AU Base Implementation Guide, published by HL7 Australia. This guide is not an authorized publication; it is the continuous build for version 4.2.2-ci-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7au/au-fhir-base/ and changes regularly. See the Directory of published versions

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Resource Profile: AU Base Pathology Result

This profile defines an observation structure to represent a pathology test result issued by a diagnostic service provider in an Australian context. This profile is intended to be capable of supporting reporting for all pathology disciplines (e.g. including microbiology, histopathology, cytology, blood transfusion) with the exception of genomics. The observation may represent the result of a simple test such as haemoglobin or it may group the set of results produced by a multi-test study or panel such as a full blood count, or urine specimen study.

This profile does not provide full support for structured pathology reporting. It is expected that this support is best handled by a set of profiles that represent the structured reporting requirements for each specific protocol (see for example RCPA’s structured pathology reporting of cancer); this is not in the scope of this implementation guide at this time.

Usage:

• Refer to this Resource Profile: AU Base Diagnostic Report, AU Base Diagnostic Result, AU Base Pathology Report and AU Base Pathology Result
• Examples for this Resource Profile: Observation/specimen-hepatitis-b-serology

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from Observation

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	A pathology test result in an Australian healthcare context inv-obs-0: A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason
Slices for category		1..*	CodeableConcept	Classification of the service requested as laboratory + more specific discipline where available Slice: Unordered, Open by value:coding.system, value:coding.code
category:lab		1..1	CodeableConcept	Observation generated by laboratories
coding		1..*	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
code		1..1	code	Symbol in syntax defined by the system Fixed Value: laboratory
category:specificDiscipline		0..*	CodeableConcept	Specific discipline of pathology Binding: Pathology Diagnostic Service Category (extensible)
coding
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
code		1..1	CodeableConcept	Pathology test or test group Binding: RCPA SPIA Pathology Reporting (preferred) Additional Bindings Purpose RCPA - SPIA Chemical Pathology Terminology Reference Set Component RCPA - SPIA Haematology Terminology Reference Set Component RCPA - SPIA Immunopathology Terminology Reference Set Component RCPA - SPIA Microbiology Serology Molecular Pathology Terminology Reference Set Component
subject		1..1	Reference(Patient)	Who and/or what the observation is about
effective[x]		1..1		Time of specimen collection
effectiveDateTime			dateTime
effectivePeriod			Period
value[x]	C	0..1	Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period	Actual result
dataAbsentReason	C	0..1	CodeableConcept	Why the result is missing
specimen		0..1	Reference(AU Base Specimen)	Specimen used for this observation
hasMember	C	0..*	Reference(AU Base Diagnostic Result | AU Base Pathology Result)	Individual tests in a group or panel
component		0..*	BackboneElement	Individual tests in a group or panel
code		1..1	CodeableConcept	Individual pathology test Binding: RCPA SPIA Pathology Reporting (preferred)
value[x]	C	0..1	Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period	Actual component result
dataAbsentReason	C	0..1	CodeableConcept	Why the component result is missing
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Observation.category:specificDiscipline	extensible	PathologyDiagnosticServiceCategory https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 from https://tx.ontoserver.csiro.au/fhir
Observation.code	preferred	RCPASPIAPathologyReporting https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 from https://tx.ontoserver.csiro.au/fhir
Observation.component.code	preferred	RCPASPIAPathologyReporting https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 from https://tx.ontoserver.csiro.au/fhir

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-obs-0	error	Observation	A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason : value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.exists()

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	A pathology test result in an Australian healthcare context 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 inv-obs-0: A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation.
Slices for category		1..*	CodeableConcept	Classification of the service requested as laboratory + more specific discipline where available Slice: Unordered, Open by value:coding.system, value:coding.code Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
category:lab		1..1	CodeableConcept	Observation generated by laboratories Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
coding	Σ	1..*	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: laboratory
category:specificDiscipline		0..*	CodeableConcept	Specific discipline of pathology Binding: Pathology Diagnostic Service Category (extensible)
code	Σ	1..1	CodeableConcept	Pathology test or test group Binding: RCPA SPIA Pathology Reporting (preferred) Additional Bindings Purpose RCPA - SPIA Chemical Pathology Terminology Reference Set Component RCPA - SPIA Haematology Terminology Reference Set Component RCPA - SPIA Immunopathology Terminology Reference Set Component RCPA - SPIA Microbiology Serology Molecular Pathology Terminology Reference Set Component
subject	Σ	1..1	Reference(Patient)	Who and/or what the observation is about
effective[x]	Σ	1..1		Time of specimen collection
effectiveDateTime			dateTime
effectivePeriod			Period
value[x]	ΣC	0..1		Actual result
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	C	0..1	CodeableConcept	Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
specimen		0..1	Reference(AU Base Specimen)	Specimen used for this observation
hasMember	ΣC	0..*	Reference(AU Base Diagnostic Result | AU Base Pathology Result)	Individual tests in a group or panel
component	Σ	0..*	BackboneElement	Individual tests in a group or panel
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	1..1	CodeableConcept	Individual pathology test Binding: RCPA SPIA Pathology Reporting (preferred)
value[x]	ΣC	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.
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	preferred	ObservationCategoryCodes http://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard
Observation.category:lab	preferred	ObservationCategoryCodes http://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard
Observation.category:specificDiscipline	extensible	PathologyDiagnosticServiceCategory https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 from https://tx.ontoserver.csiro.au/fhir
Observation.code	preferred	RCPASPIAPathologyReporting https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 from https://tx.ontoserver.csiro.au/fhir
Observation.dataAbsentReason	extensible	DataAbsentReason http://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard
Observation.component.code	preferred	RCPASPIAPathologyReporting https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 from https://tx.ontoserver.csiro.au/fhir
Observation.component.dataAbsentReason	extensible	DataAbsentReason http://hl7.org/fhir/ValueSet/data-absent-reason 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()
inv-obs-0	error	Observation	A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason : value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.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	A pathology test result in an Australian healthcare context 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 inv-obs-0: A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason
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	Σ	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.
Slices for category		1..*	CodeableConcept	Classification of the service requested as laboratory + more specific discipline where available Slice: Unordered, Open by value:coding.system, value:coding.code Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
category:lab		1..1	CodeableConcept	Observation generated by laboratories Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: laboratory
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
category:specificDiscipline		0..*	CodeableConcept	Specific discipline of pathology Binding: Pathology Diagnostic Service Category (extensible)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
code	Σ	1..1	CodeableConcept	Pathology test or test group Binding: RCPA SPIA Pathology Reporting (preferred) Additional Bindings Purpose RCPA - SPIA Chemical Pathology Terminology Reference Set Component RCPA - SPIA Haematology Terminology Reference Set Component RCPA - SPIA Immunopathology Terminology Reference Set Component RCPA - SPIA Microbiology Serology Molecular Pathology Terminology Reference Set Component
subject	Σ	1..1	Reference(Patient)	Who and/or what the observation is about
focus	Σ	0..*	Reference(Resource)	What the observation is about, when it is not about the subject of record
encounter	Σ	0..1	Reference(Encounter)	Healthcare event during which this observation is made
effective[x]	Σ	1..1		Time of specimen collection
effectiveDateTime			dateTime
effectivePeriod			Period
issued	Σ	0..1	instant	Date/Time this version was made available
performer	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)	Who is responsible for the observation
value[x]	ΣC	0..1		Actual result
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
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(AU Base Specimen)	Specimen used for this observation
device		0..1	Reference(Device | DeviceMetric)	(Measurement) Device
referenceRange	C	0..*	BackboneElement	Provides guide for interpretation obs-3: Must have at least a low or a high or text
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
low	C	0..1	SimpleQuantity	Low Range, if relevant
high	C	0..1	SimpleQuantity	High Range, if relevant
type		0..1	CodeableConcept	Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
appliesTo		0..*	CodeableConcept	Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
age		0..1	Range	Applicable age range, if relevant
text		0..1	string	Text based reference range in an observation
hasMember	ΣC	0..*	Reference(AU Base Diagnostic Result | AU Base Pathology Result)	Individual tests in a group or panel
derivedFrom	Σ	0..*	Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)	Related measurements the observation is made from
component	Σ	0..*	BackboneElement	Individual tests in a group or panel
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	Individual pathology test Binding: RCPA SPIA Pathology Reporting (preferred)
value[x]	ΣC	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 Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Observation.status	required	ObservationStatus http://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard
Observation.category	preferred	ObservationCategoryCodes http://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard
Observation.category:lab	preferred	ObservationCategoryCodes http://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard
Observation.category:specificDiscipline	extensible	PathologyDiagnosticServiceCategory https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 from https://tx.ontoserver.csiro.au/fhir
Observation.code	preferred	RCPASPIAPathologyReporting https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 from https://tx.ontoserver.csiro.au/fhir
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	preferred	RCPASPIAPathologyReporting https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 from https://tx.ontoserver.csiro.au/fhir
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()
inv-obs-0	error	Observation	A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason : value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.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: 7 elements(1 nested mandatory element)
Fixed: 3 elements

Structures

This structure refers to these other structures:

• AU Base Specimen (http://hl7.org.au/fhir/StructureDefinition/au-specimen)
• AU Base Diagnostic Result (http://hl7.org.au/fhir/StructureDefinition/au-diagnosticresult)
• AU Base Pathology Result (http://hl7.org.au/fhir/StructureDefinition/au-pathologyresult)

Slices

This structure defines the following Slices:

• The element 2 is sliced based on the values of Observation.category

Maturity: 1

Differential View

This structure is derived from Observation

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	A pathology test result in an Australian healthcare context inv-obs-0: A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason
Slices for category		1..*	CodeableConcept	Classification of the service requested as laboratory + more specific discipline where available Slice: Unordered, Open by value:coding.system, value:coding.code
category:lab		1..1	CodeableConcept	Observation generated by laboratories
coding		1..*	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
code		1..1	code	Symbol in syntax defined by the system Fixed Value: laboratory
category:specificDiscipline		0..*	CodeableConcept	Specific discipline of pathology Binding: Pathology Diagnostic Service Category (extensible)
coding
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
code		1..1	CodeableConcept	Pathology test or test group Binding: RCPA SPIA Pathology Reporting (preferred) Additional Bindings Purpose RCPA - SPIA Chemical Pathology Terminology Reference Set Component RCPA - SPIA Haematology Terminology Reference Set Component RCPA - SPIA Immunopathology Terminology Reference Set Component RCPA - SPIA Microbiology Serology Molecular Pathology Terminology Reference Set Component
subject		1..1	Reference(Patient)	Who and/or what the observation is about
effective[x]		1..1		Time of specimen collection
effectiveDateTime			dateTime
effectivePeriod			Period
value[x]	C	0..1	Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period	Actual result
dataAbsentReason	C	0..1	CodeableConcept	Why the result is missing
specimen		0..1	Reference(AU Base Specimen)	Specimen used for this observation
hasMember	C	0..*	Reference(AU Base Diagnostic Result | AU Base Pathology Result)	Individual tests in a group or panel
component		0..*	BackboneElement	Individual tests in a group or panel
code		1..1	CodeableConcept	Individual pathology test Binding: RCPA SPIA Pathology Reporting (preferred)
value[x]	C	0..1	Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period	Actual component result
dataAbsentReason	C	0..1	CodeableConcept	Why the component result is missing
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Observation.category:specificDiscipline	extensible	PathologyDiagnosticServiceCategory https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 from https://tx.ontoserver.csiro.au/fhir
Observation.code	preferred	RCPASPIAPathologyReporting https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 from https://tx.ontoserver.csiro.au/fhir
Observation.component.code	preferred	RCPASPIAPathologyReporting https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 from https://tx.ontoserver.csiro.au/fhir

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-obs-0	error	Observation	A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason : value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.exists()

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	A pathology test result in an Australian healthcare context 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 inv-obs-0: A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation.
Slices for category		1..*	CodeableConcept	Classification of the service requested as laboratory + more specific discipline where available Slice: Unordered, Open by value:coding.system, value:coding.code Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
category:lab		1..1	CodeableConcept	Observation generated by laboratories Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
coding	Σ	1..*	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: laboratory
category:specificDiscipline		0..*	CodeableConcept	Specific discipline of pathology Binding: Pathology Diagnostic Service Category (extensible)
code	Σ	1..1	CodeableConcept	Pathology test or test group Binding: RCPA SPIA Pathology Reporting (preferred) Additional Bindings Purpose RCPA - SPIA Chemical Pathology Terminology Reference Set Component RCPA - SPIA Haematology Terminology Reference Set Component RCPA - SPIA Immunopathology Terminology Reference Set Component RCPA - SPIA Microbiology Serology Molecular Pathology Terminology Reference Set Component
subject	Σ	1..1	Reference(Patient)	Who and/or what the observation is about
effective[x]	Σ	1..1		Time of specimen collection
effectiveDateTime			dateTime
effectivePeriod			Period
value[x]	ΣC	0..1		Actual result
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	C	0..1	CodeableConcept	Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
specimen		0..1	Reference(AU Base Specimen)	Specimen used for this observation
hasMember	ΣC	0..*	Reference(AU Base Diagnostic Result | AU Base Pathology Result)	Individual tests in a group or panel
component	Σ	0..*	BackboneElement	Individual tests in a group or panel
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	1..1	CodeableConcept	Individual pathology test Binding: RCPA SPIA Pathology Reporting (preferred)
value[x]	ΣC	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.
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	preferred	ObservationCategoryCodes http://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard
Observation.category:lab	preferred	ObservationCategoryCodes http://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard
Observation.category:specificDiscipline	extensible	PathologyDiagnosticServiceCategory https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 from https://tx.ontoserver.csiro.au/fhir
Observation.code	preferred	RCPASPIAPathologyReporting https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 from https://tx.ontoserver.csiro.au/fhir
Observation.dataAbsentReason	extensible	DataAbsentReason http://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard
Observation.component.code	preferred	RCPASPIAPathologyReporting https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 from https://tx.ontoserver.csiro.au/fhir
Observation.component.dataAbsentReason	extensible	DataAbsentReason http://hl7.org/fhir/ValueSet/data-absent-reason 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()
inv-obs-0	error	Observation	A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason : value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.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	A pathology test result in an Australian healthcare context 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 inv-obs-0: A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason
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	Σ	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.
Slices for category		1..*	CodeableConcept	Classification of the service requested as laboratory + more specific discipline where available Slice: Unordered, Open by value:coding.system, value:coding.code Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
category:lab		1..1	CodeableConcept	Observation generated by laboratories Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: laboratory
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
category:specificDiscipline		0..*	CodeableConcept	Specific discipline of pathology Binding: Pathology Diagnostic Service Category (extensible)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
code	Σ	1..1	CodeableConcept	Pathology test or test group Binding: RCPA SPIA Pathology Reporting (preferred) Additional Bindings Purpose RCPA - SPIA Chemical Pathology Terminology Reference Set Component RCPA - SPIA Haematology Terminology Reference Set Component RCPA - SPIA Immunopathology Terminology Reference Set Component RCPA - SPIA Microbiology Serology Molecular Pathology Terminology Reference Set Component
subject	Σ	1..1	Reference(Patient)	Who and/or what the observation is about
focus	Σ	0..*	Reference(Resource)	What the observation is about, when it is not about the subject of record
encounter	Σ	0..1	Reference(Encounter)	Healthcare event during which this observation is made
effective[x]	Σ	1..1		Time of specimen collection
effectiveDateTime			dateTime
effectivePeriod			Period
issued	Σ	0..1	instant	Date/Time this version was made available
performer	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)	Who is responsible for the observation
value[x]	ΣC	0..1		Actual result
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
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(AU Base Specimen)	Specimen used for this observation
device		0..1	Reference(Device | DeviceMetric)	(Measurement) Device
referenceRange	C	0..*	BackboneElement	Provides guide for interpretation obs-3: Must have at least a low or a high or text
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
low	C	0..1	SimpleQuantity	Low Range, if relevant
high	C	0..1	SimpleQuantity	High Range, if relevant
type		0..1	CodeableConcept	Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
appliesTo		0..*	CodeableConcept	Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
age		0..1	Range	Applicable age range, if relevant
text		0..1	string	Text based reference range in an observation
hasMember	ΣC	0..*	Reference(AU Base Diagnostic Result | AU Base Pathology Result)	Individual tests in a group or panel
derivedFrom	Σ	0..*	Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)	Related measurements the observation is made from
component	Σ	0..*	BackboneElement	Individual tests in a group or panel
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	Individual pathology test Binding: RCPA SPIA Pathology Reporting (preferred)
value[x]	ΣC	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 Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Observation.status	required	ObservationStatus http://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard
Observation.category	preferred	ObservationCategoryCodes http://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard
Observation.category:lab	preferred	ObservationCategoryCodes http://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard
Observation.category:specificDiscipline	extensible	PathologyDiagnosticServiceCategory https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 from https://tx.ontoserver.csiro.au/fhir
Observation.code	preferred	RCPASPIAPathologyReporting https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 from https://tx.ontoserver.csiro.au/fhir
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	preferred	RCPASPIAPathologyReporting https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 from https://tx.ontoserver.csiro.au/fhir
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()
inv-obs-0	error	Observation	A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason : value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.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: 7 elements(1 nested mandatory element)
Fixed: 3 elements

Structures

This structure refers to these other structures:

• AU Base Specimen (http://hl7.org.au/fhir/StructureDefinition/au-specimen)
• AU Base Diagnostic Result (http://hl7.org.au/fhir/StructureDefinition/au-diagnosticresult)
• AU Base Pathology Result (http://hl7.org.au/fhir/StructureDefinition/au-pathologyresult)

Slices

This structure defines the following Slices:

• The element 2 is sliced based on the values of Observation.category

Maturity: 1

Other representations of profile: CSV, Excel, Schematron