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/StructureDefinition/us-core-observation-screening-assessment | Version: 8.0.0-ballot | |||
Standards status: Trial-use | Maturity Level: 3 | Computable Name: USCoreObservationScreeningAssessmentProfile | ||
Other Identifiers: OID:2.16.840.1.113883.4.642.40.2.42.46 | ||||
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License |
The US Core Observation Screening Assessment Profile inherits from the FHIR Observation resource; refer to it for scope and usage definitions. This profile meets the requirements of the U.S. Core Data for Interoperability (USCDI) Health Status Assessments Data Class. It sets the minimum expectations for the Observation Resource to record, search, and fetch observations representing the questions and responses to surveys and screening and assessment tools. For example, a social history status such as education or food insecurity or an assessment of cognitive, functional, or disability status. It can represent a single response, multiple responses, and multi-select "check all that apply" type questions. This profile specifies which core elements, extensions, vocabularies, and value sets SHALL be present in the resource and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption. Before reviewing this profile, implementers are encouraged to read the Screening and Assessments guidance page, which documents the process of recording responses and capturing assertions/determinations resulting from surveys and questionnaires.
This page has new content for US Core Version 8.0.0
Example Usage Scenarios:
The following are example usage scenarios for this profile:
The following data elements must always be present (Mandatory definition) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile-specific guidance and examples are provided as well. The Formal Views below provides the formal summary, definitions, and terminology requirements.
Each Observation Must Support:
* see guidance below
Profile Specific Implementation Guidance:
Observation.code
, and the answer is in Observation.value
.Observation.code
is an overarching assessment or screening code, and the Observation.value
element SHOULD be empty. Observation.hasMember
references US Core Screening and Assessments Observations that represent the responses to each question in the screening or assessment.*The category type "survey" is required, and, at a minimum, Servers SHALL support, the US Core Screening Assessment Observation Category codes, SHOULD support the other US Core Screening Assessment Observation Maximum Category codes, and MAY support other categories.
Observation.category
element provides an efficient way of restricting search on observations to a given context such as survey observations. Example searches are shown in the Quick Start section below. However, Clients need to understand that data categorization is somewhat subjective. The categorization applied by the source may not align with the Client's expectations. Clients may find it more useful to use queries based on a specific code or set of codes or to perform additional Client-side filtering of query results.Observation.hasMember
.
Observation.dataAbsentReason
.Observation.component
without a value, SHALL include a reason why the data is absent.
Observation.component.dataAbsentReason
.Usage:
Changes since version 7.0.0:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | Survey Observation us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present | ||||
status | S | 1..1 | code | registered | preliminary | final | amended + | ||||
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this | ||||
category:survey | S | 1..1 | CodeableConcept | Classification of type of observation Required Pattern: At least the following | ||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: survey | |||||
category:screening-assessment | S | 0..* | CodeableConcept | Classification of type of observation Binding: US Core Screening Assessment Observation Maximum Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
| ||||
code | S | 1..1 | CodeableConcept | Type of observation (code / type) Binding: Screening and Assesment Survey Codes (preferred) | ||||
subject | S | 1..1 | Reference(US Core Patient Profile S | Group | Device | US Core Location Profile) | Who and/or what the observation is about | ||||
effective[x] | SC | 0..1 | Clinically relevant time/time-period for observation us-core-1: Datetime must be at least to day. | |||||
effectiveDateTime | dateTime S | |||||||
effectivePeriod | Period | |||||||
effectiveTiming | Timing | |||||||
effectiveInstant | instant | |||||||
performer | S | 0..* | Reference(US Core Practitioner Profile S | US Core Patient Profile S | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) | Who is responsible for the observation | ||||
value[x] | SC | 0..1 | Actual result us-core-3: SHALL use UCUM for coded quantity units. | |||||
valueQuantity | Quantity S | |||||||
valueCodeableConcept | CodeableConcept S | |||||||
valueString | string S | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing | ||||
hasMember | S | 0..* | Reference(US Core Observation Screening Assessment Profile S | QuestionnaireResponse | MolecularSequence) | Reference to panel members or multi-select responses or multi-select responses | ||||
derivedFrom | S | 0..* | Reference(US Core Observation Screening Assessment Profile S | US Core QuestionnaireResponse Profile S | US Core DocumentReference Profile | ImagingStudy | Media | MolecularSequence) | Related measurements the observation is made from | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Observation.category:screening-assessment | required | USCoreScreeningAssessmentObservationMaximumCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-maximum-category from this IG | ||||
Observation.code | preferred | ScreeningAndAssesmentSurveyCodes http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.13 |
Id | Grade | Path(s) | Details | Requirements |
us-core-1 | error | Observation.effective[x] | Datetime must be at least to day. : $this is dateTime implies $this.toString().length() >= 10 | |
us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
us-core-3 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org' |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | Survey Observation obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
category:survey | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following | ||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: survey | |||||
category:screening-assessment | S | 0..* | CodeableConcept | Classification of type of observation Binding: US Core Screening Assessment Observation Maximum Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
| ||||
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: Screening and Assesment Survey Codes (preferred) | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who and/or what the observation is about | ||||
effective[x] | SΣC | 0..1 | Clinically relevant time/time-period for observation us-core-1: Datetime must be at least to day. | |||||
effectiveDateTime | dateTime | |||||||
performer | SΣ | 0..* | Reference(US Core Practitioner Profile | US Core Patient Profile) | Who is responsible for the observation | ||||
value[x] | SΣC | 0..1 | Actual result us-core-3: SHALL use UCUM for coded quantity units. | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
hasMember | SΣ | 0..* | Reference(US Core Observation Screening Assessment Profile) | Reference to panel members or multi-select responses or multi-select responses | ||||
derivedFrom | SΣ | 0..* | Reference(US Core Observation Screening Assessment Profile | US Core QuestionnaireResponse Profile) | Related measurements the observation is made from | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | ||||
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.category:survey | preferred | Pattern: surveyhttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.category:screening-assessment | required | USCoreScreeningAssessmentObservationMaximumCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-maximum-category from this IG | ||||
Observation.code | preferred | ScreeningAndAssesmentSurveyCodes http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.13 | ||||
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
us-core-1 | error | Observation.effective[x] | Datetime must be at least to day. : $this is dateTime implies $this.toString().length() >= 10 | |
us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
us-core-3 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org' |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | Survey Observation obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
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 | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
category:survey | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: survey | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
category:screening-assessment | S | 0..* | CodeableConcept | Classification of type of observation Binding: US Core Screening Assessment Observation Maximum Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
| ||||
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: Screening and Assesment Survey Codes (preferred) | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile S | Group | Device | US Core Location Profile) | 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] | SΣC | 0..1 | Clinically relevant time/time-period for observation us-core-1: Datetime must be at least to day. | |||||
effectiveDateTime | dateTime S | |||||||
effectivePeriod | Period | |||||||
effectiveTiming | Timing | |||||||
effectiveInstant | instant | |||||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core Patient Profile S | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) | Who is responsible for the observation | ||||
value[x] | SΣC | 0..1 | Actual result us-core-3: SHALL use UCUM for coded quantity units. | |||||
valueQuantity | Quantity S | |||||||
valueCodeableConcept | CodeableConcept S | |||||||
valueString | string S | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
note | 0..* | Annotation | Comments about the observation | |||||
bodySite | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
method | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |||||
specimen | 0..1 | Reference(Specimen) | Specimen used for this observation | |||||
device | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
referenceRange | C | 0..* | BackboneElement | Provides guide for interpretation obs-3: Must have at least a low or a high or text | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
low | C | 0..1 | SimpleQuantity | Low Range, if relevant | ||||
high | C | 0..1 | SimpleQuantity | High Range, if relevant | ||||
type | 0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range. | |||||
appliesTo | 0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to. | |||||
age | 0..1 | Range | Applicable age range, if relevant | |||||
text | 0..1 | string | Text based reference range in an observation | |||||
hasMember | SΣ | 0..* | Reference(US Core Observation Screening Assessment Profile S | QuestionnaireResponse | MolecularSequence) | Reference to panel members or multi-select responses or multi-select responses | ||||
derivedFrom | SΣ | 0..* | Reference(US Core Observation Screening Assessment Profile S | US Core QuestionnaireResponse Profile S | US Core DocumentReference Profile | ImagingStudy | Media | MolecularSequence) | Related measurements the observation is made from | ||||
component | Σ | 0..* | BackboneElement | Component results | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
value[x] | Σ | 0..1 | Actual component result | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
referenceRange | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Observation.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | ||||
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.category:survey | preferred | Pattern: surveyhttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.category:screening-assessment | required | USCoreScreeningAssessmentObservationMaximumCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-maximum-category from this IG | ||||
Observation.code | preferred | ScreeningAndAssesmentSurveyCodes http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.13 | ||||
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard | ||||
Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methods from the FHIR Standard | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaning from the FHIR Standard | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliesto from the FHIR Standard | ||||
Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
us-core-1 | error | Observation.effective[x] | Datetime must be at least to day. : $this is dateTime implies $this.toString().length() >= 10 | |
us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
us-core-3 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org' |
This structure is derived from Observation
Summary
Mandatory: 3 elements
Must-Support: 12 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Maturity: 3
Differential View
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | Survey Observation us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present | ||||
status | S | 1..1 | code | registered | preliminary | final | amended + | ||||
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this | ||||
category:survey | S | 1..1 | CodeableConcept | Classification of type of observation Required Pattern: At least the following | ||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: survey | |||||
category:screening-assessment | S | 0..* | CodeableConcept | Classification of type of observation Binding: US Core Screening Assessment Observation Maximum Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
| ||||
code | S | 1..1 | CodeableConcept | Type of observation (code / type) Binding: Screening and Assesment Survey Codes (preferred) | ||||
subject | S | 1..1 | Reference(US Core Patient Profile S | Group | Device | US Core Location Profile) | Who and/or what the observation is about | ||||
effective[x] | SC | 0..1 | Clinically relevant time/time-period for observation us-core-1: Datetime must be at least to day. | |||||
effectiveDateTime | dateTime S | |||||||
effectivePeriod | Period | |||||||
effectiveTiming | Timing | |||||||
effectiveInstant | instant | |||||||
performer | S | 0..* | Reference(US Core Practitioner Profile S | US Core Patient Profile S | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) | Who is responsible for the observation | ||||
value[x] | SC | 0..1 | Actual result us-core-3: SHALL use UCUM for coded quantity units. | |||||
valueQuantity | Quantity S | |||||||
valueCodeableConcept | CodeableConcept S | |||||||
valueString | string S | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing | ||||
hasMember | S | 0..* | Reference(US Core Observation Screening Assessment Profile S | QuestionnaireResponse | MolecularSequence) | Reference to panel members or multi-select responses or multi-select responses | ||||
derivedFrom | S | 0..* | Reference(US Core Observation Screening Assessment Profile S | US Core QuestionnaireResponse Profile S | US Core DocumentReference Profile | ImagingStudy | Media | MolecularSequence) | Related measurements the observation is made from | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Observation.category:screening-assessment | required | USCoreScreeningAssessmentObservationMaximumCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-maximum-category from this IG | ||||
Observation.code | preferred | ScreeningAndAssesmentSurveyCodes http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.13 |
Id | Grade | Path(s) | Details | Requirements |
us-core-1 | error | Observation.effective[x] | Datetime must be at least to day. : $this is dateTime implies $this.toString().length() >= 10 | |
us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
us-core-3 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org' |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | Survey Observation obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
category:survey | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following | ||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: survey | |||||
category:screening-assessment | S | 0..* | CodeableConcept | Classification of type of observation Binding: US Core Screening Assessment Observation Maximum Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
| ||||
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: Screening and Assesment Survey Codes (preferred) | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who and/or what the observation is about | ||||
effective[x] | SΣC | 0..1 | Clinically relevant time/time-period for observation us-core-1: Datetime must be at least to day. | |||||
effectiveDateTime | dateTime | |||||||
performer | SΣ | 0..* | Reference(US Core Practitioner Profile | US Core Patient Profile) | Who is responsible for the observation | ||||
value[x] | SΣC | 0..1 | Actual result us-core-3: SHALL use UCUM for coded quantity units. | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
hasMember | SΣ | 0..* | Reference(US Core Observation Screening Assessment Profile) | Reference to panel members or multi-select responses or multi-select responses | ||||
derivedFrom | SΣ | 0..* | Reference(US Core Observation Screening Assessment Profile | US Core QuestionnaireResponse Profile) | Related measurements the observation is made from | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | ||||
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.category:survey | preferred | Pattern: surveyhttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.category:screening-assessment | required | USCoreScreeningAssessmentObservationMaximumCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-maximum-category from this IG | ||||
Observation.code | preferred | ScreeningAndAssesmentSurveyCodes http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.13 | ||||
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
us-core-1 | error | Observation.effective[x] | Datetime must be at least to day. : $this is dateTime implies $this.toString().length() >= 10 | |
us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
us-core-3 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org' |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | Survey Observation obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
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 | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
category:survey | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: survey | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
category:screening-assessment | S | 0..* | CodeableConcept | Classification of type of observation Binding: US Core Screening Assessment Observation Maximum Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
| ||||
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: Screening and Assesment Survey Codes (preferred) | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile S | Group | Device | US Core Location Profile) | 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] | SΣC | 0..1 | Clinically relevant time/time-period for observation us-core-1: Datetime must be at least to day. | |||||
effectiveDateTime | dateTime S | |||||||
effectivePeriod | Period | |||||||
effectiveTiming | Timing | |||||||
effectiveInstant | instant | |||||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core Patient Profile S | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) | Who is responsible for the observation | ||||
value[x] | SΣC | 0..1 | Actual result us-core-3: SHALL use UCUM for coded quantity units. | |||||
valueQuantity | Quantity S | |||||||
valueCodeableConcept | CodeableConcept S | |||||||
valueString | string S | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
note | 0..* | Annotation | Comments about the observation | |||||
bodySite | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
method | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |||||
specimen | 0..1 | Reference(Specimen) | Specimen used for this observation | |||||
device | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
referenceRange | C | 0..* | BackboneElement | Provides guide for interpretation obs-3: Must have at least a low or a high or text | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
low | C | 0..1 | SimpleQuantity | Low Range, if relevant | ||||
high | C | 0..1 | SimpleQuantity | High Range, if relevant | ||||
type | 0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range. | |||||
appliesTo | 0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to. | |||||
age | 0..1 | Range | Applicable age range, if relevant | |||||
text | 0..1 | string | Text based reference range in an observation | |||||
hasMember | SΣ | 0..* | Reference(US Core Observation Screening Assessment Profile S | QuestionnaireResponse | MolecularSequence) | Reference to panel members or multi-select responses or multi-select responses | ||||
derivedFrom | SΣ | 0..* | Reference(US Core Observation Screening Assessment Profile S | US Core QuestionnaireResponse Profile S | US Core DocumentReference Profile | ImagingStudy | Media | MolecularSequence) | Related measurements the observation is made from | ||||
component | Σ | 0..* | BackboneElement | Component results | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
value[x] | Σ | 0..1 | Actual component result | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
referenceRange | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Observation.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | ||||
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.category:survey | preferred | Pattern: surveyhttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.category:screening-assessment | required | USCoreScreeningAssessmentObservationMaximumCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-maximum-category from this IG | ||||
Observation.code | preferred | ScreeningAndAssesmentSurveyCodes http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.13 | ||||
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard | ||||
Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methods from the FHIR Standard | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaning from the FHIR Standard | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliesto from the FHIR Standard | ||||
Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
us-core-1 | error | Observation.effective[x] | Datetime must be at least to day. : $this is dateTime implies $this.toString().length() >= 10 | |
us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
us-core-3 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org' |
This structure is derived from Observation
Summary
Mandatory: 3 elements
Must-Support: 12 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Maturity: 3
Other representations of profile: CSV, Excel, Schematron
Below is an overview of the required Server RESTful FHIR interactions for this profile - for example, search and read operations - when supporting the US Core interactions to access this profile's information (Profile Support + Interaction Support). Note that systems that support only US Core Profiles (Profile Only Support) are not required to support these interactions. See the US Core Server CapabilityStatement for a complete list of supported RESTful interactions for this IG.
Servers providing access to assessment data SHALL support these US Core SMART Scopes:
resource level scopes: <patient|user|system>/Observation.rs
granular scopes: <patient|user|system>/Observation.rs?category=http://terminology.hl7.org/CodeSystem/observation-category|survey
granular scopes: <patient|user|system>/Observation.rs?category=http://hl7.org/fhir/us/core/CodeSystem/us-core-category|sdoh
The following search parameters and search parameter combinations SHALL be supported:
SHALL support searching using the combination of the patient
and category
search parameters:
GET [base]/Observation?patient={Type/}[id]&category=http://terminology.hl7.org/CodeSystem/observation-category|laboratory
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and a category code = laboratory
(how to search by reference and how to search by token)
patient
and code
search parameters:
code
(e.g.code={system|}[code],{system|}[code],...
)GET [base]/Observation?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and observation code(s). SHOULD support search by multiple report codes. The Observation code
parameter searches `Observation.code only. (how to search by reference and how to search by token)
patient
and category
and date
search parameters:
date
comparators: gt,lt,ge,le
date
(e.g.date=[date]&date=[date]]&...
)GET [base]/Observation?patient={Type/}[id]&category=http://terminology.hl7.org/CodeSystem/observation-category|laboratory&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and date and a category code = laboratory
(how to search by reference and how to search by token and how to search by date)
The following search parameter combinations SHOULD be supported:
patient
and category
and status
search parameters:
status
(e.g.status={system|}[code],{system|}[code],...
)GET [base]/Observation?patient={Type/}[id]&category=http://terminology.hl7.org/CodeSystem/observation-category|laboratory&status={system|}[code]{,{system|}[code],...}
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and category = laboratory
and status (how to search by reference and how to search by token)
patient
and category
and _lastUpdated
search parameters:
_lastUpdated
comparators: gt,lt,ge,le
_lastUpdated
(e.g._lastUpdated=[date]&_lastUpdated=[date]]&...
)GET [base]/Observation?patient={Type/}[id]&category={system|}[code]&_lastUpdated={gt|lt|ge|le}[date]{&_lastUpdated={gt|lt|ge|le}[date]&...}
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and category and _lastUpdated. See the US Core General Guidance page for Searching Using lastUpdated. (how to search by reference and how to search by token and how to search by date)
patient
and code
and date
search parameters:
code
(e.g.code={system|}[code],{system|}[code],...
)date
comparators: gt,lt,ge,le
date
(e.g.date=[date]&date=[date]]&...
)GET [base]/Observation?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and date and report code(s). SHOULD support search by multiple report codes. (how to search by reference and how to search by token and how to search by date)