AU Base Implementation Guide
6.0.0-ci-build - CI Build Australia flag

AU Base Implementation Guide, published by HL7 Australia. This guide is not an authorized publication; it is the continuous build for version 6.0.0-ci-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7au/au-fhir-base/ and changes regularly. See the Directory of published versions

Resource Profile: AU Base Pathology Result

Official URL: http://hl7.org.au/fhir/StructureDefinition/au-pathologyresult Version: 6.0.0-ci-build
Standards status: Trial-use Maturity Level: 1 Computable Name: AUBasePathologyResult

Copyright/Legal: HL7 Australia© 2018+; Licensed Under Creative Commons No Rights Reserved.

This profile defines an observation structure to represent a pathology test result issued by a diagnostic service provider in an Australian context. This profile is intended to be capable of supporting reporting for all pathology disciplines (e.g. including microbiology, histopathology, cytology, blood transfusion) with the exception of genomics. The observation may represent the result of a simple test such as haemoglobin or it may group the set of results produced by a multi-test study or panel such as a full blood count, or urine specimen study.

This profile does not provide full support for structured pathology reporting. It is expected that this support is best handled by a set of profiles that represent the structured reporting requirements for each specific protocol (see for example RCPA’s structured pathology reporting of cancer); this is not in the scope of this implementation guide at this time.

Usage Notes

Profile specific implementation guidance:

Usages:

You can also check for usages in the FHIR IG Statistics

Changes since version 5.0.0:

  • The data elements list has changed

    • Formal Views of Profile Content

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

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Observation C 0..* Observation A pathology test result in an Australian healthcare context
    Constraints: obs-6, obs-7, inv-obs-0
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... status ?!Σ 1..1 code registered | preliminary | final | amended +
    Binding: ObservationStatus (required): Codes providing the status of an observation.
    .... category:lab 1..1 CodeableConcept Observation generated by laboratories
    Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
    ..... coding Σ 1..* Coding Code defined by a terminology system
    ...... system Σ 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
    ...... code Σ 1..1 code Symbol in syntax defined by the system
    Fixed Value: laboratory
    .... category:specificDiscipline 0..* CodeableConcept Specific discipline of pathology
    Binding: Pathology Diagnostic Service Category . (extensible)
    ... code Σ 1..1 CodeableConcept Pathology test or test group
    Binding: RCPA SPIA Pathology Reporting . (preferred)
    Additional BindingsPurpose
    RCPA - SPIA Chemical Pathology Value Set . Component
    RCPA - SPIA Haematology Value Set . Component
    RCPA - SPIA Immunopathology Value Set . Component
    RCPA - SPIA Microbiology Serology Molecular Pathology Value Set . Component
    ... subject Σ 1..1 Reference(Patient) Who and/or what the observation is about
    ... effective[x] Σ 1..1 Time of specimen collection
    .... effectiveDateTime dateTime
    .... effectivePeriod Period
    .... effectiveTiming Timing
    .... effectiveInstant instant
    ... value[x] ΣC 0..1 Actual 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 result is missing
    Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
    ... specimen 0..1 Reference(AU Base Specimen) Specimen used for this observation
    ... hasMember ΣC 0..* Reference(AU Base Diagnostic Result | AU Base Pathology Result) Individual tests in a group or panel
    ... component Σ 0..* BackboneElement Individual tests in a group or panel
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... code Σ 1..1 CodeableConcept Individual pathology test
    Binding: RCPA SPIA Pathology Reporting . (preferred)
    .... value[x] ΣC 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.

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Observation.status Base required ObservationStatus 📍4.0.1 FHIR Std.
    Observation.category Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
    Observation.category:lab Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
    Observation.category:specificDiscipline Base extensible Pathology Diagnostic Service Category . ⏿1.0.0 tx.ontoserver.csiro.au
    Observation.code Base preferred RCPA SPIA Pathology Reporting . ⏿1.0.0 tx.ontoserver.csiro.au
    Observation.dataAbsentReason Base extensible DataAbsentReason 📍4.0.1 FHIR Std.
    Observation.component.​code Base preferred RCPA SPIA Pathology Reporting . ⏿1.0.0 tx.ontoserver.csiro.au
    Observation.component.​dataAbsentReason Base extensible DataAbsentReason 📍4.0.1 FHIR Std.

    Constraints

    Id Grade Path(s) Description Expression
    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()
    inv-obs-0 error Observation A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.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()

    This structure is derived from Observation

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Observation C 0..* Observation A pathology test result in an Australian healthcare context
    Constraints: inv-obs-0
    ... Slices for category 1..* CodeableConcept Classification of the service requested as laboratory + more specific discipline where available
    Slice: Unordered, Open by value:coding.system, value:coding.code
    .... category:lab 1..1 CodeableConcept Observation generated by laboratories
    ..... coding 1..* Coding Code defined by a terminology system
    ...... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
    ...... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: laboratory
    .... category:specificDiscipline 0..* CodeableConcept Specific discipline of pathology
    Binding: Pathology Diagnostic Service Category . (extensible)
    ..... coding
    ...... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
    ... code 1..1 CodeableConcept Pathology test or test group
    Binding: RCPA SPIA Pathology Reporting . (preferred)
    Additional BindingsPurpose
    RCPA - SPIA Chemical Pathology Value Set . Component
    RCPA - SPIA Haematology Value Set . Component
    RCPA - SPIA Immunopathology Value Set . Component
    RCPA - SPIA Microbiology Serology Molecular Pathology Value Set . Component
    ... subject 1..1 Reference(Patient) Who and/or what the observation is about
    ... value[x] C 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Actual result
    ... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
    ... specimen 0..1 Reference(AU Base Specimen) Specimen used for this observation
    ... hasMember C 0..* Reference(AU Base Diagnostic Result | AU Base Pathology Result) Individual tests in a group or panel
    ... component 0..* BackboneElement Individual tests in a group or panel
    .... code 1..1 CodeableConcept Individual pathology test
    Binding: RCPA SPIA Pathology Reporting . (preferred)
    .... value[x] C 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Actual component result
    .... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    Observation.category:specificDiscipline Base extensible Pathology Diagnostic Service Category . ⏿1.0.0 tx.ontoserver.csiro.au
    Observation.code Base preferred RCPA SPIA Pathology Reporting . ⏿1.0.0 tx.ontoserver.csiro.au
    Observation.component.​code Base preferred RCPA SPIA Pathology Reporting . ⏿1.0.0 tx.ontoserver.csiro.au

    Constraints

    Id Grade Path(s) Description Expression
    inv-obs-0 error Observation A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.exists()
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Observation C 0..* Observation A pathology test result in an Australian healthcare context
    Constraints: obs-6, obs-7, inv-obs-0
    ... id Σ 0..1 id Logical id of this artifact
    ... meta Σ 0..1 Meta Metadata about the resource
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... language 0..1 code Language of the resource content
    Binding: CommonLanguages (preferred): A human language.
    Additional BindingsPurpose
    AllLanguages Max Binding
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    This profile does not constrain the narrative in regard to content, language, or traceability to data elements
    ... contained 0..* Resource Contained, inline Resources
    ... extension 0..* Extension Additional content defined by implementations
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... identifier Σ 0..* Identifier Business Identifier for observation
    ... basedOn Σ 0..* Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Fulfills plan, proposal or order
    ... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Part of referenced event
    ... status ?!Σ 1..1 code registered | preliminary | final | amended +
    Binding: ObservationStatus (required): Codes providing the status of an observation.
    ... Slices for category 1..* CodeableConcept Classification of the service requested as laboratory + more specific discipline where available
    Slice: Unordered, Open by value:coding.system, value:coding.code
    Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
    .... category:lab 1..1 CodeableConcept Observation generated by laboratories
    Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
    ..... 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 1..* Coding Code defined by a terminology system
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    Slice: Unordered, Open by value:url
    ...... system Σ 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
    ...... version Σ 0..1 string Version of the system - if relevant
    ...... code Σ 1..1 code Symbol in syntax defined by the system
    Fixed Value: laboratory
    ...... display Σ 0..1 string Representation defined by the system
    ...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
    ..... text Σ 0..1 string Plain text representation of the concept
    .... category:specificDiscipline 0..* CodeableConcept Specific discipline of pathology
    Binding: Pathology Diagnostic Service Category . (extensible)
    ..... 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
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    Slice: Unordered, Open by value:url
    ...... system Σ 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
    ...... version Σ 0..1 string Version of the system - if relevant
    ...... code Σ 0..1 code Symbol in syntax defined by the system
    ...... display Σ 0..1 string Representation defined by the system
    ...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
    ..... text Σ 0..1 string Plain text representation of the concept
    ... code Σ 1..1 CodeableConcept Pathology test or test group
    Binding: RCPA SPIA Pathology Reporting . (preferred)
    Additional BindingsPurpose
    RCPA - SPIA Chemical Pathology Value Set . Component
    RCPA - SPIA Haematology Value Set . Component
    RCPA - SPIA Immunopathology Value Set . Component
    RCPA - SPIA Microbiology Serology Molecular Pathology Value Set . Component
    ... subject Σ 1..1 Reference(Patient) Who and/or what the observation is about
    ... focus Σ 0..* Reference(Resource) What the observation is about, when it is not about the subject of record
    ... encounter Σ 0..1 Reference(Encounter) Healthcare event during which this observation is made
    ... effective[x] Σ 1..1 Time of specimen collection
    .... effectiveDateTime dateTime
    .... effectivePeriod Period
    .... effectiveTiming Timing
    .... effectiveInstant instant
    ... issued Σ 0..1 instant Date/Time this version was made available
    ... performer Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Who is responsible for the observation
    ... value[x] ΣC 0..1 Actual 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 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(AU Base Specimen) Specimen used for this observation
    ... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
    ... referenceRange C 0..* BackboneElement Provides guide for interpretation
    Constraints: obs-3
    .... 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(4.0.1) Low Range, if relevant
    .... high C 0..1 SimpleQuantity(4.0.1) 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 ΣC 0..* Reference(AU Base Diagnostic Result | AU Base Pathology Result) Individual tests in a group or panel
    ... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
    ... component Σ 0..* BackboneElement Individual tests in a group or panel
    .... 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 Individual pathology test
    Binding: RCPA SPIA Pathology Reporting . (preferred)
    .... value[x] ΣC 0..1 Actual component result
    ..... valueQuantity Quantity
    ..... valueCodeableConcept CodeableConcept
    ..... valueString string
    ..... valueBoolean boolean
    ..... valueInteger integer
    ..... valueRange Range
    ..... valueRatio Ratio
    ..... valueSampledData SampledData
    ..... valueTime time
    ..... valueDateTime dateTime
    ..... valuePeriod Period
    .... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
    Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
    .... interpretation 0..* CodeableConcept High, low, normal, etc.
    Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
    .... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Observation.language Base preferred Common Languages 📍4.0.1 FHIR Std.
    Observation.status Base required ObservationStatus 📍4.0.1 FHIR Std.
    Observation.category Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
    Observation.category:lab Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
    Observation.category:specificDiscipline Base extensible Pathology Diagnostic Service Category . ⏿1.0.0 tx.ontoserver.csiro.au
    Observation.code Base preferred RCPA SPIA Pathology Reporting . ⏿1.0.0 tx.ontoserver.csiro.au
    Observation.dataAbsentReason Base extensible DataAbsentReason 📍4.0.1 FHIR Std.
    Observation.interpretation Base extensible Observation Interpretation Codes 📍4.0.1 FHIR Std.
    Observation.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
    Observation.method Base example Observation Methods 📍4.0.1 FHIR Std.
    Observation.referenceRange.​type Base preferred Observation Reference Range Meaning Codes 📍4.0.1 FHIR Std.
    Observation.referenceRange.​appliesTo Base example Observation Reference Range Applies To Codes 📍4.0.1 FHIR Std.
    Observation.component.​code Base preferred RCPA SPIA Pathology Reporting . ⏿1.0.0 tx.ontoserver.csiro.au
    Observation.component.​dataAbsentReason Base extensible DataAbsentReason 📍4.0.1 FHIR Std.
    Observation.component.​interpretation Base extensible Observation Interpretation Codes 📍4.0.1 FHIR Std.

    Constraints

    Id Grade Path(s) Description Expression
    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()
    inv-obs-0 error Observation A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.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()

    This structure is derived from Observation

    Summary

    Mandatory: 7 elements(1 nested mandatory element)
    Fixed: 3 elements

    Structures

    This structure refers to these other structures:

    Slices

    This structure defines the following Slices:

    • The element 2 is sliced based on the values of Observation.category

    Maturity: 1

    Key Elements View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Observation C 0..* Observation A pathology test result in an Australian healthcare context
    Constraints: obs-6, obs-7, inv-obs-0
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... status ?!Σ 1..1 code registered | preliminary | final | amended +
    Binding: ObservationStatus (required): Codes providing the status of an observation.
    .... category:lab 1..1 CodeableConcept Observation generated by laboratories
    Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
    ..... coding Σ 1..* Coding Code defined by a terminology system
    ...... system Σ 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
    ...... code Σ 1..1 code Symbol in syntax defined by the system
    Fixed Value: laboratory
    .... category:specificDiscipline 0..* CodeableConcept Specific discipline of pathology
    Binding: Pathology Diagnostic Service Category . (extensible)
    ... code Σ 1..1 CodeableConcept Pathology test or test group
    Binding: RCPA SPIA Pathology Reporting . (preferred)
    Additional BindingsPurpose
    RCPA - SPIA Chemical Pathology Value Set . Component
    RCPA - SPIA Haematology Value Set . Component
    RCPA - SPIA Immunopathology Value Set . Component
    RCPA - SPIA Microbiology Serology Molecular Pathology Value Set . Component
    ... subject Σ 1..1 Reference(Patient) Who and/or what the observation is about
    ... effective[x] Σ 1..1 Time of specimen collection
    .... effectiveDateTime dateTime
    .... effectivePeriod Period
    .... effectiveTiming Timing
    .... effectiveInstant instant
    ... value[x] ΣC 0..1 Actual 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 result is missing
    Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
    ... specimen 0..1 Reference(AU Base Specimen) Specimen used for this observation
    ... hasMember ΣC 0..* Reference(AU Base Diagnostic Result | AU Base Pathology Result) Individual tests in a group or panel
    ... component Σ 0..* BackboneElement Individual tests in a group or panel
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... code Σ 1..1 CodeableConcept Individual pathology test
    Binding: RCPA SPIA Pathology Reporting . (preferred)
    .... value[x] ΣC 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.

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Observation.status Base required ObservationStatus 📍4.0.1 FHIR Std.
    Observation.category Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
    Observation.category:lab Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
    Observation.category:specificDiscipline Base extensible Pathology Diagnostic Service Category . ⏿1.0.0 tx.ontoserver.csiro.au
    Observation.code Base preferred RCPA SPIA Pathology Reporting . ⏿1.0.0 tx.ontoserver.csiro.au
    Observation.dataAbsentReason Base extensible DataAbsentReason 📍4.0.1 FHIR Std.
    Observation.component.​code Base preferred RCPA SPIA Pathology Reporting . ⏿1.0.0 tx.ontoserver.csiro.au
    Observation.component.​dataAbsentReason Base extensible DataAbsentReason 📍4.0.1 FHIR Std.

    Constraints

    Id Grade Path(s) Description Expression
    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()
    inv-obs-0 error Observation A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.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()

    Differential View

    This structure is derived from Observation

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Observation C 0..* Observation A pathology test result in an Australian healthcare context
    Constraints: inv-obs-0
    ... Slices for category 1..* CodeableConcept Classification of the service requested as laboratory + more specific discipline where available
    Slice: Unordered, Open by value:coding.system, value:coding.code
    .... category:lab 1..1 CodeableConcept Observation generated by laboratories
    ..... coding 1..* Coding Code defined by a terminology system
    ...... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
    ...... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: laboratory
    .... category:specificDiscipline 0..* CodeableConcept Specific discipline of pathology
    Binding: Pathology Diagnostic Service Category . (extensible)
    ..... coding
    ...... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
    ... code 1..1 CodeableConcept Pathology test or test group
    Binding: RCPA SPIA Pathology Reporting . (preferred)
    Additional BindingsPurpose
    RCPA - SPIA Chemical Pathology Value Set . Component
    RCPA - SPIA Haematology Value Set . Component
    RCPA - SPIA Immunopathology Value Set . Component
    RCPA - SPIA Microbiology Serology Molecular Pathology Value Set . Component
    ... subject 1..1 Reference(Patient) Who and/or what the observation is about
    ... value[x] C 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Actual result
    ... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
    ... specimen 0..1 Reference(AU Base Specimen) Specimen used for this observation
    ... hasMember C 0..* Reference(AU Base Diagnostic Result | AU Base Pathology Result) Individual tests in a group or panel
    ... component 0..* BackboneElement Individual tests in a group or panel
    .... code 1..1 CodeableConcept Individual pathology test
    Binding: RCPA SPIA Pathology Reporting . (preferred)
    .... value[x] C 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Actual component result
    .... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    Observation.category:specificDiscipline Base extensible Pathology Diagnostic Service Category . ⏿1.0.0 tx.ontoserver.csiro.au
    Observation.code Base preferred RCPA SPIA Pathology Reporting . ⏿1.0.0 tx.ontoserver.csiro.au
    Observation.component.​code Base preferred RCPA SPIA Pathology Reporting . ⏿1.0.0 tx.ontoserver.csiro.au

    Constraints

    Id Grade Path(s) Description Expression
    inv-obs-0 error Observation A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.exists()

    Snapshot View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Observation C 0..* Observation A pathology test result in an Australian healthcare context
    Constraints: obs-6, obs-7, inv-obs-0
    ... id Σ 0..1 id Logical id of this artifact
    ... meta Σ 0..1 Meta Metadata about the resource
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... language 0..1 code Language of the resource content
    Binding: CommonLanguages (preferred): A human language.
    Additional BindingsPurpose
    AllLanguages Max Binding
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    This profile does not constrain the narrative in regard to content, language, or traceability to data elements
    ... contained 0..* Resource Contained, inline Resources
    ... extension 0..* Extension Additional content defined by implementations
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... identifier Σ 0..* Identifier Business Identifier for observation
    ... basedOn Σ 0..* Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Fulfills plan, proposal or order
    ... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Part of referenced event
    ... status ?!Σ 1..1 code registered | preliminary | final | amended +
    Binding: ObservationStatus (required): Codes providing the status of an observation.
    ... Slices for category 1..* CodeableConcept Classification of the service requested as laboratory + more specific discipline where available
    Slice: Unordered, Open by value:coding.system, value:coding.code
    Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
    .... category:lab 1..1 CodeableConcept Observation generated by laboratories
    Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
    ..... 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 1..* Coding Code defined by a terminology system
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    Slice: Unordered, Open by value:url
    ...... system Σ 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
    ...... version Σ 0..1 string Version of the system - if relevant
    ...... code Σ 1..1 code Symbol in syntax defined by the system
    Fixed Value: laboratory
    ...... display Σ 0..1 string Representation defined by the system
    ...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
    ..... text Σ 0..1 string Plain text representation of the concept
    .... category:specificDiscipline 0..* CodeableConcept Specific discipline of pathology
    Binding: Pathology Diagnostic Service Category . (extensible)
    ..... 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
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    Slice: Unordered, Open by value:url
    ...... system Σ 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
    ...... version Σ 0..1 string Version of the system - if relevant
    ...... code Σ 0..1 code Symbol in syntax defined by the system
    ...... display Σ 0..1 string Representation defined by the system
    ...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
    ..... text Σ 0..1 string Plain text representation of the concept
    ... code Σ 1..1 CodeableConcept Pathology test or test group
    Binding: RCPA SPIA Pathology Reporting . (preferred)
    Additional BindingsPurpose
    RCPA - SPIA Chemical Pathology Value Set . Component
    RCPA - SPIA Haematology Value Set . Component
    RCPA - SPIA Immunopathology Value Set . Component
    RCPA - SPIA Microbiology Serology Molecular Pathology Value Set . Component
    ... subject Σ 1..1 Reference(Patient) Who and/or what the observation is about
    ... focus Σ 0..* Reference(Resource) What the observation is about, when it is not about the subject of record
    ... encounter Σ 0..1 Reference(Encounter) Healthcare event during which this observation is made
    ... effective[x] Σ 1..1 Time of specimen collection
    .... effectiveDateTime dateTime
    .... effectivePeriod Period
    .... effectiveTiming Timing
    .... effectiveInstant instant
    ... issued Σ 0..1 instant Date/Time this version was made available
    ... performer Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Who is responsible for the observation
    ... value[x] ΣC 0..1 Actual 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 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(AU Base Specimen) Specimen used for this observation
    ... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
    ... referenceRange C 0..* BackboneElement Provides guide for interpretation
    Constraints: obs-3
    .... 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(4.0.1) Low Range, if relevant
    .... high C 0..1 SimpleQuantity(4.0.1) 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 ΣC 0..* Reference(AU Base Diagnostic Result | AU Base Pathology Result) Individual tests in a group or panel
    ... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
    ... component Σ 0..* BackboneElement Individual tests in a group or panel
    .... 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 Individual pathology test
    Binding: RCPA SPIA Pathology Reporting . (preferred)
    .... value[x] ΣC 0..1 Actual component result
    ..... valueQuantity Quantity
    ..... valueCodeableConcept CodeableConcept
    ..... valueString string
    ..... valueBoolean boolean
    ..... valueInteger integer
    ..... valueRange Range
    ..... valueRatio Ratio
    ..... valueSampledData SampledData
    ..... valueTime time
    ..... valueDateTime dateTime
    ..... valuePeriod Period
    .... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
    Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
    .... interpretation 0..* CodeableConcept High, low, normal, etc.
    Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
    .... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Observation.language Base preferred Common Languages 📍4.0.1 FHIR Std.
    Observation.status Base required ObservationStatus 📍4.0.1 FHIR Std.
    Observation.category Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
    Observation.category:lab Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
    Observation.category:specificDiscipline Base extensible Pathology Diagnostic Service Category . ⏿1.0.0 tx.ontoserver.csiro.au
    Observation.code Base preferred RCPA SPIA Pathology Reporting . ⏿1.0.0 tx.ontoserver.csiro.au
    Observation.dataAbsentReason Base extensible DataAbsentReason 📍4.0.1 FHIR Std.
    Observation.interpretation Base extensible Observation Interpretation Codes 📍4.0.1 FHIR Std.
    Observation.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
    Observation.method Base example Observation Methods 📍4.0.1 FHIR Std.
    Observation.referenceRange.​type Base preferred Observation Reference Range Meaning Codes 📍4.0.1 FHIR Std.
    Observation.referenceRange.​appliesTo Base example Observation Reference Range Applies To Codes 📍4.0.1 FHIR Std.
    Observation.component.​code Base preferred RCPA SPIA Pathology Reporting . ⏿1.0.0 tx.ontoserver.csiro.au
    Observation.component.​dataAbsentReason Base extensible DataAbsentReason 📍4.0.1 FHIR Std.
    Observation.component.​interpretation Base extensible Observation Interpretation Codes 📍4.0.1 FHIR Std.

    Constraints

    Id Grade Path(s) Description Expression
    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()
    inv-obs-0 error Observation A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.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()

    This structure is derived from Observation

    Summary

    Mandatory: 7 elements(1 nested mandatory element)
    Fixed: 3 elements

    Structures

    This structure refers to these other structures:

    Slices

    This structure defines the following Slices:

    • The element 2 is sliced based on the values of Observation.category

    Maturity: 1

     

    Other representations of profile: CSV, Excel, Schematron