EU Imaging Report R4
1.0.0-ballot - ci-build
150
EU Imaging Report R4
1.0.0-ballot - ci-build
150
EU Imaging Report R4, published by HL7 Europe. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-eu/imaging-r4/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.eu/fhir/imaging/StructureDefinition/ObservationNarrativeReport | Version: 1.0.0-ballot | ||||
| Standards status: Draft | Maturity Level: 1 | Computable Name: ObservationNarrativeReport | |||
Copyright/Legal: Copyright HL7 Europe. Licensed under Creative Commons public domain (CC0 1.0). |
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Unstructured narrative text in an imaging report.
Most radiology reports still contain a significant amount of unstructured, narrative (dictated or free-text) content. This profile defines a dedicated, explicit home to encode the source of that narrative content in a FHIR resource, so that it can be referenced from the DiagnosticReport and rendered in Composition sections.
To see how to reference this resource in the model please read Representing unstructured text (narrative) in the report
Usages:
You can also check for usages in the FHIR IG Statistics
Description Differentials, Snapshots, and other representations.
| Name | Flags | Card. | Type | Description & Constraints Filter:  |
|---|---|---|---|---|
  Observation |
C | 0..* | Observation | Measurements and simple assertions Constraints: obs-6, obs-7, im-narrative-value-1 |
  implicitRules |
0..1 | uri | A set of rules under which this content was created | |
 modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |
  Slices for basedOn |
0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order Slice: Unordered, Open by type:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
   basedOn:ServiceRequestOrderEuImagingaccession |
0..* | Reference(ServiceRequest: Imaging Order) | Fulfills plan, proposal or order | |
   identifier |
0..1 | AccessionNumberIdentifierEuImaging | Logical reference, when literal reference is not known | |
| status |
1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | |
| code |
1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. Required Pattern: At least the following | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
 coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 18782-3 | |
| display |
0..1 | string | Representation defined by the system | |
 userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| text |
0..1 | string | Plain text representation of the concept | |
 value[x] |
C | 0..1 | string | Unstructured narrative imaging report as string |
 Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
 extension:renderingXhtml |
0..1 | string | XHTML rendering of the narrative value URL: http://hl7.org/fhir/StructureDefinition/rendering-xhtml | |
| extension:renderingMarkdown |
0..1 | markdown | Markdown rendering of the narrative value URL: http://hl7.org/fhir/StructureDefinition/rendering-markdown | |
| extension:valueAttachment |
0..1 | (Complex) | Narrative report as an Attachment, conveyed via the R5 cross-version extension URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.value Constraints: ext-1 | |
 extension |
0..0 | Extension Slice: Unordered, Open by value:url Constraints: ext-1 Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | ||
| url |
1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.value" | |
| value[x] |
1..1 | Attachment | Actual result | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Observation.status | Base | required | ObservationStatus | 📍4.0.1 | FHIR Std. |
| Observation.code | Base | example | LOINC Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
| im-narrative-value-1 | error | Observation | Either the narrative value (valueString) or its Attachment cross-version extension (value.extension) SHALL be present. |
value.exists() or value.extension('http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.value').exists()
|
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present |
dataAbsentReason.empty() or value.empty()
|
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present |
value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
|
This structure is derived from Observation
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Observation |
C | 0..* | Observation | Measurements and simple assertions Constraints: im-narrative-value-1 |
| Slices for basedOn |
0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order Slice: Unordered, Open by type:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| basedOn:ServiceRequestOrderEuImagingaccession |
0..* | Reference(ServiceRequest: Imaging Order) | Fulfills plan, proposal or order | |
| identifier |
0..1 | AccessionNumberIdentifierEuImaging | Logical reference, when literal reference is not known | |
 code |
1..1 | CodeableConcept | Type of observation (code / type) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 18782-3 | |
| value[x] |
0..1 | string | Unstructured narrative imaging report as string | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| extension:renderingXhtml |
0..1 | string | XHTML rendering of the narrative value URL: http://hl7.org/fhir/StructureDefinition/rendering-xhtml | |
| extension:renderingMarkdown |
0..1 | markdown | Markdown rendering of the narrative value URL: http://hl7.org/fhir/StructureDefinition/rendering-markdown | |
| extension:valueAttachment |
0..1 | (Complex) | Narrative report as an Attachment, conveyed via the R5 cross-version extension URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.value | |
| extension |
0..0 | Extension | ||
| value[x] |
1..1 | Attachment | Actual result | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Description | Expression |
| im-narrative-value-1 | error | Observation | Either the narrative value (valueString) or its Attachment cross-version extension (value.extension) SHALL be present. |
value.exists() or value.extension('http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.value').exists()
|
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| Observation |
C | 0..* | Observation | Measurements and simple assertions Constraints: obs-6, obs-7, im-narrative-value-1 | ||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
0..1 | Meta | Metadata about the resource | |||||
| implicitRules |
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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| identifier |
0..* | Identifier | Business Identifier for observation | |||||
| Slices for basedOn |
0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order Slice: Unordered, Open by type:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| basedOn:ServiceRequestOrderEuImagingaccession |
0..* | Reference(ServiceRequest: Imaging Order) | Fulfills plan, proposal or order | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
C | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |||||
| identifier |
0..1 | AccessionNumberIdentifierEuImaging | Logical reference, when literal reference is not known | |||||
| display |
0..1 | string | Text alternative for the resource | |||||
 partOf |
0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | |||||
| status |
1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | |||||
| category |
0..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||
| code |
1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. Required Pattern: At least the following | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 18782-3 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| subject |
0..1 | Reference(Patient | Group | Device | Location) | Who and/or what the observation is about | |||||
| focus |
0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | |||||
| encounter |
0..1 | Reference(Encounter) | Healthcare event during which this observation is made | |||||
 effective[x] |
0..1 | Clinically relevant time/time-period for observation | ||||||
| effectiveDateTime |
dateTime | |||||||
| effectivePeriod |
Period | |||||||
| effectiveTiming |
Timing | |||||||
| effectiveInstant |
instant | |||||||
| issued |
0..1 | instant | Date/Time this version was made available | |||||
| performer |
0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation | |||||
| value[x] |
C | 0..1 | string | Unstructured narrative imaging report as string | ||||
| id |
0..1 | string | xml:id (or equivalent in JSON) | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| extension:renderingXhtml |
0..1 | string | XHTML rendering of the narrative value URL: http://hl7.org/fhir/StructureDefinition/rendering-xhtml | |||||
| extension:renderingMarkdown |
0..1 | markdown | Markdown rendering of the narrative value URL: http://hl7.org/fhir/StructureDefinition/rendering-markdown | |||||
| extension:valueAttachment |
0..1 | (Complex) | Narrative report as an Attachment, conveyed via the R5 cross-version extension URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.value Constraints: ext-1 | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..0 | Extension Slice: Unordered, Open by value:url Constraints: ext-1 Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | ||||||
| url |
1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.value" | |||||
| value[x] |
1..1 | Attachment | Actual result | |||||
| value |
0..1 | string | Primitive value for string Max Length:1048576 | |||||
| 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 |
0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
| method |
0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |||||
| specimen |
0..1 | Reference(Specimen) | Specimen used for this observation | |||||
| device |
0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
| referenceRange |
C | 0..* | BackboneElement | Provides guide for interpretation Constraints: obs-3 | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| low |
C | 0..1 | SimpleQuantity(4.0.1) | Low Range, if relevant Constraints: sqty-1 | ||||
| high |
C | 0..1 | SimpleQuantity(4.0.1) | High Range, if relevant Constraints: sqty-1 | ||||
| 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 |
0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | |||||
| derivedFrom |
0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | |||||
| component |
0..* | BackboneElement | Component results | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | |||||
| value[x] |
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 | Status | Usage | ValueSet | Version | Source |
| Observation.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| Observation.basedOn:ServiceRequestOrderEuImagingaccession.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| Observation.status | Base | required | ObservationStatus | 📍4.0.1 | FHIR Std. |
| Observation.category | Base | preferred | Observation Category Codes | 📍4.0.1 | FHIR Std. |
| Observation.code | Base | example | LOINC Codes | 📍4.0.1 | FHIR Std. |
| Observation.dataAbsentReason | Base | extensible | DataAbsentReason | 📍4.0.1 | FHIR Std. |
| Observation.interpretation | Base | extensible | Observation Interpretation Codes | 📍4.0.1 | FHIR Std. |
| Observation.bodySite | Base | example | SNOMED CT Body Structures | 📍4.0.1 | FHIR Std. |
| Observation.method | Base | example | Observation Methods | 📍4.0.1 | FHIR Std. |
| Observation.referenceRange.type | Base | preferred | Observation Reference Range Meaning Codes | 📍4.0.1 | FHIR Std. |
| Observation.referenceRange.appliesTo | Base | example | Observation Reference Range Applies To Codes | 📍4.0.1 | FHIR Std. |
| Observation.component.code | Base | example | LOINC Codes | 📍4.0.1 | FHIR Std. |
| Observation.component.dataAbsentReason | Base | extensible | DataAbsentReason | 📍4.0.1 | FHIR Std. |
| Observation.component.interpretation | Base | extensible | Observation Interpretation Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
| im-narrative-value-1 | error | Observation | Either the narrative value (valueString) or its Attachment cross-version extension (value.extension) SHALL be present. |
value.exists() or value.extension('http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.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()
|
| sqty-1 | error | Observation.referenceRange.low, Observation.referenceRange.high | The comparator is not used on a SimpleQuantity |
comparator.empty()
|
This structure is derived from Observation
Summary
Mandatory: 0 element(1 nested mandatory element)
Prohibited: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 1
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Observation |
C | 0..* | Observation | Measurements and simple assertions Constraints: obs-6, obs-7, im-narrative-value-1 |
| implicitRules |
0..1 | uri | A set of rules under which this content was created | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |
| Slices for basedOn |
0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order Slice: Unordered, Open by type:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| basedOn:ServiceRequestOrderEuImagingaccession |
0..* | Reference(ServiceRequest: Imaging Order) | Fulfills plan, proposal or order | |
| identifier |
0..1 | AccessionNumberIdentifierEuImaging | Logical reference, when literal reference is not known | |
| status |
1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | |
| code |
1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. Required Pattern: At least the following | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 18782-3 | |
| display |
0..1 | string | Representation defined by the system | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| text |
0..1 | string | Plain text representation of the concept | |
| value[x] |
C | 0..1 | string | Unstructured narrative imaging report as string |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| extension:renderingXhtml |
0..1 | string | XHTML rendering of the narrative value URL: http://hl7.org/fhir/StructureDefinition/rendering-xhtml | |
| extension:renderingMarkdown |
0..1 | markdown | Markdown rendering of the narrative value URL: http://hl7.org/fhir/StructureDefinition/rendering-markdown | |
| extension:valueAttachment |
0..1 | (Complex) | Narrative report as an Attachment, conveyed via the R5 cross-version extension URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.value Constraints: ext-1 | |
| extension |
0..0 | Extension Slice: Unordered, Open by value:url Constraints: ext-1 Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | ||
| url |
1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.value" | |
| value[x] |
1..1 | Attachment | Actual result | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Observation.status | Base | required | ObservationStatus | 📍4.0.1 | FHIR Std. |
| Observation.code | Base | example | LOINC Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
| im-narrative-value-1 | error | Observation | Either the narrative value (valueString) or its Attachment cross-version extension (value.extension) SHALL be present. |
value.exists() or value.extension('http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.value').exists()
|
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present |
dataAbsentReason.empty() or value.empty()
|
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present |
value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
|
Differential View
This structure is derived from Observation
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Observation |
C | 0..* | Observation | Measurements and simple assertions Constraints: im-narrative-value-1 |
| Slices for basedOn |
0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order Slice: Unordered, Open by type:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| basedOn:ServiceRequestOrderEuImagingaccession |
0..* | Reference(ServiceRequest: Imaging Order) | Fulfills plan, proposal or order | |
| identifier |
0..1 | AccessionNumberIdentifierEuImaging | Logical reference, when literal reference is not known | |
| code |
1..1 | CodeableConcept | Type of observation (code / type) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 18782-3 | |
| value[x] |
0..1 | string | Unstructured narrative imaging report as string | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| extension:renderingXhtml |
0..1 | string | XHTML rendering of the narrative value URL: http://hl7.org/fhir/StructureDefinition/rendering-xhtml | |
| extension:renderingMarkdown |
0..1 | markdown | Markdown rendering of the narrative value URL: http://hl7.org/fhir/StructureDefinition/rendering-markdown | |
| extension:valueAttachment |
0..1 | (Complex) | Narrative report as an Attachment, conveyed via the R5 cross-version extension URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.value | |
| extension |
0..0 | Extension | ||
| value[x] |
1..1 | Attachment | Actual result | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Description | Expression |
| im-narrative-value-1 | error | Observation | Either the narrative value (valueString) or its Attachment cross-version extension (value.extension) SHALL be present. |
value.exists() or value.extension('http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.value').exists()
|
Snapshot ViewView
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| Observation |
C | 0..* | Observation | Measurements and simple assertions Constraints: obs-6, obs-7, im-narrative-value-1 | ||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
0..1 | Meta | Metadata about the resource | |||||
| implicitRules |
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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| identifier |
0..* | Identifier | Business Identifier for observation | |||||
| Slices for basedOn |
0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order Slice: Unordered, Open by type:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| basedOn:ServiceRequestOrderEuImagingaccession |
0..* | Reference(ServiceRequest: Imaging Order) | Fulfills plan, proposal or order | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
C | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |||||
| identifier |
0..1 | AccessionNumberIdentifierEuImaging | Logical reference, when literal reference is not known | |||||
| display |
0..1 | string | Text alternative for the resource | |||||
| partOf |
0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | |||||
| status |
1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | |||||
| category |
0..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||
| code |
1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. Required Pattern: At least the following | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 18782-3 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| subject |
0..1 | Reference(Patient | Group | Device | Location) | Who and/or what the observation is about | |||||
| focus |
0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | |||||
| encounter |
0..1 | Reference(Encounter) | Healthcare event during which this observation is made | |||||
| effective[x] |
0..1 | Clinically relevant time/time-period for observation | ||||||
| effectiveDateTime |
dateTime | |||||||
| effectivePeriod |
Period | |||||||
| effectiveTiming |
Timing | |||||||
| effectiveInstant |
instant | |||||||
| issued |
0..1 | instant | Date/Time this version was made available | |||||
| performer |
0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation | |||||
| value[x] |
C | 0..1 | string | Unstructured narrative imaging report as string | ||||
| id |
0..1 | string | xml:id (or equivalent in JSON) | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| extension:renderingXhtml |
0..1 | string | XHTML rendering of the narrative value URL: http://hl7.org/fhir/StructureDefinition/rendering-xhtml | |||||
| extension:renderingMarkdown |
0..1 | markdown | Markdown rendering of the narrative value URL: http://hl7.org/fhir/StructureDefinition/rendering-markdown | |||||
| extension:valueAttachment |
0..1 | (Complex) | Narrative report as an Attachment, conveyed via the R5 cross-version extension URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.value Constraints: ext-1 | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..0 | Extension Slice: Unordered, Open by value:url Constraints: ext-1 Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | ||||||
| url |
1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.value" | |||||
| value[x] |
1..1 | Attachment | Actual result | |||||
| value |
0..1 | string | Primitive value for string Max Length:1048576 | |||||
| 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 |
0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
| method |
0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |||||
| specimen |
0..1 | Reference(Specimen) | Specimen used for this observation | |||||
| device |
0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
| referenceRange |
C | 0..* | BackboneElement | Provides guide for interpretation Constraints: obs-3 | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| low |
C | 0..1 | SimpleQuantity(4.0.1) | Low Range, if relevant Constraints: sqty-1 | ||||
| high |
C | 0..1 | SimpleQuantity(4.0.1) | High Range, if relevant Constraints: sqty-1 | ||||
| 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 |
0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | |||||
| derivedFrom |
0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | |||||
| component |
0..* | BackboneElement | Component results | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | |||||
| value[x] |
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 | Status | Usage | ValueSet | Version | Source |
| Observation.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| Observation.basedOn:ServiceRequestOrderEuImagingaccession.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| Observation.status | Base | required | ObservationStatus | 📍4.0.1 | FHIR Std. |
| Observation.category | Base | preferred | Observation Category Codes | 📍4.0.1 | FHIR Std. |
| Observation.code | Base | example | LOINC Codes | 📍4.0.1 | FHIR Std. |
| Observation.dataAbsentReason | Base | extensible | DataAbsentReason | 📍4.0.1 | FHIR Std. |
| Observation.interpretation | Base | extensible | Observation Interpretation Codes | 📍4.0.1 | FHIR Std. |
| Observation.bodySite | Base | example | SNOMED CT Body Structures | 📍4.0.1 | FHIR Std. |
| Observation.method | Base | example | Observation Methods | 📍4.0.1 | FHIR Std. |
| Observation.referenceRange.type | Base | preferred | Observation Reference Range Meaning Codes | 📍4.0.1 | FHIR Std. |
| Observation.referenceRange.appliesTo | Base | example | Observation Reference Range Applies To Codes | 📍4.0.1 | FHIR Std. |
| Observation.component.code | Base | example | LOINC Codes | 📍4.0.1 | FHIR Std. |
| Observation.component.dataAbsentReason | Base | extensible | DataAbsentReason | 📍4.0.1 | FHIR Std. |
| Observation.component.interpretation | Base | extensible | Observation Interpretation Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
| im-narrative-value-1 | error | Observation | Either the narrative value (valueString) or its Attachment cross-version extension (value.extension) SHALL be present. |
value.exists() or value.extension('http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.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()
|
| sqty-1 | error | Observation.referenceRange.low, Observation.referenceRange.high | The comparator is not used on a SimpleQuantity |
comparator.empty()
|
This structure is derived from Observation
Summary
Mandatory: 0 element(1 nested mandatory element)
Prohibited: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 1
Other representations of profile: CSV, Excel, Schematron
IG © 2025+ HL7 Europe.
Package hl7.fhir.eu.imaging#1.0.0-ballot based on FHIR 4.0.1.
Generated
2026-10-13
