QI-Core Implementation Guide
7.0.0 - STU7
QI-Core Implementation Guide
7.0.0 - STU7
QI-Core Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 7.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-qi-core/ and changes regularly. See the Directory of published versions
{
"resourceType" : "Observation",
"id" : "example",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-simple-observation"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Observation example</b></p><a name=\"example\"> </a><a name=\"hcexample\"> </a><a name=\"example-en-US\"> </a><p><b>Observation Body Position</b>: <span title=\"Codes:{http://snomed.info/sct 33586001}\">Sitting position (finding)</span></p><p><b>status</b>: Final</p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/observation-category vital-signs}\">Vital Signs</span></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 30350-3}\">Hemoglobin [Mass/volume] in Venous blood</span></p><p><b>subject</b>: <a href=\"Patient-example.html\">Jim Chalmers Male, DoB: 1974-12-25 ( Medical record number\u00a0(use:\u00a0usual,\u00a0period:\u00a02001-05-06 --> (ongoing)))</a></p><p><b>encounter</b>: <a href=\"Encounter-example.html\">Encounter: status = in-progress; class = inpatient encounter (ActCode#IMP); type = Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.</a></p><p><b>effective</b>: 2013-04-02 10:30:10+0100 --> 2013-04-05 10:30:10+0100</p><p><b>issued</b>: 2013-04-03 15:30:10+0100</p><p><b>performer</b>: <a href=\"Practitioner-example.html\">Practitioner</a></p><p><b>value</b>: 7.2 g/dl<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codeg/dL = 'g/dL')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v2-0078 L}\">Below low normal</span></p><p><b>bodySite</b>: <span title=\"Codes:{http://snomed.info/sct 308046002}\">Superficial forearm vein</span></p><p><b>method</b>: <span title=\"Codes:{http://snomed.info/sct 120220003}\">Injection to forearm</span></p><p><b>derivedFrom</b>: <a href=\"Observation-example.html\">Observation Hemoglobin [Mass/volume] in Venous blood</a></p><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 8480-6}, {http://snomed.info/sct 271649006}\">Systolic blood pressure</span></p><p><b>value</b>: 107 mmHg<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codemm[Hg] = 'mm[Hg]')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v2-0078 N}\">Normal</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 8462-4}\">Diastolic blood pressure</span></p><p><b>value</b>: 60 mmHg<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codemm[Hg] = 'mm[Hg]')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v2-0078 L}\">Below low normal</span></p></blockquote></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/observation-bodyPosition",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "33586001",
"display" : "Sitting position (finding)"
}
]
}
}
],
"status" : "final",
"category" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/observation-category",
"code" : "vital-signs",
"display" : "Vital Signs"
}
]
}
],
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "30350-3",
"display" : "Hemoglobin [Mass/volume] in Venous blood"
}
]
},
"subject" : {
🔗 "reference" : "Patient/example"
},
"encounter" : {
🔗 "reference" : "Encounter/example"
},
"effectivePeriod" : {
"start" : "2013-04-02T10:30:10+01:00",
"end" : "2013-04-05T10:30:10+01:00"
},
"issued" : "2013-04-03T15:30:10+01:00",
"performer" : [
{
🔗 "reference" : "Practitioner/example",
"display" : "Practitioner"
}
],
"valueQuantity" : {
"value" : 7.2,
"unit" : "g/dl",
"system" : "http://unitsofmeasure.org",
"code" : "g/dL"
},
"interpretation" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0078",
"code" : "L",
"display" : "Low"
}
],
"text" : "Below low normal"
}
],
"bodySite" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "308046002",
"display" : "Superficial forearm vein"
}
]
},
"method" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "120220003",
"display" : "Injection to forearm"
}
]
},
"derivedFrom" : [
{
🔗 "reference" : "Observation/example"
}
],
"component" : [
// Should have a refrange as well
{
"code" : //
Observations are often coded in multiple code systems.
- LOINC provides a very specific code (though not more specific in this particular
case)
- snomed provides a clinically relevant code that is usually less granular
than LOINC
- the source system provides its own code, which may be less or more granular
than LOINC
this is shown here to demonstrate the concept of translations within the codeableConcept
datatype. The diastolic code below only has a LOINC code
{
"coding" : [
// LOINC -code
{
"system" : "http://loinc.org",
"code" : "8480-6",
"display" : "Systolic blood pressure"
},
{
"system" : "http://snomed.info/sct",
"code" : "271649006",
"display" : "Systolic blood pressure"
}
]
},
"valueQuantity" : // SNOMED CT Codes
{
"value" : 107,
"unit" : "mmHg",
"system" : "http://unitsofmeasure.org",
"code" : "mm[Hg]"
},
"interpretation" : [
// an interpretation for the individual composite observation
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0078",
"code" : "N",
"display" : "normal"
}
],
"text" : "Normal"
}
]
},
{
"code" : // this codes only has a LOINC code
{
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8462-4",
"display" : "Diastolic blood pressure"
}
]
},
"valueQuantity" : {
"value" : 60,
"unit" : "mmHg",
"system" : "http://unitsofmeasure.org",
"code" : "mm[Hg]"
},
"interpretation" : [
// an interpretation for the individual composite observation
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0078",
"code" : "L",
"display" : "low"
}
],
"text" : "Below low normal"
}
]
}
]
}
IG © 2019+ HL7 International / Clinical Quality Information. Package hl7.fhir.us.qicore#7.0.0 based on FHIR 4.0.1. Generated 2024-11-21
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