Bản hướng dẫn thực thi (IG) dành cho các hệ thống thông tin Y tế tại Việt Nam
1.0.0 - CI Build
Bản hướng dẫn thực thi (IG) dành cho các hệ thống thông tin Y tế tại Việt Nam, published by Cục Công nghệ thông tin - Bộ Y tế. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7vn/vn-core-ig/ and changes regularly. See the Directory of published versions
Thông tin về kết quả thực hiện dịch vụ kỹ thuật - Giải phẫu bệnh
Đường dẫn URL chính thức của Profile này:
http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-observation-pathology-code
Profile này được dựa trên Resource VNCoreObservationResultBase
Summary
Mandatory: 4 elements
Must-Support: 8 elements
Fixed: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Profile này được dựa trên Resource VNCoreObservationResultBase
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | VNCoreObservationResultBase | |||
identifier | S | 0..* | Identifier | Business Identifier for observation |
basedOn | 1..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | ServiceRequest profile - VN Core R4) | Fulfills plan, proposal or order | |
partOf | 1..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy | Procedure Profile - VN Core R4) | Part of referenced event | |
Slices for category | 1..* | VNCoreCodeableConcept | Concept - reference to a terminology or just text Slice: Unordered, Open by value:coding.system, value:coding.code | |
category:laboratory | 1..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Laboratory | |
text | 1..1 | string | Plain text representation of the concept Fixed Value: laboratory | |
code | 1..1 | VNCoreCodeableConcept | Pathology Result Code Binding: Results Pathology Observation - IPS (extensible): LOINC codes | |
subject | 1..1 | Reference(Patient Profile - VN Core R4) | Who and/or what the observation is about | |
encounter | S | 0..1 | Reference(Encounter Profile - VN Core R4) | Healthcare event during which this observation is made |
performer | 0..* | Reference(Practitioner Profile - VN Core R4) | Who is responsible for the observation | |
Slices for value[x] | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual result Slice: Unordered, Open by type:$this | |
Slices for valueQuantity | Content/Rules for all slices | |||
valueQuantity:valueQuantity | 0..1 | QuantityIPS | A measured amount using UCUM | |
Slices for value[x] | Content/Rules for all slices | |||
value[x]:valueCodeableConcept | 0..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text Binding: Results Coded Values Laboratory (GPS) - IPS (preferred) | |
value[x]:valueString | 0..1 | string | Actual result | |
value[x]:valueBoolean | 0..1 | boolean | Actual result | |
value[x]:valueInteger | 0..1 | integer | Actual result | |
Slices for valueRange | Content/Rules for all slices | |||
valueRange:valueRange | 0..1 | RangeIPS | Set of values bounded by low and high | |
Slices for valueRatio | Content/Rules for all slices | |||
valueRatio:valueRatio | 0..1 | RatioIPS | A ratio of two Quantity values - a numerator and a denominator | |
Slices for value[x] | Content/Rules for all slices | |||
value[x]:valueSampledData | 0..1 | SampledData | Actual result | |
value[x]:valueTime | 0..1 | time | Actual result | |
value[x]:valueDateTime | 0..1 | dateTime | Actual result | |
value[x]:valuePeriod | 0..1 | Period | Actual result | |
interpretation | S | 0..* | VNCoreCodeableConcept | Concept - reference to a terminology or just text |
bodySite | S | 0..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text |
method | S | 0..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text |
specimen | S | 0..1 | Reference(Specimen | Specimen profile - VN Core R4) | Specimen used for this observation |
device | S | 0..1 | Reference(Device | DeviceMetric | Device profile - VN Core R4) | (Measurement) Device |
referenceRange | S | 0..* | BackboneElement | Provides guide for interpretation |
hasMember | 0..* | Reference(QuestionnaireResponse | MolecularSequence | Observation - Result Base profile - VN Core R4 | Observation - Pathology Result Code Profile - VN Core R4) | Related resource that belongs to the Observation group | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | SC | 0..* | VNCoreObservationResultBase | Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | SΣ | 0..* | Identifier | Business Identifier for observation | ||||
basedOn | Σ | 1..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | ServiceRequest profile - VN Core R4) | Fulfills plan, proposal or order | ||||
partOf | Σ | 1..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy | Procedure Profile - VN Core R4) | Part of referenced event | ||||
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: final | ||||
Slices for category | S | 1..* | VNCoreCodeableConcept | Concept - reference to a terminology or just text Slice: Unordered, Open by value:coding.system, value:coding.code Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
category:laboratory | S | 1..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Fixed Value: As shown | ||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Laboratory | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 1..1 | string | Plain text representation of the concept Fixed Value: laboratory | |||||
code | S | 1..1 | VNCoreCodeableConcept | Pathology Result Code Binding: Results Pathology Observation - IPS (extensible): LOINC codes | ||||
subject | SΣ | 1..1 | Reference(Patient Profile - VN Core R4) | Who and/or what the observation is about | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
display | Σ | 0..1 | string | Text alternative for the resource | ||||
focus | Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
encounter | SΣ | 0..1 | Reference(Encounter Profile - VN Core R4) | Healthcare event during which this observation is made | ||||
effective[x] | SΣ | 1..1 | Clinically relevant time/time-period for observation | |||||
effective[x]All Types | Content/Rules for all Types | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
data-absent-reason | S | 0..1 | code | effective[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Slice: Unordered, Open by value:url Binding: DataAbsentReason (required) | ||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
issued | SΣ | 0..1 | instant | Date/Time this version was made available | ||||
performer | SΣ | 0..* | Reference(Practitioner Profile - VN Core R4) | Who is responsible for the observation | ||||
Slices for value[x] | SΣC | 0..1 | Actual result Slice: Unordered, Closed 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 | SC | 0..1 | QuantityIPS | A measured amount using UCUM qty-3: If a code for the unit is present, the system SHALL also be present | ||||
value[x]:valueCodeableConcept | S | 0..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text Binding: Results Coded Values Laboratory (GPS) - IPS (preferred) | ||||
value[x]:valueString | SΣC | 0..1 | string | Actual result | ||||
value[x]:valueBoolean | SΣC | 0..1 | boolean | Actual result | ||||
value[x]:valueInteger | SΣC | 0..1 | integer | Actual result | ||||
value[x]:valueRange | SC | 0..1 | RangeIPS | Set of values bounded by low and high rng-2: If present, low SHALL have a lower value than high | ||||
value[x]:valueRatio | SC | 0..1 | RatioIPS | A ratio of two Quantity values - a numerator and a denominator rat-1: Numerator and denominator SHALL both be present, or both are absent. If both are absent, there SHALL be some extension present | ||||
value[x]:valueSampledData | SΣC | 0..1 | SampledData | Actual result | ||||
value[x]:valueTime | SΣC | 0..1 | time | Actual result | ||||
value[x]:valueDateTime | SΣC | 0..1 | dateTime | Actual result | ||||
value[x]:valuePeriod | SΣC | 0..1 | Period | Actual result | ||||
dataAbsentReason | C | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | S | 0..* | VNCoreCodeableConcept | Concept - reference to a terminology or just text Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | ||||
note | 0..* | Annotation | Comments about the observation | |||||
bodySite | S | 0..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
method | S | 0..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text Binding: ObservationMethods (example): Methods for simple observations. | ||||
specimen | S | 0..1 | Reference(Specimen | Specimen profile - VN Core R4) | Specimen used for this observation | ||||
device | S | 0..1 | Reference(Device | DeviceMetric | Device profile - VN Core R4) | (Measurement) Device | ||||
referenceRange | SC | 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 | SΣ | 0..* | Reference(QuestionnaireResponse | MolecularSequence | Observation - Result Base profile - VN Core R4 | Observation - Pathology Result Code Profile - VN Core R4) | Related resource that belongs to the Observation group | ||||
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
component | SΣ | 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 | 1..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text Binding: LOINCCodes (example): Codes identifying names of simple observations. | |||||
value[x] | Σ | 0..1 | Actual component result | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | 0..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | |||||
interpretation | 0..* | VNCoreCodeableConcept | Concept - reference to a terminology or just text Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
referenceRange | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |||||
Documentation for this format |
Profile này được dựa trên Resource VNCoreObservationResultBase
Summary
Mandatory: 4 elements
Must-Support: 8 elements
Fixed: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
Profile này được dựa trên Resource VNCoreObservationResultBase
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | VNCoreObservationResultBase | |||
identifier | S | 0..* | Identifier | Business Identifier for observation |
basedOn | 1..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | ServiceRequest profile - VN Core R4) | Fulfills plan, proposal or order | |
partOf | 1..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy | Procedure Profile - VN Core R4) | Part of referenced event | |
Slices for category | 1..* | VNCoreCodeableConcept | Concept - reference to a terminology or just text Slice: Unordered, Open by value:coding.system, value:coding.code | |
category:laboratory | 1..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Laboratory | |
text | 1..1 | string | Plain text representation of the concept Fixed Value: laboratory | |
code | 1..1 | VNCoreCodeableConcept | Pathology Result Code Binding: Results Pathology Observation - IPS (extensible): LOINC codes | |
subject | 1..1 | Reference(Patient Profile - VN Core R4) | Who and/or what the observation is about | |
encounter | S | 0..1 | Reference(Encounter Profile - VN Core R4) | Healthcare event during which this observation is made |
performer | 0..* | Reference(Practitioner Profile - VN Core R4) | Who is responsible for the observation | |
Slices for value[x] | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual result Slice: Unordered, Open by type:$this | |
Slices for valueQuantity | Content/Rules for all slices | |||
valueQuantity:valueQuantity | 0..1 | QuantityIPS | A measured amount using UCUM | |
Slices for value[x] | Content/Rules for all slices | |||
value[x]:valueCodeableConcept | 0..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text Binding: Results Coded Values Laboratory (GPS) - IPS (preferred) | |
value[x]:valueString | 0..1 | string | Actual result | |
value[x]:valueBoolean | 0..1 | boolean | Actual result | |
value[x]:valueInteger | 0..1 | integer | Actual result | |
Slices for valueRange | Content/Rules for all slices | |||
valueRange:valueRange | 0..1 | RangeIPS | Set of values bounded by low and high | |
Slices for valueRatio | Content/Rules for all slices | |||
valueRatio:valueRatio | 0..1 | RatioIPS | A ratio of two Quantity values - a numerator and a denominator | |
Slices for value[x] | Content/Rules for all slices | |||
value[x]:valueSampledData | 0..1 | SampledData | Actual result | |
value[x]:valueTime | 0..1 | time | Actual result | |
value[x]:valueDateTime | 0..1 | dateTime | Actual result | |
value[x]:valuePeriod | 0..1 | Period | Actual result | |
interpretation | S | 0..* | VNCoreCodeableConcept | Concept - reference to a terminology or just text |
bodySite | S | 0..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text |
method | S | 0..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text |
specimen | S | 0..1 | Reference(Specimen | Specimen profile - VN Core R4) | Specimen used for this observation |
device | S | 0..1 | Reference(Device | DeviceMetric | Device profile - VN Core R4) | (Measurement) Device |
referenceRange | S | 0..* | BackboneElement | Provides guide for interpretation |
hasMember | 0..* | Reference(QuestionnaireResponse | MolecularSequence | Observation - Result Base profile - VN Core R4 | Observation - Pathology Result Code Profile - VN Core R4) | Related resource that belongs to the Observation group | |
Documentation for this format |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | SC | 0..* | VNCoreObservationResultBase | Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | SΣ | 0..* | Identifier | Business Identifier for observation | ||||
basedOn | Σ | 1..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | ServiceRequest profile - VN Core R4) | Fulfills plan, proposal or order | ||||
partOf | Σ | 1..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy | Procedure Profile - VN Core R4) | Part of referenced event | ||||
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: final | ||||
Slices for category | S | 1..* | VNCoreCodeableConcept | Concept - reference to a terminology or just text Slice: Unordered, Open by value:coding.system, value:coding.code Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
category:laboratory | S | 1..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Fixed Value: As shown | ||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Laboratory | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 1..1 | string | Plain text representation of the concept Fixed Value: laboratory | |||||
code | S | 1..1 | VNCoreCodeableConcept | Pathology Result Code Binding: Results Pathology Observation - IPS (extensible): LOINC codes | ||||
subject | SΣ | 1..1 | Reference(Patient Profile - VN Core R4) | Who and/or what the observation is about | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
display | Σ | 0..1 | string | Text alternative for the resource | ||||
focus | Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
encounter | SΣ | 0..1 | Reference(Encounter Profile - VN Core R4) | Healthcare event during which this observation is made | ||||
effective[x] | SΣ | 1..1 | Clinically relevant time/time-period for observation | |||||
effective[x]All Types | Content/Rules for all Types | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
data-absent-reason | S | 0..1 | code | effective[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Slice: Unordered, Open by value:url Binding: DataAbsentReason (required) | ||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
issued | SΣ | 0..1 | instant | Date/Time this version was made available | ||||
performer | SΣ | 0..* | Reference(Practitioner Profile - VN Core R4) | Who is responsible for the observation | ||||
Slices for value[x] | SΣC | 0..1 | Actual result Slice: Unordered, Closed 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 | SC | 0..1 | QuantityIPS | A measured amount using UCUM qty-3: If a code for the unit is present, the system SHALL also be present | ||||
value[x]:valueCodeableConcept | S | 0..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text Binding: Results Coded Values Laboratory (GPS) - IPS (preferred) | ||||
value[x]:valueString | SΣC | 0..1 | string | Actual result | ||||
value[x]:valueBoolean | SΣC | 0..1 | boolean | Actual result | ||||
value[x]:valueInteger | SΣC | 0..1 | integer | Actual result | ||||
value[x]:valueRange | SC | 0..1 | RangeIPS | Set of values bounded by low and high rng-2: If present, low SHALL have a lower value than high | ||||
value[x]:valueRatio | SC | 0..1 | RatioIPS | A ratio of two Quantity values - a numerator and a denominator rat-1: Numerator and denominator SHALL both be present, or both are absent. If both are absent, there SHALL be some extension present | ||||
value[x]:valueSampledData | SΣC | 0..1 | SampledData | Actual result | ||||
value[x]:valueTime | SΣC | 0..1 | time | Actual result | ||||
value[x]:valueDateTime | SΣC | 0..1 | dateTime | Actual result | ||||
value[x]:valuePeriod | SΣC | 0..1 | Period | Actual result | ||||
dataAbsentReason | C | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | S | 0..* | VNCoreCodeableConcept | Concept - reference to a terminology or just text Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | ||||
note | 0..* | Annotation | Comments about the observation | |||||
bodySite | S | 0..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
method | S | 0..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text Binding: ObservationMethods (example): Methods for simple observations. | ||||
specimen | S | 0..1 | Reference(Specimen | Specimen profile - VN Core R4) | Specimen used for this observation | ||||
device | S | 0..1 | Reference(Device | DeviceMetric | Device profile - VN Core R4) | (Measurement) Device | ||||
referenceRange | SC | 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 | SΣ | 0..* | Reference(QuestionnaireResponse | MolecularSequence | Observation - Result Base profile - VN Core R4 | Observation - Pathology Result Code Profile - VN Core R4) | Related resource that belongs to the Observation group | ||||
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
component | SΣ | 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 | 1..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text Binding: LOINCCodes (example): Codes identifying names of simple observations. | |||||
value[x] | Σ | 0..1 | Actual component result | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | 0..1 | VNCoreCodeableConcept | Concept - reference to a terminology or just text Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | |||||
interpretation | 0..* | VNCoreCodeableConcept | Concept - reference to a terminology or just text Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
referenceRange | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |||||
Documentation for this format |
Hình thức mô tả khác: Schematron
Path | Conformance | ValueSet / Code | URI | |||
Observation.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Observation.status | required | Fixed Value: finalhttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | ||||
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.category:laboratory | preferred | Fixed Value: "laboratory"http://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.code | extensible | ResultsPathObservationUvIpshttp://hl7.org/fhir/uv/ips/ValueSet/results-pathology-observations-uv-ips | ||||
Observation.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Observation.value[x]:valueCodeableConcept | preferred | ResultsCodedValuesLabGpsUvIpshttp://hl7.org/fhir/uv/ips/ValueSet/result-coded-value-laboratory-gps-uv-ips | ||||
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard | ||||
Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methods from the FHIR Standard | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaning from the FHIR Standard | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliesto from the FHIR Standard | ||||
Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
qty-3 | error | Observation.value[x]:valueQuantity | If a code for the unit is present, the system SHALL also be present : code.empty() or system.exists() | |
rat-1 | error | Observation.value[x]:valueRatio | Numerator and denominator SHALL both be present, or both are absent. If both are absent, there SHALL be some extension present : (numerator.empty() xor denominator.exists()) and (numerator.exists() or extension.exists()) | |
rng-2 | error | Observation.value[x]:valueRange | If present, low SHALL have a lower value than high : low.empty() or high.empty() or (low <= high) |