This capability statement describes the expected capabilities of the US Quality Core Client, which is responsible for initiating queries for USCDI+ Quality V2 data from US Quality Core Servers. The set of FHIR RESTful operations and search parameters required to be supported by US Quality Core Servers is provided in the US Quality Core Server Capability Statement. US Quality Core Clients have the option of choosing from this list to access necessary data based on their local use cases and other contextual requirements.

This capability statement describes the expected capabilities of US Quality Core Servers that respond to USCDI+ Quality V2 queries submitted by US Quality Core Clients. It describes a minimum set of FHIR RESTful operations and search parameters needed to enable access to the USCDI+ Quality data in scope for this implementation guide. This version of US Quality Core builds directly on US Core 9.0.0, and US Quality Core Servers SHALL support the capabilities described in the US Core Server CapabilityStatement for in-scope USCDI+ Quality data. RESTful operations and search parameters in this CapabilityStatement identify the capabilities specifically relevant to USCDI+ Quality V2 and may duplicate US Core Server capabilities. For more information about which USCDI+ Quality data elements are in scope, please review the USCDI+ Quality section of this implementation guide.

US Quality Core AdverseEvent event Search Parameter

US Quality Core AdverseEvent recorded-date Search Parameter

US Quality Core AdverseEvent subject Search Parameter

US Quality Core AllergyIntolerance patient Search Parameter

US Quality Core CarePlan category Search Parameter

US Quality Core CarePlan patient Search Parameter

US Quality Core CareTeam patient Search Parameter

US Quality Core CareTeam status Search Parameter

US Quality Core Communication status Search Parameter

US Quality Core Communication subject Search Parameter

US Quality Core Communication topic Search Parameter

US Quality Core Condition category Search Parameter

US Quality Core Condition code Search Parameter

US Quality Core Condition patient Search Parameter

US Quality Core Coverage patient Search Parameter

US Quality Core DeviceRequest code Search Parameter

US Quality Core DeviceRequest do-not-perform Search Parameter

US Quality Core DeviceRequest patient Search Parameter

US Quality Core DiagnosticReport category Search Parameter

US Quality Core DiagnosticReport code Search Parameter

US Quality Core DiagnosticReport date Search Parameter

US Quality Core DiagnosticReport patient Search Parameter

US Quality Core Encounter date Search Parameter

US Quality Core Encounter _id Search Parameter

US Quality Core Encounter patient Search Parameter

US Quality Core Encounter type Search Parameter

US Quality Core Goal patient Search Parameter

US Quality Core ImagingStudy subject Search Parameter

US Quality Core Immunization patient Search Parameter

US Quality Core Immunization status Search Parameter

US Quality Core MedicationAdministration code Search Parameter

US Quality Core MedicationAdministration effective-time Search Parameter

US Quality Core MedicationAdministration patient Search Parameter

US Quality Core MedicationAdministration status Search Parameter

US Quality Core Medication code Search Parameter

US Quality Core MedicationDispense patient Search Parameter

US Quality Core MedicationDispense status Search Parameter

US Quality Core MedicationRequest do-not-perform Search Parameter

US Quality Core MedicationRequest intent Search Parameter

US Quality Core MedicationRequest patient Search Parameter

US Quality Core NutritionOrder patient Search Parameter

US Quality Core Observation category Search Parameter

US Quality Core Observation code Search Parameter

US Quality Core Observation date Search Parameter

US Quality Core Observation patient Search Parameter

US Quality Core Observation status Search Parameter

US Quality Core Patient _id Search Parameter

US Quality Core Procedure date Search Parameter

US Quality Core Procedure patient Search Parameter

US Quality Core Procedure status Search Parameter

US Quality Core QuestionnaireResponse patient Search Parameter

US Quality Core QuestionnaireResponse questionnaire Search Parameter

US Quality Core RelatedPerson _id Search Parameter

US Quality Core RelatedPerson patient Search Parameter

US Quality Core ServiceRequest authored Search Parameter

US Quality Core ServiceRequest category Search Parameter

US Quality Core ServiceRequest code Search Parameter

US Quality Core ServiceRequest do-not-perform Search Parameter

US Quality Core ServiceRequest _id Search Parameter

US Quality Core ServiceRequest patient Search Parameter

US Quality Core Task code Search Parameter

US Quality Core Task patient Search Parameter

US Quality Core Task status Search Parameter

Actual or potential/avoided event causing unintended physical injury resulting from or contributed to by medical care, a research study or other healthcare setting factors that requires additional monitoring, treatment, or hospitalization, or that results in death.

Profile of AllergyIntolerance for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Defines constraints and extensions on the CarePlan resource for the minimal set of data to query and retrieve a patient's Care Plan.

Profile of CareTeam for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Profile of Communication for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Negation profile of Communication for decision support/quality metrics. Indicates that the communication was not performed for a reason.

Positive profile of Communication for decision support/quality metrics. Indicates that the communication was performed (as opposed to the not done profile).

The US Quality Core Condition Encounter Diagnosis Profile is based upon the US Core Condition Encounter Diagnosis Profile. In version 5.0.0, the US Quality Core Condition Profile has been split into the US Quality Core Condition Encounter Diagnosis Profile and US Quality Core Condition Problems and Health Concerns Profile. To promote interoperability and adoption through consistent implementation, this profile defines constraints and extensions on the Condition resource for the minimal set of data to record, search, and retrieve information about an encounter diagnosis. It defines the core set of elements and extensions for quality rule and measure authors.

Profile of Condition for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Profile of Coverage for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Negation profile of DeviceRequest for decision support/quality metrics. Indicates a proposal, plan, or order not to provide a device.

Profile of DeviceRequest for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Positive profile of DeviceRequest for decision support/quality metrics. Indicates a proposal, plan, or order for a device.

Profile of DiagnosticReport for laboratory results for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Profile of DiagnosticReport for Note exchange for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Profile of Encounter for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Profile of Goal for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Profile of ImagingStudy for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Profile of Immunization for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Positive profile of Immunization for decision support/quality metrics. Indicates that the immunization is being or was performed (as opposed to the not done profile).

Negation profile of Communication for decision support/quality metrics. Indicates that the communication was not performed for a reason.

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.

Profile of Location for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Profile of Medication for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Negation profile of MedicationRequest for decision support/quality metrics. Indicates a proposal, plan, or order not to provide a medication.

Profile of MedicationAdministration for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Positive profile of MedicationAdministration for decision support/quality metrics. Indicates that a medication administration is being or was performed (as opposed to the negative profile)

Negation profile of MedicationAdministration for decision support/quality metrics. Indicates that a medication was not administered for a reason.

Profile of MedicationDispense for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Negation profile of MedicationDispense for decision support/quality metrics. Indicates that a medication dispense was declined for a reason.

Positive profile of MedicationDispense for decision support/quality metrics. Indicates that a medication is being or was dispensed

Profile of MedicationRequest for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Positive profile of MedicationRequest for decision support/quality metrics. Indicates that a medication was proposed, planned, or ordered.

Defines constraints and extensions on the NutritionOrder resource for the minimal set of data to query and retrieve a patient's Nutrition Order.

This profile sets minimum expectations for the Observation resource to record and search non-laboratory clinical test results (e.g., radiology and other clinical observations generated from procedures). An example would be when a gastroenterologist reports the size of a polyp observed during a colonoscopy. This profile is the basis for the US Core Clinical Result Profile, which defines additional data elements to record and search laboratory test results.

The US Quality Core Observation Screening Assessment Profile is based upon the US Core Observation Screening Assessment Profile which can be used to represent individual responses, panels of multi-question surveys, and multi-select responses to “check all that apply” questions. The US Quality Core Observation Survey Profile sets minimum expectations for the Observation Resource to record, search, and fetch retrieve observations that represent the questions and responses to form/survey and defines the core set of elements and extensions for quality rule and measure authors.

Profile of Organization for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Profile of Patient for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Profile of Practitioner for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Profile of PractitionerRole for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Profile of Procedure for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Positive profile of Procedure for decision support/quality metrics. Indicates that a procedure is being or was performed.

Negative profile of Procedure for decision support/quality metrics. Indicates that a procedure was not done for a reason.

The US Quality Core QuestionnaireResponse Profile is based upon the US Core QuestionnaireResponse Profile and sets minimum expectations for the QuestionnaireResponse resource to record, search, and fetch retrieve captures the responses to form/survey and defines the core set of elements and extensions for quality rule and measure authors.

Profile of RelatedPerson for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Negation profile of ServiceRequest for decision support/quality metrics. Indicates a request not to provide a service

Profile of ServiceRequest for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Positive profile of ServiceRequest for decision support/quality metrics. Indicates that a service is proposed, planned, or ordered.

Profile of Simple Observation for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Profile of Task for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Positive profile of Task for decision support/quality metrics. Indicates a task that with a positive status

Profile of TaskRejected for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Indicator of whether the Encounter diagnosis was present at the time of admission.

This extension is used only in US Quality Core profile StructureDefinitions. It flags elements, types, and target profiles that represent USCDI+ Quality data elements. Systems are expected to support flagged content as applicable to their role in US Quality Core data exchange. See the Must Support and USCDI+ Quality pages for more information.

This value set defines the set of codes that indicate a positive event status (i.e. codes that indicate an event is in preparation, progress, on-hold, stopped, or has completed)

This value set defines the set of codes that indicate a positive medication administration status (i.e. codes that indicate at least some medication is being or was administered)

This value set defines the set of codes that indicate a positive medication dispense status (i.e. codes that indicate at least some medication was dispensed)

This value set defines the set of codes that indicate a positive medication request status (i.e. codes that a medication is proposed, planned, or ordered)

This value set defines the set of codes that indicate a positive request status (i.e. codes that indicate an activity is proposed, planned, or ordered).

This value set defines the set of codes that indicate a positive task status

This value set defines the set of codes that can be used to indicate the reason an action was not taken

SNOMED CT code system values descending from the following:'body position finding' 9851009

Value Set for US Quality Core Present On Admission.

This value set includes all the "Dosages" SNOMED CT codes (i.e. codes with an is-a relationship with 277406006: Dosages).

Example of a 10 minute Apgar Heart Rate Observation Screening Assessment

Example of an allergic reaction adverse event

Example of a clinical assessment record of an allergy

Example of a clinical assessment record of an allergy that has been refuted

Example of an assessment and care plan for a pregnancy

Example of a CareTeam involved in the delivery of care for a pregnancy

Example of a notification sent to a patient about an abnormal test result (using the General Communication profile)

Example of a notification that was not sent to a patient and reason why

Example of a notification sent to a patient about an abnormal test result (using the Positive Communication profile)

Example of a condition encounter diagnosis resource used to record information about a burn of the left ear

Example of a patient with a health concern regarding fear of blood

Example of a condition resource used to record information about an appendicitis

Example of a coverage resource used to provide information about an individual's specific plan

Example of a obstetric delivery datetime Observation

Example of a delivery date estimate Observation

Request to employ a medical device (using the General Profile)

Example of a request not to employ a specific medical device

Example of a request not to employ any of a class of medical devices

Example of a request to employ a medical device (using the Positive Profile)

Example of a final blood glucose laboratory report

Example of a DiagnosticReport Note

Example of an Encounter

Example of a gestation age at birth observation

Example of a glucose laboratory result observation

Example of a patient-defined weight-management goal

Example of a Heart rate rhythm clinical result observation

Example hospital organization

Example of ImagingStudy based on CT imaging study

Immunization example (using the General Profile)

Example of an immunization that was not administered, with the vaccine identified by code

Example of an immunization that was not administered, with the vaccine identified by value set

Immunization example (using the Positive Profile)

Infant patient example

Example of a hospital location on the second floor of the South Wing

Example of Alemtuzumab Medication

Intravenous example of MedicationAdministration (using the General Profile)

Example of medication not administered using a code to indicate that a particular medication was not administered

Example of medication not administered using a value set to indicate what was not administered

Intravenous example of MedicationAdministration (using the Positive Profile)

Penicillin MedicationDispense Example (using the General Profile)

Example of medication not dispensed using a code to indicate the reason

Example of medication not dispensed using a value set to indicate the reason

Penicillin MedicationDispense Example (using the Positive Profile)

Example of request not to provide a medication using a code

Example of request not to provide a medication using a value set

Patient Reported Example

Patient Requester Example

Practitioner Ordered Example

Penicillin MedicationRequest Example (using the General Profile)

Penicillin MedicationRequest Example (using the Positive Profile)

Example of an observation documenting regular mobility-aid use

Example number of full-term births Observation

Example number of parity Observation

Example number of pregnancies Observation

Example number of preterm births Observation

Example of a NutritionOrder for a consistent carbohydrate diet

Example of occupational data added to observation measure

Example of Decreased Hemoglobin Observation

Older adult patient example

Example organization

Example of a PHQ-9 Questionnaire Response

Basic Patient example

Example of a portable chest X-ray imaging study

Example of a narrative radiology finding for a portable chest X-ray

Referring Practitioner example

PractitionerRole example

Appendectomy Procedure example (using the General Profile)

Appendectomy Procedure example (using the Positive Profile)

Example of procedure not done using a code

Example of procedure not done using a value set

Emergency contact example

Patient example used by pregnancy and obstetric observations

Example of request not to provide a service using a code

Example of request not to provide a service using a value set

ServiceRequest for Myringotomy Procedure example

ServiceRequest appropriateness example

Elective procedure ServiceRequest example

Request for Appendectomy ServiceRequest example (using the General Profile)

Request for Graduated compression elastic hosiery using a code example (using the Positive Profile)

Request for Intermittent pneumatic compression devices using a value set example (using the Positive Profile)

Appendectomy ServiceRequested example

Example of a task rejecting a proposal that identifies the requested activity with a code

Example of a task rejecting a proposal that identifies the requested activity with a value set

Task example (using the General Profile)

Task example (using the Positive Profile)

Example of a whole blood specimen collected for a laboratory result

This Parameters resource represents a manifest to the versions of the canonical artifacts, such as CodeSystem, ValueSet, StructureDefinition and SearchParameter used in this IG. It also specifies the SNOMED CT Edition.