Laboratory Base Class FHIR Profiles
0.1 - Draft
Laboratory Base Class FHIR Profiles
0.1 - Draft
Laboratory Base Class FHIR Profiles, published by HL7 International - Clinical Information Modeling Initiative. This is not an authorized publication; it is the continuous build for version 0.1). This version is based on the current content of https://github.com/HL7/cimi-labs/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/us/cimi-labs/StructureDefinition/standard-lab-obs-narrative | Version: 0.1 | |||
| Draft as of 2023-08-02 | Computable Name: StandardLabObsNarrative | |||
Copyright/Legal: Graphite Health, all rights reserved Creative Commons License |
||||
The base profile for all LOINC lab tests that have textual results in a string format.
The Standard Lab Coded Narrative profile is intended to be used for laboratory tests where the results are reported using strings of text.
This element is constrained to a set of LOINC codes that have a LOINC scale of Narrative (Nar).
This element is constrained to the string data type.
The following example is provided to illustrate conformant resource content to this profile
-Standard Lab Coded Observation
| Value Set | Purpose |
|---|---|
| Standard Lab Obs Narrative value set | This is a subset of lab LOINC where the scale is Nar. |
| Null Flavor value set | This value set contains terms that are used for the dataAbsentReason element. |
| Abnormal Interpretation value set | This value set contains coded terms that are used to identify the level of abnormality of a lab test. |
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from StandardLabObs
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Observation | 0..* | StandardLabObs | Measurements and simple assertions | |
  code | 1..1 | CodeableConcept | Laboratory Test Name Binding: Standard Lab Obs Narrative value set (extensible) | |
 value[x] | 0..1 | string | Result Value | |
| interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: Abnmormal Interpretation value set (extensible) | |
 referenceRange | ||||
  Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
  RefRangeNominal | S | 0..1 | CodeableConcept | Reference Range Nominal URL: http://hl7.org/fhir/us/cimi-labs/StructureDefinition/ref-range-nominal |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.code | extensible | StandardLabObsNarrative_VSET |
| Observation.interpretation | extensible | AbnormalInterpretation_VSET |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | C | 0..* | StandardLabObs | Measurements and simple assertions |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
  Slices for identifier | SΣ | 0..* | Identifier | Business Identifier for observation Slice: Unordered, Open by pattern:type |
  identifier:accessionIdentifier | Σ | 0..1 | Identifier | Business Identifier for observation |
  use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
  type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. 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/v2-0203 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: ACSN | |
| identifier:fillerOrderNumber | Σ | 0..1 | Identifier | Business Identifier for observation |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
| type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. 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/v2-0203 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: FILL | |
 identifier:placerOrderNumber | Σ | 0..1 | Identifier | Business Identifier for observation |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
| type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. 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/v2-0203 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PLAC | |
| 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 pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
| category:Laboratory | 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: laboratory | |
| code | SΣ | 1..1 | CodeableConcept | Laboratory Test Name Binding: Standard Lab Obs Narrative value set (extensible) |
 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 | |
| effectiveDateTime | dateTime | |||
| effectivePeriod | Period | |||
| Slices for performer | SΣ | 0..* | Reference(Practitioner | Organization) | Who is responsible for the observation Slice: Unordered, Open by exists:Observation.performer |
 performer:responsibleObserver | Σ | 0..1 | Reference(Practitioner) | Who is responsible for the observation |
| performer:performingLaboratory | Σ | 0..1 | Reference(Organization) | Who is responsible for the observation |
 performer:performingOrganizationMedicalDirector | Σ | 0..1 | Reference(Practitioner) | Who is responsible for the observation |
| value[x] | SΣC | 0..1 | string | Result Value |
| dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: Null Flavor value set (extensible) |
| interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: Abnmormal Interpretation value set (extensible) | |
| referenceRange | C | 0..* | BackboneElement | Provides guide for interpretation |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| RefRangeNominal | S | 0..1 | CodeableConcept | Reference Range Nominal URL: http://hl7.org/fhir/us/cimi-labs/StructureDefinition/ref-range-nominal |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.identifier:accessionIdentifier.use | required | IdentifierUse |
| Observation.identifier:accessionIdentifier.type | extensible | Pattern: ACSN |
| Observation.identifier:fillerOrderNumber.use | required | IdentifierUse |
| Observation.identifier:fillerOrderNumber.type | extensible | Pattern: FILL |
| Observation.identifier:placerOrderNumber.use | required | IdentifierUse |
| Observation.identifier:placerOrderNumber.type | extensible | Pattern: PLAC |
| Observation.status | required | ObservationStatus |
| Observation.category | preferred | ObservationCategoryCodes |
| Observation.category:Laboratory | preferred | Pattern: laboratory |
| Observation.code | extensible | StandardLabObsNarrative_VSET |
| Observation.dataAbsentReason | extensible | NullFlavor_VSET |
| Observation.interpretation | extensible | AbnormalInterpretation_VSET |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Observation | C | 0..* | StandardLabObs | Measurements and simple assertions | ||||
| 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 | ||||
| Slices for identifier | SΣ | 0..* | Identifier | Business Identifier for observation Slice: Unordered, Open by pattern:type | ||||
| identifier:accessionIdentifier | Σ | 0..1 | Identifier | Business Identifier for observation | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
 type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. 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/v2-0203 | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: ACSN | |||||
| 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 | |||||
| system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
 assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| identifier:fillerOrderNumber | Σ | 0..1 | Identifier | Business Identifier for observation | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. 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/v2-0203 | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: FILL | |||||
| 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 | |||||
| system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| identifier:placerOrderNumber | Σ | 0..1 | Identifier | Business Identifier for observation | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. 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/v2-0203 | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PLAC | |||||
| 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 | |||||
| system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| 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 pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
| category:Laboratory | 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: laboratory | |||||
| 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 | |||||
| code | SΣ | 1..1 | CodeableConcept | Laboratory Test Name Binding: Standard Lab Obs Narrative value set (extensible) | ||||
| subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who and/or what the observation is about | ||||
| focus | ΣTU | 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 | |||||
| effectiveDateTime | dateTime | |||||||
| effectivePeriod | Period | |||||||
| issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
| Slices for performer | SΣ | 0..* | Reference(Practitioner | Organization) | Who is responsible for the observation Slice: Unordered, Open by exists:Observation.performer | ||||
| performer:responsibleObserver | Σ | 0..1 | Reference(Practitioner) | Who is responsible for the observation | ||||
| performer:performingLaboratory | Σ | 0..1 | Reference(Organization) | Who is responsible for the observation | ||||
| performer:performingOrganizationMedicalDirector | Σ | 0..1 | Reference(Practitioner) | Who is responsible for the observation | ||||
| value[x] | SΣC | 0..1 | string | Result Value | ||||
| dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: Null Flavor value set (extensible) | ||||
| interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: Abnmormal Interpretation value set (extensible) | |||||
| 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| RefRangeNominal | S | 0..1 | CodeableConcept | Reference Range Nominal URL: http://hl7.org/fhir/us/cimi-labs/StructureDefinition/ref-range-nominal | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| low | C | 0..1 | SimpleQuantity | Low Range, if relevant | ||||
| high | C | 0..1 | SimpleQuantity | High Range, if relevant | ||||
| type | 0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range. | |||||
| appliesTo | 0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to. | |||||
| age | 0..1 | Range | Applicable age range, if relevant | |||||
| text | 0..1 | string | Text based reference range in an observation | |||||
| hasMember | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
| derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
| component | 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 | ||||
| Observation.language | preferred | CommonLanguages
| ||||
| Observation.identifier:accessionIdentifier.use | required | IdentifierUse | ||||
| Observation.identifier:accessionIdentifier.type | extensible | Pattern: ACSN | ||||
| Observation.identifier:fillerOrderNumber.use | required | IdentifierUse | ||||
| Observation.identifier:fillerOrderNumber.type | extensible | Pattern: FILL | ||||
| Observation.identifier:placerOrderNumber.use | required | IdentifierUse | ||||
| Observation.identifier:placerOrderNumber.type | extensible | Pattern: PLAC | ||||
| Observation.status | required | ObservationStatus | ||||
| Observation.category | preferred | ObservationCategoryCodes | ||||
| Observation.category:Laboratory | preferred | Pattern: laboratory | ||||
| Observation.code | extensible | StandardLabObsNarrative_VSET | ||||
| Observation.dataAbsentReason | extensible | NullFlavor_VSET | ||||
| Observation.interpretation | extensible | AbnormalInterpretation_VSET | ||||
| Observation.bodySite | example | SNOMEDCTBodyStructures | ||||
| Observation.method | example | ObservationMethods | ||||
| Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes | ||||
| Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes | ||||
| Observation.component.code | example | LOINCCodes (a valid code from LOINC) | ||||
| Observation.component.dataAbsentReason | extensible | DataAbsentReason | ||||
| Observation.component.interpretation | extensible | ObservationInterpretationCodes |
This structure is derived from StandardLabObs
Differential View
This structure is derived from StandardLabObs
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 0..* | StandardLabObs | Measurements and simple assertions | |
| code | 1..1 | CodeableConcept | Laboratory Test Name Binding: Standard Lab Obs Narrative value set (extensible) | |
| value[x] | 0..1 | string | Result Value | |
| interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: Abnmormal Interpretation value set (extensible) | |
| referenceRange | ||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| RefRangeNominal | S | 0..1 | CodeableConcept | Reference Range Nominal URL: http://hl7.org/fhir/us/cimi-labs/StructureDefinition/ref-range-nominal |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.code | extensible | StandardLabObsNarrative_VSET |
| Observation.interpretation | extensible | AbnormalInterpretation_VSET |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | C | 0..* | StandardLabObs | Measurements and simple assertions |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| Slices for identifier | SΣ | 0..* | Identifier | Business Identifier for observation Slice: Unordered, Open by pattern:type |
| identifier:accessionIdentifier | Σ | 0..1 | Identifier | Business Identifier for observation |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
| type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. 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/v2-0203 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: ACSN | |
| identifier:fillerOrderNumber | Σ | 0..1 | Identifier | Business Identifier for observation |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
| type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. 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/v2-0203 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: FILL | |
| identifier:placerOrderNumber | Σ | 0..1 | Identifier | Business Identifier for observation |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
| type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. 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/v2-0203 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PLAC | |
| 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 pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
| category:Laboratory | 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: laboratory | |
| code | SΣ | 1..1 | CodeableConcept | Laboratory Test Name Binding: Standard Lab Obs Narrative value set (extensible) |
| 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 | |
| effectiveDateTime | dateTime | |||
| effectivePeriod | Period | |||
| Slices for performer | SΣ | 0..* | Reference(Practitioner | Organization) | Who is responsible for the observation Slice: Unordered, Open by exists:Observation.performer |
| performer:responsibleObserver | Σ | 0..1 | Reference(Practitioner) | Who is responsible for the observation |
| performer:performingLaboratory | Σ | 0..1 | Reference(Organization) | Who is responsible for the observation |
| performer:performingOrganizationMedicalDirector | Σ | 0..1 | Reference(Practitioner) | Who is responsible for the observation |
| value[x] | SΣC | 0..1 | string | Result Value |
| dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: Null Flavor value set (extensible) |
| interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: Abnmormal Interpretation value set (extensible) | |
| referenceRange | C | 0..* | BackboneElement | Provides guide for interpretation |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| RefRangeNominal | S | 0..1 | CodeableConcept | Reference Range Nominal URL: http://hl7.org/fhir/us/cimi-labs/StructureDefinition/ref-range-nominal |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.identifier:accessionIdentifier.use | required | IdentifierUse |
| Observation.identifier:accessionIdentifier.type | extensible | Pattern: ACSN |
| Observation.identifier:fillerOrderNumber.use | required | IdentifierUse |
| Observation.identifier:fillerOrderNumber.type | extensible | Pattern: FILL |
| Observation.identifier:placerOrderNumber.use | required | IdentifierUse |
| Observation.identifier:placerOrderNumber.type | extensible | Pattern: PLAC |
| Observation.status | required | ObservationStatus |
| Observation.category | preferred | ObservationCategoryCodes |
| Observation.category:Laboratory | preferred | Pattern: laboratory |
| Observation.code | extensible | StandardLabObsNarrative_VSET |
| Observation.dataAbsentReason | extensible | NullFlavor_VSET |
| Observation.interpretation | extensible | AbnormalInterpretation_VSET |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Observation | C | 0..* | StandardLabObs | Measurements and simple assertions | ||||
| 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 | ||||
| Slices for identifier | SΣ | 0..* | Identifier | Business Identifier for observation Slice: Unordered, Open by pattern:type | ||||
| identifier:accessionIdentifier | Σ | 0..1 | Identifier | Business Identifier for observation | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. 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/v2-0203 | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: ACSN | |||||
| 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 | |||||
| system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| identifier:fillerOrderNumber | Σ | 0..1 | Identifier | Business Identifier for observation | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. 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/v2-0203 | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: FILL | |||||
| 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 | |||||
| system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| identifier:placerOrderNumber | Σ | 0..1 | Identifier | Business Identifier for observation | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. 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/v2-0203 | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PLAC | |||||
| 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 | |||||
| system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| 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 pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
| category:Laboratory | 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: laboratory | |||||
| 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 | |||||
| code | SΣ | 1..1 | CodeableConcept | Laboratory Test Name Binding: Standard Lab Obs Narrative value set (extensible) | ||||
| subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who and/or what the observation is about | ||||
| focus | ΣTU | 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 | |||||
| effectiveDateTime | dateTime | |||||||
| effectivePeriod | Period | |||||||
| issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
| Slices for performer | SΣ | 0..* | Reference(Practitioner | Organization) | Who is responsible for the observation Slice: Unordered, Open by exists:Observation.performer | ||||
| performer:responsibleObserver | Σ | 0..1 | Reference(Practitioner) | Who is responsible for the observation | ||||
| performer:performingLaboratory | Σ | 0..1 | Reference(Organization) | Who is responsible for the observation | ||||
| performer:performingOrganizationMedicalDirector | Σ | 0..1 | Reference(Practitioner) | Who is responsible for the observation | ||||
| value[x] | SΣC | 0..1 | string | Result Value | ||||
| dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: Null Flavor value set (extensible) | ||||
| interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: Abnmormal Interpretation value set (extensible) | |||||
| 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 | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| RefRangeNominal | S | 0..1 | CodeableConcept | Reference Range Nominal URL: http://hl7.org/fhir/us/cimi-labs/StructureDefinition/ref-range-nominal | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| low | C | 0..1 | SimpleQuantity | Low Range, if relevant | ||||
| high | C | 0..1 | SimpleQuantity | High Range, if relevant | ||||
| type | 0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range. | |||||
| appliesTo | 0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to. | |||||
| age | 0..1 | Range | Applicable age range, if relevant | |||||
| text | 0..1 | string | Text based reference range in an observation | |||||
| hasMember | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
| derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
| component | 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 | ||||
| Observation.language | preferred | CommonLanguages
| ||||
| Observation.identifier:accessionIdentifier.use | required | IdentifierUse | ||||
| Observation.identifier:accessionIdentifier.type | extensible | Pattern: ACSN | ||||
| Observation.identifier:fillerOrderNumber.use | required | IdentifierUse | ||||
| Observation.identifier:fillerOrderNumber.type | extensible | Pattern: FILL | ||||
| Observation.identifier:placerOrderNumber.use | required | IdentifierUse | ||||
| Observation.identifier:placerOrderNumber.type | extensible | Pattern: PLAC | ||||
| Observation.status | required | ObservationStatus | ||||
| Observation.category | preferred | ObservationCategoryCodes | ||||
| Observation.category:Laboratory | preferred | Pattern: laboratory | ||||
| Observation.code | extensible | StandardLabObsNarrative_VSET | ||||
| Observation.dataAbsentReason | extensible | NullFlavor_VSET | ||||
| Observation.interpretation | extensible | AbnormalInterpretation_VSET | ||||
| Observation.bodySite | example | SNOMEDCTBodyStructures | ||||
| Observation.method | example | ObservationMethods | ||||
| Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes | ||||
| Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes | ||||
| Observation.component.code | example | LOINCCodes (a valid code from LOINC) | ||||
| Observation.component.dataAbsentReason | extensible | DataAbsentReason | ||||
| Observation.component.interpretation | extensible | ObservationInterpretationCodes |
This structure is derived from StandardLabObs
Other representations of profile: CSV, Excel, Schematron
IG © 2021+ HL7 International - Clinical Information Modeling Initiative. Package hl7.fhir.us.cimilabs#0.1 based on FHIR 4.0.1. Generated 2023-08-02
Links: Table of Contents |
QA Report
| Version History |
|
Propose a change