Scope and usage

KLGatewayChildrenExamResult is a profile for holding structured qualitative history and examination findings. Note that each finding should have its own instance of KLGatewayChildrenExamResult, and that nothing should be reported if things are normal.

Observation.code.coding, always hold a fixed SNOMED CT code, that states that this is a history and/or examination observation.

Observation.value[x] is a coded value Observation.valueCodeableConcept. Values should be derived from the required ValueSet.

The effective time of the observation is documented in Observation.effectiveDateTime, all results should use the time, where the health nurse has an encounter with the family or child, not try to guess the time where a problem first occurred. Note that only current findings are registered, making this a correct use of efffectiveDateTime.

Observation.subject holds the reference to the child or parent, who is observed. Observation.encounter holds the reference to the encounter in which the observation is performed. For parent's observations do not reference the child's encounter, just leave it blank.

Notice that the status-attribute is mandatory. For normal use, just set to "final". If data is missing or another problem has occurred, follow the FHIR guidance to populate the field correctly.

Conversions between Danish information model and FHIR-profile

Nedenstående tabel oversætter mellem de attributter der er defineret i den fælleskommunale informationsmodel (FKI), definerer kort den enkelte attribut på dansk og specificerer hvilke af FHIR-profilens atributter der skal bruges til specifikation af indholdet.

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

This structure is derived from DkCoreObservation

Name	Flags	Card.	Type	Description & Constraints
Observation		0..*	DkCoreObservation	Measurements and simple assertions
identifier		0..0
basedOn		0..0
partOf		0..0
status		1..1	code	[DK] UndersøgelsesStatus
category		0..0
code		1..1	CodeableConcept	[DK] undersøgelsesKode
Slices for coding		1..1	Coding	Code defined by a terminology system Slice: Unordered, Closed by value:system
coding:LOINC		0..0
coding:SNOMEDCT		0..1	Coding	SNOMED CT code for the observation Required Pattern: At least the following
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 363788007
coding:NPU		0..0
coding:IEEE		0..0
coding:MedCom		0..0
coding:SKS		0..0
subject		1..1	Reference(KLGatewayChildrenCitizen) {b}	[DK] Undersøgelsessubjekt
focus		0..0
encounter		0..1	Reference(KLGatewayChildrenEncounter) {b}	[DK] Undersøgelseskontakt
Slices for effective[x]		1..1	dateTime, Period, Timing, instant	Clinically relevant time/time-period for observation Slice: Unordered, Open by type:$this
effective[x]:effectiveDateTime		0..1	dateTime	[DK] Undersøgelsestid
issued		0..0
performer		0..0
value[x]		0..1	CodeableConcept	[DK] UndersøgelsesResultat
Slices for value[x]				Content/Rules for all slices
value[x]:valueCodeableConcept		0..1	CodeableConcept	Actual result
coding		1..1	Coding	Code defined by a terminology system Binding: UndersøgelsesResultatKoder (required)
dataAbsentReason		0..0
interpretation		0..0
note		0..0
bodySite		0..0
method		0..0
specimen		0..0
device		0..0
hasMember		0..0
derivedFrom		0..0
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Observation.value[x]:valueCodeableConcept.coding	required	ExamResults http://fhir.kl.dk/children/ValueSet/ExamResults from this IG

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	DkCoreObservation	Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present dk-core-observation-mandatory-units: If value is specified then unit and/or code must be specified
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	[DK] UndersøgelsesStatus Binding: ObservationStatus (required): Codes providing the status of an observation.
code	Σ	1..1	CodeableConcept	[DK] undersøgelsesKode Binding: LOINCCodes (example): Codes identifying names of simple observations.
Slices for coding	Σ	1..1	Coding	Code defined by a terminology system Slice: Unordered, Closed by value:system
coding:SNOMEDCT	Σ	0..1	Coding	SNOMED CT code for the observation Required Pattern: At least the following
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 363788007
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code	Σ	1..1	code	Symbol in syntax defined by the system
subject	Σ	1..1	Reference(KLGatewayChildrenCitizen) {b}	[DK] Undersøgelsessubjekt
encounter	Σ	0..1	Reference(KLGatewayChildrenEncounter) {b}	[DK] Undersøgelseskontakt
Slices for effective[x]	Σ	1..1		Clinically relevant time/time-period for observation Slice: Unordered, Open by type:$this
effectiveDateTime			dateTime
effectivePeriod			Period
effectiveTiming			Timing
effectiveInstant			instant
effective[x]:effectiveDateTime	Σ	0..1	dateTime	[DK] Undersøgelsestid
Slices for value[x]	ΣC	0..1	CodeableConcept	[DK] UndersøgelsesResultat Slice: Unordered, Closed by type:$this
value[x]:valueCodeableConcept	ΣC	0..1	CodeableConcept	Actual result
coding	Σ	1..1	Coding	Code defined by a terminology system Binding: UndersøgelsesResultatKoder (required)
value[x]:valueQuantity	ΣC	0..1	Quantity	Actual result
comparator	?!Σ	0..1	code	< | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented.
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.code	example	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Observation.value[x]:valueCodeableConcept.coding	required	ExamResults http://fhir.kl.dk/children/ValueSet/ExamResults from this IG
Observation.value[x]:valueQuantity.comparator	required	QuantityComparator http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard
Observation.method.coding:SCTCode	example	TechniquesSCTCodes http://hl7.dk/fhir/core/ValueSet/dk-core-TechniquesSCTCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
dk-core-observation-mandatory-units	error	Observation	If value is specified then unit and/or code must be specified : value.ofType(Quantity).value.exists() implies value.ofType(Quantity).unit.exists() or value.ofType(Quantity).code.exists()
dom-2	error	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Observation	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Observation	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Observation	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Observation	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
obs-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..*	DkCoreObservation	Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present dk-core-observation-mandatory-units: If value is specified then unit and/or code must be specified
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
status	?!Σ	1..1	code	[DK] UndersøgelsesStatus Binding: ObservationStatus (required): Codes providing the status of an observation.
code	Σ	1..1	CodeableConcept	[DK] undersøgelsesKode Binding: LOINCCodes (example): Codes identifying names of simple observations.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	Σ	1..1	Coding	Code defined by a terminology system Slice: Unordered, Closed by value:system
coding:SNOMEDCT	Σ	0..1	Coding	SNOMED CT code for the observation Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 363788007
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
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://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..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
subject	Σ	1..1	Reference(KLGatewayChildrenCitizen) {b}	[DK] Undersøgelsessubjekt
encounter	Σ	0..1	Reference(KLGatewayChildrenEncounter) {b}	[DK] Undersøgelseskontakt
Slices for effective[x]	Σ	1..1		Clinically relevant time/time-period for observation Slice: Unordered, Open by type:$this
effectiveDateTime			dateTime
effectivePeriod			Period
effectiveTiming			Timing
effectiveInstant			instant
effective[x]:effectiveDateTime	Σ	0..1	dateTime	[DK] Undersøgelsestid
Slices for value[x]	ΣC	0..1	CodeableConcept	[DK] UndersøgelsesResultat Slice: Unordered, Closed by type:$this
value[x]:valueCodeableConcept	ΣC	0..1	CodeableConcept	Actual result
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..1	Coding	Code defined by a terminology system Binding: UndersøgelsesResultatKoder (required)
text	Σ	0..1	string	Plain text representation of the concept
value[x]:valueQuantity	ΣC	0..1	Quantity	Actual result
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	Σ	0..1	decimal	Numerical value (with implicit precision)
comparator	?!Σ	0..1	code	< | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented.
unit	Σ	0..1	string	Unit representation
system	ΣC	0..1	uri	System that defines coded unit form Required Pattern: http://unitsofmeasure.org
code	Σ	0..1	code	Coded form of the unit
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
component	Σ	0..*	BackboneElement	Component results
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	1..1	CodeableConcept	Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	Σ	0..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:LOINC	Σ	0..1	Coding	LOINC code for the observation
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://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..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
coding:SNOMEDCT	Σ	0..1	Coding	SNOMED CT code for the observation
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://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..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
coding:NPU	Σ	0..1	Coding	NPU code for the observation. NPU codes are administred by the Danish Health Data Authority.
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: urn:oid:1.2.208.176.2.1
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..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
coding:IEEE	Σ	0..1	Coding	IEEE code for the observation
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: urn:iso:std:iso:11073:10101
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..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
coding:MedCom	Σ	0..1	Coding	MedCom code for the observation. MedCom codes are administred by the MedCom.
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://medcomfhir.dk/ig/terminology/CodeSystem/medcom-observation-codes
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..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
coding:SKS	Σ	0..1	Coding	SKS code for the observation.
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: urn:oid:1.2.208.176.2.4
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..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
Slices for value[x]	Σ	0..1		Actual component result Slice: Unordered, Open by type:$this
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
value[x]:valueQuantity	Σ	0..1	Quantity	Actual component result
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	Σ	0..1	decimal	Numerical value (with implicit precision)
comparator	?!Σ	0..1	code	< | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented.
unit	Σ	0..1	string	Unit representation
system	ΣC	0..1	uri	System that defines coded unit form Required Pattern: http://unitsofmeasure.org
code	Σ	0..1	code	Coded form of the unit
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.code	example	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Observation.value[x]:valueCodeableConcept.coding	required	ExamResults http://fhir.kl.dk/children/ValueSet/ExamResults from this IG
Observation.value[x]:valueQuantity.comparator	required	QuantityComparator http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard
Observation.method.coding:SCTCode	example	TechniquesSCTCodes http://hl7.dk/fhir/core/ValueSet/dk-core-TechniquesSCTCodes
Observation.referenceRange.type	preferred	ObservationReferenceRangeMeaningCodes http://hl7.org/fhir/ValueSet/referencerange-meaning from the FHIR Standard
Observation.referenceRange.appliesTo	example	ObservationReferenceRangeAppliesToCodes http://hl7.org/fhir/ValueSet/referencerange-appliesto from the FHIR Standard
Observation.component.code	example	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Observation.component.value[x]:valueQuantity.comparator	required	QuantityComparator http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard
Observation.component.dataAbsentReason	extensible	DataAbsentReason http://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard
Observation.component.interpretation	extensible	ObservationInterpretationCodes http://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dk-core-observation-mandatory-units	error	Observation	If value is specified then unit and/or code must be specified : value.ofType(Quantity).value.exists() implies value.ofType(Quantity).unit.exists() or value.ofType(Quantity).code.exists()
dom-2	error	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Observation	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Observation	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Observation	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Observation	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
obs-3	error	Observation.referenceRange	Must have at least a low or a high or text : low.exists() or high.exists() or text.exists()
obs-6	error	Observation	dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty()
obs-7	error	Observation	If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()

Differential View

This structure is derived from DkCoreObservation

Name	Flags	Card.	Type	Description & Constraints
Observation		0..*	DkCoreObservation	Measurements and simple assertions
identifier		0..0
basedOn		0..0
partOf		0..0
status		1..1	code	[DK] UndersøgelsesStatus
category		0..0
code		1..1	CodeableConcept	[DK] undersøgelsesKode
Slices for coding		1..1	Coding	Code defined by a terminology system Slice: Unordered, Closed by value:system
coding:LOINC		0..0
coding:SNOMEDCT		0..1	Coding	SNOMED CT code for the observation Required Pattern: At least the following
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 363788007
coding:NPU		0..0
coding:IEEE		0..0
coding:MedCom		0..0
coding:SKS		0..0
subject		1..1	Reference(KLGatewayChildrenCitizen) {b}	[DK] Undersøgelsessubjekt
focus		0..0
encounter		0..1	Reference(KLGatewayChildrenEncounter) {b}	[DK] Undersøgelseskontakt
Slices for effective[x]		1..1	dateTime, Period, Timing, instant	Clinically relevant time/time-period for observation Slice: Unordered, Open by type:$this
effective[x]:effectiveDateTime		0..1	dateTime	[DK] Undersøgelsestid
issued		0..0
performer		0..0
value[x]		0..1	CodeableConcept	[DK] UndersøgelsesResultat
Slices for value[x]				Content/Rules for all slices
value[x]:valueCodeableConcept		0..1	CodeableConcept	Actual result
coding		1..1	Coding	Code defined by a terminology system Binding: UndersøgelsesResultatKoder (required)
dataAbsentReason		0..0
interpretation		0..0
note		0..0
bodySite		0..0
method		0..0
specimen		0..0
device		0..0
hasMember		0..0
derivedFrom		0..0
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Observation.value[x]:valueCodeableConcept.coding	required	ExamResults http://fhir.kl.dk/children/ValueSet/ExamResults from this IG

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	DkCoreObservation	Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present dk-core-observation-mandatory-units: If value is specified then unit and/or code must be specified
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	[DK] UndersøgelsesStatus Binding: ObservationStatus (required): Codes providing the status of an observation.
code	Σ	1..1	CodeableConcept	[DK] undersøgelsesKode Binding: LOINCCodes (example): Codes identifying names of simple observations.
Slices for coding	Σ	1..1	Coding	Code defined by a terminology system Slice: Unordered, Closed by value:system
coding:SNOMEDCT	Σ	0..1	Coding	SNOMED CT code for the observation Required Pattern: At least the following
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 363788007
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code	Σ	1..1	code	Symbol in syntax defined by the system
subject	Σ	1..1	Reference(KLGatewayChildrenCitizen) {b}	[DK] Undersøgelsessubjekt
encounter	Σ	0..1	Reference(KLGatewayChildrenEncounter) {b}	[DK] Undersøgelseskontakt
Slices for effective[x]	Σ	1..1		Clinically relevant time/time-period for observation Slice: Unordered, Open by type:$this
effectiveDateTime			dateTime
effectivePeriod			Period
effectiveTiming			Timing
effectiveInstant			instant
effective[x]:effectiveDateTime	Σ	0..1	dateTime	[DK] Undersøgelsestid
Slices for value[x]	ΣC	0..1	CodeableConcept	[DK] UndersøgelsesResultat Slice: Unordered, Closed by type:$this
value[x]:valueCodeableConcept	ΣC	0..1	CodeableConcept	Actual result
coding	Σ	1..1	Coding	Code defined by a terminology system Binding: UndersøgelsesResultatKoder (required)
value[x]:valueQuantity	ΣC	0..1	Quantity	Actual result
comparator	?!Σ	0..1	code	< | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented.
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.code	example	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Observation.value[x]:valueCodeableConcept.coding	required	ExamResults http://fhir.kl.dk/children/ValueSet/ExamResults from this IG
Observation.value[x]:valueQuantity.comparator	required	QuantityComparator http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard
Observation.method.coding:SCTCode	example	TechniquesSCTCodes http://hl7.dk/fhir/core/ValueSet/dk-core-TechniquesSCTCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
dk-core-observation-mandatory-units	error	Observation	If value is specified then unit and/or code must be specified : value.ofType(Quantity).value.exists() implies value.ofType(Quantity).unit.exists() or value.ofType(Quantity).code.exists()
dom-2	error	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Observation	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Observation	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Observation	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Observation	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
obs-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..*	DkCoreObservation	Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present dk-core-observation-mandatory-units: If value is specified then unit and/or code must be specified
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
status	?!Σ	1..1	code	[DK] UndersøgelsesStatus Binding: ObservationStatus (required): Codes providing the status of an observation.
code	Σ	1..1	CodeableConcept	[DK] undersøgelsesKode Binding: LOINCCodes (example): Codes identifying names of simple observations.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	Σ	1..1	Coding	Code defined by a terminology system Slice: Unordered, Closed by value:system
coding:SNOMEDCT	Σ	0..1	Coding	SNOMED CT code for the observation Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 363788007
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
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://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..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
subject	Σ	1..1	Reference(KLGatewayChildrenCitizen) {b}	[DK] Undersøgelsessubjekt
encounter	Σ	0..1	Reference(KLGatewayChildrenEncounter) {b}	[DK] Undersøgelseskontakt
Slices for effective[x]	Σ	1..1		Clinically relevant time/time-period for observation Slice: Unordered, Open by type:$this
effectiveDateTime			dateTime
effectivePeriod			Period
effectiveTiming			Timing
effectiveInstant			instant
effective[x]:effectiveDateTime	Σ	0..1	dateTime	[DK] Undersøgelsestid
Slices for value[x]	ΣC	0..1	CodeableConcept	[DK] UndersøgelsesResultat Slice: Unordered, Closed by type:$this
value[x]:valueCodeableConcept	ΣC	0..1	CodeableConcept	Actual result
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..1	Coding	Code defined by a terminology system Binding: UndersøgelsesResultatKoder (required)
text	Σ	0..1	string	Plain text representation of the concept
value[x]:valueQuantity	ΣC	0..1	Quantity	Actual result
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	Σ	0..1	decimal	Numerical value (with implicit precision)
comparator	?!Σ	0..1	code	< | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented.
unit	Σ	0..1	string	Unit representation
system	ΣC	0..1	uri	System that defines coded unit form Required Pattern: http://unitsofmeasure.org
code	Σ	0..1	code	Coded form of the unit
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
component	Σ	0..*	BackboneElement	Component results
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	1..1	CodeableConcept	Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	Σ	0..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:LOINC	Σ	0..1	Coding	LOINC code for the observation
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://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..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
coding:SNOMEDCT	Σ	0..1	Coding	SNOMED CT code for the observation
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://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..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
coding:NPU	Σ	0..1	Coding	NPU code for the observation. NPU codes are administred by the Danish Health Data Authority.
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: urn:oid:1.2.208.176.2.1
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..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
coding:IEEE	Σ	0..1	Coding	IEEE code for the observation
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: urn:iso:std:iso:11073:10101
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..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
coding:MedCom	Σ	0..1	Coding	MedCom code for the observation. MedCom codes are administred by the MedCom.
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://medcomfhir.dk/ig/terminology/CodeSystem/medcom-observation-codes
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..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
coding:SKS	Σ	0..1	Coding	SKS code for the observation.
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: urn:oid:1.2.208.176.2.4
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..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
Slices for value[x]	Σ	0..1		Actual component result Slice: Unordered, Open by type:$this
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
value[x]:valueQuantity	Σ	0..1	Quantity	Actual component result
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	Σ	0..1	decimal	Numerical value (with implicit precision)
comparator	?!Σ	0..1	code	< | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented.
unit	Σ	0..1	string	Unit representation
system	ΣC	0..1	uri	System that defines coded unit form Required Pattern: http://unitsofmeasure.org
code	Σ	0..1	code	Coded form of the unit
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.code	example	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Observation.value[x]:valueCodeableConcept.coding	required	ExamResults http://fhir.kl.dk/children/ValueSet/ExamResults from this IG
Observation.value[x]:valueQuantity.comparator	required	QuantityComparator http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard
Observation.method.coding:SCTCode	example	TechniquesSCTCodes http://hl7.dk/fhir/core/ValueSet/dk-core-TechniquesSCTCodes
Observation.referenceRange.type	preferred	ObservationReferenceRangeMeaningCodes http://hl7.org/fhir/ValueSet/referencerange-meaning from the FHIR Standard
Observation.referenceRange.appliesTo	example	ObservationReferenceRangeAppliesToCodes http://hl7.org/fhir/ValueSet/referencerange-appliesto from the FHIR Standard
Observation.component.code	example	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Observation.component.value[x]:valueQuantity.comparator	required	QuantityComparator http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 from the FHIR Standard
Observation.component.dataAbsentReason	extensible	DataAbsentReason http://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard
Observation.component.interpretation	extensible	ObservationInterpretationCodes http://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dk-core-observation-mandatory-units	error	Observation	If value is specified then unit and/or code must be specified : value.ofType(Quantity).value.exists() implies value.ofType(Quantity).unit.exists() or value.ofType(Quantity).code.exists()
dom-2	error	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Observation	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Observation	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Observation	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Observation	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
obs-3	error	Observation.referenceRange	Must have at least a low or a high or text : low.exists() or high.exists() or text.exists()
obs-6	error	Observation	dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty()
obs-7	error	Observation	If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()

This structure is derived from DkCoreObservation

Summary

Mandatory: 2 elements(1 nested mandatory element)
Prohibited: 21 elements

Structures

This structure refers to these other structures:

• KLGatewayChildrenCitizen (http://fhir.kl.dk/children/StructureDefinition/klgateway-children-citizen)
• KLGatewayChildrenEncounter (http://fhir.kl.dk/children/StructureDefinition/klgateway-children-encounter)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Observation.code.coding (Closed)
• The element 1 is sliced based on the value of Observation.effective[x]