HL7 FHIR Implementation Guide: Transversal Clinical Core
1.0.1 - STU1
HL7 FHIR Implementation Guide: Transversal Clinical Core, published by eHealth Platform. This guide is not an authorized publication; it is the continuous build for version 1.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-be/core-clinical/ and changes regularly. See the Directory of published versions
Official URL: https://www.ehealth.fgov.be/standards/fhir/core-clinical/StructureDefinition/be-scoreresult | Version: 1.0.1 | |||
Active as of 2021-01-10 | Maturity Level: 1 | Computable Name: BeScoreResult |
To support the standard exchange of scores such as pain assessment scores, or risk score, etc
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 | 0..* | Observation | Measurements and simple assertions | |
identifier | S | 0..* | Identifier | Business Identifier for observation |
category | S | 0..* | CodeableConcept | The high-level group or category of the score - e.g. 'Risk score' or 'Pain score' Binding: Score Category Value Set (required) |
code | S | 1..1 | CodeableConcept | The code of the score that is being calculated. Binding: Score Value Set (required) |
subject | S | 1..1 | Reference(BePatient | Group) | The patient that this score refers to |
Slices for effective[x] | 1..1 | Period | Clinically relevant time/time-period for observation Slice: Unordered, Open by type:$this | |
effective[x]:effectivePeriod | S | 1..1 | Period | The time period that the score refers to. |
issued | S | 1..1 | instant | The date and time when the score was made available |
performer | S | 0..* | Reference(BePatient | BePractitioner | BePractitionerRole | BeOrganization) | The care provider that took the assessment |
value[x] | S | 1..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | The actual score value. |
interpretation | S | 0..* | CodeableConcept | The interpretation of the result from the value. For example if value is 12, the interpretation can be 'elevated' |
bodySite | S | 0..1 | CodeableConcept | The body site to which the score applies, when applicable |
Slices for extension | Content/Rules for all slices | |||
laterality | S | 0..1 | Coding | BeExtLaterality URL: https://www.ehealth.fgov.be/standards/fhir/core-clinical/StructureDefinition/be-ext-laterality Binding: Laterality (required) |
referenceRange | S | 0..* | BackboneElement | The different ranges of the value |
derivedFrom | S | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | The source values for the assessment - for example a QuestionnaireResponse |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.category | required | BeVSScoreCategory (a valid code from Score Category)https://www.ehealth.fgov.be/standards/fhir/core-clinical/ValueSet/be-vs-scorecategory from this IG | |
Observation.code | required | BeVSScorehttps://www.ehealth.fgov.be/standards/fhir/core-clinical/ValueSet/be-vs-score from this IG |
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.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 | Business Identifier for observation |
status | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
category | S | 0..* | CodeableConcept | The high-level group or category of the score - e.g. 'Risk score' or 'Pain score' Binding: Score Category Value Set (required) |
code | SΣ | 1..1 | CodeableConcept | The code of the score that is being calculated. Binding: Score Value Set (required) |
subject | SΣ | 1..1 | Reference(BePatient | Group) | The patient that this score refers to |
Slices for effective[x] | Σ | 1..1 | Period | Clinically relevant time/time-period for observation Slice: Unordered, Closed by type:$this |
effective[x]:effectivePeriod | SΣ | 1..1 | Period | The time period that the score refers to. |
issued | SΣ | 1..1 | instant | The date and time when the score was made available |
performer | SΣ | 0..* | Reference(BePatient | BePractitioner | BePractitionerRole | BeOrganization) | The care provider that took the assessment |
value[x] | SΣC | 1..1 | The actual score value. | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
interpretation | S | 0..* | CodeableConcept | The interpretation of the result from the value. For example if value is 12, the interpretation can be 'elevated' Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. |
bodySite | S | 0..1 | CodeableConcept | The body site to which the score applies, when applicable Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
Slices for extension | Content/Rules for all slices | |||
laterality | S | 0..1 | Coding | BeExtLaterality URL: https://www.ehealth.fgov.be/standards/fhir/core-clinical/StructureDefinition/be-ext-laterality Binding: Laterality (required) |
referenceRange | SC | 0..* | BackboneElement | The different ranges of the value obs-3: Must have at least a low or a high or text |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
derivedFrom | SΣ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | The source values for the assessment - for example a QuestionnaireResponse |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | |
Observation.category | required | BeVSScoreCategory (a valid code from Score Category)https://www.ehealth.fgov.be/standards/fhir/core-clinical/ValueSet/be-vs-scorecategory from this IG | |
Observation.code | required | BeVSScorehttps://www.ehealth.fgov.be/standards/fhir/core-clinical/ValueSet/be-vs-score from this IG | |
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 |
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() |
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.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 | 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 | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
category | S | 0..* | CodeableConcept | The high-level group or category of the score - e.g. 'Risk score' or 'Pain score' Binding: Score Category Value Set (required) | ||||
code | SΣ | 1..1 | CodeableConcept | The code of the score that is being calculated. Binding: Score Value Set (required) | ||||
subject | SΣ | 1..1 | Reference(BePatient | Group) | The patient that this score refers to | ||||
focus | Σ | 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] | Σ | 1..1 | Period | Clinically relevant time/time-period for observation Slice: Unordered, Closed by type:$this | ||||
effective[x]:effectivePeriod | SΣ | 1..1 | Period | The time period that the score refers to. | ||||
issued | SΣ | 1..1 | instant | The date and time when the score was made available | ||||
performer | SΣ | 0..* | Reference(BePatient | BePractitioner | BePractitionerRole | BeOrganization) | The care provider that took the assessment | ||||
value[x] | SΣC | 1..1 | The actual score value. | |||||
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 result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | S | 0..* | CodeableConcept | The interpretation of the result from the value. For example if value is 12, the interpretation can be 'elevated' Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | ||||
note | 0..* | Annotation | Comments about the observation | |||||
bodySite | S | 0..1 | CodeableConcept | The body site to which the score applies, when applicable Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
laterality | S | 0..1 | Coding | BeExtLaterality URL: https://www.ehealth.fgov.be/standards/fhir/core-clinical/StructureDefinition/be-ext-laterality Binding: Laterality (required) | ||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
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 | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
referenceRange | SC | 0..* | BackboneElement | The different ranges of the value 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 | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
derivedFrom | SΣ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | The source values for the assessment - for example a QuestionnaireResponse | ||||
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 | 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 | required | BeVSScoreCategory (a valid code from Score Category)https://www.ehealth.fgov.be/standards/fhir/core-clinical/ValueSet/be-vs-scorecategory from this IG | ||||
Observation.code | required | BeVSScorehttps://www.ehealth.fgov.be/standards/fhir/core-clinical/ValueSet/be-vs-score from this IG | ||||
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() |
This structure is derived from Observation
Summary
Mandatory: 5 elements
Must-Support: 13 elements
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 Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | Observation | Measurements and simple assertions | |
identifier | S | 0..* | Identifier | Business Identifier for observation |
category | S | 0..* | CodeableConcept | The high-level group or category of the score - e.g. 'Risk score' or 'Pain score' Binding: Score Category Value Set (required) |
code | S | 1..1 | CodeableConcept | The code of the score that is being calculated. Binding: Score Value Set (required) |
subject | S | 1..1 | Reference(BePatient | Group) | The patient that this score refers to |
Slices for effective[x] | 1..1 | Period | Clinically relevant time/time-period for observation Slice: Unordered, Open by type:$this | |
effective[x]:effectivePeriod | S | 1..1 | Period | The time period that the score refers to. |
issued | S | 1..1 | instant | The date and time when the score was made available |
performer | S | 0..* | Reference(BePatient | BePractitioner | BePractitionerRole | BeOrganization) | The care provider that took the assessment |
value[x] | S | 1..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | The actual score value. |
interpretation | S | 0..* | CodeableConcept | The interpretation of the result from the value. For example if value is 12, the interpretation can be 'elevated' |
bodySite | S | 0..1 | CodeableConcept | The body site to which the score applies, when applicable |
Slices for extension | Content/Rules for all slices | |||
laterality | S | 0..1 | Coding | BeExtLaterality URL: https://www.ehealth.fgov.be/standards/fhir/core-clinical/StructureDefinition/be-ext-laterality Binding: Laterality (required) |
referenceRange | S | 0..* | BackboneElement | The different ranges of the value |
derivedFrom | S | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | The source values for the assessment - for example a QuestionnaireResponse |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.category | required | BeVSScoreCategory (a valid code from Score Category)https://www.ehealth.fgov.be/standards/fhir/core-clinical/ValueSet/be-vs-scorecategory from this IG | |
Observation.code | required | BeVSScorehttps://www.ehealth.fgov.be/standards/fhir/core-clinical/ValueSet/be-vs-score from this IG |
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.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 | Business Identifier for observation |
status | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
category | S | 0..* | CodeableConcept | The high-level group or category of the score - e.g. 'Risk score' or 'Pain score' Binding: Score Category Value Set (required) |
code | SΣ | 1..1 | CodeableConcept | The code of the score that is being calculated. Binding: Score Value Set (required) |
subject | SΣ | 1..1 | Reference(BePatient | Group) | The patient that this score refers to |
Slices for effective[x] | Σ | 1..1 | Period | Clinically relevant time/time-period for observation Slice: Unordered, Closed by type:$this |
effective[x]:effectivePeriod | SΣ | 1..1 | Period | The time period that the score refers to. |
issued | SΣ | 1..1 | instant | The date and time when the score was made available |
performer | SΣ | 0..* | Reference(BePatient | BePractitioner | BePractitionerRole | BeOrganization) | The care provider that took the assessment |
value[x] | SΣC | 1..1 | The actual score value. | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
interpretation | S | 0..* | CodeableConcept | The interpretation of the result from the value. For example if value is 12, the interpretation can be 'elevated' Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. |
bodySite | S | 0..1 | CodeableConcept | The body site to which the score applies, when applicable Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
Slices for extension | Content/Rules for all slices | |||
laterality | S | 0..1 | Coding | BeExtLaterality URL: https://www.ehealth.fgov.be/standards/fhir/core-clinical/StructureDefinition/be-ext-laterality Binding: Laterality (required) |
referenceRange | SC | 0..* | BackboneElement | The different ranges of the value obs-3: Must have at least a low or a high or text |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
derivedFrom | SΣ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | The source values for the assessment - for example a QuestionnaireResponse |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | |
Observation.category | required | BeVSScoreCategory (a valid code from Score Category)https://www.ehealth.fgov.be/standards/fhir/core-clinical/ValueSet/be-vs-scorecategory from this IG | |
Observation.code | required | BeVSScorehttps://www.ehealth.fgov.be/standards/fhir/core-clinical/ValueSet/be-vs-score from this IG | |
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 |
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() |
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.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 | 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 | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
category | S | 0..* | CodeableConcept | The high-level group or category of the score - e.g. 'Risk score' or 'Pain score' Binding: Score Category Value Set (required) | ||||
code | SΣ | 1..1 | CodeableConcept | The code of the score that is being calculated. Binding: Score Value Set (required) | ||||
subject | SΣ | 1..1 | Reference(BePatient | Group) | The patient that this score refers to | ||||
focus | Σ | 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] | Σ | 1..1 | Period | Clinically relevant time/time-period for observation Slice: Unordered, Closed by type:$this | ||||
effective[x]:effectivePeriod | SΣ | 1..1 | Period | The time period that the score refers to. | ||||
issued | SΣ | 1..1 | instant | The date and time when the score was made available | ||||
performer | SΣ | 0..* | Reference(BePatient | BePractitioner | BePractitionerRole | BeOrganization) | The care provider that took the assessment | ||||
value[x] | SΣC | 1..1 | The actual score value. | |||||
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 result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | S | 0..* | CodeableConcept | The interpretation of the result from the value. For example if value is 12, the interpretation can be 'elevated' Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | ||||
note | 0..* | Annotation | Comments about the observation | |||||
bodySite | S | 0..1 | CodeableConcept | The body site to which the score applies, when applicable Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
laterality | S | 0..1 | Coding | BeExtLaterality URL: https://www.ehealth.fgov.be/standards/fhir/core-clinical/StructureDefinition/be-ext-laterality Binding: Laterality (required) | ||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
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 | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
referenceRange | SC | 0..* | BackboneElement | The different ranges of the value 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 | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
derivedFrom | SΣ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | The source values for the assessment - for example a QuestionnaireResponse | ||||
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 | 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 | required | BeVSScoreCategory (a valid code from Score Category)https://www.ehealth.fgov.be/standards/fhir/core-clinical/ValueSet/be-vs-scorecategory from this IG | ||||
Observation.code | required | BeVSScorehttps://www.ehealth.fgov.be/standards/fhir/core-clinical/ValueSet/be-vs-score from this IG | ||||
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() |
This structure is derived from Observation
Summary
Mandatory: 5 elements
Must-Support: 13 elements
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