Point-of-Care Device Implementation Guide, published by HL7 International - Devices Work Group. This is not an authorized publication; it is the continuous build for version current). This version is based on the current content of https://github.com/HL7/uv-pocd/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/uv/pocd/StructureDefinition/EnumerationObservation | Version: current | |||
Draft as of 2022-01-21 | Computable Name: EnumerationObservation |
StructureDefinition for Observation resources that represent coded or text status, annotations, or settings.
This profile sets minimum expectations for the Observation resource that represents coded or text status, annotation, or setting.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Observation | Measurements and simple assertions pocd-obs-1: If there is no value a dataAbsentReason shall be present |
meta | 0..1 | Meta | Metadata about the resource | |
security | S | 0..* | Coding | Security Labels applied to this resource |
status | S | 1..1 | code | registered | preliminary | final | amended + |
category | S | 0..* | CodeableConcept | Classification of type of observation |
code | 1..1 | CodeableConcept | Type of observation (code / type) Binding: MDC Metric nomenclature (extensible) | |
coding | 0..* | Coding | Code defined by a terminology system | |
system | 0..1 | uri | Identity of the terminology system | |
version | 0..1 | string | Version of the system - if relevant | |
code | 0..1 | code | Symbol in syntax defined by the system | |
subject | S | 1..1 | Reference(Patient | MDS Device profile) | Who and/or what the observation is about |
Slices for effective[x] | S | 1..1 | Clinically relevant time/time-period for observation Slice: Unordered, Closed by type:$this | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
effective[x]:effectiveDateTime | 0..1 | dateTime | Clinically relevant time/time-period for observation | |
effective[x]:effectivePeriod | 0..1 | Period | Clinically relevant time/time-period for observation | |
start | 0..1 | dateTime | Starting time with inclusive boundary | |
end | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | |
value[x] | SC | 0..1 | Actual result Slice: Unordered, Closed by type:$this | |
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing |
interpretation | S | 0..* | CodeableConcept | High, low, normal, etc. Binding: Observation interpretation codes (extensible) |
bodySite | S | 0..1 | CodeableConcept | Observed body part |
coding | 0..* | Coding | Code defined by a terminology system | |
system | 0..1 | uri | Identity of the terminology system | |
version | 0..1 | string | Version of the system - if relevant | |
code | 0..1 | code | Symbol in syntax defined by the system | |
device | S | 1..1 | Reference(Enumeration DeviceMetric profile) | (Measurement) Device |
Documentation for this format |
Path | Conformance | ValueSet |
Observation.code | extensible | MdcMetric |
Observation.interpretation | extensible | ObservationInterpretation |
Id | Grade | Path(s) | Details | Requirements |
pocd-obs-1 | error | Observation | If there is no value a dataAbsentReason shall be present : value.exists() or dataAbsentReason.exists() |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Observation | Measurements and simple assertions pocd-obs-1: If there is no value a dataAbsentReason shall be present |
meta | Σ | 0..1 | Meta | Metadata about the resource |
security | SΣ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
category | S | 0..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
code | Σ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: MDC Metric nomenclature (extensible) |
coding | Σ | 0..* | Coding | Code defined by a terminology system |
system | Σ | 0..1 | uri | Identity of the terminology system |
version | Σ | 0..1 | string | Version of the system - if relevant |
code | Σ | 0..1 | code | Symbol in syntax defined by the system |
subject | SΣ | 1..1 | Reference(Patient | MDS Device profile) | Who and/or what the observation is about |
Slices for effective[x] | SΣ | 1..1 | Clinically relevant time/time-period for observation Slice: Unordered, Closed by type:$this | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
effective[x]:effectiveDateTime | Σ | 0..1 | dateTime | Clinically relevant time/time-period for observation |
effective[x]:effectivePeriod | Σ | 0..1 | Period | Clinically relevant time/time-period for observation |
start | ΣC | 0..1 | dateTime | Starting time with inclusive boundary |
end | ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing |
value[x] | SΣC | 0..1 | Actual result Slice: Unordered, Open by type:$this | |
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
interpretation | S | 0..* | CodeableConcept | High, low, normal, etc. Binding: Observation interpretation codes (extensible) |
bodySite | S | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
coding | Σ | 0..* | Coding | Code defined by a terminology system |
system | Σ | 0..1 | uri | Identity of the terminology system |
version | Σ | 0..1 | string | Version of the system - if relevant |
code | Σ | 0..1 | code | Symbol in syntax defined by the system |
device | S | 1..1 | Reference(Enumeration DeviceMetric profile) | (Measurement) Device |
Documentation for this format |
Path | Conformance | ValueSet |
Observation.meta.security | extensible | All Security Labels |
Observation.status | required | ObservationStatus |
Observation.category | preferred | ObservationCategoryCodes |
Observation.code | extensible | MdcMetric |
Observation.dataAbsentReason | extensible | DataAbsentReason |
Observation.interpretation | extensible | ObservationInterpretation |
Observation.bodySite | example | SNOMEDCTBodyStructures |
Id | Grade | Path(s) | Details | Requirements |
pocd-obs-1 | error | Observation | If there is no value a dataAbsentReason shall be present : value.exists() or dataAbsentReason.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | Measurements and simple assertions pocd-obs-1: If there is no value a dataAbsentReason shall be present | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | Σ | 0..1 | id | Version specific identifier | ||||
lastUpdated | Σ | 0..1 | instant | When the resource version last changed | ||||
source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
profile | Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
security | SΣ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
tag | 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". | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business Identifier for observation | ||||
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | ||||
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
category | S | 0..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
code | Σ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: MDC Metric nomenclature (extensible) | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 0..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
subject | SΣ | 1..1 | Reference(Patient | MDS Device profile) | Who and/or what the observation is about | ||||
focus | ΣTU | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made | ||||
Slices for effective[x] | SΣ | 1..1 | Clinically relevant time/time-period for observation Slice: Unordered, Closed by type:$this | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
effective[x]:effectiveDateTime | Σ | 0..1 | dateTime | Clinically relevant time/time-period for observation | ||||
effective[x]:effectivePeriod | Σ | 0..1 | Period | Clinically relevant time/time-period for observation | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
start | ΣC | 0..1 | dateTime | Starting time with inclusive boundary | ||||
end | ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation | ||||
value[x] | SΣC | 0..1 | Actual result Slice: Unordered, Open by type:$this | |||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | S | 0..* | CodeableConcept | High, low, normal, etc. Binding: Observation interpretation codes (extensible) | ||||
note | 0..* | Annotation | Comments about the observation | |||||
bodySite | S | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 0..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
method | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |||||
specimen | 0..1 | Reference(Specimen) | Specimen used for this observation | |||||
device | S | 1..1 | Reference(Enumeration DeviceMetric profile) | (Measurement) Device | ||||
referenceRange | C | 0..* | BackboneElement | Provides guide for interpretation | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
low | C | 0..1 | SimpleQuantity | Low Range, if relevant | ||||
high | C | 0..1 | SimpleQuantity | High Range, if relevant | ||||
type | 0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range. | |||||
appliesTo | 0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to. | |||||
age | 0..1 | Range | Applicable age range, if relevant | |||||
text | 0..1 | string | Text based reference range in an observation | |||||
hasMember | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
component | Σ | 0..* | BackboneElement | Component results | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
value[x] | Σ | 0..1 | Actual component result | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
referenceRange | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
Observation.meta.security | extensible | All Security Labels | ||||
Observation.meta.tag | example | CommonTags | ||||
Observation.language | preferred | CommonLanguages
| ||||
Observation.status | required | ObservationStatus | ||||
Observation.category | preferred | ObservationCategoryCodes | ||||
Observation.code | extensible | MdcMetric | ||||
Observation.dataAbsentReason | extensible | DataAbsentReason | ||||
Observation.interpretation | extensible | ObservationInterpretation | ||||
Observation.bodySite | example | SNOMEDCTBodyStructures | ||||
Observation.method | example | ObservationMethods | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes | ||||
Observation.component.code | example | LOINCCodes (a valid code from LOINC) | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReason | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodes |
This structure is derived from Observation
The profile defines the following rules:
Observation.code
shall have a coding from the ISO/IEEE 11073 MDC Metric nomenclature if there is an appropriate code available.Observation.subject
shall be present and refer to a Patient resource or MDS Device resource.Observation.effectiveDateTime
or Observation.effectivePeriod
shall be present.Observation.valueCodeableConcept
or Observation.valueString
or, if there is no value, Observation.dataAbsentReason
shall be present.Observation.interpretation
coding includes measurement status.Observation.device
shall be present and refer to the Enumeration DeviceMetric resource which this observation belongs to.Differential View
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Observation | Measurements and simple assertions pocd-obs-1: If there is no value a dataAbsentReason shall be present |
meta | 0..1 | Meta | Metadata about the resource | |
security | S | 0..* | Coding | Security Labels applied to this resource |
status | S | 1..1 | code | registered | preliminary | final | amended + |
category | S | 0..* | CodeableConcept | Classification of type of observation |
code | 1..1 | CodeableConcept | Type of observation (code / type) Binding: MDC Metric nomenclature (extensible) | |
coding | 0..* | Coding | Code defined by a terminology system | |
system | 0..1 | uri | Identity of the terminology system | |
version | 0..1 | string | Version of the system - if relevant | |
code | 0..1 | code | Symbol in syntax defined by the system | |
subject | S | 1..1 | Reference(Patient | MDS Device profile) | Who and/or what the observation is about |
Slices for effective[x] | S | 1..1 | Clinically relevant time/time-period for observation Slice: Unordered, Closed by type:$this | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
effective[x]:effectiveDateTime | 0..1 | dateTime | Clinically relevant time/time-period for observation | |
effective[x]:effectivePeriod | 0..1 | Period | Clinically relevant time/time-period for observation | |
start | 0..1 | dateTime | Starting time with inclusive boundary | |
end | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | |
value[x] | SC | 0..1 | Actual result Slice: Unordered, Closed by type:$this | |
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing |
interpretation | S | 0..* | CodeableConcept | High, low, normal, etc. Binding: Observation interpretation codes (extensible) |
bodySite | S | 0..1 | CodeableConcept | Observed body part |
coding | 0..* | Coding | Code defined by a terminology system | |
system | 0..1 | uri | Identity of the terminology system | |
version | 0..1 | string | Version of the system - if relevant | |
code | 0..1 | code | Symbol in syntax defined by the system | |
device | S | 1..1 | Reference(Enumeration DeviceMetric profile) | (Measurement) Device |
Documentation for this format |
Path | Conformance | ValueSet |
Observation.code | extensible | MdcMetric |
Observation.interpretation | extensible | ObservationInterpretation |
Id | Grade | Path(s) | Details | Requirements |
pocd-obs-1 | error | Observation | If there is no value a dataAbsentReason shall be present : value.exists() or dataAbsentReason.exists() |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Observation | Measurements and simple assertions pocd-obs-1: If there is no value a dataAbsentReason shall be present |
meta | Σ | 0..1 | Meta | Metadata about the resource |
security | SΣ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
category | S | 0..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
code | Σ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: MDC Metric nomenclature (extensible) |
coding | Σ | 0..* | Coding | Code defined by a terminology system |
system | Σ | 0..1 | uri | Identity of the terminology system |
version | Σ | 0..1 | string | Version of the system - if relevant |
code | Σ | 0..1 | code | Symbol in syntax defined by the system |
subject | SΣ | 1..1 | Reference(Patient | MDS Device profile) | Who and/or what the observation is about |
Slices for effective[x] | SΣ | 1..1 | Clinically relevant time/time-period for observation Slice: Unordered, Closed by type:$this | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
effective[x]:effectiveDateTime | Σ | 0..1 | dateTime | Clinically relevant time/time-period for observation |
effective[x]:effectivePeriod | Σ | 0..1 | Period | Clinically relevant time/time-period for observation |
start | ΣC | 0..1 | dateTime | Starting time with inclusive boundary |
end | ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing |
value[x] | SΣC | 0..1 | Actual result Slice: Unordered, Open by type:$this | |
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
interpretation | S | 0..* | CodeableConcept | High, low, normal, etc. Binding: Observation interpretation codes (extensible) |
bodySite | S | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
coding | Σ | 0..* | Coding | Code defined by a terminology system |
system | Σ | 0..1 | uri | Identity of the terminology system |
version | Σ | 0..1 | string | Version of the system - if relevant |
code | Σ | 0..1 | code | Symbol in syntax defined by the system |
device | S | 1..1 | Reference(Enumeration DeviceMetric profile) | (Measurement) Device |
Documentation for this format |
Path | Conformance | ValueSet |
Observation.meta.security | extensible | All Security Labels |
Observation.status | required | ObservationStatus |
Observation.category | preferred | ObservationCategoryCodes |
Observation.code | extensible | MdcMetric |
Observation.dataAbsentReason | extensible | DataAbsentReason |
Observation.interpretation | extensible | ObservationInterpretation |
Observation.bodySite | example | SNOMEDCTBodyStructures |
Id | Grade | Path(s) | Details | Requirements |
pocd-obs-1 | error | Observation | If there is no value a dataAbsentReason shall be present : value.exists() or dataAbsentReason.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | Measurements and simple assertions pocd-obs-1: If there is no value a dataAbsentReason shall be present | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | Σ | 0..1 | id | Version specific identifier | ||||
lastUpdated | Σ | 0..1 | instant | When the resource version last changed | ||||
source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
profile | Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
security | SΣ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
tag | 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". | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business Identifier for observation | ||||
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | ||||
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
category | S | 0..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
code | Σ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: MDC Metric nomenclature (extensible) | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 0..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
subject | SΣ | 1..1 | Reference(Patient | MDS Device profile) | Who and/or what the observation is about | ||||
focus | ΣTU | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made | ||||
Slices for effective[x] | SΣ | 1..1 | Clinically relevant time/time-period for observation Slice: Unordered, Closed by type:$this | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
effective[x]:effectiveDateTime | Σ | 0..1 | dateTime | Clinically relevant time/time-period for observation | ||||
effective[x]:effectivePeriod | Σ | 0..1 | Period | Clinically relevant time/time-period for observation | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
start | ΣC | 0..1 | dateTime | Starting time with inclusive boundary | ||||
end | ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation | ||||
value[x] | SΣC | 0..1 | Actual result Slice: Unordered, Open by type:$this | |||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | S | 0..* | CodeableConcept | High, low, normal, etc. Binding: Observation interpretation codes (extensible) | ||||
note | 0..* | Annotation | Comments about the observation | |||||
bodySite | S | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 0..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
method | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |||||
specimen | 0..1 | Reference(Specimen) | Specimen used for this observation | |||||
device | S | 1..1 | Reference(Enumeration DeviceMetric profile) | (Measurement) Device | ||||
referenceRange | C | 0..* | BackboneElement | Provides guide for interpretation | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
low | C | 0..1 | SimpleQuantity | Low Range, if relevant | ||||
high | C | 0..1 | SimpleQuantity | High Range, if relevant | ||||
type | 0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range. | |||||
appliesTo | 0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to. | |||||
age | 0..1 | Range | Applicable age range, if relevant | |||||
text | 0..1 | string | Text based reference range in an observation | |||||
hasMember | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
component | Σ | 0..* | BackboneElement | Component results | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
value[x] | Σ | 0..1 | Actual component result | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
referenceRange | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
Observation.meta.security | extensible | All Security Labels | ||||
Observation.meta.tag | example | CommonTags | ||||
Observation.language | preferred | CommonLanguages
| ||||
Observation.status | required | ObservationStatus | ||||
Observation.category | preferred | ObservationCategoryCodes | ||||
Observation.code | extensible | MdcMetric | ||||
Observation.dataAbsentReason | extensible | DataAbsentReason | ||||
Observation.interpretation | extensible | ObservationInterpretation | ||||
Observation.bodySite | example | SNOMEDCTBodyStructures | ||||
Observation.method | example | ObservationMethods | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes | ||||
Observation.component.code | example | LOINCCodes (a valid code from LOINC) | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReason | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodes |
This structure is derived from Observation
The profile defines the following rules:
Observation.code
shall have a coding from the ISO/IEEE 11073 MDC Metric nomenclature if there is an appropriate code available.Observation.subject
shall be present and refer to a Patient resource or MDS Device resource.Observation.effectiveDateTime
or Observation.effectivePeriod
shall be present.Observation.valueCodeableConcept
or Observation.valueString
or, if there is no value, Observation.dataAbsentReason
shall be present.Observation.interpretation
coding includes measurement status.Observation.device
shall be present and refer to the Enumeration DeviceMetric resource which this observation belongs to.
Other representations of profile: CSV, Excel, Schematron