US Quality Core Implementation Guide
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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

US Quality Core Negation

Page standards status: Informative

US Quality Core Negation Profile Index

For common workflow activities, US Quality Core defines general profiles and two derived profiles for making positive and negative statements about activities:

US Quality Core General Profile US Quality Core Positive Profile US Quality Core Negation Profile Base Resource
US Quality Core Communication US Quality Core Communication Done US Quality Core Communication Not Done Communication
US Quality Core DeviceRequest US Quality Core Device Requested US Quality Core Device Prohibited DeviceRequest
US Quality Core Immunization US Quality Core Immunization Done US Quality Core Immunization Not Done Immunization
US Quality Core MedicationAdministration US Quality Core MedicationAdministration Done US Quality Core MedicationAdministration Not Done MedicationAdministration
US Quality Core MedicationDispense US Quality Core MedicationDispense Done US Quality Core MedicationDispense Declined MedicationDispense
US Quality Core MedicationRequest US Quality Core MedicationRequested US Quality Core Medication Prohibited MedicationRequest
US Quality Core Procedure US Quality Core Procedure Done US Quality Core Procedure Not Done Procedure
US Quality Core ServiceRequest US Quality Core ServiceRequested US Quality Core Service Prohibited ServiceRequest
US Quality Core Task US Quality Core Task Done US Quality Core Task Rejected Task

Each US Quality Core Negation Profile defines at least the following information:

  • The activity or event that did not occur, typically represented by a value set or as a reference to a request
  • An explicit indication that the action or event did not or should not occur, for example such as doNotPerform is set to true or a status of not-done
  • The date, and optionally the time, when a clinician documented a reason for not performing the activity or event
  • The reason the activity or event did not occur, represented using an established Negation Reason Codes where applicable

NOTE: Although these aspects are all present within each negation profile defined by US Quality Core, they are represented differently in the various FHIR resources. As a result, each negation profile uses a combination of constraints and extensions to ensure complete representation of negated actions or events within US Quality Core.

Using US Quality Core Negation Profiles

The US Quality Core negation profiles support three general classes of negation statements:

  1. Activity Not Done for a Reason - documentation that an activity was not performed for a reason (i.e. a not-done event)
  2. Do Not Perform Requests - documentation that an activity should not be performed for a reason (i.e. a doNotPerform request)
  3. Rejected Requests - documentation that a request was not performed for a reason (i.e. a taskRejected)

Activity Not Done for a Reason

The negation profiles in US Quality Core can be used to make two different types of negative statements:

  1. Documenting that one member of a value set was not performed for a given reason. This is to document that a particular activity or event, represented with a specific code, should not or did not occur
  2. Documenting that no members of an entire value set were performed for a given reason. This is to documentation that a class of activities or events, typically represented with a value set, should not or did not occur
Documenting that one member of a value set was not performed for a given reason

In the following example, the quality measure numerator criterion allows for documentation that specifies a single antithrombotic medication drawn from the list of possible expected medications, as defined by the “Antithrombotic Therapy for Ischemic Stroke” value set, was not administered. In this example, the profiled MedicationAdministration resource documents that the clinician did not administer ticagrelor 90 MG Oral Tablet because drug treatment is not indicated. The evidence of documented reason for not administering this medication, which is a member of the “Antithrombotic Therapy for Ischemic Stroke” value set, satisfies the numerator criteria.

{
    "resourceType" : "MedicationAdministration",
    "id" : "negation-with-code-example",
    "meta" : {
        "profile" : ["http://hl7.org/fhir/us/quality-core/StructureDefinition/us-quality-core-medicationadministrationnotdone"]
    },
    "status" : "not-done",
    "statusReason" : [{
        "coding" : [{
            "system" : "http://snomed.info/sct",
            "code" : "183966005",
            "display" : "Drug treatment not indicated (situation)"
        }]
    }],
    "medicationCodeableConcept" : {
        "coding" : [{
            "system" : "http://www.nlm.nih.gov/research/umls/rxnorm",
            "code" : "1116635",
            "display" : "ticagrelor 90 MG Oral Tablet"
        }]
    },
    "subject" : ...,
    "context" : ...,
    "supportingInformation" : ...,
    "effectivePeriod" : ...,
    "request" : ...,
    "note" : ...,
    "dosage" : ...
}

See the MedicationAdministration example using a specific code for a complete example.

Documenting that no members of an entire value set were performed for a given reason

This type of negation statement applies when a quality measure criterion can be satisfied if none of the concepts in a value set represent an appropriate treatment. It allows a system to document that no activities in a given value set were performed using a single profiled data instance, rather than requiring documentation of eacha activity in the value set.

Using the codeOptions extension, the following example documents that providers did not administer any of the medications in the "Antithrombotic Therapy for Ischemic Stroke" value set, thereby satisfying the numerator criteria.

NOTE: Implementing systems must ensure that this approach does not result in conflicting data. For example, the above example indicating no administration of a medication in the Antithrombotic Therapy value set should not be used if there are administrations of individual medications in the same value set. In other words, it is contradictory to say "a provider administered a specific medication" at the same time as "a provider did not administer any of the medications in this value set" if that value set includes the medication that was administered in the specific case.

{
    "resourceType" : "MedicationAdministration",
    "id" : "negation-example",
    "meta" : {
        "profile" : ["http://hl7.org/fhir/us/quality-core/StructureDefinition/us-quality-core-medicationadministrationnotdone"]
    },
    "status" : "not-done",
    "statusReason" : [{
        "coding" : [{
            "system" : "http://snomed.info/sct",
            "code" : "183966005",
            "display" : "Drug treatment not indicated (situation)"
        }]
    }],
    "medicationCodeableConcept" : {
        "extension" : [{
            "url" : "http://hl7.org/fhir/StructureDefinition/codeOptions",
            "valueCanonical" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1110.62"
        }],
        "text" : "Value Set: Antithrombotic Therapy for Ischemic Stroke"
    },
    "subject" : ...,
    "context" : ...,
    "supportingInformation" : ...,
    "effectivePeriod" : ...,
    "request" : ...,
    "note" : ...,
    "dosage" : ...
}

See the MedicationAdministration example using a value set for a complete example.

Do Not Perform Requests

To indicate that an activity should not be performed, use the "Prohibited" profiles:

Request not to perform a specific activity

The following example illustrates a request not to apply Graduated compression elastic hosiery:

{
  "resourceType" : "ServiceRequest",
  "id" : "negation-example-code",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/quality-core/StructureDefinition/us-quality-core-serviceprohibited"]
  },
  "status" : "completed",
  "intent" : "order",
  "category" : [{
    "coding" : [{
      "system" : "http://snomed.info/sct",
      "code" : "387713003",
      "display" : "Surgical Procedure"
    }]
  }],
  "priority" : "urgent",
  "doNotPerform" : true,
  "code" : {
    "coding" : [{
      "system" : "http://snomed.info/sct",
      "code" : "348681001",
      "display" : "Graduated compression elastic hosiery (physical object)"
    }]
  },
  "subject" : ...,
  "encounter" : ...,
  "occurrenceDateTime" : "2026-08-02",
  "authoredOn" : "2026-07-30",
  "reasonCode" : [{
    "coding" : [{
      "system" : "http://snomed.info/sct",
      "code" : "416406003",
      "display" : "Procedure discontinued (situation)"
    }]
  }]
}

See the Service Prohibited With Code Example for a complete example.

Request not to perform any of a class of activities

The following example illustrates a request not to apply any of a class of devices, indicated by the Intermittent pneumatic compression devices value set:

{
  "resourceType" : "ServiceRequest",
  "id" : "negation-example",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/quality-core/StructureDefinition/us-quality-core-serviceprohibited"]
  },
  "status" : "completed",
  "intent" : "order",
  "category" : [{
    "coding" : [{
      "system" : "http://snomed.info/sct",
      "code" : "387713003",
      "display" : "Surgical Procedure"
    }]
  }],
  "priority" : "urgent",
  "doNotPerform" : true,
  "code" : {
    "extension" : [{
      "url" : "http://hl7.org/fhir/StructureDefinition/codeOptions",
      "valueCanonical" : "http://cts.nlm.nih.gov/fhir/2.16.840.1.113883.3.117.1.7.1.214"
    }],
    "text" : "Value Set: Intermittent pneumatic compression devices (IPC)"
  },
  "subject" : ...,
  "encounter" : ...,
  "occurrenceDateTime" : "2026-08-02",
  "authoredOn" : "2026-07-30",
  "reasonCode" : [{
    "coding" : [{
      "system" : "http://snomed.info/sct",
      "code" : "416406003",
      "display" : "Procedure discontinued (situation)"
    }]
  }],
  "bodySite" : ...
}

See the Service Prohibited Example for a complete example.

Rejected Requests

To indicate that a request to perform an activity was rejected, use the task pattern:

  1. A request resource indicating the activity to be performed (or not performed)
  2. A TaskRejected with the request resource as focus, indicating the request to perform the activity was rejected

As with not done events and orders not to perform, the extent of negation for a rejected request can be a single activity, or any of a class of activities:

Rejecting a proposal to perform a specific activity

To indicate that a request to perform a specific activity was rejected:

First, the request to perform a specific activity as a ServiceRequest:

{
  "resourceType" : "ServiceRequest",
  "id" : "proposal-example-code",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/quality-core/StructureDefinition/us-quality-core-servicerequested"]
  },
  "status" : "active",
  "intent" : "proposal",
  "priority" : "urgent",
  "code" : {
    "coding" : [{
      "system" : "http://snomed.info/sct",
      "code" : "348681001",
      "display" : "Graduated compression elastic hosiery (physical object)"
    }]
  },
  "subject" : ...,
  "encounter" : ...,
  "occurrenceDateTime" : "2026-08-02",
  "authoredOn" : "2026-07-30"
}

Second, a fulfillment task with a status of rejected and the focus referencing the proposal:

{
  "resourceType" : "Task",
  "id" : "negation-with-code-example",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/quality-core/StructureDefinition/us-quality-core-taskrejected"]
  },
  "status" : "rejected",
  "statusReason" : {
    "coding" : [{
      "system" : "http://snomed.info/sct",
      "code" : "1296859006",
      "display" : "Procedure declined (situation)"
    }]
  },
  "intent" : "proposal",
  "code" : {
    "coding" : [{
      "system" : "http://hl7.org/fhir/CodeSystem/task-code",
      "code" : "fulfill",
      "display" : "Fulfill the focal request"
    }]
  },
  "focus" : {
    "reference" : "ServiceRequest/proposal-example-code"
  },
  "for" : ...,
  "executionPeriod" : ...
}

See the Service Requested With Code and Task Rejected With Code Example for complete examples.

Rejecting a proposal to perform any of a class of activities

To indicate that a request to perform any of a class of activities was rejected:

Similar to the specific activity case, first a request to perform any of a class of activities:

{
  "resourceType" : "ServiceRequest",
  "id" : "proposal-example",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/quality-core/StructureDefinition/us-quality-core-servicerequested"]
  },
  "status" : "active",
  "intent" : "proposal",
  "category" : [{
    "coding" : [{
      "system" : "http://snomed.info/sct",
      "code" : "387713003",
      "display" : "Surgical Procedure"
    }]
  }],
  "priority" : "urgent",
  "code" : {
    "extension" : [{
      "url" : "http://hl7.org/fhir/StructureDefinition/codeOptions",
      "valueCanonical" : "http://cts.nlm.nih.gov/fhir/2.16.840.1.113883.3.117.1.7.1.214"
    }],
    "text" : "Value Set: Intermittent pneumatic compression devices (IPC)"
  },
  "subject" : ...,
  "encounter" : ...,
  "occurrenceDateTime" : "2026-08-02",
  "authoredOn" : "2026-07-30"
}

Followed by a fulfillment task with a status of rejected and the focus referencing the proposal:

{
  "resourceType" : "Task",
  "id" : "negation-example",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/quality-core/StructureDefinition/us-quality-core-taskrejected"]
  },
  "status" : "rejected",
  "statusReason" : {
    "coding" : [{
      "system" : "http://snomed.info/sct",
      "code" : "1296859006",
      "display" : "Procedure declined (situation)"
    }]
  },
  "intent" : "proposal",
  "code" : {
    "coding" : [{
      "system" : "http://hl7.org/fhir/CodeSystem/task-code",
      "code" : "fulfill",
      "display" : "Fulfill the focal request"
    }]
  },
  "focus" : {
    "reference" : "ServiceRequest/proposal-example"
  },
  "for" : ...,
  "executionPeriod" : ...
}

See the Service Requested Example and Task Rejected Example for complete examples.