minimal Common Oncology Data Elements (mCODE) Implementation Guide
4.0.0 - STU4 United States of America flag

minimal Common Oncology Data Elements (mCODE) Implementation Guide, published by HL7 International / Clinical Interoperability Council. This guide is not an authorized publication; it is the continuous build for version 4.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-mCODE-ig/ and changes regularly. See the Directory of published versions

Resource Profile: Cancer Disease Status Profile

Official URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-cancer-disease-status Version: 4.0.0
Active as of 2024-12-03 Maturity Level: 3 Computable Name: CancerDiseaseStatus
Other Identifiers: OID:2.16.840.1.113883.4.642.40.15.42.6

A clinician's qualitative judgment on the current trend of the cancer, e.g., whether it is stable, worsening (progressing), or improving (responding). The judgment may be based a single type or multiple kinds of evidence, such as imaging data, assessment of symptoms, tumor markers, laboratory data, etc.

Conformance

Observation resources associated with an in-scope patient with Observation.code LOINC 97509-4 SHALL conform to this profile. Beyond this requirement, a producer of resources SHOULD ensure that any resource instance associated with an in-scope patient that would reasonably be expected to conform to this profile SHOULD be published in this form.

In some cases, multiple values for Cancer Disease Status may be true at the same time. For example, a patient's condition may have improved AND the patient is in partial remission. However, this profile is derived from the Observation resource, which restricts value[x] to one value. If a patient has experienced multiple values for Cancer Disease Status, multiple instances should be created.

Usage:

Changes since version true:

  • No changes

    • Formal Views of Profile Content

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

    This structure is derived from Observation

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Observation 0..* Observation Measurements and simple assertions
    ... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... evidenceType S 0..* CodeableConcept Cancer Disease Status Evidence Type Extension
    URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-cancer-disease-status-evidence-type
    Binding: Cancer Disease Status Evidence Type Value Set (required)
    ... status S 1..1 code registered | preliminary | final | amended +
    ... code S 1..1 CodeableConcept Type of observation (code / type)
    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://loinc.org
    ..... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: 97509-4
    ... focus S 0..* Reference(US Core Condition Problems and Health Concerns Profile | Tumor Profile | Radiotherapy Volume Profile) What the observation is about, when it is not about the subject of record
    ... effective[x] S 0..1 dateTime Clinically relevant time/time-period for observation
    ... performer 0..* Reference(US Core Practitioner Profile) Who is responsible for the observation
    ... value[x] S 0..1 CodeableConcept Actual result
    Binding: Condition Status Trend Value Set (preferred)
    Additional BindingsPurpose
    Condition Status Trend Maximum Value Set Max Binding
    ... specimen 0..1 Reference(Specimen) Not used in this profile
    ... device 0..1 Reference(Device | DeviceMetric) Not used in this profile
    ... referenceRange 0..* BackboneElement Not used in this profile
    ... hasMember 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Not used in this profile
    ... component 0..* BackboneElement Not used in this profile

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Observation.value[x]preferredConditionStatusTrendVS
    Additional Bindings Purpose
    Condition Status Trend Maximum Value Set Max Binding
    http://hl7.org/fhir/us/mcode/ValueSet/mcode-condition-status-trend-vs
    from this IG
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Observation C 0..* Observation Measurements and simple assertions
    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
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... evidenceType S 0..* CodeableConcept Cancer Disease Status Evidence Type Extension
    URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-cancer-disease-status-evidence-type
    Binding: Cancer Disease Status Evidence Type Value Set (required)
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... code SΣ 1..1 CodeableConcept Type of observation (code / type)
    Binding: LOINCCodes (example): Codes identifying names of simple observations.


    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://loinc.org
    ..... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: 97509-4
    ... subject SΣ 1..1 Reference(Cancer Patient Profile) Who and/or what the observation is about
    ... focus SΣ 0..* Reference(US Core Condition Problems and Health Concerns Profile | Tumor Profile | Radiotherapy Volume Profile) What the observation is about, when it is not about the subject of record
    ... effective[x] SΣ 0..1 dateTime Clinically relevant time/time-period for observation
    ... performer Σ 0..* Reference(US Core Practitioner Profile) Who is responsible for the observation
    ... value[x] SΣC 0..1 CodeableConcept Actual result
    Binding: Condition Status Trend Value Set (preferred)
    Additional BindingsPurpose
    Condition Status Trend Maximum Value Set Max Binding
    ... specimen 0..1 Reference(Specimen) Not used in this profile
    ... device 0..1 Reference(Device | DeviceMetric) Not used in this profile
    ... referenceRange C 0..* BackboneElement Not used in this profile
    obs-3: Must have at least a low or a high or text
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ... hasMember Σ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Not used in this profile
    ... component Σ 0..* BackboneElement Not used in this profile
    .... 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.


    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Observation.statusrequiredObservationStatus
    http://hl7.org/fhir/ValueSet/observation-status|4.0.1
    from the FHIR Standard
    Observation.codeexamplePattern: LOINC Code 97509-4
    http://hl7.org/fhir/ValueSet/observation-codes
    from the FHIR Standard
    Observation.value[x]preferredConditionStatusTrendVS
    Additional Bindings Purpose
    Condition Status Trend Maximum Value Set Max Binding
    http://hl7.org/fhir/us/mcode/ValueSet/mcode-condition-status-trend-vs
    from this IG
    Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
    http://hl7.org/fhir/ValueSet/observation-codes
    from the FHIR Standard
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Observation C 0..* Observation Measurements and simple assertions
    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
    ... id Σ 0..1 id Logical id of this artifact
    ... meta Σ 0..1 Meta Metadata about the resource
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... language 0..1 code Language of the resource content
    Binding: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguages Max Binding
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    ... contained 0..* Resource Contained, inline Resources
    ... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... evidenceType S 0..* CodeableConcept Cancer Disease Status Evidence Type Extension
    URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-cancer-disease-status-evidence-type
    Binding: Cancer Disease Status Evidence Type Value Set (required)
    ... 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.

    ... category 0..* CodeableConcept Classification of type of observation
    Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


    ... code SΣ 1..1 CodeableConcept Type of observation (code / type)
    Binding: LOINCCodes (example): Codes identifying names of simple observations.


    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://loinc.org
    ..... version 0..1 string Version of the system - if relevant
    ..... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: 97509-4
    ..... 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
    ... subject SΣ 1..1 Reference(Cancer Patient Profile) Who and/or what the observation is about
    ... focus SΣ 0..* Reference(US Core Condition Problems and Health Concerns Profile | Tumor Profile | Radiotherapy Volume Profile) 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] SΣ 0..1 dateTime Clinically relevant time/time-period for observation
    ... issued Σ 0..1 instant Date/Time this version was made available
    ... performer Σ 0..* Reference(US Core Practitioner Profile) Who is responsible for the observation
    ... value[x] SΣC 0..1 CodeableConcept Actual result
    Binding: Condition Status Trend Value Set (preferred)
    Additional BindingsPurpose
    Condition Status Trend Maximum Value Set Max Binding
    ... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
    Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

    ... interpretation 0..* CodeableConcept High, low, normal, etc.
    Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


    ... note 0..* Annotation Comments about the observation
    ... bodySite 0..1 CodeableConcept Observed body part
    Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

    ... method 0..1 CodeableConcept How it was done
    Binding: ObservationMethods (example): Methods for simple observations.

    ... specimen 0..1 Reference(Specimen) Not used in this profile
    ... device 0..1 Reference(Device | DeviceMetric) Not used in this profile
    ... referenceRange C 0..* BackboneElement Not used in this profile
    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(Observation | QuestionnaireResponse | MolecularSequence) Not used in this profile
    ... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
    ... component Σ 0..* BackboneElement Not used in this profile
    .... 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

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Observation.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Observation.statusrequiredObservationStatus
    http://hl7.org/fhir/ValueSet/observation-status|4.0.1
    from the FHIR Standard
    Observation.categorypreferredObservationCategoryCodes
    http://hl7.org/fhir/ValueSet/observation-category
    from the FHIR Standard
    Observation.codeexamplePattern: LOINC Code 97509-4
    http://hl7.org/fhir/ValueSet/observation-codes
    from the FHIR Standard
    Observation.value[x]preferredConditionStatusTrendVS
    Additional Bindings Purpose
    Condition Status Trend Maximum Value Set Max Binding
    http://hl7.org/fhir/us/mcode/ValueSet/mcode-condition-status-trend-vs
    from this IG
    Observation.dataAbsentReasonextensibleDataAbsentReason
    http://hl7.org/fhir/ValueSet/data-absent-reason
    from the FHIR Standard
    Observation.interpretationextensibleObservationInterpretationCodes
    http://hl7.org/fhir/ValueSet/observation-interpretation
    from the FHIR Standard
    Observation.bodySiteexampleSNOMEDCTBodyStructures
    http://hl7.org/fhir/ValueSet/body-site
    from the FHIR Standard
    Observation.methodexampleObservationMethods
    http://hl7.org/fhir/ValueSet/observation-methods
    from the FHIR Standard
    Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
    http://hl7.org/fhir/ValueSet/referencerange-meaning
    from the FHIR Standard
    Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
    http://hl7.org/fhir/ValueSet/referencerange-appliesto
    from the FHIR Standard
    Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
    http://hl7.org/fhir/ValueSet/observation-codes
    from the FHIR Standard
    Observation.component.dataAbsentReasonextensibleDataAbsentReason
    http://hl7.org/fhir/ValueSet/data-absent-reason
    from the FHIR Standard
    Observation.component.interpretationextensibleObservationInterpretationCodes
    http://hl7.org/fhir/ValueSet/observation-interpretation
    from the FHIR Standard

    Differential View

    This structure is derived from Observation

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Observation 0..* Observation Measurements and simple assertions
    ... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... evidenceType S 0..* CodeableConcept Cancer Disease Status Evidence Type Extension
    URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-cancer-disease-status-evidence-type
    Binding: Cancer Disease Status Evidence Type Value Set (required)
    ... status S 1..1 code registered | preliminary | final | amended +
    ... code S 1..1 CodeableConcept Type of observation (code / type)
    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://loinc.org
    ..... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: 97509-4
    ... focus S 0..* Reference(US Core Condition Problems and Health Concerns Profile | Tumor Profile | Radiotherapy Volume Profile) What the observation is about, when it is not about the subject of record
    ... effective[x] S 0..1 dateTime Clinically relevant time/time-period for observation
    ... performer 0..* Reference(US Core Practitioner Profile) Who is responsible for the observation
    ... value[x] S 0..1 CodeableConcept Actual result
    Binding: Condition Status Trend Value Set (preferred)
    Additional BindingsPurpose
    Condition Status Trend Maximum Value Set Max Binding
    ... specimen 0..1 Reference(Specimen) Not used in this profile
    ... device 0..1 Reference(Device | DeviceMetric) Not used in this profile
    ... referenceRange 0..* BackboneElement Not used in this profile
    ... hasMember 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Not used in this profile
    ... component 0..* BackboneElement Not used in this profile

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Observation.value[x]preferredConditionStatusTrendVS
    Additional Bindings Purpose
    Condition Status Trend Maximum Value Set Max Binding
    http://hl7.org/fhir/us/mcode/ValueSet/mcode-condition-status-trend-vs
    from this IG

    Key Elements View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Observation C 0..* Observation Measurements and simple assertions
    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
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... evidenceType S 0..* CodeableConcept Cancer Disease Status Evidence Type Extension
    URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-cancer-disease-status-evidence-type
    Binding: Cancer Disease Status Evidence Type Value Set (required)
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... code SΣ 1..1 CodeableConcept Type of observation (code / type)
    Binding: LOINCCodes (example): Codes identifying names of simple observations.


    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://loinc.org
    ..... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: 97509-4
    ... subject SΣ 1..1 Reference(Cancer Patient Profile) Who and/or what the observation is about
    ... focus SΣ 0..* Reference(US Core Condition Problems and Health Concerns Profile | Tumor Profile | Radiotherapy Volume Profile) What the observation is about, when it is not about the subject of record
    ... effective[x] SΣ 0..1 dateTime Clinically relevant time/time-period for observation
    ... performer Σ 0..* Reference(US Core Practitioner Profile) Who is responsible for the observation
    ... value[x] SΣC 0..1 CodeableConcept Actual result
    Binding: Condition Status Trend Value Set (preferred)
    Additional BindingsPurpose
    Condition Status Trend Maximum Value Set Max Binding
    ... specimen 0..1 Reference(Specimen) Not used in this profile
    ... device 0..1 Reference(Device | DeviceMetric) Not used in this profile
    ... referenceRange C 0..* BackboneElement Not used in this profile
    obs-3: Must have at least a low or a high or text
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ... hasMember Σ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Not used in this profile
    ... component Σ 0..* BackboneElement Not used in this profile
    .... 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.


    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Observation.statusrequiredObservationStatus
    http://hl7.org/fhir/ValueSet/observation-status|4.0.1
    from the FHIR Standard
    Observation.codeexamplePattern: LOINC Code 97509-4
    http://hl7.org/fhir/ValueSet/observation-codes
    from the FHIR Standard
    Observation.value[x]preferredConditionStatusTrendVS
    Additional Bindings Purpose
    Condition Status Trend Maximum Value Set Max Binding
    http://hl7.org/fhir/us/mcode/ValueSet/mcode-condition-status-trend-vs
    from this IG
    Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
    http://hl7.org/fhir/ValueSet/observation-codes
    from the FHIR Standard

    Snapshot View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Observation C 0..* Observation Measurements and simple assertions
    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
    ... id Σ 0..1 id Logical id of this artifact
    ... meta Σ 0..1 Meta Metadata about the resource
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... language 0..1 code Language of the resource content
    Binding: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguages Max Binding
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    ... contained 0..* Resource Contained, inline Resources
    ... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... evidenceType S 0..* CodeableConcept Cancer Disease Status Evidence Type Extension
    URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-cancer-disease-status-evidence-type
    Binding: Cancer Disease Status Evidence Type Value Set (required)
    ... 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.

    ... category 0..* CodeableConcept Classification of type of observation
    Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


    ... code SΣ 1..1 CodeableConcept Type of observation (code / type)
    Binding: LOINCCodes (example): Codes identifying names of simple observations.


    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://loinc.org
    ..... version 0..1 string Version of the system - if relevant
    ..... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: 97509-4
    ..... 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
    ... subject SΣ 1..1 Reference(Cancer Patient Profile) Who and/or what the observation is about
    ... focus SΣ 0..* Reference(US Core Condition Problems and Health Concerns Profile | Tumor Profile | Radiotherapy Volume Profile) 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] SΣ 0..1 dateTime Clinically relevant time/time-period for observation
    ... issued Σ 0..1 instant Date/Time this version was made available
    ... performer Σ 0..* Reference(US Core Practitioner Profile) Who is responsible for the observation
    ... value[x] SΣC 0..1 CodeableConcept Actual result
    Binding: Condition Status Trend Value Set (preferred)
    Additional BindingsPurpose
    Condition Status Trend Maximum Value Set Max Binding
    ... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
    Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

    ... interpretation 0..* CodeableConcept High, low, normal, etc.
    Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


    ... note 0..* Annotation Comments about the observation
    ... bodySite 0..1 CodeableConcept Observed body part
    Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

    ... method 0..1 CodeableConcept How it was done
    Binding: ObservationMethods (example): Methods for simple observations.

    ... specimen 0..1 Reference(Specimen) Not used in this profile
    ... device 0..1 Reference(Device | DeviceMetric) Not used in this profile
    ... referenceRange C 0..* BackboneElement Not used in this profile
    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(Observation | QuestionnaireResponse | MolecularSequence) Not used in this profile
    ... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
    ... component Σ 0..* BackboneElement Not used in this profile
    .... 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

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Observation.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Observation.statusrequiredObservationStatus
    http://hl7.org/fhir/ValueSet/observation-status|4.0.1
    from the FHIR Standard
    Observation.categorypreferredObservationCategoryCodes
    http://hl7.org/fhir/ValueSet/observation-category
    from the FHIR Standard
    Observation.codeexamplePattern: LOINC Code 97509-4
    http://hl7.org/fhir/ValueSet/observation-codes
    from the FHIR Standard
    Observation.value[x]preferredConditionStatusTrendVS
    Additional Bindings Purpose
    Condition Status Trend Maximum Value Set Max Binding
    http://hl7.org/fhir/us/mcode/ValueSet/mcode-condition-status-trend-vs
    from this IG
    Observation.dataAbsentReasonextensibleDataAbsentReason
    http://hl7.org/fhir/ValueSet/data-absent-reason
    from the FHIR Standard
    Observation.interpretationextensibleObservationInterpretationCodes
    http://hl7.org/fhir/ValueSet/observation-interpretation
    from the FHIR Standard
    Observation.bodySiteexampleSNOMEDCTBodyStructures
    http://hl7.org/fhir/ValueSet/body-site
    from the FHIR Standard
    Observation.methodexampleObservationMethods
    http://hl7.org/fhir/ValueSet/observation-methods
    from the FHIR Standard
    Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
    http://hl7.org/fhir/ValueSet/referencerange-meaning
    from the FHIR Standard
    Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
    http://hl7.org/fhir/ValueSet/referencerange-appliesto
    from the FHIR Standard
    Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
    http://hl7.org/fhir/ValueSet/observation-codes
    from the FHIR Standard
    Observation.component.dataAbsentReasonextensibleDataAbsentReason
    http://hl7.org/fhir/ValueSet/data-absent-reason
    from the FHIR Standard
    Observation.component.interpretationextensibleObservationInterpretationCodes
    http://hl7.org/fhir/ValueSet/observation-interpretation
    from the FHIR Standard

     

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