2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

Profile: CCDAAssessmentScaleObservation

The official URL for this profile is: 

http://hl7.org/fhir/Profile/observation-ccda-assessmentscale-ccdaassessmentscaleobservation

. C-CDA Assessment Scale Observation template to FHIR Profile mapping : C-CDA Assessment Scale Observation

This profile was published on Sat, Sep 20, 2014 00:00+1000 as a draft by HL7 International - Orders and Observations WG.

Summary

Required/Prohibited Elements

  • The element Observation is required
  • The element Observation.code is required
  • The element Observation.value[x] is required
  • The element Observation.appliesDateTime is required
  • The element Observation.status is required
  • The element Observation.identifier is required
  • The element Observation.subject is required
  • The element Observation.device is prohibited
  • The element Observation.related.type is required
  • The element Observation.related.target is required

Fixed Values

  • The element Observation.status value has been fixed to final
  • The element Observation.related.type value has been fixed to has-component

Extensions

Formal Views of Profile Content

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

Differential View

This structure is derived from Observation.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1
... code 1..1Assessment Scale
... value[x] 1..1
... comments 0..1Derivation expression
... appliesDateTime 1..1dateTimeClinically effective time
... status 1..1codeFixed Value: final
... identifier 1..1
... subject 1..1Patient
... device 0..0
... referenceRange 0..*
.... text 0..1
... related 0..*
.... type 1..1codeFixed Value: has-component
.... target 1..1http://hl7.org/fhir/ExtensionDefinition/CCDAAssessmentSupporting
... additionalobservationid 0..*IdentifierAdditional observation Ids

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I1..1Measurements and simple assertions
obs-6: Shall only be present if Observation.value[x] is not present
... id 0..1idLogical id of this artefact
... meta 0..1MetaMetadata about the resource
... implicitRules M0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Language (required, not extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... additionalobservationid 0..*IdentifierAdditional observation Ids
... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... code 1..1CodeableConceptAssessment Scale
Binding: ObservationType (example, extensible)
... value[x] 1..1Quantity, CodeableConcept, Attachment, Ratio, dateTime, Period, SampledData, string, timeActual result
... dataAbsentReason I0..1codeunknown | asked | temp | notasked +
Binding: DataAbsentReason (required, not extensible)
Example: unknown
... interpretation 0..1CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretation (preferred, extensible)
... comments 0..1stringDerivation expression
... appliesDateTime 1..1dateTimeClinically effective time
... issued 0..1instantDate/Time this was made available
... status M1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required, not extensible)
Fixed Value: final
... reliability M0..1codeok | ongoing | early | questionable | calibrating | error +
Binding: ObservationReliability (required, not extensible)
... bodySite[x] 0..1CodeableConcept, BodySiteObserved body part
Binding: BodySite (example, extensible)
... method 0..1CodeableConceptHow it was done
Binding: ObservationMethod (example, extensible)
... identifier 1..1IdentifierUnique Id for this particular observation
... subject 1..1PatientWho and/or what this is about
... specimen 0..1SpecimenSpecimen used for this observation
... performer 0..*Practitioner, Organization, Patient, RelatedPersonWho did the observation
... encounter 0..1EncounterHealthcare event during which this observation is made
... referenceRange I0..*Provides guide for interpretation
obs-3: Must have at least a low or a high or text
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... low I0..1QuantityLow Range, if relevant
obs-4: Low range comparators can only be '>' or '>=' or empty
.... high I0..1QuantityHigh Range, if relevant
obs-5: High range comparators can only be '<' or '<=' or empty
.... meaning 0..1CodeableConceptIndicates the meaning/use of this range of this range
Binding: ObservationRangeMeaning (example, extensible)
.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... related 0..*Observations related to this observation
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... type 1..1codehas-component | has-member | derived-from | sequel-to | replaces | qualified-by | interfered-by
Binding: ObservationRelationshipType (required, not extensible)
Fixed Value: has-component
.... target 1..1http://hl7.org/fhir/ExtensionDefinition/CCDAAssessmentSupportingObservation that is related to this one

XML Template

JSON Template

todo

Differential View

This structure is derived from Observation.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 1..1
... code 1..1Assessment Scale
... value[x] 1..1
... comments 0..1Derivation expression
... appliesDateTime 1..1dateTimeClinically effective time
... status 1..1codeFixed Value: final
... identifier 1..1
... subject 1..1Patient
... device 0..0
... referenceRange 0..*
.... text 0..1
... related 0..*
.... type 1..1codeFixed Value: has-component
.... target 1..1http://hl7.org/fhir/ExtensionDefinition/CCDAAssessmentSupporting
... additionalobservationid 0..*IdentifierAdditional observation Ids

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I1..1Measurements and simple assertions
obs-6: Shall only be present if Observation.value[x] is not present
... id 0..1idLogical id of this artefact
... meta 0..1MetaMetadata about the resource
... implicitRules M0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Language (required, not extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... additionalobservationid 0..*IdentifierAdditional observation Ids
... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... code 1..1CodeableConceptAssessment Scale
Binding: ObservationType (example, extensible)
... value[x] 1..1Quantity, CodeableConcept, Attachment, Ratio, dateTime, Period, SampledData, string, timeActual result
... dataAbsentReason I0..1codeunknown | asked | temp | notasked +
Binding: DataAbsentReason (required, not extensible)
Example: unknown
... interpretation 0..1CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretation (preferred, extensible)
... comments 0..1stringDerivation expression
... appliesDateTime 1..1dateTimeClinically effective time
... issued 0..1instantDate/Time this was made available
... status M1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required, not extensible)
Fixed Value: final
... reliability M0..1codeok | ongoing | early | questionable | calibrating | error +
Binding: ObservationReliability (required, not extensible)
... bodySite[x] 0..1CodeableConcept, BodySiteObserved body part
Binding: BodySite (example, extensible)
... method 0..1CodeableConceptHow it was done
Binding: ObservationMethod (example, extensible)
... identifier 1..1IdentifierUnique Id for this particular observation
... subject 1..1PatientWho and/or what this is about
... specimen 0..1SpecimenSpecimen used for this observation
... performer 0..*Practitioner, Organization, Patient, RelatedPersonWho did the observation
... encounter 0..1EncounterHealthcare event during which this observation is made
... referenceRange I0..*Provides guide for interpretation
obs-3: Must have at least a low or a high or text
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... low I0..1QuantityLow Range, if relevant
obs-4: Low range comparators can only be '>' or '>=' or empty
.... high I0..1QuantityHigh Range, if relevant
obs-5: High range comparators can only be '<' or '<=' or empty
.... meaning 0..1CodeableConceptIndicates the meaning/use of this range of this range
Binding: ObservationRangeMeaning (example, extensible)
.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... related 0..*Observations related to this observation
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... type 1..1codehas-component | has-member | derived-from | sequel-to | replaces | qualified-by | interfered-by
Binding: ObservationRelationshipType (required, not extensible)
Fixed Value: has-component
.... target 1..1http://hl7.org/fhir/ExtensionDefinition/CCDAAssessmentSupportingObservation that is related to this one

XML Template

JSON Template

todo

 

Other definitions: (todo)

Terminology Bindings

PathNameConformanceValueSet
Observation.languageLanguagerequiredhttp://tools.ietf.org/html/bcp47
Observation.codeObservationTypeexample (extensible)LOINC Codes
Observation.dataAbsentReasonDataAbsentReasonrequiredDataAbsentReason
Observation.interpretationObservationInterpretationpreferred (extensible)Observation Interpretation Codes
Observation.statusObservationStatusrequiredObservationStatus
Observation.reliabilityObservationReliabilityrequiredObservationReliability
Observation.bodySite[x]BodySiteexample (extensible)SNOMED CT Body Structures
Observation.methodObservationMethodexample (extensible)Observation Methods
Observation.referenceRange.meaningObservationRangeMeaningexample (extensible)Observation Reference Range Meaning Codes
Observation.related.typeObservationRelationshipTyperequiredObservationRelationshipType

Constraints

IdPathNameDetails
obs-6Observationdata absent reasonShall only be present if Observation.value[x] is not present
XPath: not(exists(f:dataAbsentReason)) or (not(exists(*[starts-with(local-name(.), 'value')])))
obs-3Observation.referenceRangereference rangeMust have at least a low or a high or text
XPath: (exists(f:low) or exists(f:high)or exists(f:text))
obs-4Observation.referenceRange.lowlow range comparatorsLow range comparators can only be '>' or '>=' or empty
XPath: not(exists(f:comparator)) or boolean(f:comparator/@value = '<') or boolean(f:comparator/@value = '<=')
obs-5Observation.referenceRange.highhigh range comparatorsHigh range comparators can only be '<' or '<=' or empty
XPath: not(exists(f:comparator)) or boolean(f:comparator/@value = '>') or boolean(f:comparator/@value = '>=')
.