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

Terminology Bindings (Differential)

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	BeVSScore https://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 dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier	SΣ	0..*	Identifier	Business Identifier for observation ele-1: All FHIR elements must have a @value or children
status	?!Σ	1..1	code	registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. ele-1: All FHIR elements must have a @value or children
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) ele-1: All FHIR elements must have a @value or children
code	SΣ	1..1	CodeableConcept	The code of the score that is being calculated. Binding: Score Value Set (required) ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(BePatient | Group)	The patient that this score refers to ele-1: All FHIR elements must have a @value or children
Slices for effective[x]	Σ	1..1	Period	Clinically relevant time/time-period for observation Slice: Unordered, Closed by type:$this ele-1: All FHIR elements must have a @value or children
effective[x]:effectivePeriod	SΣ	1..1	Period	The time period that the score refers to. ele-1: All FHIR elements must have a @value or children
issued	SΣ	1..1	instant	The date and time when the score was made available ele-1: All FHIR elements must have a @value or children
performer	SΣ	0..*	Reference(BePatient | BePractitioner | BePractitionerRole | BeOrganization)	The care provider that took the assessment ele-1: All FHIR elements must have a @value or children
value[x]	SΣC	1..1		The actual score value. ele-1: All FHIR elements must have a @value or children
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. ele-1: All FHIR elements must have a @value or children
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. ele-1: All FHIR elements must have a @value or children
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) ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
referenceRange	SC	0..*	BackboneElement	The different ranges of the value ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
derivedFrom	SΣ	0..*	Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)	The source values for the assessment - for example a QuestionnaireResponse ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Observation.status	required	ObservationStatus http://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	BeVSScore https://www.ehealth.fgov.be/standards/fhir/core-clinical/ValueSet/be-vs-score from this IG
Observation.interpretation	extensible	ObservationInterpretationCodes http://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard
Observation.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard

Constraints

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. Additional Bindings Purpose AllLanguages Max Binding
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

Terminology Bindings

Path	Conformance	ValueSet	URI
Observation.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Observation.status	required	ObservationStatus http://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	BeVSScore https://www.ehealth.fgov.be/standards/fhir/core-clinical/ValueSet/be-vs-score from this IG
Observation.dataAbsentReason	extensible	DataAbsentReason http://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard
Observation.interpretation	extensible	ObservationInterpretationCodes http://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard
Observation.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Observation.method	example	ObservationMethods http://hl7.org/fhir/ValueSet/observation-methods from the FHIR Standard
Observation.referenceRange.type	preferred	ObservationReferenceRangeMeaningCodes http://hl7.org/fhir/ValueSet/referencerange-meaning from the FHIR Standard
Observation.referenceRange.appliesTo	example	ObservationReferenceRangeAppliesToCodes http://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	DataAbsentReason http://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard
Observation.component.interpretation	extensible	ObservationInterpretationCodes http://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard

Constraints

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()

Summary

Mandatory: 5 elements
Must-Support: 13 elements

Structures

This structure refers to these other structures:

• BePatient (https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-patient)
• BePractitioner (https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-practitioner)
• BePractitionerRole (https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-practitionerrole)
• BeOrganization (https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-organization)

Extensions

This structure refers to these extensions:

• https://www.ehealth.fgov.be/standards/fhir/core-clinical/StructureDefinition/be-ext-laterality

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Observation.effective[x]

Maturity: 1

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

Terminology Bindings (Differential)

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	BeVSScore https://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 dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier	SΣ	0..*	Identifier	Business Identifier for observation ele-1: All FHIR elements must have a @value or children
status	?!Σ	1..1	code	registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. ele-1: All FHIR elements must have a @value or children
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) ele-1: All FHIR elements must have a @value or children
code	SΣ	1..1	CodeableConcept	The code of the score that is being calculated. Binding: Score Value Set (required) ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(BePatient | Group)	The patient that this score refers to ele-1: All FHIR elements must have a @value or children
Slices for effective[x]	Σ	1..1	Period	Clinically relevant time/time-period for observation Slice: Unordered, Closed by type:$this ele-1: All FHIR elements must have a @value or children
effective[x]:effectivePeriod	SΣ	1..1	Period	The time period that the score refers to. ele-1: All FHIR elements must have a @value or children
issued	SΣ	1..1	instant	The date and time when the score was made available ele-1: All FHIR elements must have a @value or children
performer	SΣ	0..*	Reference(BePatient | BePractitioner | BePractitionerRole | BeOrganization)	The care provider that took the assessment ele-1: All FHIR elements must have a @value or children
value[x]	SΣC	1..1		The actual score value. ele-1: All FHIR elements must have a @value or children
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. ele-1: All FHIR elements must have a @value or children
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. ele-1: All FHIR elements must have a @value or children
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) ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
referenceRange	SC	0..*	BackboneElement	The different ranges of the value ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
derivedFrom	SΣ	0..*	Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)	The source values for the assessment - for example a QuestionnaireResponse ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Observation.status	required	ObservationStatus http://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	BeVSScore https://www.ehealth.fgov.be/standards/fhir/core-clinical/ValueSet/be-vs-score from this IG
Observation.interpretation	extensible	ObservationInterpretationCodes http://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard
Observation.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard

Constraints

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. Additional Bindings Purpose AllLanguages Max Binding
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

Terminology Bindings

Path	Conformance	ValueSet	URI
Observation.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Observation.status	required	ObservationStatus http://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	BeVSScore https://www.ehealth.fgov.be/standards/fhir/core-clinical/ValueSet/be-vs-score from this IG
Observation.dataAbsentReason	extensible	DataAbsentReason http://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard
Observation.interpretation	extensible	ObservationInterpretationCodes http://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard
Observation.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Observation.method	example	ObservationMethods http://hl7.org/fhir/ValueSet/observation-methods from the FHIR Standard
Observation.referenceRange.type	preferred	ObservationReferenceRangeMeaningCodes http://hl7.org/fhir/ValueSet/referencerange-meaning from the FHIR Standard
Observation.referenceRange.appliesTo	example	ObservationReferenceRangeAppliesToCodes http://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	DataAbsentReason http://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard
Observation.component.interpretation	extensible	ObservationInterpretationCodes http://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard

Constraints

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()

Summary

Mandatory: 5 elements
Must-Support: 13 elements

Structures

This structure refers to these other structures:

• BePatient (https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-patient)
• BePractitioner (https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-practitioner)
• BePractitionerRole (https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-practitionerrole)
• BeOrganization (https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-organization)

Extensions

This structure refers to these extensions:

• https://www.ehealth.fgov.be/standards/fhir/core-clinical/StructureDefinition/be-ext-laterality

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Observation.effective[x]

Maturity: 1