Imaging Diagnostic Report
0.0.1-current - ci-build
Imaging Diagnostic Report, published by IHE Radiology Technical Committee. This guide is not an authorized publication; it is the continuous build for version 0.0.1-current built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IHE/RAD.IDR/ and changes regularly. See the Directory of published versions
Official URL: https://profiles.ihe.net/RAD/IDR/StructureDefinition/idr-observation | Version: 0.0.1-current | |||
Draft as of 2024-06-25 | Computable Name: IDRObservation |
Findings or Impressions in Diagnostic Reports
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 | Observation | |||
text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
Slices for basedOn | S | 1..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order Slice: Unordered, Open by type:resolve() |
basedOn:serviceRequest | 1..* | Reference(Imaging ServiceRequest) | Fulfills plan, proposal or order | |
partOf | S | 0..* | Reference(IDR ImagingStudy) | Part of referenced event |
status | S | 1..1 | code | registered | preliminary | final | amended + Required Pattern: final |
Slices for category | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:coding | |
category:imaging | S | 1..1 | CodeableConcept | Classification of type of observation |
coding | 1..* | Coding | Code defined by a terminology system Required Pattern: At least the following | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging | |
subject | 1..1 | Reference(Patient) | Who and/or what the observation is about | |
encounter | S | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made |
performer | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Who is responsible for the observation | |
Slices for derivedFrom | S | 0..* | Reference(DocumentReference | ImagingStudy | ImagingSelection | QuestionnaireResponse | Observation | MolecularSequence | GenomicStudy) | Related resource from which the observation is made Slice: Unordered, Open by type:resolve() |
derivedFrom:imagingSelection | 0..* | Reference(ImagingSelection) | Related resource from which the observation is made | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Observation | Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.component.code is the same as Observation.code, then Observation.value SHALL NOT be present (the Observation.component.value[x] holds the value). obs-8: bodyStructure SHALL only be present if Observation.bodySite is not present |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
contained | 0..* | Resource | Contained, inline Resources | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
Slices for basedOn | SΣ | 1..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order Slice: Unordered, Open by type:resolve() |
basedOn:serviceRequest | Σ | 1..* | Reference(Imaging ServiceRequest) | Fulfills plan, proposal or order |
partOf | SΣ | 0..* | Reference(IDR ImagingStudy) | Part of referenced event |
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. Required Pattern: final |
Slices for category | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:coding Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |
category:imaging | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
coding | Σ | 1..* | Coding | Code defined by a terminology system Required Pattern: At least the following |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging | |
code | ΣC | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. |
subject | Σ | 1..1 | Reference(Patient) | Who and/or what the observation is about |
encounter | SΣ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made |
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Who is responsible for the observation |
value[x] | ΣC | 0..1 | Actual result | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
valueAttachment | Attachment | |||
valueReference | Reference(MolecularSequence) | |||
Slices for derivedFrom | SΣ | 0..* | Reference(DocumentReference | ImagingStudy | ImagingSelection | QuestionnaireResponse | Observation | MolecularSequence | GenomicStudy) | Related resource from which the observation is made Slice: Unordered, Open by type:resolve() |
derivedFrom:imagingSelection | Σ | 0..* | Reference(ImagingSelection) | Related resource from which the observation is made |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Observation.status | required | Pattern: finalhttp://hl7.org/fhir/ValueSet/observation-status|5.0.0 from the FHIR Standard | |
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.category:imaging | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.component.code is the same as Observation.code, then Observation.value SHALL NOT be present (the Observation.component.value[x] holds the value). obs-8: bodyStructure SHALL only be present if Observation.bodySite is not 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: AllLanguages (required): IETF language tag for a human language
| |||||
text | S | 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business Identifier for observation | ||||
instantiates[x] | Σ | 0..1 | canonical(ObservationDefinition), Reference(ObservationDefinition) | Instantiates FHIR ObservationDefinition | ||||
Slices for basedOn | SΣ | 1..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order Slice: Unordered, Open by type:resolve() | ||||
basedOn:serviceRequest | Σ | 1..* | Reference(Imaging ServiceRequest) | Fulfills plan, proposal or order | ||||
triggeredBy | 0..* | BackboneElement | Triggering observation(s) | |||||
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 | ||||
observation | Σ | 1..1 | Reference(Observation) | Triggering observation | ||||
type | Σ | 1..1 | code | reflex | repeat | re-run Binding: TriggeredBytype (required): The type of TriggeredBy Observation. | ||||
reason | 0..1 | string | Reason that the observation was triggered | |||||
partOf | SΣ | 0..* | Reference(IDR ImagingStudy) | Part of referenced event | ||||
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. Required Pattern: final | ||||
Slices for category | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:coding Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||
category:imaging | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 1..* | Coding | Code defined by a terminology system Required Pattern: At least the following | ||||
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://terminology.hl7.org/CodeSystem/observation-category | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
code | ΣC | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
subject | Σ | 1..1 | Reference(Patient) | Who and/or what the observation is about | ||||
focus | Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
encounter | SΣ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made | ||||
effective[x] | Σ | 0..1 | Clinically relevant time/time-period for observation | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
effectiveTiming | Timing | |||||||
effectiveInstant | instant | |||||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Who is responsible for the observation | ||||
value[x] | ΣC | 0..1 | Actual result | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
valueAttachment | Attachment | |||||||
valueReference | Reference(MolecularSequence) | |||||||
dataAbsentReason | C | 0..1 | CodeableConcept | Why the 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. | |||||
note | 0..* | Annotation | Comments about the observation | |||||
bodySite | C | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): SNOMED CT Body site concepts | ||||
bodyStructure | C | 0..1 | Reference(BodyStructure) | Observed body structure | ||||
method | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |||||
specimen | C | 0..1 | Reference(Specimen | Group) | Specimen used for this observation obs-9: If Observation.specimen is a reference to Group, the group can only have specimens | ||||
device | 0..1 | Reference(Device | DeviceMetric) | A reference to the device that generates the measurements or the device settings for the 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 | ||||
normalValue | 0..1 | CodeableConcept | Normal value, if relevant Binding: ObservationReferenceRangeNormalValueCodes (extensible): Codes identifying the normal value of the observation. | |||||
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 | C | 0..1 | markdown | Text based reference range in an observation | ||||
hasMember | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
Slices for derivedFrom | SΣ | 0..* | Reference(DocumentReference | ImagingStudy | ImagingSelection | QuestionnaireResponse | Observation | MolecularSequence | GenomicStudy) | Related resource from which the observation is made Slice: Unordered, Open by type:resolve() | ||||
derivedFrom:imagingSelection | Σ | 0..* | Reference(ImagingSelection) | Related resource from which the observation is made | ||||
component | ΣC | 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 | ΣC | 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 | |||||||
valueAttachment | Attachment | |||||||
valueReference | Reference(MolecularSequence) | |||||||
dataAbsentReason | 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 / Code | URI |
Observation.language | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages|5.0.0 from the FHIR Standard | |
Observation.triggeredBy.type | required | TriggeredBytypehttp://hl7.org/fhir/ValueSet/observation-triggeredbytype|5.0.0 from the FHIR Standard | |
Observation.status | required | Pattern: finalhttp://hl7.org/fhir/ValueSet/observation-status|5.0.0 from the FHIR Standard | |
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.category:imaging | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes 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.normalValue | extensible | ObservationReferenceRangeNormalValueCodeshttp://hl7.org/fhir/ValueSet/observation-referencerange-normalvalue 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 |
This structure is derived from Observation
Summary
Mandatory: 6 elements
Must-Support: 7 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | Observation | |||
text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
Slices for basedOn | S | 1..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order Slice: Unordered, Open by type:resolve() |
basedOn:serviceRequest | 1..* | Reference(Imaging ServiceRequest) | Fulfills plan, proposal or order | |
partOf | S | 0..* | Reference(IDR ImagingStudy) | Part of referenced event |
status | S | 1..1 | code | registered | preliminary | final | amended + Required Pattern: final |
Slices for category | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:coding | |
category:imaging | S | 1..1 | CodeableConcept | Classification of type of observation |
coding | 1..* | Coding | Code defined by a terminology system Required Pattern: At least the following | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging | |
subject | 1..1 | Reference(Patient) | Who and/or what the observation is about | |
encounter | S | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made |
performer | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Who is responsible for the observation | |
Slices for derivedFrom | S | 0..* | Reference(DocumentReference | ImagingStudy | ImagingSelection | QuestionnaireResponse | Observation | MolecularSequence | GenomicStudy) | Related resource from which the observation is made Slice: Unordered, Open by type:resolve() |
derivedFrom:imagingSelection | 0..* | Reference(ImagingSelection) | Related resource from which the observation is made | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Observation | Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.component.code is the same as Observation.code, then Observation.value SHALL NOT be present (the Observation.component.value[x] holds the value). obs-8: bodyStructure SHALL only be present if Observation.bodySite is not present |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
contained | 0..* | Resource | Contained, inline Resources | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
Slices for basedOn | SΣ | 1..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order Slice: Unordered, Open by type:resolve() |
basedOn:serviceRequest | Σ | 1..* | Reference(Imaging ServiceRequest) | Fulfills plan, proposal or order |
partOf | SΣ | 0..* | Reference(IDR ImagingStudy) | Part of referenced event |
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. Required Pattern: final |
Slices for category | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:coding Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |
category:imaging | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
coding | Σ | 1..* | Coding | Code defined by a terminology system Required Pattern: At least the following |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging | |
code | ΣC | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. |
subject | Σ | 1..1 | Reference(Patient) | Who and/or what the observation is about |
encounter | SΣ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made |
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Who is responsible for the observation |
value[x] | ΣC | 0..1 | Actual result | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
valueAttachment | Attachment | |||
valueReference | Reference(MolecularSequence) | |||
Slices for derivedFrom | SΣ | 0..* | Reference(DocumentReference | ImagingStudy | ImagingSelection | QuestionnaireResponse | Observation | MolecularSequence | GenomicStudy) | Related resource from which the observation is made Slice: Unordered, Open by type:resolve() |
derivedFrom:imagingSelection | Σ | 0..* | Reference(ImagingSelection) | Related resource from which the observation is made |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Observation.status | required | Pattern: finalhttp://hl7.org/fhir/ValueSet/observation-status|5.0.0 from the FHIR Standard | |
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.category:imaging | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.component.code is the same as Observation.code, then Observation.value SHALL NOT be present (the Observation.component.value[x] holds the value). obs-8: bodyStructure SHALL only be present if Observation.bodySite is not 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: AllLanguages (required): IETF language tag for a human language
| |||||
text | S | 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business Identifier for observation | ||||
instantiates[x] | Σ | 0..1 | canonical(ObservationDefinition), Reference(ObservationDefinition) | Instantiates FHIR ObservationDefinition | ||||
Slices for basedOn | SΣ | 1..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order Slice: Unordered, Open by type:resolve() | ||||
basedOn:serviceRequest | Σ | 1..* | Reference(Imaging ServiceRequest) | Fulfills plan, proposal or order | ||||
triggeredBy | 0..* | BackboneElement | Triggering observation(s) | |||||
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 | ||||
observation | Σ | 1..1 | Reference(Observation) | Triggering observation | ||||
type | Σ | 1..1 | code | reflex | repeat | re-run Binding: TriggeredBytype (required): The type of TriggeredBy Observation. | ||||
reason | 0..1 | string | Reason that the observation was triggered | |||||
partOf | SΣ | 0..* | Reference(IDR ImagingStudy) | Part of referenced event | ||||
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. Required Pattern: final | ||||
Slices for category | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:coding Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||
category:imaging | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 1..* | Coding | Code defined by a terminology system Required Pattern: At least the following | ||||
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://terminology.hl7.org/CodeSystem/observation-category | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
code | ΣC | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
subject | Σ | 1..1 | Reference(Patient) | Who and/or what the observation is about | ||||
focus | Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
encounter | SΣ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made | ||||
effective[x] | Σ | 0..1 | Clinically relevant time/time-period for observation | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
effectiveTiming | Timing | |||||||
effectiveInstant | instant | |||||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Who is responsible for the observation | ||||
value[x] | ΣC | 0..1 | Actual result | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
valueAttachment | Attachment | |||||||
valueReference | Reference(MolecularSequence) | |||||||
dataAbsentReason | C | 0..1 | CodeableConcept | Why the 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. | |||||
note | 0..* | Annotation | Comments about the observation | |||||
bodySite | C | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): SNOMED CT Body site concepts | ||||
bodyStructure | C | 0..1 | Reference(BodyStructure) | Observed body structure | ||||
method | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |||||
specimen | C | 0..1 | Reference(Specimen | Group) | Specimen used for this observation obs-9: If Observation.specimen is a reference to Group, the group can only have specimens | ||||
device | 0..1 | Reference(Device | DeviceMetric) | A reference to the device that generates the measurements or the device settings for the 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 | ||||
normalValue | 0..1 | CodeableConcept | Normal value, if relevant Binding: ObservationReferenceRangeNormalValueCodes (extensible): Codes identifying the normal value of the observation. | |||||
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 | C | 0..1 | markdown | Text based reference range in an observation | ||||
hasMember | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
Slices for derivedFrom | SΣ | 0..* | Reference(DocumentReference | ImagingStudy | ImagingSelection | QuestionnaireResponse | Observation | MolecularSequence | GenomicStudy) | Related resource from which the observation is made Slice: Unordered, Open by type:resolve() | ||||
derivedFrom:imagingSelection | Σ | 0..* | Reference(ImagingSelection) | Related resource from which the observation is made | ||||
component | ΣC | 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 | ΣC | 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 | |||||||
valueAttachment | Attachment | |||||||
valueReference | Reference(MolecularSequence) | |||||||
dataAbsentReason | 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 / Code | URI |
Observation.language | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages|5.0.0 from the FHIR Standard | |
Observation.triggeredBy.type | required | TriggeredBytypehttp://hl7.org/fhir/ValueSet/observation-triggeredbytype|5.0.0 from the FHIR Standard | |
Observation.status | required | Pattern: finalhttp://hl7.org/fhir/ValueSet/observation-status|5.0.0 from the FHIR Standard | |
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.category:imaging | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | |
Observation.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes 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.normalValue | extensible | ObservationReferenceRangeNormalValueCodeshttp://hl7.org/fhir/ValueSet/observation-referencerange-normalvalue 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 |
This structure is derived from Observation
Summary
Mandatory: 6 elements
Must-Support: 7 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron