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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

Resource Profile: VNCoreObservationRadiologyCode

Thông tin về kết quả thực hiện dịch vụ kỹ thuật - Chẩn đoán hình ảnh

Đường dẫn URL chính thức của Profile này: 

http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-observation-radiology-code

Nội dung Profile

Thông tin bổ sung cho các thông tin hiển thị (Nội dung mô tả, Differential Table, Snapshot Table, ...).

Profile này được dựa trên Resource VNCoreObservationResultBase

Summary

Mandatory: 4 elements(6 nested mandatory elements)
Must-Support: 8 elements
Fixed: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of Observation.category
  • The element 1 is sliced based on the values of Observation.component

Profile này được dựa trên Resource VNCoreObservationResultBase

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
.... 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: imaging
...... display 1..1 string Representation defined by the system
Fixed Value: Imaging
..... text 1..1 string Plain text representation of the concept
Fixed Value: laboratory
... code 1..1 VNCoreCodeableConcept Pathology Result Code
Binding: Results Radiology 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
... value[x] 0..1 string 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
... Slices for component 0..* BackboneElement Component results
Slice: Unordered, Open by type:value[x]
.... component:observationText 0..* BackboneElement Component results
..... code 1..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Results Radiology Textual Observations (GPS-DICOM-LOINC) - IPS (extensible)
..... value[x] 1..1 string Actual component result
.... component:observationCode 0..* BackboneElement Component results
..... code 1..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Results Radiology Observation - IPS (extensible)
..... value[x] 1..1 CodeableConcept Actual component result
.... component:numericQuantityMeasurement 0..* BackboneElement Component results
..... code 1..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Results Radiology Measurement Observation (GPS-DICOM) - IPS (extensible)
..... value[x] 1..1 QuantityIPS A measured amount using UCUM
.... component:numericRangeMeasurement 0..* BackboneElement Component results
..... code 1..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Results Radiology Measurement Observation (GPS-DICOM) - IPS (extensible)
..... value[x] 1..1 Range Actual component result
.... component:numericRatioMeasurement 0..* BackboneElement Component results
..... code 1..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Results Radiology Measurement Observation (GPS-DICOM) - IPS (extensible)
..... value[x] 1..1 RatioIPS A ratio of two Quantity values - a numerator and a denominator
.... component:numericSampledDataMeasurement 0..* BackboneElement Component results
..... code 1..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Results Radiology Measurement Observation (GPS-DICOM) - IPS (extensible)
..... value[x] 1..1 SampledData Actual component result

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 0..* Identifier Business Identifier for observation
... basedOn Σ 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: imaging
...... display 1..1 string Representation defined by the system
Fixed Value: Imaging
...... 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 Radiology 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
... value[x] SΣC 0..1 string 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
... Slices for component SΣ 0..* BackboneElement Component results
Slice: Unordered, Open by type:value[x]
.... component:All Slices Content/Rules for all slices
..... 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
.... component:observationText 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: Results Radiology Textual Observations (GPS-DICOM-LOINC) - IPS (extensible)
..... value[x] Σ 1..1 string Actual component result
..... 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
.... component:observationCode 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: Results Radiology Observation - IPS (extensible)
..... value[x] Σ 1..1 CodeableConcept Actual component result
..... 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
.... component:numericQuantityMeasurement 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: Results Radiology Measurement Observation (GPS-DICOM) - IPS (extensible)
..... value[x] SC 1..1 QuantityIPS A measured amount using UCUM
qty-3: If a code for the unit is present, the system SHALL also be present
..... 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
.... component:numericRangeMeasurement 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: Results Radiology Measurement Observation (GPS-DICOM) - IPS (extensible)
..... value[x] Σ 1..1 Range Actual component result
..... 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
.... component:numericRatioMeasurement 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: Results Radiology Measurement Observation (GPS-DICOM) - IPS (extensible)
..... value[x] SC 1..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
..... 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
.... component:numericSampledDataMeasurement 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: Results Radiology Measurement Observation (GPS-DICOM) - IPS (extensible)
..... value[x] Σ 1..1 SampledData Actual component result
..... 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

doco Documentation for this format

Profile này được dựa trên Resource VNCoreObservationResultBase

Summary

Mandatory: 4 elements(6 nested mandatory elements)
Must-Support: 8 elements
Fixed: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of Observation.category
  • The element 1 is sliced based on the values of Observation.component

Differential View

Profile này được dựa trên Resource VNCoreObservationResultBase

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
.... 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: imaging
...... display 1..1 string Representation defined by the system
Fixed Value: Imaging
..... text 1..1 string Plain text representation of the concept
Fixed Value: laboratory
... code 1..1 VNCoreCodeableConcept Pathology Result Code
Binding: Results Radiology 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
... value[x] 0..1 string 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
... Slices for component 0..* BackboneElement Component results
Slice: Unordered, Open by type:value[x]
.... component:observationText 0..* BackboneElement Component results
..... code 1..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Results Radiology Textual Observations (GPS-DICOM-LOINC) - IPS (extensible)
..... value[x] 1..1 string Actual component result
.... component:observationCode 0..* BackboneElement Component results
..... code 1..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Results Radiology Observation - IPS (extensible)
..... value[x] 1..1 CodeableConcept Actual component result
.... component:numericQuantityMeasurement 0..* BackboneElement Component results
..... code 1..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Results Radiology Measurement Observation (GPS-DICOM) - IPS (extensible)
..... value[x] 1..1 QuantityIPS A measured amount using UCUM
.... component:numericRangeMeasurement 0..* BackboneElement Component results
..... code 1..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Results Radiology Measurement Observation (GPS-DICOM) - IPS (extensible)
..... value[x] 1..1 Range Actual component result
.... component:numericRatioMeasurement 0..* BackboneElement Component results
..... code 1..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Results Radiology Measurement Observation (GPS-DICOM) - IPS (extensible)
..... value[x] 1..1 RatioIPS A ratio of two Quantity values - a numerator and a denominator
.... component:numericSampledDataMeasurement 0..* BackboneElement Component results
..... code 1..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Results Radiology Measurement Observation (GPS-DICOM) - IPS (extensible)
..... value[x] 1..1 SampledData Actual component result

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 0..* Identifier Business Identifier for observation
... basedOn Σ 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: imaging
...... display 1..1 string Representation defined by the system
Fixed Value: Imaging
...... 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 Radiology 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
... value[x] SΣC 0..1 string 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
... Slices for component SΣ 0..* BackboneElement Component results
Slice: Unordered, Open by type:value[x]
.... component:All Slices Content/Rules for all slices
..... 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
.... component:observationText 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: Results Radiology Textual Observations (GPS-DICOM-LOINC) - IPS (extensible)
..... value[x] Σ 1..1 string Actual component result
..... 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
.... component:observationCode 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: Results Radiology Observation - IPS (extensible)
..... value[x] Σ 1..1 CodeableConcept Actual component result
..... 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
.... component:numericQuantityMeasurement 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: Results Radiology Measurement Observation (GPS-DICOM) - IPS (extensible)
..... value[x] SC 1..1 QuantityIPS A measured amount using UCUM
qty-3: If a code for the unit is present, the system SHALL also be present
..... 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
.... component:numericRangeMeasurement 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: Results Radiology Measurement Observation (GPS-DICOM) - IPS (extensible)
..... value[x] Σ 1..1 Range Actual component result
..... 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
.... component:numericRatioMeasurement 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: Results Radiology Measurement Observation (GPS-DICOM) - IPS (extensible)
..... value[x] SC 1..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
..... 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
.... component:numericSampledDataMeasurement 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: Results Radiology Measurement Observation (GPS-DICOM) - IPS (extensible)
..... value[x] Σ 1..1 SampledData Actual component result
..... 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

doco Documentation for this format

 

Hình thức mô tả khác: Schematron

Thông tin bổ sung

Terminology Bindings

Terminology Bindings

PathConformanceValueSet / CodeURI
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Observation.statusrequiredFixed Value: final
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:laboratorypreferredFixed Value: "laboratory"
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.codeextensibleResultsRadObservationUvIps
http://hl7.org/fhir/uv/ips/ValueSet/results-radiology-observations-uv-ips
Observation.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Observation.methodexampleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
http://hl7.org/fhir/ValueSet/referencerange-meaning
from the FHIR Standard
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
http://hl7.org/fhir/ValueSet/referencerange-appliesto
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.component:observationText.codeextensibleResultsRadTxtObsGpsDicomLoincUvIps
http://hl7.org/fhir/uv/ips/ValueSet/results-radiology-txtobs-gps-dicom-loinc-uv-ips
Observation.component:observationText.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component:observationText.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.component:observationCode.codeextensibleResultsRadObservationUvIps
http://hl7.org/fhir/uv/ips/ValueSet/results-radiology-observations-uv-ips
Observation.component:observationCode.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component:observationCode.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.component:numericQuantityMeasurement.codeextensibleResultsRadMeasuresObservationGpsDicomUvIps
http://hl7.org/fhir/uv/ips/ValueSet/results-radiology-numobs-gps-dicom-uv-ips
Observation.component:numericQuantityMeasurement.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component:numericQuantityMeasurement.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.component:numericRangeMeasurement.codeextensibleResultsRadMeasuresObservationGpsDicomUvIps
http://hl7.org/fhir/uv/ips/ValueSet/results-radiology-numobs-gps-dicom-uv-ips
Observation.component:numericRangeMeasurement.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component:numericRangeMeasurement.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.component:numericRatioMeasurement.codeextensibleResultsRadMeasuresObservationGpsDicomUvIps
http://hl7.org/fhir/uv/ips/ValueSet/results-radiology-numobs-gps-dicom-uv-ips
Observation.component:numericRatioMeasurement.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component:numericRatioMeasurement.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.component:numericSampledDataMeasurement.codeextensibleResultsRadMeasuresObservationGpsDicomUvIps
http://hl7.org/fhir/uv/ips/ValueSet/results-radiology-numobs-gps-dicom-uv-ips
Observation.component:numericSampledDataMeasurement.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component:numericSampledDataMeasurement.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard

Constraints

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorObservationIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorObservationIf 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-4errorObservationIf 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-5errorObservationIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceObservationA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
obs-3errorObservation.referenceRangeMust have at least a low or a high or text
: low.exists() or high.exists() or text.exists()
obs-6errorObservationdataAbsentReason SHALL only be present if Observation.value[x] is not present
: dataAbsentReason.empty() or value.empty()
obs-7errorObservationIf 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-3errorObservation.component:numericQuantityMeasurement.value[x]If a code for the unit is present, the system SHALL also be present
: code.empty() or system.exists()
rat-1errorObservation.component:numericRatioMeasurement.value[x]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())