Resumen Clínico de Paciente de Chile (IPS-CL)
0.2.0 - ci-build
Resumen Clínico de Paciente de Chile (IPS-CL), published by HL7 Chile. This guide is not an authorized publication; it is the continuous build for version 0.2.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7Chile/IPS-CL/ and changes regularly. See the Directory of published versions
Official URL: https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Observation-uso-de-alcohol-cl-ips | Version: 0.2.0 | |||
Standards status: Draft | Maturity Level: 1 | Computable Name: ObservationUsoAlcoholClIps |
Este perfil restringe el recurso Observation para representar la evaluación del consumo de alcohol del paciente.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ObservacionCL
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | ObservacionCL | |||
code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 74013-4 | |
subject | 1..1 | Reference(Paciente (IPS-CL)) | Sobre Quien o Que se esta realizando la observación | |
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
effective[x] | 1..1 | dateTime | Tiempo/Tiempo-periodo de relevancia clínica para la observación | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
data-absent-reason | S | 0..1 | (Complex) | effective[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason |
value[x] | 1..1 | code | Value of extension Binding: DataAbsentReason (required): Es usado para especificar porque el elemento esperado por algún motivo no se encuentra el dato | |
Slices for value[x] | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual Resultado Slice: Unordered, Open by type:$this | |
value[x]:valueQuantity | 0..1 | QuantityIPS | A measured amount using UCUM | |
component | 0..0 | |||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.effective[x].extension:data-absent-reason.value[x] | required | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | ObservacionCL | Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | SΣ | 0..* | Identifier | Identificación para la observación |
status | ?!SΣ | 1..1 | code | registered|preliminary|final|amended|corrected|cancelled|entered-in-error|unknown Binding: ObservationStatus (required): Códigos provistos para el estado de una observación |
category | S | 0..* | CodeableConcept | Clasificación del tipo de observación Binding: ObservationCategoryCodes (preferred): Códigos de alto nivel para la categoría de una observación |
code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: LOINCCodes (example): Códigos de identficación simple para el nombre de una observación Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 74013-4 | |
subject | SΣ | 1..1 | Reference(Paciente (IPS-CL)) | Sobre Quien o Que se esta realizando la observación |
reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
encounter | SΣ | 0..1 | Reference(CL Encuentro Clínico) | Evento clínico durante el cual se hizo esta observación |
effective[x] | SΣ | 1..1 | dateTime | Tiempo/Tiempo-periodo de relevancia clínica para la observación |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
data-absent-reason | S | 0..1 | (Complex) | effective[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason" | |
value[x] | 1..1 | code | Value of extension Binding: DataAbsentReason (required): Es usado para especificar porque el elemento esperado por algún motivo no se encuentra el dato | |
performer | SΣ | 0..* | Reference(CL Prestador | CL RolClinico | CL Organización | CareTeam | CL Paciente | RelatedPerson) | Quien es responsable por la observación |
Slices for value[x] | SΣC | 0..1 | Actual Resultado Slice: Unordered, Open by type:$this | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
value[x]:valueQuantity | SC | 0..1 | QuantityIPS | A measured amount using UCUM qty-3: If a code for the unit is present, the system SHALL also be present |
interpretation | S | 0..* | CodeableConcept | Alta, baja, normal, etc Binding: ObservationInterpretationCodes (extensible): Códigos de identificción para la interpretación de la observación |
note | S | 0..* | Annotation | Comentarios sobre la observación |
specimen | S | 0..1 | Reference(Specimen) | Muestra tomada para la observación |
hasMember | SΣ | 0..* | Reference(CL Observación | QuestionnaireResponse | MolecularSequence) | Grupo de recursos relacionados a la observación |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | |
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.code | example | Pattern: LOINC Code 74013-4http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | |
Observation.effective[x].extension:data-absent-reason.value[x] | required | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | |
Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard | |
Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | |
Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
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-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() | |
qty-3 | error | Observation.value[x]:valueQuantity | If a code for the unit is present, the system SHALL also be present : code.empty() or system.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | ObservacionCL | Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
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 | SΣ | 0..* | Identifier | Identificación para la observación | ||||
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|corrected|cancelled|entered-in-error|unknown Binding: ObservationStatus (required): Códigos provistos para el estado de una observación | ||||
category | S | 0..* | CodeableConcept | Clasificación del tipo de observación Binding: ObservationCategoryCodes (preferred): Códigos de alto nivel para la categoría de una observación | ||||
code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: LOINCCodes (example): Códigos de identficación simple para el nombre de una observación Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 74013-4 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
subject | SΣ | 1..1 | Reference(Paciente (IPS-CL)) | Sobre Quien o Que se esta realizando la observación | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
display | Σ | 0..1 | string | Text alternative for the resource | ||||
focus | Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
encounter | SΣ | 0..1 | Reference(CL Encuentro Clínico) | Evento clínico durante el cual se hizo esta observación | ||||
effective[x] | SΣ | 1..1 | dateTime | Tiempo/Tiempo-periodo de relevancia clínica para la observación | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
data-absent-reason | S | 0..1 | (Complex) | effective[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason | ||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason" | |||||
value[x] | 1..1 | code | Value of extension Binding: DataAbsentReason (required): Es usado para especificar porque el elemento esperado por algún motivo no se encuentra el dato | |||||
value | 0..1 | dateTime | Primitive value for dateTime | |||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | SΣ | 0..* | Reference(CL Prestador | CL RolClinico | CL Organización | CareTeam | CL Paciente | RelatedPerson) | Quien es responsable por la observación | ||||
Slices for value[x] | SΣC | 0..1 | Actual Resultado Slice: Unordered, Open by type:$this | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
value[x]:valueQuantity | SC | 0..1 | QuantityIPS | A measured amount using UCUM qty-3: If a code for the unit is present, the system SHALL also be present | ||||
dataAbsentReason | C | 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 | Alta, baja, normal, etc Binding: ObservationInterpretationCodes (extensible): Códigos de identificción para la interpretación de la observación | ||||
note | S | 0..* | Annotation | Comentarios sobre la observación | ||||
bodySite | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
method | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |||||
specimen | S | 0..1 | Reference(Specimen) | Muestra tomada para la observación | ||||
device | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
referenceRange | C | 0..* | BackboneElement | Provides guide for interpretation obs-3: Must have at least a low or a high or text | ||||
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 | SΣ | 0..* | Reference(CL Observación | QuestionnaireResponse | MolecularSequence) | Grupo de recursos relacionados a la observación | ||||
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Observation.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | ||||
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.code | example | Pattern: LOINC Code 74013-4http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | ||||
Observation.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Observation.effective[x].extension:data-absent-reason.value[x] | required | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard | ||||
Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methods from the FHIR Standard | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaning from the FHIR Standard | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliesto from the FHIR Standard | ||||
Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
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() | |
qty-3 | error | Observation.value[x]:valueQuantity | If a code for the unit is present, the system SHALL also be present : code.empty() or system.exists() |
This structure is derived from ObservacionCL
Summary
Mandatory: 3 elements
Must-Support: 2 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 1
Differential View
This structure is derived from ObservacionCL
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | ObservacionCL | |||
code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 74013-4 | |
subject | 1..1 | Reference(Paciente (IPS-CL)) | Sobre Quien o Que se esta realizando la observación | |
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
effective[x] | 1..1 | dateTime | Tiempo/Tiempo-periodo de relevancia clínica para la observación | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
data-absent-reason | S | 0..1 | (Complex) | effective[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason |
value[x] | 1..1 | code | Value of extension Binding: DataAbsentReason (required): Es usado para especificar porque el elemento esperado por algún motivo no se encuentra el dato | |
Slices for value[x] | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual Resultado Slice: Unordered, Open by type:$this | |
value[x]:valueQuantity | 0..1 | QuantityIPS | A measured amount using UCUM | |
component | 0..0 | |||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.effective[x].extension:data-absent-reason.value[x] | required | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | ObservacionCL | Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | SΣ | 0..* | Identifier | Identificación para la observación |
status | ?!SΣ | 1..1 | code | registered|preliminary|final|amended|corrected|cancelled|entered-in-error|unknown Binding: ObservationStatus (required): Códigos provistos para el estado de una observación |
category | S | 0..* | CodeableConcept | Clasificación del tipo de observación Binding: ObservationCategoryCodes (preferred): Códigos de alto nivel para la categoría de una observación |
code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: LOINCCodes (example): Códigos de identficación simple para el nombre de una observación Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 74013-4 | |
subject | SΣ | 1..1 | Reference(Paciente (IPS-CL)) | Sobre Quien o Que se esta realizando la observación |
reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
encounter | SΣ | 0..1 | Reference(CL Encuentro Clínico) | Evento clínico durante el cual se hizo esta observación |
effective[x] | SΣ | 1..1 | dateTime | Tiempo/Tiempo-periodo de relevancia clínica para la observación |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
data-absent-reason | S | 0..1 | (Complex) | effective[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason" | |
value[x] | 1..1 | code | Value of extension Binding: DataAbsentReason (required): Es usado para especificar porque el elemento esperado por algún motivo no se encuentra el dato | |
performer | SΣ | 0..* | Reference(CL Prestador | CL RolClinico | CL Organización | CareTeam | CL Paciente | RelatedPerson) | Quien es responsable por la observación |
Slices for value[x] | SΣC | 0..1 | Actual Resultado Slice: Unordered, Open by type:$this | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
value[x]:valueQuantity | SC | 0..1 | QuantityIPS | A measured amount using UCUM qty-3: If a code for the unit is present, the system SHALL also be present |
interpretation | S | 0..* | CodeableConcept | Alta, baja, normal, etc Binding: ObservationInterpretationCodes (extensible): Códigos de identificción para la interpretación de la observación |
note | S | 0..* | Annotation | Comentarios sobre la observación |
specimen | S | 0..1 | Reference(Specimen) | Muestra tomada para la observación |
hasMember | SΣ | 0..* | Reference(CL Observación | QuestionnaireResponse | MolecularSequence) | Grupo de recursos relacionados a la observación |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | |
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.code | example | Pattern: LOINC Code 74013-4http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | |
Observation.effective[x].extension:data-absent-reason.value[x] | required | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | |
Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard | |
Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | |
Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
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-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() | |
qty-3 | error | Observation.value[x]:valueQuantity | If a code for the unit is present, the system SHALL also be present : code.empty() or system.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | ObservacionCL | Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
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 | SΣ | 0..* | Identifier | Identificación para la observación | ||||
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|corrected|cancelled|entered-in-error|unknown Binding: ObservationStatus (required): Códigos provistos para el estado de una observación | ||||
category | S | 0..* | CodeableConcept | Clasificación del tipo de observación Binding: ObservationCategoryCodes (preferred): Códigos de alto nivel para la categoría de una observación | ||||
code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: LOINCCodes (example): Códigos de identficación simple para el nombre de una observación Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 74013-4 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
subject | SΣ | 1..1 | Reference(Paciente (IPS-CL)) | Sobre Quien o Que se esta realizando la observación | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
display | Σ | 0..1 | string | Text alternative for the resource | ||||
focus | Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
encounter | SΣ | 0..1 | Reference(CL Encuentro Clínico) | Evento clínico durante el cual se hizo esta observación | ||||
effective[x] | SΣ | 1..1 | dateTime | Tiempo/Tiempo-periodo de relevancia clínica para la observación | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
data-absent-reason | S | 0..1 | (Complex) | effective[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason | ||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason" | |||||
value[x] | 1..1 | code | Value of extension Binding: DataAbsentReason (required): Es usado para especificar porque el elemento esperado por algún motivo no se encuentra el dato | |||||
value | 0..1 | dateTime | Primitive value for dateTime | |||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | SΣ | 0..* | Reference(CL Prestador | CL RolClinico | CL Organización | CareTeam | CL Paciente | RelatedPerson) | Quien es responsable por la observación | ||||
Slices for value[x] | SΣC | 0..1 | Actual Resultado Slice: Unordered, Open by type:$this | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
value[x]:valueQuantity | SC | 0..1 | QuantityIPS | A measured amount using UCUM qty-3: If a code for the unit is present, the system SHALL also be present | ||||
dataAbsentReason | C | 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 | Alta, baja, normal, etc Binding: ObservationInterpretationCodes (extensible): Códigos de identificción para la interpretación de la observación | ||||
note | S | 0..* | Annotation | Comentarios sobre la observación | ||||
bodySite | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
method | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |||||
specimen | S | 0..1 | Reference(Specimen) | Muestra tomada para la observación | ||||
device | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
referenceRange | C | 0..* | BackboneElement | Provides guide for interpretation obs-3: Must have at least a low or a high or text | ||||
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 | SΣ | 0..* | Reference(CL Observación | QuestionnaireResponse | MolecularSequence) | Grupo de recursos relacionados a la observación | ||||
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Observation.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | ||||
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.code | example | Pattern: LOINC Code 74013-4http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | ||||
Observation.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Observation.effective[x].extension:data-absent-reason.value[x] | required | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard | ||||
Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methods from the FHIR Standard | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaning from the FHIR Standard | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliesto from the FHIR Standard | ||||
Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
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() | |
qty-3 | error | Observation.value[x]:valueQuantity | If a code for the unit is present, the system SHALL also be present : code.empty() or system.exists() |
This structure is derived from ObservacionCL
Summary
Mandatory: 3 elements
Must-Support: 2 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 1
Other representations of profile: CSV, Excel, Schematron