Observation.value[x] | All dateTime data elements should be truncated to a year only for de-identified resources. : $this is dateTime implies $this.toString().length() = 4 | |
| uds-plus-obs-7 | error | Observation.value[x] | All Period.start data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.start.exists() implies $this.start.toString().length() = 4 | |
| uds-plus-obs-8 | error | Observation.value[x] | All Period.end data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.end.exists() implies $this.end.toString().length() = 4 | |
| uds-plus-obs-9 | error | Observation.component.value[x] | All dateTime data elements should be truncated to a year only for de-identified resources. : $this is dateTime implies $this.toString().length() = 4 | |
| uds-plus-obs-10 | error | Observation.component.value[x] | All Period.start data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.start.exists() implies $this.start.toString().length() = 4 | |
| uds-plus-obs-11 | error | Observation.component.value[x] | All Period.end data elements should be truncated to a year only for de-identified resources. : $this is Period and Period.end.exists() implies $this.end.toString().length() = 4 |
This structure is derived from Observation
Summary
Mandatory: 4 elements(1 nested mandatory element)
Must-Support: 13 elements
Prohibited: 7 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 2
Other representations of profile: CSV, Excel, Schematron