US Core Implementation Guide, published by HL7 International / Cross-Group Projects. This guide is not an authorized publication; it is the continuous build for version 8.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/US-Core/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/us/core/CapabilityStatement/us-core-server | Version: 8.0.0-ballot | |||
Standards status: Trial-use | Maturity Level: 3 | Computable Name: UsCoreServerCapabilityStatement | ||
Other Identifiers: OID:2.16.840.1.113883.4.642.40.2.13.2 | ||||
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License |
This Section describes the expected capabilities of the US Core Server actor which is responsible for providing responses to the queries submitted by the US Core Requestors. The complete list of FHIR profiles, RESTful operations, and search parameters supported by US Core Servers are defined. Systems implementing this capability statement should meet the ONC 2015 Common Clinical Data Set (CCDS) access requirement for Patient Selection 170.315(g)(7) and Application Access - Data Category Request 170.315(g)(8) and the ONC U.S. Core Data for Interoperability (USCDI) Version 5 July 2024.
Raw OpenAPI-Swagger Definition file | Download
The US Core Server SHALL:
The US Core Server SHOULD:
meta.profile
attribute for each instance.NOTE: US Core SearchParameters referenced in this CapabilityStatement that are derived from standard FHIR SearchParameters are only defined to document Server and Client expectations. They specify additional expectations for the following SearchParameter elements:
multipleAnd
multipleOr
comparator
modifier
chain
They SHALL NOT be interpreted as search parameters for search. Servers and Clients SHOULD use the standard FHIR SearchParameters.
Security:
HTTP 401
"Unauthorized", HTTP 403
"Forbidden", or HTTP 404
"Not Found"Summary of System Wide Interactions
transaction
interaction.batch
interaction.search-system
interaction.history-system
interaction.Resource Type | Supported Profiles | Supported Searches | Supported _includes | Supported _revincludes | Supported Operations |
---|---|---|---|---|---|
AllergyIntolerance | US Core AllergyIntolerance Profile | clinical-status, patient patient+clinical-status | - | Provenance:target | - |
CarePlan | US Core CarePlan Profile | category, date, patient, status patient+category+status+date, patient+category+status, patient+category, patient+category+date | - | Provenance:target | - |
CareTeam | US Core CareTeam Profile | patient, role, status patient+status, patient+role | CareTeam:participant:PractitionerRole, CareTeam:participant:Practitioner, CareTeam:participant:Patient, CareTeam:participant:RelatedPerson | Provenance:target | - |
Condition | US Core Condition Encounter Diagnosis Profile, US Core Condition Problems and Health Concerns Profile | abatement-date, asserted-date, category, clinical-status, code, encounter, onset-date, patient, recorded-date, _lastUpdated patient+onset-date, patient+_lastUpdated, patient+category+encounter, patient+category+clinical-status, patient+recorded-date, patient+asserted-date, patient+abatement-date, patient+code, patient+category, patient+clinical-status | - | Provenance:target | - |
Coverage | US Core Coverage Profile | patient | - | Provenance:target | - |
Device | US Core Implantable Device Profile | patient, status, type patient+type, patient+status | - | Provenance:target | - |
DiagnosticReport | US Core DiagnosticReport Profile for Report and Note exchange, US Core DiagnosticReport Profile for Laboratory Results Reporting | category, code, date, _lastUpdated, patient, status patient+status, patient+code+date, patient+category+date, patient+code, patient+category+_lastUpdated, patient+category | - | Provenance:target | - |
DocumentReference | US Core DocumentReference Profile | _id, category, date, patient, period, status, type patient+status, patient+category+date, patient+type+period, patient+type, patient+category | - | Provenance:target | docref |
Encounter | US Core Encounter Profile | _id, class, date, _lastUpdated, discharge-disposition, identifier, location, patient, status, type patient+status, patient+_lastUpdated, date+patient, patient+type, patient+location, patient+discharge-disposition, class+patient | - | Provenance:target | - |
Endpoint | - | - | - | - | - |
Goal | US Core Goal Profile | description, lifecycle-status, patient, target-date patient+target-date, patient+lifecycle-status, patient+description | - | Provenance:target | - |
HealthcareService | - | - | - | - | - |
Immunization | US Core Immunization Profile | date, patient, status patient+status, patient+date | - | Provenance:target | - |
Location | US Core Location Profile | address, address-city, address-postalcode, address-state, name | - | - | - |
Media | - | - | - | - | - |
Medication | US Core Medication Profile | - | - | - | - |
MedicationDispense | US Core MedicationDispense Profile | patient, status, type patient+status, patient+status+type | MedicationDispense:medication | Provenance:target | - |
MedicationRequest | US Core MedicationRequest Profile | authoredon, encounter, intent, patient, status patient+intent+authoredon, patient+intent+status, patient+intent, patient+intent+encounter | MedicationRequest:medication | Provenance:target | - |
Observation | US Core Laboratory Result Observation Profile, US Core Observation Pregnancy Status Profile, US Core Observation Pregnancy Intent Profile, US Core Observation Occupation Profile, US Core Respiratory Rate Profile, US Core Simple Observation Profile, US Core Treatment Intervention Preference Profile, US Core Care Experience Preference Profile, US Core Heart Rate Profile, US Core Body Temperature Profile, US Core Pediatric Weight for Height Observation Profile, US Core Pulse Oximetry Profile, US Core Smoking Status Observation Profile, US Core Observation Sexual Orientation Profile, US Core Head Circumference Profile, US Core Body Height Profile, US Core BMI Profile, US Core Observation Screening Assessment Profile, US Core Average Blood Pressure Profile, US Core Blood Pressure Profile, US Core Observation Clinical Result Profile, US Core Pediatric BMI for Age Observation Profile, US Core Pediatric Head Occipital Frontal Circumference Percentile Profile, US Core Body Weight Profile, US Core Vital Signs Profile | category, code, date, _lastUpdated, patient, status patient+code+date, patient+category+date, patient+code, patient+category+_lastUpdated, patient+category, patient+category+status | - | Provenance:target | - |
Organization | US Core Organization Profile | address, name | - | - | - |
Patient | US Core Patient Profile | _id, birthdate, death-date, family, gender, given, identifier, name family+gender, birthdate+name, death-date+family, gender+name, birthdate+family | - | Provenance:target | - |
Practitioner | US Core Practitioner Profile | _id, identifier, name | - | - | - |
PractitionerRole | US Core PractitionerRole Profile | practitioner, specialty | PractitionerRole:endpoint, PractitionerRole:practitioner | - | - |
Procedure | US Core Procedure Profile | code, date, patient, status patient+status, patient+date, patient+code+date | - | Provenance:target | - |
Provenance | US Core Provenance Profile | - | - | - | - |
Questionnaire | SDC Base Questionnaire Profile | - | - | - | - |
QuestionnaireResponse | US Core QuestionnaireResponse Profile | _id, authored, patient, questionnaire, status patient+status, patient+questionnaire, patient+authored | - | Provenance:target | - |
RelatedPerson | US Core RelatedPerson Profile | _id, name, patient patient+name | - | Provenance:target | - |
ServiceRequest | US Core ServiceRequest Profile | _id, authored, category, code, patient, status patient+status, patient+code+authored, patient+code, patient+category+authored, patient+category | - | Provenance:target | - |
Specimen | US Core Specimen Profile | _id, patient | - | - | - |
ValueSet | - | - | - | - | expand |
Conformance Expectation: SHALL
Supported Profiles:
Profile Interaction Summary:
search-type
, read
.vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/AllergyIntolerance/[id]
GET [base]/AllergyIntolerance?[parameter=value]&_revinclude=Provenance:target
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHALL | patient | reference |
Search Parameter Combination Summary:
Conformance | Parameter Combination | Types |
---|---|---|
SHOULD | patient+ clinical-status | reference+token |
Search Parameter Requirements (When Used Alone or in Combination):
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
Conformance Expectation: SHALL
Resource Specific Documentation:
- Additional considerations for systems aligning with HL7 Consolidated (C-CDA) Care Plan requirements:
- US Core Goal SHOULD be present in CarePlan.goal
- US Core Condition SHOULD be present in CarePlan.addresses
- Assessment and Plan MAY be included as narrative text
Supported Profiles:
Profile Interaction Summary:
search-type
, read
.vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/CarePlan/[id]
GET [base]/CarePlan?[parameter=value]&_revinclude=Provenance:target
Search Parameter Combination Summary:
Conformance | Parameter Combination | Types |
---|---|---|
SHOULD | patient+ category+ status+ date | reference+token+token+date |
SHOULD | patient+ category+ status | reference+token+token |
SHALL | patient+ category | reference+token |
SHOULD | patient+ category+ date | reference+token+date |
Search Parameter Requirements (When Used Alone or in Combination):
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
A client SHALL provide a value precise to the second + time offset.
A server SHALL support a value precise to the second + time offset.
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
Conformance Expectation: SHALL
Resource Specific Documentation:
- In order to access care team member's names, identifiers, locations, and contact information, the CareTeam profile supports several types of care team participants. They are represented as references to other profiles and include the following four profiles which are marked as must support:
- US Core Practitioner Profile
- US Core PractitionerRole Profile
- US Core Patient Profile
- US Core RelatedPerson Profile
- Although both US Core Practitioner Profile and US Core PractitionerRole are must support, the server system is not required to support both types of references, but SHALL support at least one of them.
- The client application SHALL support all four profile references.
- Bacause the US Core PractitionerRole Profile supplies the provider's location and contact information and a reference to the Practitioner, server systems SHOULD reference it instead of the US Core Practitioner Profile.
- Servers that support only US Core Practitioner Profile and do not support the US Core PractitionerRole Profile SHALL provide implementation specific guidance how to access a provider’s location and contact information using only the Practitioner resource.
Supported Profiles:
Profile Interaction Summary:
search-type
, read
.vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/CareTeam/[id]
GET [base]/CareTeam?[parameter=value]&_include=CareTeam:participant:PractitionerRole
GET [base]/CareTeam?[parameter=value]&_include=CareTeam:participant:Practitioner
GET [base]/CareTeam?[parameter=value]&_include=CareTeam:participant:Patient
GET [base]/CareTeam?[parameter=value]&_include=CareTeam:participant:RelatedPerson
GET [base]/CareTeam?[parameter=value]&_revinclude=Provenance:target
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHOULD | role | token |
Search Parameter Combination Summary:
Conformance | Parameter Combination | Types |
---|---|---|
SHALL | patient+ status | reference+token |
SHOULD | patient+ role | reference+token |
Search Parameter Requirements (When Used Alone or in Combination):
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
Conformance Expectation: SHALL
Resource Specific Documentation:
- For Encounter Diagnosis use the US Core Condition Encounter Diagnosis Profile.
- When
Condition.category
is "encounter-diagnosis" the encounter, SHOULD be referenced inCondition.encounter
.- For Problems and Health Concerns use the US Core Condition Problems and Health Concerns Profile.
- When
Condition.category
is a "problems-list-item", the `Condition.clinicalStatus SHOULD NOT be unknown.- There is no single element in Condition that represents the date of diagnosis. It may be the assertedDate Extension,
Condition.onsetDateTime
, orCondition.recordedDate
.
- Although all three are marked as must support, the server is not required to support all.
- A server SHALL support
Condition.recordedDate
.- A server SHALL support at least one of the assertedDate Extension and
Condition.onsetDateTime
. A server may support both, which means they support all three elements.- The client application SHALL support all three elements.
Supported Profiles:
Profile Interaction Summary:
search-type
, read
.vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/Condition/[id]
GET [base]/Condition?[parameter=value]&_revinclude=Provenance:target
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHALL | patient | reference |
Search Parameter Combination Summary:
Conformance | Parameter Combination | Types |
---|---|---|
SHOULD | patient+ onset-date | reference+date |
SHOULD | patient+ _lastUpdated | reference+date |
SHOULD | patient+ category+ encounter | reference+token+reference |
SHOULD | patient+ category+ clinical-status | reference+token+token |
SHOULD | patient+ recorded-date | reference+date |
SHOULD | patient+ asserted-date | reference+date |
SHOULD | patient+ abatement-date | reference+date |
SHOULD | patient+ code | reference+token |
SHALL | patient+ category | reference+token |
SHOULD | patient+ clinical-status | reference+token |
Search Parameter Requirements (When Used Alone or in Combination):
A client SHALL provide a value precise to the second + time offset.
A server SHALL support a value precise to the second + time offset.
A client SHALL provide a value precise to the second + time offset.
A server SHALL support a value precise to the second + time offset.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
A client SHALL provide a value precise to the second + time offset.
A server SHALL support a value precise to the second + time offset.
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
A client SHALL provide a value precise to the second + time offset.
A server SHALL support a value precise to the second + time offset.
A server SHALL document the types of changes that can be detected using this parameter.
A client SHALL provide a value precise to the second + time offset.
A server SHALL support a value precise to the second + time offset.
Conformance Expectation: SHALL
Supported Profiles:
Profile Interaction Summary:
search-type
, read
.vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/Coverage/[id]
GET [base]/Coverage?[parameter=value]&_revinclude=Provenance:target
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHALL | patient | reference |
Search Parameter Requirements (When Used Alone or in Combination):
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
Conformance Expectation: SHALL
Resource Specific Documentation:
Implantable medical devices that have UDI information SHALL represent the UDI code in
Device.udiCarrier.carrierHRF
.
- All of the five UDI-PI elements that are present in the UDI code SHALL be represented in the corresponding US Core Implantable Device Profile element.
UDI may not be present in all scenarios such as historical implantable devices, patient reported implant information, payer reported devices, or improperly documented implants. If UDI is not present and the manufacturer and/or model number information is available, they SHOULD be included to support historical reports of implantable medical devices as follows:
manufacturer ->
Device.manufacturer
model ->Device.model
Servers SHOULD support query by Device.type to allow clients to request the patient's devices by a specific type. Note: The Device.type is too granular to differentiate implantable vs. non-implantable devices.
Supported Profiles:
Profile Interaction Summary:
search-type
, read
.vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/Device/[id]
GET [base]/Device?[parameter=value]&_revinclude=Provenance:target
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHALL | patient | reference |
Search Parameter Combination Summary:
Conformance | Parameter Combination | Types |
---|---|---|
SHOULD | patient+ type | reference+token |
SHOULD | patient+ status | reference+token |
Search Parameter Requirements (When Used Alone or in Combination):
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
Conformance Expectation: SHALL
Resource Specific Documentation:
- When
DiagnosticReport.category
is "LAB" the encounter, Updates to Meta.lastUpdated SHOULD reflect:
- New laboratory reports
- Changes in the status of laboratory reports including events that trigger the same status (e.g., amended → amended).
Supported Profiles:
Profile Interaction Summary:
create
†, search-type
, read
.vread
, history-instance
.update
, patch
, delete
, history-type
.create†This conformance expectation applies only to the US Core DiagnosticReport Profile for Report and Note exchange profile. The conformance expectation for the US Core DiagnosticReport Profile for Laboratory Results Reporting is MAY.
Fetch and Search Criteria:
GET [base]/DiagnosticReport/[id]
GET [base]/DiagnosticReport?[parameter=value]&_revinclude=Provenance:target
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHALL | patient | reference |
Search Parameter Combination Summary:
Conformance | Parameter Combination | Types |
---|---|---|
SHOULD | patient+ status | reference+token |
SHOULD | patient+ code+ date | reference+token+date |
SHALL | patient+ category+ date | reference+token+date |
SHALL | patient+ code | reference+token |
SHOULD | patient+ category+ _lastUpdated | reference+token+date |
SHALL | patient+ category | reference+token |
Search Parameter Requirements (When Used Alone or in Combination):
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
A client SHALL provide a value precise to the second + time offset.
A server SHALL support a value precise to the second + time offset.
A server SHALL document the types of changes that can be detected using this parameter.
A client SHALL provide a value precise to the second + time offset.
A server SHALL support a value precise to the second + time offset.
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
Conformance Expectation: SHALL
Resource Specific Documentation:
- The
DocumentReference.type
binding SHALL support at a minimum the 5 Common Clinical Notes and may extend to the full US Core DocumentReference Type Value Set- The DocumentReference resources can represent the referenced content using either an address where the document can be retrieved using
DocumentReference.attachment.url
or the content as inline base64 encoded data usingDocumentReference.attachment.data
.
- Although both are marked as must support, the server system is not required to support an address, and inline base64 encoded data, but SHALL support at least one of these elements.
- The client application SHALL support both elements.
- The
content.url
may refer to a FHIR Binary Resource (i.e. [base]/Binary/[id]), FHIR Document Bundle (i.e [base]/Bundle/[id] or another endpoint.
- If the endpoint is outside the FHIR base URL, it SHOULD NOT require additional authorization to access.
- If there are multiple
DocumentReference.content
element repetitions, these SHALL all represent the same document in different format or attachment metadata. The content element SHALL NOT contain different versions of the same content. For version handling use multiple DocumentReferences withDocumentReference.relatesTo
- Every DocumentReference must have a responsible Organization. The organization responsible for the DocumentReference SHALL be present either in
DocumentReference.custodian
or accessible in the Provenance resource targeting the DocumentReference usingProvenance.agent.who
orProvenance.agent.onBehalfOf
.
Supported Profiles:
Profile Interaction Summary:
create
, search-type
, read
.vread
, history-instance
.update
, patch
, delete
, history-type
.Operation Summary:
A server SHALL be capable of responding to a $docref operation and capable of returning at least a reference to a generated CCD document, if available. MAY provide references to other 'on-demand' and 'stable' documents (or 'delayed/deferred assembly') that meet the query parameters as well. If a context date range is supplied the server ** SHOULD** provide references to any document that falls within the date range. If no date range is supplied, then the server SHALL provide references to last or current document(s). SHOULD document what resources, if any, are returned as included resources
GET [base]/DocumentReference/$docref?patient=[id]
Fetch and Search Criteria:
GET [base]/DocumentReference/[id]
GET [base]/DocumentReference?[parameter=value]&_revinclude=Provenance:target
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHALL | _id | token |
SHALL | patient | reference |
Search Parameter Combination Summary:
Conformance | Parameter Combination | Types |
---|---|---|
SHOULD | patient+ status | reference+token |
SHALL | patient+ category+ date | reference+token+date |
SHOULD | patient+ type+ period | reference+token+date |
SHALL | patient+ type | reference+token |
SHALL | patient+ category | reference+token |
Search Parameter Requirements (When Used Alone or in Combination):
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
A client SHALL provide a value precise to the second + time offset.
A server SHALL support a value precise to the second + time offset.
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
A client SHALL provide a value precise to the second + time offset.
A server SHALL support a value precise to the second + time offset.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
Conformance Expectation: SHALL
Resource Specific Documentation:
The Encounter resource can represent a reason using either a code with
Encounter.reasonCode
, or a reference withEncounter.reasonReference
to Condition or other resource.
- Although both are marked as must support, the server systems are not required to support both a code and a reference, but they SHALL support at least one of these elements.
- The client application SHALL support both elements.
- if
Encounter.reasonReference
references an Observation, it SHOULD conform to a US Core Observation if applicable. (for example, a laboratory result should conform to the US Core Laboratory Result Observation Profile)The location address can be represented by either by the Location referenced by
Encounter.location.location
or indirectly through the Organization referenced byEncounter.serviceProvider
.
- Although both are marked as must support, the server systems are not required to support both
Encounter.location.location
andEncounter.serviceProvider
, but they SHALL support at least one of these elements.- The client application SHALL support both elements.
If the event facility/location differs from the
Encounter.location
, systems SHOULD reference it directly:
Supported Profiles:
Profile Interaction Summary:
search-type
, read
.vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/Encounter/[id]
GET [base]/Encounter?[parameter=value]&_revinclude=Provenance:target
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHALL | _id | token |
SHOULD | identifier | token |
SHALL | patient | reference |
Search Parameter Combination Summary:
Conformance | Parameter Combination | Types |
---|---|---|
SHOULD | patient+ status | reference+token |
SHOULD | patient+ _lastUpdated | reference+date |
SHALL | date+ patient | date+reference |
SHOULD | patient+ type | reference+token |
SHOULD | patient+ location | reference+reference |
SHOULD | patient+ discharge-disposition | reference+token |
SHOULD | class+ patient | token+reference |
Search Parameter Requirements (When Used Alone or in Combination):
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
A client SHALL provide a value precise to the second + time offset.
A server SHALL support a value precise to the second + time offset.
A server SHALL document the types of changes that can be detected using this parameter.
A client SHALL provide a value precise to the second + time offset.
A server SHALL support a value precise to the second + time offset.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
Conformance Expectation: SHALL
Resource Specific Documentation:
The Media Resource is a Must Support referenced resource when using the US Core PractitionerRole Profile.
Profile Interaction Summary:
read
, vread
.create
, search-type
, update
, patch
, delete
, history-instance
, history-type
.Fetch and Search Criteria:
GET [base]/Endpoint/[id]
Conformance Expectation: SHALL
Resource Specific Documentation:
- Although both
Goal.startDate
andGoal.target.dueDate
are marked as must support, the server system is not required to support both, but SHALL support at least one of these elements. The client application SHALL support both elements.
Supported Profiles:
Profile Interaction Summary:
search-type
, read
.vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/Goal/[id]
GET [base]/Goal?[parameter=value]&_revinclude=Provenance:target
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHALL | patient | reference |
Search Parameter Combination Summary:
Conformance | Parameter Combination | Types |
---|---|---|
SHOULD | patient+ target-date | reference+date |
SHOULD | patient+ lifecycle-status | reference+token |
SHOULD | patient+ description | reference+token |
Search Parameter Requirements (When Used Alone or in Combination):
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
A client SHALL provide a value precise to the day.
A server SHALL support a value a value precise to the day.
Conformance Expectation: MAY
Resource Specific Documentation:
The HealthcareService Resource is a referenced resource when using the US Core PracitionRole Profile and subject to constraint us-core-13: "SHALL have a practitioner, an organization, a healthcare service, or a location."
Profile Interaction Summary:
read
, vread
.create
, search-type
, update
, patch
, delete
, history-instance
, history-type
.Fetch and Search Criteria:
GET [base]/HealthcareService/[id]
Conformance Expectation: SHALL
Resource Specific Documentation:
- Based upon the ONC U.S. Core Data for Interoperability (USCDI) requirements, CVX vaccine codes are required and the NDC vaccine codes SHOULD be supported as translations to them.
Supported Profiles:
Profile Interaction Summary:
search-type
, read
.vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/Immunization/[id]
GET [base]/Immunization?[parameter=value]&_revinclude=Provenance:target
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHALL | patient | reference |
Search Parameter Combination Summary:
Conformance | Parameter Combination | Types |
---|---|---|
SHOULD | patient+ status | reference+token |
SHOULD | patient+ date | reference+date |
Search Parameter Requirements (When Used Alone or in Combination):
A client SHALL provide a value precise to the second + time offset.
A server SHALL support a value precise to the second + time offset.
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
Conformance Expectation: SHALL
Resource Specific Documentation:
- Systems SHOULD follow the Project US@ Technical Specification for Patient Addresses Final Version 1.0 as the standard style guide for
Location.address.line
andLocation.address.city
.
Supported Profiles:
Profile Interaction Summary:
search-type
, read
.vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/Location/[id]
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHALL | address | string |
SHOULD | address-city | string |
SHOULD | address-postalcode | string |
SHOULD | address-state | string |
SHALL | name | string |
Conformance Expectation: SHALL
Resource Specific Documentation:
The Media Resource is a Must Support referenced resource when using the US Core DiagnosticReport Profile for Report and Note Exchange.
Profile Interaction Summary:
read
, vread
.create
, search-type
, update
, patch
, delete
, history-instance
, history-type
.Fetch and Search Criteria:
GET [base]/Media/[id]
Conformance Expectation: SHALL
Resource Specific Documentation:
- The MedicationRequest resource can represent a medication, using an external reference to a Medication resource. If an external Medication Resource is used in a MedicationRequest, then the READ SHALL be supported.
Supported Profiles:
Profile Interaction Summary:
read
.vread
, history-instance
.create
, search-type
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/Medication/[id]
Conformance Expectation: SHALL
Resource Specific Documentation:
- The MedicationDispense resources can represent a medication using either a code or refer to the Medication resource. When referencing Medication, the resource may be contained or an external resource. The server application MAY choose any one way or more than one method, but if an external reference to Medication is used, the server SHALL support the _include` parameter for searching this element. The client application must support all methods.
- For example, A server SHALL be capable of returning dispense records for all medications for a patient using one of or both:
GET /MedicationDispense?patient=[id]
GET /MedicationDispense?patient=[id]&_include=MedicationDispense:medication
Supported Profiles:
Profile Interaction Summary:
search-type
, read
.vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/MedicationDispense/[id]
GET [base]/MedicationDispense?[parameter=value]&_include=MedicationDispense:medication
GET [base]/MedicationDispense?[parameter=value]&_revinclude=Provenance:target
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHALL | patient | reference |
Search Parameter Combination Summary:
Conformance | Parameter Combination | Types |
---|---|---|
SHOULD | patient+ status | reference+token |
SHOULD | patient+ status+ type | reference+token+token |
Search Parameter Requirements (When Used Alone or in Combination):
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
Conformance Expectation: SHALL
Resource Specific Documentation:
The MedicationRequest resources can represent a medication using either a code or refer to the Medication resource. When referencing Medication, the resource may be contained or an external resource. The server application MAY choose any one way or more than one method, but if an external reference to Medication is used, the server SHALL support the _include` parameter for searching this element. The client application must support all methods.
- For example, A server SHALL be capable of returning all medications for a patient using one of or both:
GET /MedicationRequest?patient=[id]
GET /MedicationRequest?patient=[id]&_include=MedicationRequest:medication
The MedicationRequest resource can represent that information is from a secondary source using either a boolean flag or reference in
MedicationRequest.reportedBoolean
, or a reference usingMedicationRequest.reportedReference
to Practitioner or other resource.
- Although both are marked as must support, the server systems are not required to support both a boolean and a reference, but SHALL choose to support at least one of these elements.
- The client application SHALL support both elements.
When recording “self-prescribed” medication, requester SHOULD be used to indicate the Patient or RelatedPerson as the prescriber. (See the Medication List section for guidance on accessing a patient medications including over the counter (OTC) medication and other substances taken for medical and recreational use.)
The MedicationRequest resource can communicate the reason or indication for treatment using either a code in MedicationRequest.reasonCode or a reference using MedicationRequest.reasonReference.
Although both
MedicationRequest.reasonCode
andMedicationRequest.reasonReference
are marked as Additional USCDI Requirements. The certifying server system is not required to support both but SHALL support at least one of these elements. The certifying client application SHALL support both elements.
- when using MedicationRequest.reasonReference:
- Servers SHALL support at least one target resource in
MedicationRequest.reasonReference
. Clients SHALL support all target resources.- The referenced resources SHOULD be a US Core Profile as documented in Referencing US Core Profiles.
Supported Profiles:
Profile Interaction Summary:
search-type
, read
.vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/MedicationRequest/[id]
GET [base]/MedicationRequest?[parameter=value]&_include=MedicationRequest:medication
GET [base]/MedicationRequest?[parameter=value]&_revinclude=Provenance:target
Search Parameter Combination Summary:
Conformance | Parameter Combination | Types |
---|---|---|
SHOULD | patient+ intent+ authoredon | reference+token+date |
SHALL | patient+ intent+ status | reference+token+token |
SHALL | patient+ intent | reference+token |
SHOULD | patient+ intent+ encounter | reference+token+reference |
Search Parameter Requirements (When Used Alone or in Combination):
A client SHALL provide a value precise to the second + time offset.
A server SHALL support a value precise to the second + time offset.
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
Conformance Expectation: SHALL
Resource Specific Documentation:
- Systems SHOULD support
Observation.effectivePeriod
to accurately represent tests that are collected over a period of time (for example, a 24-Hour Urine Collection test).- An Observation without a value, SHALL include a reason why the data is absent unless there are component observations, or references to other Observations that are grouped within it
- Systems that never provide an observation without a value are not required to support
Observation.dataAbsentReason
- An
Observation.component
without a value, SHALL include a reason why the data is absent.
- Systems that never provide an component observation without a component value are not required to support
Observation.component.dataAbsentReason
.- When
Observation.category
is "laboratory" the encounter, Updates to Meta.lastUpdated SHOULD reflect:
- New laboratory results
- Changes in the status of laboratory results including events that trigger the same status (e.g., amended → amended).
Supported Profiles:
Profile Interaction Summary:
search-type
, read
.vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/Observation/[id]
GET [base]/Observation?[parameter=value]&_revinclude=Provenance:target
Search Parameter Combination Summary:
Conformance | Parameter Combination | Types |
---|---|---|
SHOULD | patient+ code+ date | reference+token+date |
SHALL | patient+ category+ date | reference+token+date |
SHALL | patient+ code | reference+token |
SHOULD | patient+ category+ _lastUpdated | reference+token+date |
SHALL | patient+ category | reference+token |
SHOULD | patient+ category+ status | reference+token+token |
Search Parameter Requirements (When Used Alone or in Combination):
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
A client SHALL provide a value precise to the second + time offset.
A server SHALL support a value precise to the second + time offset.
A server SHALL document the types of changes that can be detected using this parameter.
A client SHALL provide a value precise to the second + time offset.
A server SHALL support a value precise to the second + time offset.
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
Conformance Expectation: SHALL
Resource Specific Documentation:
- Systems SHALL support National Provider Identifier (NPI) for organizations and SHOULD support Clinical Laboratory Improvement Amendments (CLIA) identifiers for
Organization.Identifier
.- Systems SHOULD follow the Project US@ Technical Specification for Patient Addresses Final Version 1.0 as the standard style guide for
Organization.address.line
andOrganization.address.city
.
Supported Profiles:
Profile Interaction Summary:
search-type
, read
.vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/Organization/[id]
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHALL | address | string |
SHALL | name | string |
Conformance Expectation: SHALL
Resource Specific Documentation:
For ONC's USCDI requirements, each Patient must support the following additional elements. These elements are included in the formal definition of the profile. The patient examples include all of these elements.
- contact detail (e.g. a telephone number or an email address)
- a communication language
- a race
- an ethnicity
- a birth sex*
- previous name
- Previous name is represented by providing an end date in the
Patient.name.period
element for a previous name.- suffix
- Suffix is represented using the
Patient.name.suffix
element.The Patient's Social Security Numbers SHOULD NOT be used as a patient identifier in
Patient.identifier.value
.Although Patient.deceased[x] is marked as 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜, certifying systems are not required to support both choices, but SHALL support at least
Patient.deceasedDateTime
.Certifying systems SHALL and non-certifying systems SHOULD follow the Project US@ Technical Specification for Patient Addresses Final Version 1.0 as the standard style guide for
Patient.address.line
andPatient.address.city
for new and updated records.
Supported Profiles:
Profile Interaction Summary:
search-type
, read
.vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/Patient/[id]
GET [base]/Patient?[parameter=value]&_revinclude=Provenance:target
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHALL | _id | token |
SHALL | identifier | token |
SHALL | name | string |
Search Parameter Combination Summary:
Conformance | Parameter Combination | Types |
---|---|---|
SHOULD | family+ gender | string+token |
SHALL | birthdate+ name | date+string |
SHOULD | death-date+ family | date+string |
SHALL | gender+ name | token+string |
SHOULD | birthdate+ family | date+string |
Search Parameter Requirements (When Used Alone or in Combination):
A client SHALL provide a value precise to the day.
A server SHALL support a value a value precise to the day.
A client SHALL provide a value precise to the day.
A server SHALL support a value a value precise to the day.
A server SHALL support a value precise to the day.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
Conformance Expectation: SHALL
Resource Specific Documentation:
- Servers that support only US Core Practitioner Profile SHALL provide implementation specific guidance how to access a provider’s location and contact information using only the Practitioner resource.
- Although Practitioner.address is marked as Must Support, the server system is not required to support it if they support the US Core PractitionerRole Profile, but SHALL support it if they do not support the US Core PractitionerRole Profile. The client application SHALL support both.
- Systems SHOULD follow the Project US@ Technical Specification for Patient Addresses Final Version 1.0 as the standard style guide for
Practitioner.address.line
andPractitioner.address.city
.
Supported Profiles:
Profile Interaction Summary:
search-type
, read
.vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/Practitioner/[id]
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHOULD | _id | token |
SHALL | identifier | token |
SHALL | name | string |
Search Parameter Requirements (When Used Alone or in Combination):
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
Conformance Expectation: SHALL
Resource Specific Documentation:
- Due to implementer feedback, some US Core Profiles reference the PractitionerRole resource instead of the US Core PractitionerRole Profile. However the US Core PractitionerRole Profile SHOULD be used as the default profile if referenced by another US Core profile.
Supported Profiles:
Profile Interaction Summary:
search-type
, read
.vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/PractitionerRole/[id]
GET [base]/PractitionerRole?[parameter=value]&_include=PractitionerRole:endpoint
GET [base]/PractitionerRole?[parameter=value]&_include=PractitionerRole:practitioner
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHALL | practitioner | reference |
SHALL | specialty | token |
Search Parameter Requirements (When Used Alone or in Combination):
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
Conformance Expectation: SHALL
Resource Specific Documentation:
- Procedure codes can be taken from SNOMED-CT, CPT, HCPCS II, ICD-10-PCS, CDT. LOINC.
- Only LOINC concepts that reflect actual procedures SHOULD be used
- A procedure including an implantable device SHOULD use
Procedure.focalDevice
with a reference to the US Core Implantable Device Profile.- Servers and Clients SHALL support both US Core ServiceRequest and US Core Procedure Profiles for communicating the reason or justification for a referral as Additional USCDI Requirements. Typically, the reason or justification for a referral or consultation is communicated through
Procedure.basedOn
linking the Procedure to the US Core ServiceRequest Profile that includes eitherServiceRequest.reasonCode
orServiceRequest.reasonReference
. When the Procedure does not have an associated ServiceRequest, it is communicated through the US Core Procedure Profile'sProcedure.reasonCode
orProcedure.reasonReference
. Depending on the procedure being documented, a server will select the appropriate Profile to use.
- Although both
Procedure.reasonCode
andProcedure.reasonReference
are marked as Additional USCDI Requirements. The certifying server system is not required to support both but SHALL support at least one of these elements. The certifying client application SHALL support both elements.
- when using
Procedure.reasonReference
:
- Servers SHALL support at least one target resource in
Procedure.reasonReference
. Clients SHALL support all target resources .- The referenced resources SHOULD be a US Core Profile.
Supported Profiles:
Profile Interaction Summary:
search-type
, read
.vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/Procedure/[id]
GET [base]/Procedure?[parameter=value]&_revinclude=Provenance:target
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHALL | patient | reference |
Search Parameter Combination Summary:
Conformance | Parameter Combination | Types |
---|---|---|
SHOULD | patient+ status | reference+token |
SHALL | patient+ date | reference+date |
SHOULD | patient+ code+ date | reference+token+date |
Search Parameter Requirements (When Used Alone or in Combination):
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
A client SHALL provide a value precise to the second + time offset.
A server SHALL support a value precise to the second + time offset.
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
Conformance Expectation: SHALL
Resource Specific Documentation:
- The US Core Provenance resource SHALL be supported for these US Core resources:
- AllergyIntolerance
- CarePlan
- CareTeam
- Condition
- Coverage
- Device
- DiagnosticReport
- DocumentReference
- Encounter
- Goal
- Immunization
- MedicationDispense
- MedicationRequest
- Observation
- Patient
- Procedure
- QuestionnaireResponse
- RelatedPerson
- ServiceRequest
- If a system receives a provider in
Provenance.agent.who
as free text they must capture who sent them the information as the organization. On request they SHALL provide this organization as the source and MAY include the free text provider.- Systems that need to know the activity has occurred SHOULD populate the activity.
Supported Profiles:
Profile Interaction Summary:
read
.vread
, history-instance
.create
, search-type
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/Provenance/[id]
Conformance Expectation: SHOULD
Resource Specific Documentation:
US Core defines two ways to represent the questions and responses to screening and assessment instruments:
- Observation: US Core Observation Screening Assessment Profile
- Questionnaire/QuestionnaireResponse: SDC Base Questionnaire/US Core QuestionnaireResponse Profile
US Core Servers SHALL support US Core Observation Screening Assessment Profile and SHOULD support the SDC Base Questionnaire Profile/US Core QuestionnaireResponse Profile
Supported Profiles:
Profile Interaction Summary:
read
, vread
.create
, search-type
, update
, patch
, delete
, history-instance
, history-type
.Fetch and Search Criteria:
GET [base]/Questionnaire/[id]
Conformance Expectation: SHOULD
Resource Specific Documentation:
US Core defines two ways to represent the questions and responses to screening and assessment instruments:
- Observation: US Core Observation Screening Assessment Profile
- Questionnaire/QuestionnaireResponse: SDC Base Questionnaire/US Core QuestionnaireResponse Profile
US Core Servers SHALL support US Core Observation Screening Assessment Profile and SHOULD support the SDC Base Questionnaire Profile/US Core QuestionnaireResponse Profile
Supported Profiles:
Profile Interaction Summary:
search-type
, read
, vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/QuestionnaireResponse/[id]
GET [base]/QuestionnaireResponse?[parameter=value]&_revinclude=Provenance:target
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHALL | _id | token |
SHALL | patient | reference |
Search Parameter Combination Summary:
Conformance | Parameter Combination | Types |
---|---|---|
SHOULD | patient+ status | reference+token |
SHOULD | patient+ questionnaire | reference+reference |
SHOULD | patient+ authored | reference+date |
Search Parameter Requirements (When Used Alone or in Combination):
A client SHALL provide a value precise to the second + time offset.
A server SHALL support a value precise to the second + time offset.
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
Conformance Expectation: SHALL
Resource Specific Documentation:
- Systems SHOULD follow the Project US@ Technical Specification for Patient Addresses Final Version 1.0 as the standard style guide for
RelatedPerson.address.line
andRelatedPerson.address.city
.
Supported Profiles:
Profile Interaction Summary:
search-type
, read
.vread
, history-instance
.create
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/RelatedPerson/[id]
GET [base]/RelatedPerson?[parameter=value]&_revinclude=Provenance:target
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHALL | _id | token |
SHOULD | name | string |
SHOULD | patient | reference |
Search Parameter Combination Summary:
Conformance | Parameter Combination | Types |
---|---|---|
SHOULD | patient+ name | reference+string |
Search Parameter Requirements (When Used Alone or in Combination):
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
Conformance Expectation: SHALL
Resource Specific Documentation:
The Must Support
ServiceRequest.category
is bound, at a minimum, to the [US Core ServiceRequest Category Codes], and other category codes can be used. API consumers can query by category when accessing patient information. For the USCDI Laboratory Order, Imaging Order, Clinical Test Order, and Procedure Order Data Elements, implementers SHOULD use the corresponding category codes listed in the table below. For example, laboratory orders would have the category code "108252007" (Laboratory procedure).|USCDI Order Data Element|Category Codes| |---|---| |Laboratory Order| 108252007 Laboratory procedure (procedure)| |Imaging Order|363679005 Imaging (procedure)| |Clinical Test Order|386053000 Evaluation procedure (procedure), 410606002 Social service procedure (procedure), or 387713003 Surgical procedure (procedure)| |Procedure Order|386053000 Evaluation procedure (procedure), 410606002 Social service procedure (procedure), or 387713003 Surgical procedure (procedure)|
The
ServiceRequest.code
value set is broad to accommodate a wide variety of use cases and SHOULD be constrained to a subset for a particular use case or domain. These value sets contain concepts that span many use cases and are not bound to any USCDI Data Element. However, the table below identifies additional value set bindings for the USCDI Laboratory Order, Imaging Order and Clinical Test Order Data Elements. Implementers SHOULD conform to the binding strengths listed for each USCDI Order context. For example, laboratory orders are extensibly bound to the LOINC Common Laboratory Orders Value Set. Note that the USCDI Class Procedure Order Data Element has no additional binding.|USCDI Order Data Element|Additional Binding|Binding Strength|Comments| |---|---|---|---| |Laboratory Order|LOINC Common Laboratory Orders Value Set|extensible|The LOINC Common Laboratory Orders Value Set is a "starter set" for mapping commonly used laboratory orders. It does not attempt to include all possible laboratory order codes. For additional information on LOINC Common Laboratory Orders Value Set, refer to www.loinc.org/usage/orders.| |Imaging Order|LOINC Radiology Codes|preferred|The LOINC Radiology Codes include all imaging codes minus concepts that are deprecated or discouraged.| |Clinical Test Order|LOINC Clinical Test Codes|example|LOINC Clinical Test Codes include all non-laboratory and non-imaging clinical test codes|
*Servers and Clients SHALL support both US Core ServiceRequest and US Core Procedure Profiles for communicating the reason or justification for a referral as Additional USCDI Requirements. Typically, the reason or justification for a referral or consultation is communicated through
Procedure.basedOn
linking the Procedure to the US Core ServiceRequest Profile that includes eitherServiceRequest.reasonCode
orServiceRequest.reasonReference
. When the Procedure does not have an associated ServiceRequest, it is communicated through the US Core Procedure Profile'sProcedure.reasonCode
orProcedure.reasonReference
. Depending on the procedure being documented, a server will select the appropriate Profile to use.
- Although both
ServiceRequest.reasonCode
andServiceRequest.reasonReference
are marked as Additional USCDI Requirements, the certifying server system is not required to support both, but SHALL support at least one of these elements. The certifying client application SHALL support both elements.
- when using
ServiceRequest.reasonReference
:
- Servers SHALL support at least one target resource in
ServiceRequest.reasonReference
. Clients SHALL support all target resources.- The referenced resources SHOULD be a US Core Profile as documented in [Referencing US Core Profiles].
Supported Profiles:
Profile Interaction Summary:
read
.vread
, history-instance
.create
, search-type
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/ServiceRequest/[id]
GET [base]/ServiceRequest?[parameter=value]&_revinclude=Provenance:target
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHALL | _id | token |
SHALL | patient | reference |
Search Parameter Combination Summary:
Conformance | Parameter Combination | Types |
---|---|---|
SHOULD | patient+ status | reference+token |
SHOULD | patient+ code+ authored | reference+token+date |
SHALL | patient+ code | reference+token |
SHALL | patient+ category+ authored | reference+token+date |
SHALL | patient+ category | reference+token |
Search Parameter Requirements (When Used Alone or in Combination):
A client SHALL provide a value precise to the second + time offset.
A server SHALL support a value precise to the second + time offset.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
The client SHALL provide at least a id value and MAY provide both the Type and id values.
The server SHALL support both.
The client SHALL provide at least a code value and MAY provide both the system and code values.
The server SHALL support both.
Conformance Expectation: SHALL
Resource Specific Documentation:
- Although both
Specimen.identifier
andSpecimen.accessionIdentifier
are marked as Must Support, the server system is not required to support both, but SHALL support at least one of these elements. The client application SHALL support both.
Supported Profiles:
Profile Interaction Summary:
read
.vread
, history-instance
.create
, search-type
, update
, patch
, delete
, history-type
.Fetch and Search Criteria:
GET [base]/Specimen/[id]
Search Parameter Summary:
Conformance | Parameter | Type |
---|---|---|
SHALL | _id | token |
SHOULD | patient | reference |
Conformance Expectation: SHOULD
Operation Summary:
If a server supports DocumentReference for creating, using, and sharing clinical notes, it SHOULD also support the context
and contextdirection
parameters of the $expand operation to enable clients to determine the supported note and report types, as well as the supported read/write formats for notes on the server.