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 7.0.0 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-vital-signs | Version: 7.0.0 | |||
Standards status: Trial-use | Maturity Level: 3 | Computable Name: USCoreVitalSignsProfile | ||
Other Identifiers: OID:2.16.840.1.113883.4.642.40.2.42.60 | ||||
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License |
This profile is based on the base FHIR Vital Signs Profile and defines additional constraints on the Observation resource to represent vital signs observations. It 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. This US Core profiles that are derived from this profile are listed below.
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. The “Snapshot Table (Must Support)” tab below displays all the Mandatory and Must Support data elements for this profile and those inherited from the US Core Vital Signs Profile.
Each Observation Must Have:
Each Observation Must Support:
*see guidance below
Profile Specific Implementation Guidance:
A code system value SHOULD be supplied for each additional code.
Observation.hasMember
.
Observation.dataAbsentReason
.Observation.component
without a value, SHALL include a reason why the data is absent.
Observation.component.dataAbsentReason
.This profile conforms to the base FHIR ver 4.0.1 vitals profile, which defines a required binding for Quantity.code
concepts. This means validation errors occur when validating derived profiles that use other Quantity.code
concepts such as L/min
for Observation.component.value(x)
in the US Core Pulse Oximetry Profile. This known issue has been corrected in the base FHIR specification since version 4.3.0 (“Release 4B”).
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from observation-vitalsigns
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | observation-vitalsigns | US Core Vital Signs Profile | |
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:coding.code, value:coding.system |
category:VSCat | S | 1..1 | CodeableConcept | Classification of type of observation |
coding | S | 1..* | Coding | Code defined by a terminology system |
system | S | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category |
code | S | 1..1 | code | Symbol in syntax defined by the system Fixed Value: vital-signs |
code | S | 1..1 | CodeableConcept | Coded vital sign result type Binding: Vital Sign Result Type (extensible): Vital sign result types |
subject | S | 1..1 | Reference(US Core Patient Profile) | Who and/or what the observation is about |
effective[x] | S | 1..1 | Often just a dateTime for Vital Signs | |
effectiveDateTime | dateTime S | |||
effectivePeriod | Period | |||
value[x] | S | 0..1 | Vital Signs Value Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs. | |
valueQuantity | Quantity S | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
dataAbsentReason | S | 0..1 | CodeableConcept | Why the result is missing |
component | S | 0..* | BackboneElement | Component observations |
code | S | 1..1 | CodeableConcept | Coded vital sign result type Binding: Vital Sign Result Type (extensible): Vital sign result types |
value[x] | S | 0..1 | Vital Sign Component Value Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs. | |
valueQuantity | Quantity S | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
dataAbsentReason | S | 0..1 | CodeableConcept | Why the component result is missing |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.code | extensible | VitalSignResultType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.62 | |
Observation.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1 from the FHIR Standard | |
Observation.component.code | extensible | VitalSignResultType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.62 | |
Observation.component.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1 from the FHIR Standard |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | observation-vitalsigns | US Core Vital Signs Profile 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 vs-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) |
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:coding.code, value:coding.system Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
category:VSCat | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
coding | SΣ | 1..* | Coding | Code defined by a terminology system |
system | SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category |
code | SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: vital-signs |
code | SΣ | 1..1 | CodeableConcept | Coded vital sign result type Binding: Vital Sign Result Type (extensible): Vital sign result types |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who and/or what the observation is about |
effective[x] | SΣC | 1..1 | Often just a dateTime for Vital Signs vs-1: if Observation.effective[x] is dateTime and has a value then that value shall be precise to the day | |
effectiveDateTime | dateTime | |||
value[x] | SΣC | 0..1 | Vital Signs Value Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs. | |
valueQuantity | Quantity | |||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
component | SΣC | 0..* | BackboneElement | Component observations vs-3: If there is no a value a data absent reason must be present |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | SΣ | 1..1 | CodeableConcept | Coded vital sign result type Binding: Vital Sign Result Type (extensible): Vital sign result types |
value[x] | SΣC | 0..1 | Vital Sign Component Value Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs. | |
valueQuantity | Quantity | |||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
Documentation for this format |
Path | Conformance | ValueSet | 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:VSCat | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.code | extensible | VitalSignResultType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.62 | |
Observation.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1 from the FHIR Standard | |
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | |
Observation.component.code | extensible | VitalSignResultType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.62 | |
Observation.component.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1 from the FHIR Standard | |
Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | observation-vitalsigns | US Core Vital Signs Profile 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 vs-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) | ||||
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:coding.code, value:coding.system Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
category:VSCat | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | SΣ | 1..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: vital-signs | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
code | SΣ | 1..1 | CodeableConcept | Coded vital sign result type Binding: Vital Sign Result Type (extensible): Vital sign result types | ||||
subject | SΣ | 1..1 | Reference(US Core Patient 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 | 1..1 | Often just a dateTime for Vital Signs vs-1: if Observation.effective[x] is dateTime and has a value then that value shall be precise to the day | |||||
effectiveDateTime | dateTime S | |||||||
effectivePeriod | Period | |||||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation | ||||
value[x] | SΣC | 0..1 | Vital Signs Value Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs. | |||||
valueQuantity | Quantity S | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
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 | Σ | 0..* | Reference(QuestionnaireResponse | MolecularSequence | Vital Signs Profile) | Used when reporting vital signs panel components | ||||
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | MolecularSequence | Vital Signs Profile) | Related measurements the observation is made from | ||||
component | SΣC | 0..* | BackboneElement | Component observations vs-3: If there is no a value a data absent reason must be present | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | SΣ | 1..1 | CodeableConcept | Coded vital sign result type Binding: Vital Sign Result Type (extensible): Vital sign result types | ||||
value[x] | SΣC | 0..1 | Vital Sign Component Value Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs. | |||||
valueQuantity | Quantity S | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
referenceRange | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Observation.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/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:VSCat | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.code | extensible | VitalSignResultType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.62 | ||||
Observation.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1 from the FHIR Standard | ||||
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 | extensible | VitalSignResultType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.62 | ||||
Observation.component.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1 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 |
This structure is derived from observation-vitalsigns
Differential View
This structure is derived from observation-vitalsigns
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | observation-vitalsigns | US Core Vital Signs Profile | |
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:coding.code, value:coding.system |
category:VSCat | S | 1..1 | CodeableConcept | Classification of type of observation |
coding | S | 1..* | Coding | Code defined by a terminology system |
system | S | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category |
code | S | 1..1 | code | Symbol in syntax defined by the system Fixed Value: vital-signs |
code | S | 1..1 | CodeableConcept | Coded vital sign result type Binding: Vital Sign Result Type (extensible): Vital sign result types |
subject | S | 1..1 | Reference(US Core Patient Profile) | Who and/or what the observation is about |
effective[x] | S | 1..1 | Often just a dateTime for Vital Signs | |
effectiveDateTime | dateTime S | |||
effectivePeriod | Period | |||
value[x] | S | 0..1 | Vital Signs Value Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs. | |
valueQuantity | Quantity S | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
dataAbsentReason | S | 0..1 | CodeableConcept | Why the result is missing |
component | S | 0..* | BackboneElement | Component observations |
code | S | 1..1 | CodeableConcept | Coded vital sign result type Binding: Vital Sign Result Type (extensible): Vital sign result types |
value[x] | S | 0..1 | Vital Sign Component Value Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs. | |
valueQuantity | Quantity S | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
dataAbsentReason | S | 0..1 | CodeableConcept | Why the component result is missing |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.code | extensible | VitalSignResultType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.62 | |
Observation.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1 from the FHIR Standard | |
Observation.component.code | extensible | VitalSignResultType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.62 | |
Observation.component.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1 from the FHIR Standard |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | observation-vitalsigns | US Core Vital Signs Profile 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 vs-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) |
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:coding.code, value:coding.system Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
category:VSCat | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
coding | SΣ | 1..* | Coding | Code defined by a terminology system |
system | SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category |
code | SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: vital-signs |
code | SΣ | 1..1 | CodeableConcept | Coded vital sign result type Binding: Vital Sign Result Type (extensible): Vital sign result types |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who and/or what the observation is about |
effective[x] | SΣC | 1..1 | Often just a dateTime for Vital Signs vs-1: if Observation.effective[x] is dateTime and has a value then that value shall be precise to the day | |
effectiveDateTime | dateTime | |||
value[x] | SΣC | 0..1 | Vital Signs Value Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs. | |
valueQuantity | Quantity | |||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
component | SΣC | 0..* | BackboneElement | Component observations vs-3: If there is no a value a data absent reason must be present |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | SΣ | 1..1 | CodeableConcept | Coded vital sign result type Binding: Vital Sign Result Type (extensible): Vital sign result types |
value[x] | SΣC | 0..1 | Vital Sign Component Value Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs. | |
valueQuantity | Quantity | |||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
Documentation for this format |
Path | Conformance | ValueSet | 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:VSCat | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.code | extensible | VitalSignResultType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.62 | |
Observation.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1 from the FHIR Standard | |
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | |
Observation.component.code | extensible | VitalSignResultType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.62 | |
Observation.component.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1 from the FHIR Standard | |
Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | observation-vitalsigns | US Core Vital Signs Profile 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 vs-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) | ||||
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:coding.code, value:coding.system Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
category:VSCat | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | SΣ | 1..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: vital-signs | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
code | SΣ | 1..1 | CodeableConcept | Coded vital sign result type Binding: Vital Sign Result Type (extensible): Vital sign result types | ||||
subject | SΣ | 1..1 | Reference(US Core Patient 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 | 1..1 | Often just a dateTime for Vital Signs vs-1: if Observation.effective[x] is dateTime and has a value then that value shall be precise to the day | |||||
effectiveDateTime | dateTime S | |||||||
effectivePeriod | Period | |||||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation | ||||
value[x] | SΣC | 0..1 | Vital Signs Value Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs. | |||||
valueQuantity | Quantity S | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
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 | Σ | 0..* | Reference(QuestionnaireResponse | MolecularSequence | Vital Signs Profile) | Used when reporting vital signs panel components | ||||
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | MolecularSequence | Vital Signs Profile) | Related measurements the observation is made from | ||||
component | SΣC | 0..* | BackboneElement | Component observations vs-3: If there is no a value a data absent reason must be present | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | SΣ | 1..1 | CodeableConcept | Coded vital sign result type Binding: Vital Sign Result Type (extensible): Vital sign result types | ||||
value[x] | SΣC | 0..1 | Vital Sign Component Value Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs. | |||||
valueQuantity | Quantity S | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
referenceRange | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Observation.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/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:VSCat | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.code | extensible | VitalSignResultType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.62 | ||||
Observation.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1 from the FHIR Standard | ||||
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 | extensible | VitalSignResultType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.62 | ||||
Observation.component.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1 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 |
This structure is derived from observation-vitalsigns
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 vital signs 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|vital-signs
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|vital-signs
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and a category code = vital-signs
(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 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|vital-signs&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 = vital-signs
(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|vital-signs&status={system|}[code]{,{system|}[code],...}
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and category 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 codes. (how to search by reference and how to search by token and how to search by date)