US Quality Core Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-us-quality-core/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/us/quality-core/StructureDefinition/us-quality-core-observation-lab | Version: 1.0.0-ballot | ||||
| Standards status: Trial-use | Maturity Level: 4 | Computable Name: USQualityCoreObservationLab | |||
| Other Identifiers: OID:2.16.840.1.113883.4.642.40.78.42.36 | |||||
The US Quality Core Laboratory Result Observation Profile is based upon the US Laboratory Result Observation Resource. Defines the core set of elements and extensions for quality rule and measure authors.
Systems are expected to support this profile as part of implementing USCDI+ Quality V2 in FHIR and meeting the conformance requirements of this guide.
The following elements are specifically relevant to USCDI+ Quality V2 data classes and elements. Systems are expected to support these elements as applicable to their role in US Quality Core data exchange. See the Must Support section of this guide for more information. These elements are flagged as (USCDI+ Quality) in the formal profile views.
USCDI+ Quality Elements:
| Profile element | Description | USCDI+ Quality Data Element(s) |
|---|---|---|
category |
Classification of type of observation | Laboratory: Tests |
category:us-core |
Classification of type of observation | Laboratory: Tests |
code |
Laboratory Test Name | Laboratory: Tests |
effective[x] |
Clinically relevant time/time-period for observation | Laboratory: Specimen Collection Date and Time |
interpretation |
High, low, normal, etc. | Laboratory: Result Interpretation |
issued |
Date/Time this version was made available | Laboratory: Laboratory Result Report Date and Time |
performer |
Who is responsible for the observation | Provenance: Author |
referenceRange |
Result reference range | Laboratory: Result Reference Range |
specimen |
Specimen used for this observation | Laboratory: Specimen Condition Acceptability, Laboratory: Specimen Identifier, Laboratory: Specimen Source Site, Laboratory: Specimen Type, Laboratory: Specimen Collection Date and Time |
status |
registered | preliminary | final | amended | corrected | cancelled | entered-in-error | unknown | Laboratory: Result Status |
value[x] |
Result Value | Laboratory: Result Unit of Measure, Laboratory: Values/Results |
Because this profile is derived directly or indirectly from US Core, systems are also expected to support the Must Support and Additional USCDI requirements specified by the US Core profile this profile inherits from. For more information about those requirements, refer to the US Core Laboratory Result Observation Profile. The Formal Views section also provides the formal summary, definitions, terminology requirements, and mandatory element requirements.
Usages:
You can also check for usages in the FHIR IG Statistics
Description Differentials, Snapshots, and other representations.
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
|---|---|---|---|---|
![]() |
C | 0..* | USCoreLaboratoryResultObservationProfile(9.0.0) | Measurements and simple assertions Constraints: obs-6, obs-7, us-core-2 |
![]() ![]() |
SΣ | 0..1 | Meta | Metadata about the resource |
![]() ![]() ![]() |
SΣ | 0..1 | instant | When the resource last changed |
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored |
![]() ![]() |
?!SΣ | 1..1 | code | (USCDI+ Quality) registered | preliminary | final | amended | corrected | cancelled | entered-in-error | unknown Binding: ObservationStatus (required): Codes providing the status of an observation. |
![]() ![]() |
S | 1..* | CodeableConcept | (USCDI+ Quality) Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
![]() ![]() ![]() |
S | 1..1 | CodeableConcept | (USCDI+ Quality) Classification of type of observation Binding: US Core Clinical Result Observation Category (required) Required Pattern: At least the following |
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |
![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |
![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |
![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory | |
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |
![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |
![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |
![]() ![]() |
SΣ | 1..1 | CodeableConcept | (USCDI+ Quality) Laboratory Test Name Binding: US Core Laboratory Test Codes (extensible): Laboratory LOINC Codes |
![]() ![]() |
SΣ | 1..1 | Reference(US Quality Core Patient) | Who and/or what the observation is about |
![]() ![]() |
SΣ | 0..1 | Reference(US Quality Core Encounter) | Encounter associated with Observation |
![]() ![]() |
SΣC | 0..1 | (USCDI+ Quality) Clinically relevant time/time-period for observation Constraints: us-core-1 | |
![]() ![]() ![]() |
dateTime S | |||
![]() ![]() ![]() |
Period | |||
![]() ![]() ![]() |
Timing | |||
![]() ![]() ![]() |
instant | |||
![]() ![]() |
Σ | 0..1 | instant | (USCDI+ Quality) Date/Time this version was made available |
![]() ![]() |
SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) | (USCDI+ Quality) Who is responsible for the observation |
![]() ![]() |
SΣC | 0..1 | (USCDI+ Quality) Result Value Constraints: us-core-3, us-core-4 | |
![]() ![]() ![]() |
Quantity S | |||
![]() ![]() ![]() |
CodeableConcept S | |||
![]() ![]() ![]() |
string S | |||
![]() ![]() ![]() |
boolean | |||
![]() ![]() ![]() |
integer | |||
![]() ![]() ![]() |
Range | |||
![]() ![]() ![]() |
Ratio | |||
![]() ![]() ![]() |
SampledData | |||
![]() ![]() ![]() |
time | |||
![]() ![]() ![]() |
dateTime | |||
![]() ![]() ![]() |
Period | |||
![]() ![]() |
SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
![]() ![]() |
S | 0..* | CodeableConcept | (USCDI+ Quality) High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. |
![]() ![]() |
S | 0..1 | Reference(US Core Specimen Profile) | (USCDI+ Quality) Specimen used for this observation |
![]() ![]() |
SC | 0..* | BackboneElement | (USCDI+ Quality) Result reference range Constraints: obs-3, us-core-22 |
![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Observation.status | Base | required | ObservationStatus | 📍4.0.1 | FHIR Std. |
| Observation.category | Base | preferred | Observation Category Codes | 📦4.0.1 | FHIR Std. |
| Observation.category:us-core | Base | required | US Core Clinical Result Observation Category | 📦9.0.0 | US Core v9.0 |
| Observation.code | Base | extensible | US Core Laboratory Test Codes | 📦9.0.0 | US Core v9.0 |
| Observation.dataAbsentReason | Base | extensible | DataAbsentReason | 📍4.0.1 | FHIR Std. |
| Observation.interpretation | Base | extensible | Observation Interpretation Codes | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | Observation | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
| obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text |
low.exists() or high.exists() or text.exists()
|
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present |
dataAbsentReason.empty() or value.empty()
|
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present |
value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
|
| us-core-1 | error | Observation.effective[x] | Datetime must be at least to day. |
$this is dateTime implies $this.toString().length() >= 10
|
| us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present |
(component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists())
|
| us-core-3 | error | Observation.value[x] | The system SHALL be UCUM for coded quantity units. |
ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org'
|
| us-core-4 | best practice | Observation.value[x] | SHOULD use SNOMED CT for coded Results |
ofType(CodeableConcept).coding.system.empty() or (ofType(CodeableConcept).coding.system contains 'http://snomed.info/sct')
|
| us-core-22 | error | Observation.referenceRange | The system SHALL be UCUM for coded quantity units. |
(low.system.empty() or low.system = 'http://unitsofmeasure.org') and (high.system.empty() or high.system = 'http://unitsofmeasure.org')
|
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
|---|---|---|---|---|
![]() |
0..* | USCoreLaboratoryResultObservationProfile(9.0.0) | Measurements and simple assertions | |
![]() ![]() |
1..1 | code | (USCDI+ Quality) registered | preliminary | final | amended | corrected | cancelled | entered-in-error | unknown | |
![]() ![]() |
1..* | CodeableConcept | (USCDI+ Quality) Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |
![]() ![]() |
Content/Rules for all slices | |||
![]() ![]() ![]() |
1..1 | CodeableConcept | (USCDI+ Quality) Classification of type of observation Binding: US Core Clinical Result Observation Category (required) | |
![]() ![]() |
1..1 | CodeableConcept | (USCDI+ Quality) Laboratory Test Name | |
![]() ![]() |
1..1 | Reference(US Quality Core Patient) | Who and/or what the observation is about | |
![]() ![]() |
0..1 | Reference(US Quality Core Encounter) | Encounter associated with Observation | |
![]() ![]() |
0..1 | dateTime, Period, Timing, instant | (USCDI+ Quality) Clinically relevant time/time-period for observation | |
![]() ![]() |
0..1 | instant | (USCDI+ Quality) Date/Time this version was made available | |
![]() ![]() |
0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) | (USCDI+ Quality) Who is responsible for the observation | |
![]() ![]() |
0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | (USCDI+ Quality) Result Value | |
![]() ![]() |
0..* | CodeableConcept | (USCDI+ Quality) High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |
![]() ![]() |
0..1 | Reference(US Core Specimen Profile) | (USCDI+ Quality) Specimen used for this observation | |
![]() ![]() |
0..* | BackboneElement | (USCDI+ Quality) Result reference range | |
Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Observation.category | Base | preferred | Observation Category Codes | 📦4.0.1 | FHIR Std. |
| Observation.category:us-core | Base | required | US Core Clinical Result Observation Category | 📦9.0.0 | US Core v9.0 |
| Observation.interpretation | Base | extensible | Observation Interpretation Codes | 📦4.0.1 | FHIR Std. |
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
|---|---|---|---|---|---|---|---|---|
![]() |
C | 0..* | USCoreLaboratoryResultObservationProfile(9.0.0) | Measurements and simple assertions Constraints: obs-6, obs-7, us-core-2 | ||||
![]() ![]() |
Σ | 0..1 | id | Logical id of this artifact | ||||
![]() ![]() |
SΣ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() |
Σ | 0..1 | id | Version specific identifier | ||||
![]() ![]() ![]() |
SΣ | 0..1 | instant | When the resource last changed | ||||
![]() ![]() ![]() |
Σ | 0..1 | uri | Identifies where the resource comes from | ||||
![]() ![]() ![]() |
Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
![]() ![]() ![]() |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
![]() ![]() ![]() |
Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
![]() ![]() |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
![]() ![]() |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
![]() ![]() |
0..* | Resource | Contained, inline Resources | |||||
![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
![]() ![]() |
Σ | 0..* | Identifier | Business Identifier for observation | ||||
![]() ![]() |
Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | ||||
![]() ![]() |
Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
![]() ![]() |
?!SΣ | 1..1 | code | (USCDI+ Quality) registered | preliminary | final | amended | corrected | cancelled | entered-in-error | unknown Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
![]() ![]() |
S | 1..* | CodeableConcept | (USCDI+ Quality) Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
![]() ![]() ![]() |
S | 1..1 | CodeableConcept | (USCDI+ Quality) Classification of type of observation Binding: US Core Clinical Result Observation Category (required) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() |
SΣ | 1..1 | CodeableConcept | (USCDI+ Quality) Laboratory Test Name Binding: US Core Laboratory Test Codes (extensible): Laboratory LOINC Codes | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() |
Σ | 0..* | Coding | Code defined by a terminology system | ||||
![]() ![]() ![]() |
Σ | 0..1 | string | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: The name of the test that was performed. | ||||
![]() ![]() |
SΣ | 1..1 | Reference(US Quality Core Patient) | Who and/or what the observation is about | ||||
![]() ![]() |
Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
![]() ![]() |
SΣ | 0..1 | Reference(US Quality Core Encounter) | Encounter associated with Observation | ||||
![]() ![]() |
SΣC | 0..1 | (USCDI+ Quality) Clinically relevant time/time-period for observation Constraints: us-core-1 | |||||
![]() ![]() ![]() |
dateTime S | |||||||
![]() ![]() ![]() |
Period | |||||||
![]() ![]() ![]() |
Timing | |||||||
![]() ![]() ![]() |
instant | |||||||
![]() ![]() |
Σ | 0..1 | instant | (USCDI+ Quality) Date/Time this version was made available | ||||
![]() ![]() |
SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) | (USCDI+ Quality) Who is responsible for the observation | ||||
![]() ![]() |
SΣC | 0..1 | (USCDI+ Quality) Result Value Constraints: us-core-3, us-core-4 | |||||
![]() ![]() ![]() |
Quantity S | |||||||
![]() ![]() ![]() |
CodeableConcept S | |||||||
![]() ![]() ![]() |
string S | |||||||
![]() ![]() ![]() |
boolean | |||||||
![]() ![]() ![]() |
integer | |||||||
![]() ![]() ![]() |
Range | |||||||
![]() ![]() ![]() |
Ratio | |||||||
![]() ![]() ![]() |
SampledData | |||||||
![]() ![]() ![]() |
time | |||||||
![]() ![]() ![]() |
dateTime | |||||||
![]() ![]() ![]() |
Period | |||||||
![]() ![]() |
SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
![]() ![]() |
S | 0..* | CodeableConcept | (USCDI+ Quality) High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | ||||
![]() ![]() |
0..* | Annotation | Comments about the observation | |||||
![]() ![]() |
0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
![]() ![]() |
0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |||||
![]() ![]() |
S | 0..1 | Reference(US Core Specimen Profile) | (USCDI+ Quality) Specimen used for this observation | ||||
![]() ![]() |
0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
![]() ![]() |
SC | 0..* | BackboneElement | (USCDI+ Quality) Result reference range Constraints: obs-3, us-core-22 | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() |
C | 0..1 | SimpleQuantity(4.0.1) | Low Range, if relevant | ||||
![]() ![]() ![]() |
C | 0..1 | SimpleQuantity(4.0.1) | High Range, if relevant | ||||
![]() ![]() ![]() |
0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range. | |||||
![]() ![]() ![]() |
0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to. | |||||
![]() ![]() ![]() |
0..1 | Range | Applicable age range, if relevant | |||||
![]() ![]() ![]() |
0..1 | string | Text based reference range in an observation | |||||
![]() ![]() |
Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
![]() ![]() |
Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
![]() ![]() |
Σ | 0..* | BackboneElement | Component results | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() |
Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
![]() ![]() ![]() |
Σ | 0..1 | Actual component result | |||||
![]() ![]() ![]() ![]() |
Quantity | |||||||
![]() ![]() ![]() ![]() |
CodeableConcept | |||||||
![]() ![]() ![]() ![]() |
string | |||||||
![]() ![]() ![]() ![]() |
boolean | |||||||
![]() ![]() ![]() ![]() |
integer | |||||||
![]() ![]() ![]() ![]() |
Range | |||||||
![]() ![]() ![]() ![]() |
Ratio | |||||||
![]() ![]() ![]() ![]() |
SampledData | |||||||
![]() ![]() ![]() ![]() |
time | |||||||
![]() ![]() ![]() ![]() |
dateTime | |||||||
![]() ![]() ![]() ![]() |
Period | |||||||
![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
![]() ![]() ![]() |
0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
![]() ![]() ![]() |
0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |||||
Documentation for this format | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| Observation.meta.security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std. |
| Observation.meta.tag | Base | example | Common Tags | 📍4.0.1 | FHIR Std. |
| Observation.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| Observation.status | Base | required | ObservationStatus | 📍4.0.1 | FHIR Std. |
| Observation.category | Base | preferred | Observation Category Codes | 📦4.0.1 | FHIR Std. |
| Observation.category:us-core | Base | required | US Core Clinical Result Observation Category | 📦9.0.0 | US Core v9.0 |
| Observation.code | Base | extensible | US Core Laboratory Test Codes | 📦9.0.0 | US Core v9.0 |
| Observation.dataAbsentReason | Base | extensible | DataAbsentReason | 📍4.0.1 | FHIR Std. |
| Observation.interpretation | Base | extensible | Observation Interpretation Codes | 📦4.0.1 | FHIR Std. |
| Observation.bodySite | Base | example | SNOMED CT Body Structures | 📍4.0.1 | FHIR Std. |
| Observation.method | Base | example | Observation Methods | 📍4.0.1 | FHIR Std. |
| Observation.referenceRange.type | Base | preferred | Observation Reference Range Meaning Codes | 📍4.0.1 | FHIR Std. |
| Observation.referenceRange.appliesTo | Base | example | Observation Reference Range Applies To Codes | 📍4.0.1 | FHIR Std. |
| Observation.component.code | Base | example | LOINC Codes | 📍4.0.1 | FHIR Std. |
| Observation.component.dataAbsentReason | Base | extensible | DataAbsentReason | 📍4.0.1 | FHIR Std. |
| Observation.component.interpretation | Base | extensible | Observation Interpretation Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | Observation | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
| obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text |
low.exists() or high.exists() or text.exists()
|
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present |
dataAbsentReason.empty() or value.empty()
|
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present |
value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
|
| us-core-1 | error | Observation.effective[x] | Datetime must be at least to day. |
$this is dateTime implies $this.toString().length() >= 10
|
| us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present |
(component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists())
|
| us-core-3 | error | Observation.value[x] | The system SHALL be UCUM for coded quantity units. |
ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org'
|
| us-core-4 | best practice | Observation.value[x] | SHOULD use SNOMED CT for coded Results |
ofType(CodeableConcept).coding.system.empty() or (ofType(CodeableConcept).coding.system contains 'http://snomed.info/sct')
|
| us-core-22 | error | Observation.referenceRange | The system SHALL be UCUM for coded quantity units. |
(low.system.empty() or low.system = 'http://unitsofmeasure.org') and (high.system.empty() or high.system = 'http://unitsofmeasure.org')
|
Summary
Structures
This structure refers to these other structures:
Maturity: 4
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
|---|---|---|---|---|
![]() |
C | 0..* | USCoreLaboratoryResultObservationProfile(9.0.0) | Measurements and simple assertions Constraints: obs-6, obs-7, us-core-2 |
![]() ![]() |
SΣ | 0..1 | Meta | Metadata about the resource |
![]() ![]() ![]() |
SΣ | 0..1 | instant | When the resource last changed |
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored |
![]() ![]() |
?!SΣ | 1..1 | code | (USCDI+ Quality) registered | preliminary | final | amended | corrected | cancelled | entered-in-error | unknown Binding: ObservationStatus (required): Codes providing the status of an observation. |
![]() ![]() |
S | 1..* | CodeableConcept | (USCDI+ Quality) Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
![]() ![]() ![]() |
S | 1..1 | CodeableConcept | (USCDI+ Quality) Classification of type of observation Binding: US Core Clinical Result Observation Category (required) Required Pattern: At least the following |
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |
![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |
![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |
![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory | |
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |
![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |
![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |
![]() ![]() |
SΣ | 1..1 | CodeableConcept | (USCDI+ Quality) Laboratory Test Name Binding: US Core Laboratory Test Codes (extensible): Laboratory LOINC Codes |
![]() ![]() |
SΣ | 1..1 | Reference(US Quality Core Patient) | Who and/or what the observation is about |
![]() ![]() |
SΣ | 0..1 | Reference(US Quality Core Encounter) | Encounter associated with Observation |
![]() ![]() |
SΣC | 0..1 | (USCDI+ Quality) Clinically relevant time/time-period for observation Constraints: us-core-1 | |
![]() ![]() ![]() |
dateTime S | |||
![]() ![]() ![]() |
Period | |||
![]() ![]() ![]() |
Timing | |||
![]() ![]() ![]() |
instant | |||
![]() ![]() |
Σ | 0..1 | instant | (USCDI+ Quality) Date/Time this version was made available |
![]() ![]() |
SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) | (USCDI+ Quality) Who is responsible for the observation |
![]() ![]() |
SΣC | 0..1 | (USCDI+ Quality) Result Value Constraints: us-core-3, us-core-4 | |
![]() ![]() ![]() |
Quantity S | |||
![]() ![]() ![]() |
CodeableConcept S | |||
![]() ![]() ![]() |
string S | |||
![]() ![]() ![]() |
boolean | |||
![]() ![]() ![]() |
integer | |||
![]() ![]() ![]() |
Range | |||
![]() ![]() ![]() |
Ratio | |||
![]() ![]() ![]() |
SampledData | |||
![]() ![]() ![]() |
time | |||
![]() ![]() ![]() |
dateTime | |||
![]() ![]() ![]() |
Period | |||
![]() ![]() |
SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
![]() ![]() |
S | 0..* | CodeableConcept | (USCDI+ Quality) High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. |
![]() ![]() |
S | 0..1 | Reference(US Core Specimen Profile) | (USCDI+ Quality) Specimen used for this observation |
![]() ![]() |
SC | 0..* | BackboneElement | (USCDI+ Quality) Result reference range Constraints: obs-3, us-core-22 |
![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Observation.status | Base | required | ObservationStatus | 📍4.0.1 | FHIR Std. |
| Observation.category | Base | preferred | Observation Category Codes | 📦4.0.1 | FHIR Std. |
| Observation.category:us-core | Base | required | US Core Clinical Result Observation Category | 📦9.0.0 | US Core v9.0 |
| Observation.code | Base | extensible | US Core Laboratory Test Codes | 📦9.0.0 | US Core v9.0 |
| Observation.dataAbsentReason | Base | extensible | DataAbsentReason | 📍4.0.1 | FHIR Std. |
| Observation.interpretation | Base | extensible | Observation Interpretation Codes | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | Observation | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
| obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text |
low.exists() or high.exists() or text.exists()
|
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present |
dataAbsentReason.empty() or value.empty()
|
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present |
value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
|
| us-core-1 | error | Observation.effective[x] | Datetime must be at least to day. |
$this is dateTime implies $this.toString().length() >= 10
|
| us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present |
(component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists())
|
| us-core-3 | error | Observation.value[x] | The system SHALL be UCUM for coded quantity units. |
ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org'
|
| us-core-4 | best practice | Observation.value[x] | SHOULD use SNOMED CT for coded Results |
ofType(CodeableConcept).coding.system.empty() or (ofType(CodeableConcept).coding.system contains 'http://snomed.info/sct')
|
| us-core-22 | error | Observation.referenceRange | The system SHALL be UCUM for coded quantity units. |
(low.system.empty() or low.system = 'http://unitsofmeasure.org') and (high.system.empty() or high.system = 'http://unitsofmeasure.org')
|
Differential View
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
|---|---|---|---|---|
![]() |
0..* | USCoreLaboratoryResultObservationProfile(9.0.0) | Measurements and simple assertions | |
![]() ![]() |
1..1 | code | (USCDI+ Quality) registered | preliminary | final | amended | corrected | cancelled | entered-in-error | unknown | |
![]() ![]() |
1..* | CodeableConcept | (USCDI+ Quality) Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |
![]() ![]() |
Content/Rules for all slices | |||
![]() ![]() ![]() |
1..1 | CodeableConcept | (USCDI+ Quality) Classification of type of observation Binding: US Core Clinical Result Observation Category (required) | |
![]() ![]() |
1..1 | CodeableConcept | (USCDI+ Quality) Laboratory Test Name | |
![]() ![]() |
1..1 | Reference(US Quality Core Patient) | Who and/or what the observation is about | |
![]() ![]() |
0..1 | Reference(US Quality Core Encounter) | Encounter associated with Observation | |
![]() ![]() |
0..1 | dateTime, Period, Timing, instant | (USCDI+ Quality) Clinically relevant time/time-period for observation | |
![]() ![]() |
0..1 | instant | (USCDI+ Quality) Date/Time this version was made available | |
![]() ![]() |
0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) | (USCDI+ Quality) Who is responsible for the observation | |
![]() ![]() |
0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | (USCDI+ Quality) Result Value | |
![]() ![]() |
0..* | CodeableConcept | (USCDI+ Quality) High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |
![]() ![]() |
0..1 | Reference(US Core Specimen Profile) | (USCDI+ Quality) Specimen used for this observation | |
![]() ![]() |
0..* | BackboneElement | (USCDI+ Quality) Result reference range | |
Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Observation.category | Base | preferred | Observation Category Codes | 📦4.0.1 | FHIR Std. |
| Observation.category:us-core | Base | required | US Core Clinical Result Observation Category | 📦9.0.0 | US Core v9.0 |
| Observation.interpretation | Base | extensible | Observation Interpretation Codes | 📦4.0.1 | FHIR Std. |
Snapshot ViewView
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
|---|---|---|---|---|---|---|---|---|
![]() |
C | 0..* | USCoreLaboratoryResultObservationProfile(9.0.0) | Measurements and simple assertions Constraints: obs-6, obs-7, us-core-2 | ||||
![]() ![]() |
Σ | 0..1 | id | Logical id of this artifact | ||||
![]() ![]() |
SΣ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() |
Σ | 0..1 | id | Version specific identifier | ||||
![]() ![]() ![]() |
SΣ | 0..1 | instant | When the resource last changed | ||||
![]() ![]() ![]() |
Σ | 0..1 | uri | Identifies where the resource comes from | ||||
![]() ![]() ![]() |
Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
![]() ![]() ![]() |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
![]() ![]() ![]() |
Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
![]() ![]() |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
![]() ![]() |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
![]() ![]() |
0..* | Resource | Contained, inline Resources | |||||
![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
![]() ![]() |
Σ | 0..* | Identifier | Business Identifier for observation | ||||
![]() ![]() |
Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | ||||
![]() ![]() |
Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
![]() ![]() |
?!SΣ | 1..1 | code | (USCDI+ Quality) registered | preliminary | final | amended | corrected | cancelled | entered-in-error | unknown Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
![]() ![]() |
S | 1..* | CodeableConcept | (USCDI+ Quality) Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
![]() ![]() ![]() |
S | 1..1 | CodeableConcept | (USCDI+ Quality) Classification of type of observation Binding: US Core Clinical Result Observation Category (required) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() |
SΣ | 1..1 | CodeableConcept | (USCDI+ Quality) Laboratory Test Name Binding: US Core Laboratory Test Codes (extensible): Laboratory LOINC Codes | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() |
Σ | 0..* | Coding | Code defined by a terminology system | ||||
![]() ![]() ![]() |
Σ | 0..1 | string | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: The name of the test that was performed. | ||||
![]() ![]() |
SΣ | 1..1 | Reference(US Quality Core Patient) | Who and/or what the observation is about | ||||
![]() ![]() |
Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
![]() ![]() |
SΣ | 0..1 | Reference(US Quality Core Encounter) | Encounter associated with Observation | ||||
![]() ![]() |
SΣC | 0..1 | (USCDI+ Quality) Clinically relevant time/time-period for observation Constraints: us-core-1 | |||||
![]() ![]() ![]() |
dateTime S | |||||||
![]() ![]() ![]() |
Period | |||||||
![]() ![]() ![]() |
Timing | |||||||
![]() ![]() ![]() |
instant | |||||||
![]() ![]() |
Σ | 0..1 | instant | (USCDI+ Quality) Date/Time this version was made available | ||||
![]() ![]() |
SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) | (USCDI+ Quality) Who is responsible for the observation | ||||
![]() ![]() |
SΣC | 0..1 | (USCDI+ Quality) Result Value Constraints: us-core-3, us-core-4 | |||||
![]() ![]() ![]() |
Quantity S | |||||||
![]() ![]() ![]() |
CodeableConcept S | |||||||
![]() ![]() ![]() |
string S | |||||||
![]() ![]() ![]() |
boolean | |||||||
![]() ![]() ![]() |
integer | |||||||
![]() ![]() ![]() |
Range | |||||||
![]() ![]() ![]() |
Ratio | |||||||
![]() ![]() ![]() |
SampledData | |||||||
![]() ![]() ![]() |
time | |||||||
![]() ![]() ![]() |
dateTime | |||||||
![]() ![]() ![]() |
Period | |||||||
![]() ![]() |
SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
![]() ![]() |
S | 0..* | CodeableConcept | (USCDI+ Quality) High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | ||||
![]() ![]() |
0..* | Annotation | Comments about the observation | |||||
![]() ![]() |
0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
![]() ![]() |
0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |||||
![]() ![]() |
S | 0..1 | Reference(US Core Specimen Profile) | (USCDI+ Quality) Specimen used for this observation | ||||
![]() ![]() |
0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
![]() ![]() |
SC | 0..* | BackboneElement | (USCDI+ Quality) Result reference range Constraints: obs-3, us-core-22 | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() |
C | 0..1 | SimpleQuantity(4.0.1) | Low Range, if relevant | ||||
![]() ![]() ![]() |
C | 0..1 | SimpleQuantity(4.0.1) | High Range, if relevant | ||||
![]() ![]() ![]() |
0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range. | |||||
![]() ![]() ![]() |
0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to. | |||||
![]() ![]() ![]() |
0..1 | Range | Applicable age range, if relevant | |||||
![]() ![]() ![]() |
0..1 | string | Text based reference range in an observation | |||||
![]() ![]() |
Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
![]() ![]() |
Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
![]() ![]() |
Σ | 0..* | BackboneElement | Component results | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() |
Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
![]() ![]() ![]() |
Σ | 0..1 | Actual component result | |||||
![]() ![]() ![]() ![]() |
Quantity | |||||||
![]() ![]() ![]() ![]() |
CodeableConcept | |||||||
![]() ![]() ![]() ![]() |
string | |||||||
![]() ![]() ![]() ![]() |
boolean | |||||||
![]() ![]() ![]() ![]() |
integer | |||||||
![]() ![]() ![]() ![]() |
Range | |||||||
![]() ![]() ![]() ![]() |
Ratio | |||||||
![]() ![]() ![]() ![]() |
SampledData | |||||||
![]() ![]() ![]() ![]() |
time | |||||||
![]() ![]() ![]() ![]() |
dateTime | |||||||
![]() ![]() ![]() ![]() |
Period | |||||||
![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
![]() ![]() ![]() |
0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
![]() ![]() ![]() |
0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |||||
Documentation for this format | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| Observation.meta.security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std. |
| Observation.meta.tag | Base | example | Common Tags | 📍4.0.1 | FHIR Std. |
| Observation.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| Observation.status | Base | required | ObservationStatus | 📍4.0.1 | FHIR Std. |
| Observation.category | Base | preferred | Observation Category Codes | 📦4.0.1 | FHIR Std. |
| Observation.category:us-core | Base | required | US Core Clinical Result Observation Category | 📦9.0.0 | US Core v9.0 |
| Observation.code | Base | extensible | US Core Laboratory Test Codes | 📦9.0.0 | US Core v9.0 |
| Observation.dataAbsentReason | Base | extensible | DataAbsentReason | 📍4.0.1 | FHIR Std. |
| Observation.interpretation | Base | extensible | Observation Interpretation Codes | 📦4.0.1 | FHIR Std. |
| Observation.bodySite | Base | example | SNOMED CT Body Structures | 📍4.0.1 | FHIR Std. |
| Observation.method | Base | example | Observation Methods | 📍4.0.1 | FHIR Std. |
| Observation.referenceRange.type | Base | preferred | Observation Reference Range Meaning Codes | 📍4.0.1 | FHIR Std. |
| Observation.referenceRange.appliesTo | Base | example | Observation Reference Range Applies To Codes | 📍4.0.1 | FHIR Std. |
| Observation.component.code | Base | example | LOINC Codes | 📍4.0.1 | FHIR Std. |
| Observation.component.dataAbsentReason | Base | extensible | DataAbsentReason | 📍4.0.1 | FHIR Std. |
| Observation.component.interpretation | Base | extensible | Observation Interpretation Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | Observation | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
| obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text |
low.exists() or high.exists() or text.exists()
|
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present |
dataAbsentReason.empty() or value.empty()
|
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present |
value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
|
| us-core-1 | error | Observation.effective[x] | Datetime must be at least to day. |
$this is dateTime implies $this.toString().length() >= 10
|
| us-core-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present |
(component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists())
|
| us-core-3 | error | Observation.value[x] | The system SHALL be UCUM for coded quantity units. |
ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org'
|
| us-core-4 | best practice | Observation.value[x] | SHOULD use SNOMED CT for coded Results |
ofType(CodeableConcept).coding.system.empty() or (ofType(CodeableConcept).coding.system contains 'http://snomed.info/sct')
|
| us-core-22 | error | Observation.referenceRange | The system SHALL be UCUM for coded quantity units. |
(low.system.empty() or low.system = 'http://unitsofmeasure.org') and (high.system.empty() or high.system = 'http://unitsofmeasure.org')
|
Summary
Structures
This structure refers to these other structures:
Maturity: 4
Other representations of profile: CSV, Excel, Schematron
Badges identify the profile layer where each conformance indicator is first introduced. Indicators introduced in an earlier layer remain applicable in later derived profiles.
| Profile element | FHIR | US Core | US Quality Core |
|---|---|---|---|
meta |
Must Support | ||
meta.lastUpdated |
Must Support | ||
status |
Mandatory | Must Support | USCDI+ Quality |
category |
Mandatory Must Support | USCDI+ Quality | |
category:us-core |
Mandatory Must Support | USCDI+ Quality | |
code |
Mandatory | Must Support | USCDI+ Quality |
code.text |
Additional USCDI | ||
subject |
Mandatory Must Support | ||
encounter |
Must Support | ||
effective[x] |
Must Support | USCDI+ Quality | |
issued |
USCDI+ Quality | ||
performer |
Must Support | USCDI+ Quality | |
value[x] |
Must Support | USCDI+ Quality | |
dataAbsentReason |
Must Support | ||
interpretation |
Must Support | USCDI+ Quality | |
specimen |
Must Support | USCDI+ Quality | |
referenceRange |
Must Support | USCDI+ Quality | |
component.code |
Mandatory |
Cardinality note: “Mandatory” means the element has a minimum cardinality greater than zero. For nested elements, the cardinality indicator applies when the containing element is present.
The searches below are the focused set identified by US Quality Core as needed to retrieve USCDI+ Quality data for quality measurement and reporting. See the US Core FHIR RESTful Search API Requirements for detailed information on requirements by search parameter type.
Because this profile derives directly or indirectly from US Core, servers SHALL also support all mandatory searches described in the US Core Server CapabilityStatement requirements for Observation. When possible, this guide reuses mandatory searches from US Core and notes them with the EXISTING US CORE REQUIREMENT flag. While US Quality Core may restate US Core requirements to highlight searches directly relevant to USCDI+ Quality data access, US Core requirements not restated here remain applicable.
See the US Quality Core Server CapabilityStatement for complete requirements for the underlying Observation resource and Search Requirement Selection for how this focused set was selected.
Servers supporting this profile SHALL support the following search parameters and search parameter combinations:
SHALL support searching for all Observation resources for a patient using the combination of the patient, category, and status search parameters.
Including optional support for OR search on category (e.g.category={system|}[search_code],{system|}[search_code],...).
Including support for OR search on status (e.g.status=[status],[status],...).
GET [base]/Observation?patient={Patient/}[id]&category={system|}[search_code]&status=[status]
Example:
GET [base]/Observation?patient=Patient/example&category=http://terminology.hl7.org/CodeSystem/observation-category|exam&status=final
Implementation Notes: Fetches a bundle of US Quality Core Laboratory Result Observation resources matching the specified search criteria. See how to search by reference and how to search by token.
Rationale for inclusion: Supports patient-scoped retrieval of Observation resources filtered by category and status for status-sensitive quality workflows.
SHALL support searching for all Observation resources for a patient using the combination of the patient and category search parameters. EXISTING US CORE REQUIREMENT
category (e.g.category={system|}[search_code],{system|}[search_code],...).GET [base]/Observation?patient={Patient/}[id]&category={system|}[search_code]
Example:
GET [base]/Observation?patient=Patient/example&category=http://terminology.hl7.org/CodeSystem/observation-category|exam
Implementation Notes: Fetches a bundle of US Quality Core Laboratory Result Observation resources matching the specified search criteria. See how to search by reference and how to search by token.
Rationale for inclusion: Supports patient-scoped retrieval of Observation resources filtered by category for USCDI+ Quality workflows.
SHALL support searching for all Observation resources for a patient using the combination of the patient, category, and date search parameters. EXISTING US CORE REQUIREMENT
Including optional support for OR search on category (e.g.category={system|}[search_code],{system|}[search_code],...).
Including optional support for AND search on date (e.g.date=[date]&date=[date]&...).
Including support for these date comparators: "gt", "lt", "ge", "le".
GET [base]/Observation?patient={Patient/}[id]&category={system|}[search_code]&date={gt|lt|ge|le}[dateTime]
Example:
GET [base]/Observation?patient=Patient/example&category=http://terminology.hl7.org/CodeSystem/observation-category|exam&date=ge2020-01-01T00:00:00Z
Implementation Notes: Fetches a bundle of US Quality Core Laboratory Result Observation resources matching the specified search criteria. See how to search by reference, how to search by token, and how to search by date.
Rationale for inclusion: Supports patient-scoped retrieval of Observation resources filtered by category and date so quality workflows can constrain results to relevant reporting periods.
SHALL support searching for all Observation resources for a patient using the combination of the patient and code search parameters. EXISTING US CORE REQUIREMENT
code (e.g.code={system|}[search_code],{system|}[search_code],...).GET [base]/Observation?patient={Patient/}[id]&code={system|}[search_code]
Example:
GET [base]/Observation?patient=Patient/example&code=http://loinc.org|8884-9
Implementation Notes: Fetches a bundle of US Quality Core Laboratory Result Observation resources matching the specified search criteria. See how to search by reference and how to search by token.
Rationale for inclusion: Supports patient-scoped retrieval of Observation resources filtered by code for USCDI+ Quality workflows.