minimal Common Oncology Data Elements (mCODE) Implementation Guide
4.0.0-ballot - STU4 Ballot
minimal Common Oncology Data Elements (mCODE) Implementation Guide
4.0.0-ballot - STU4 Ballot
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-ballot 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
| Official URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-body-surface-area | Version: 4.0.0-ballot | |||
| Active as of 2024-04-03 | Computable Name: BodySurfaceArea | |||
| Other Identifiers: OID:2.16.840.1.113883.4.642.40.15.42.4 | ||||
Entire body surface area, either measured or calculated.
Usage:
Changes since version true:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreVitalSignsProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Observation | 0..* | USCoreVitalSignsProfile | US Core Vital Signs Profile | |
  code | 1..1 | CodeableConcept | Coded Responses from C-CDA Vital Sign Results 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: 8277-6 | |
 value[x] | 0..1 | Quantity | Vital Signs Value | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | C | 0..* | USCoreVitalSignsProfile | 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 Responses from C-CDA Vital Sign Results Binding: US Core Vital Signs ValueSet (extensible): The vital sign codes from the base FHIR and US Core Vital Signs. 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: 8277-6 | |
 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 | Quantity | Vital Signs Value Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs. |
| 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 | Type of component observation (code / type) Binding: US Core Vital Signs ValueSet (extensible): The vital sign codes from the base FHIR and US Core Vital Signs. |
| 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 / Code | URI |
| Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1from the FHIR Standard | |
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | |
| Observation.category:VSCat | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | |
| Observation.code | extensible | Pattern: LOINC code 8277-6http://hl7.org/fhir/us/core/ValueSet/us-core-vital-signs | |
| Observation.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1from the FHIR Standard | |
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | |
| Observation.component.code | extensible | UsCoreVitalSignshttp://hl7.org/fhir/us/core/ValueSet/us-core-vital-signs | |
| Observation.component.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1from the FHIR Standard | |
| Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Observation | C | 0..* | USCoreVitalSignsProfile | 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 Responses from C-CDA Vital Sign Results Binding: US Core Vital Signs ValueSet (extensible): The vital sign codes from the base FHIR and US Core Vital Signs. 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: 8277-6 | |||||
| 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(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 | Quantity S | Vital Signs Value Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs. | ||||
| 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 | Type of component observation (code / type) Binding: US Core Vital Signs ValueSet (extensible): The vital sign codes from the base FHIR and US Core Vital Signs. | ||||
| 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 / Code | URI | |||
| Observation.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1from the FHIR Standard | ||||
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | ||||
| Observation.category:VSCat | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | ||||
| Observation.code | extensible | Pattern: LOINC code 8277-6http://hl7.org/fhir/us/core/ValueSet/us-core-vital-signs | ||||
| Observation.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1from the FHIR Standard | ||||
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard | ||||
| Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methodsfrom the FHIR Standard | ||||
| Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaningfrom the FHIR Standard | ||||
| Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliestofrom the FHIR Standard | ||||
| Observation.component.code | extensible | UsCoreVitalSignshttp://hl7.org/fhir/us/core/ValueSet/us-core-vital-signs | ||||
| Observation.component.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1from the FHIR Standard | ||||
| Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard |
This structure is derived from USCoreVitalSignsProfile
Differential View
This structure is derived from USCoreVitalSignsProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 0..* | USCoreVitalSignsProfile | US Core Vital Signs Profile | |
| code | 1..1 | CodeableConcept | Coded Responses from C-CDA Vital Sign Results 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: 8277-6 | |
| value[x] | 0..1 | Quantity | Vital Signs Value | |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | C | 0..* | USCoreVitalSignsProfile | 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 Responses from C-CDA Vital Sign Results Binding: US Core Vital Signs ValueSet (extensible): The vital sign codes from the base FHIR and US Core Vital Signs. 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: 8277-6 | |
| 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 | Quantity | Vital Signs Value Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs. |
| 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 | Type of component observation (code / type) Binding: US Core Vital Signs ValueSet (extensible): The vital sign codes from the base FHIR and US Core Vital Signs. |
| 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 / Code | URI |
| Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1from the FHIR Standard | |
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | |
| Observation.category:VSCat | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | |
| Observation.code | extensible | Pattern: LOINC code 8277-6http://hl7.org/fhir/us/core/ValueSet/us-core-vital-signs | |
| Observation.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1from the FHIR Standard | |
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | |
| Observation.component.code | extensible | UsCoreVitalSignshttp://hl7.org/fhir/us/core/ValueSet/us-core-vital-signs | |
| Observation.component.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1from the FHIR Standard | |
| Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Observation | C | 0..* | USCoreVitalSignsProfile | 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 Responses from C-CDA Vital Sign Results Binding: US Core Vital Signs ValueSet (extensible): The vital sign codes from the base FHIR and US Core Vital Signs. 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: 8277-6 | |||||
| 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(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 | Quantity S | Vital Signs Value Binding: VitalSignsUnits (extensible): Common UCUM units for recording Vital Signs. | ||||
| 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 | Type of component observation (code / type) Binding: US Core Vital Signs ValueSet (extensible): The vital sign codes from the base FHIR and US Core Vital Signs. | ||||
| 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 / Code | URI | |||
| Observation.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1from the FHIR Standard | ||||
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | ||||
| Observation.category:VSCat | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | ||||
| Observation.code | extensible | Pattern: LOINC code 8277-6http://hl7.org/fhir/us/core/ValueSet/us-core-vital-signs | ||||
| Observation.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1from the FHIR Standard | ||||
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard | ||||
| Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methodsfrom the FHIR Standard | ||||
| Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaningfrom the FHIR Standard | ||||
| Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliestofrom the FHIR Standard | ||||
| Observation.component.code | extensible | UsCoreVitalSignshttp://hl7.org/fhir/us/core/ValueSet/us-core-vital-signs | ||||
| Observation.component.value[x] | extensible | VitalSignsUnitshttp://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1from the FHIR Standard | ||||
| Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard |
This structure is derived from USCoreVitalSignsProfile
Other representations of profile: CSV, Excel, Schematron
IG © 2019+ HL7 International / Clinical Interoperability Council. Package hl7.fhir.us.mcode#4.0.0-ballot based on FHIR 4.0.1. Generated 2024-04-03
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