This page is part of the FHIR Specification (v5.0.0-ballot: R5 Ballot - see ballot notes). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2
Orders and Observations Work Group | Maturity Level: 0 | Trial Use | Use Context: Not yet ready for Production use, Not yet ready for Production use |
The canonical URL for this profile is:
http://hl7.org/fhir/StructureDefinition/cholesterol
Describes how the lab report is used for a standard Lipid Profile - Cholesterol, Triglyceride and Cholesterol fractions. Uses LOINC codes
This profile was published on Sat, Feb 21, 2015 00:00+1100 as a draft by Health Level Seven, Inc. - FHIR WG.
Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.
This structure is derived from Observation.
Summary
Mandatory: 3 elements (+3 nested mandatory elements)
Must-Support: 9 elements
Fixed Value: 5 elements
Prohibited: 7 elements
This indicates the differences between this profile and the base Observation structure.
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 1..1 | Observation | Measurements and simple assertions | |
code | S | 1..1 | CodeableConcept | Cholesterol 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 35200-5 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Cholesterol [Moles/volume] in Serum or Plasma | |
valueQuantity | S | 0..1 | Quantity | Cholesterol value |
value | S | 0..1 | decimal | Actual numerical value |
comparator | 0..0 | |||
unit | S | 1..1 | string | Unit representation Fixed Value: mmol/L |
system | S | 1..1 | uri | System that defines coded unit form Fixed Value: http://unitsofmeasure.org |
code | S | 1..1 | code | Coded form of the unit Fixed Value: mmol/L |
interpretation | S | 0..1 | CodeableConcept | + | ++ | +++ | - | -- | --- |
note | S | 0..* | Annotation | Comments about result |
referenceRange | S | 1..1 | BackboneElement | Provides guide for interpretation |
low | 0..0 | |||
high | 1..1 | SimpleQuantity | A fixed quantity (no comparator) Fixed Value: As shown | |
value | 1..1 | decimal | Numerical value (with implicit precision) Fixed Value: 4.5 | |
type | 0..0 | |||
appliesTo | 0..0 | |||
age | 0..0 | |||
hasMember | 0..0 | |||
derivedFrom | 0..0 | |||
Documentation for this format |
This provides the consolidated view (aka snapshot) of the profile after applying the changes in this profile to the base Observation structure.
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 1..1 | Observation | Measurements and simple assertions | ||||
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: Common Languages (preferred): IETF language tag
| |||||
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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business Identifier for observation | ||||
instantiates[x] | Σ | 0..1 | canonical(ObservationDefinition), Reference(ObservationDefinition) | Instantiates FHIR ObservationDefinition | ||||
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | ||||
triggeredBy | 0..* | BackboneElement | Triggering observation(s) | |||||
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 | ||||
observation | Σ | 1..1 | Reference(Observation) | Triggering observation | ||||
type | Σ | 1..1 | code | reflex | repeat | re-run Binding: triggeredBytype (required): The type of TriggeredBy Observation. | ||||
reason | 0..1 | string | Reason that the observation was triggered | |||||
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationUsage | Procedure | Immunization | ImagingStudy | GenomicStudy) | Part of referenced event | ||||
status | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
category | 0..* | CodeableConcept | Classification of type of observation Binding: Observation Category Codes (preferred): Codes for high level observation categories. | |||||
code | SΣ | 1..1 | CodeableConcept | Cholesterol Binding: LOINC Codes (example): Codes identifying names of simple observations. Fixed Value: As shown | ||||
id | 0..0 | id | 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 | id | 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://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 35200-5 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Cholesterol [Moles/volume] in Serum or Plasma | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
subject | Σ | 0..1 | Reference(Patient | Group | Device | Location | Organization | Procedure | Practitioner | Medication | Substance | BiologicallyDerivedProduct | NutritionProduct) | Who and/or what the observation is about | ||||
focus | Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made | ||||
effective[x] | Σ | 0..1 | Clinically relevant time/time-period for observation | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
effectiveTiming | Timing | |||||||
effectiveInstant | instant | |||||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation | ||||
Slices for value[x] | ΣC | 0..1 | Quantity | Actual result Slice: Unordered, Closed by type:$this | ||||
value[x]:valueQuantity | SΣC | 0..1 | Quantity | Cholesterol value | ||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
value | SΣ | 0..1 | decimal | Actual numerical value | ||||
unit | SΣ | 1..1 | string | Unit representation Fixed Value: mmol/L | ||||
system | SΣC | 1..1 | uri | System that defines coded unit form Fixed Value: http://unitsofmeasure.org | ||||
code | SΣ | 1..1 | code | Coded form of the unit Fixed Value: mmol/L | ||||
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..1 | CodeableConcept | + | ++ | +++ | - | -- | --- Binding: Observation Interpretation Codes (extensible): Codes identifying interpretations of observations. | ||||
note | S | 0..* | Annotation | Comments about result | ||||
bodySite | 0..1 | CodeableConcept | Observed body part Binding: SNOMED CT Body Structures (example): SNOMED CT Body site concepts | |||||
bodyStructure | C | 0..1 | Reference(BodyStructure) | Observed body structure | ||||
method | 0..1 | CodeableConcept | How it was done Binding: Observation Methods (example): Methods for simple observations. | |||||
specimen | C | 0..1 | Reference(Specimen | Group) | Specimen used for this observation | ||||
device | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
referenceRange | SC | 1..1 | BackboneElement | Provides guide for interpretation | ||||
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 | ||||
high | C | 1..1 | SimpleQuantity | A fixed quantity (no comparator) Fixed Value: As shown | ||||
id | 0..0 | id | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
value | 1..1 | decimal | Numerical value (with implicit precision) Fixed Value: 4.5 | |||||
comparator | 0..0 | code | < | <= | >= | > | ad - how to understand the value | |||||
unit | 0..0 | string | Unit representation | |||||
system | 0..0 | uri | System that defines coded unit form | |||||
code | 0..0 | code | Coded form of the unit | |||||
normalValue | C | 0..1 | CodeableConcept | Normal value, if relevant Binding: Observation Reference Range Normal Value Codes (extensible): Codes identifying the normal value of the observation. | ||||
text | 0..1 | string | Text based reference range in an observation | |||||
component | Σ | 0..* | BackboneElement | Component results | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINC Codes (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 | |||||||
valueAttachment | Attachment | |||||||
dataAbsentReason | C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: Observation Interpretation Codes (extensible): Codes identifying interpretations of observations. | |||||
referenceRange | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |||||
Documentation for this format |
<!-- Example Lipid Profile --> <Observation xmlns="http://hl7.org/fhir" > <!-- from Element: extension --> <id value="[id]"/><!-- 0..1 Logical id of this artifact --> <meta><!-- I 0..1 Meta Metadata about the resource --></meta> <implicitRules value="[uri]"/><!-- I 0..1 A set of rules under which this content was created --> <language value="[code]"/><!-- I 0..1 Language of the resource content --> <text><!-- I 0..1 Narrative Text summary of the resource, for human interpretation --></text> <contained><!-- 0..* Resource Contained, inline Resources --></contained> <modifierExtension><!-- I 0..* Extension Extensions that cannot be ignored --></modifierExtension> <identifier><!-- I 0..* Identifier Business Identifier for observation --></identifier> <instantiates[x]><!-- I 0..1 canonical|Reference(ObservationDefinition) Instantiates FHIR ObservationDefinition --></instantiates[x]> <basedOn><!-- I 0..* Reference(CarePlan) Fulfills plan, proposal or order --></basedOn> <triggeredBy> I 0..* BackboneElement <!-- I 0..* Triggering observation(s) --> <modifierExtension><!-- I 0..* Extension Extensions that cannot be ignored even if unrecognized --></modifierExtension> <observation><!-- I 1..1 Reference(Observation) Triggering observation --></observation> <type value="[code]"/><!-- I 1..1 reflex | repeat | re-run --> <reason value="[string]"/><!-- I 0..1 Reason that the observation was triggered --> </triggeredBy> <partOf><!-- I 0..* Reference(MedicationAdministration) Part of referenced event --></partOf> <status value="[code]"/><!-- I 1..1 registered | preliminary | final | amended + --> <category><!-- I 0..* CodeableConcept Classification of type of observation --></category> <code><!-- I 1..1 CodeableConcept Cholesterol --></code> <subject><!-- I 0..1 Reference(Patient) Who and/or what the observation is about --></subject> <focus><!-- I 0..* Reference(Resource) What the observation is about, when it is not about the subject of record --></focus> <encounter><!-- I 0..1 Reference(Encounter) Healthcare event during which this observation is made --></encounter> <effective[x]><!-- I 0..1 dateTime|Period|Timing|instant Clinically relevant time/time-period for observation --></effective[x]> <issued value="[instant]"/><!-- I 0..1 Date/Time this version was made available --> <performer><!-- I 0..* Reference(Practitioner) Who is responsible for the observation --></performer> <-- valueQuantity sliced by type:$this in the specified orderClosed--> <valueQuantity> I 0..1 Quantity <!-- I 0..1 Cholesterol value --> <value value="[decimal]"/><!-- I 0..1 Actual numerical value --> <comparator value="[code]"/><!-- I 0..0 < | <= | >= | > | ad - how to understand the value --> <unit value="[string]"/><!-- I 1..1 Unit representation --> <system value="[uri]"/><!-- I 1..1 System that defines coded unit form --> <code value="[code]"/><!-- I 1..1 Coded form of the unit --> </valueQuantity> <dataAbsentReason><!-- I 0..1 CodeableConcept Why the result is missing --></dataAbsentReason> <interpretation><!-- I 0..1 CodeableConcept + | ++ | +++ | - | -- | --- --></interpretation> <note><!-- I 0..* Annotation Comments about result --></note> <bodySite><!-- I 0..1 CodeableConcept Observed body part --></bodySite> <bodyStructure><!-- I 0..1 Reference(BodyStructure) Observed body structure --></bodyStructure> <method><!-- I 0..1 CodeableConcept How it was done --></method> <specimen><!-- I 0..1 Reference(Specimen) Specimen used for this observation --></specimen> <device><!-- I 0..1 Reference(Device) (Measurement) Device --></device> <referenceRange> I 1..1 BackboneElement <!-- I 1..1 Provides guide for interpretation --> <modifierExtension><!-- I 0..* Extension Extensions that cannot be ignored even if unrecognized --></modifierExtension> <low><!-- I 0..0 Quantity Low Range, if relevant --></low> <high><!-- I 1..1 Quantity A fixed quantity (no comparator) --></high> <normalValue><!-- I 0..1 CodeableConcept Normal value, if relevant --></normalValue> <type><!-- I 0..0 CodeableConcept Reference range qualifier --></type> <appliesTo><!-- I 0..0 CodeableConcept Reference range population --></appliesTo> <age><!-- I 0..0 Range Applicable age range, if relevant --></age> <text value="[string]"/><!-- I 0..1 Text based reference range in an observation --> </referenceRange> <hasMember><!-- I 0..0 Reference(Observation) Related resource that belongs to the Observation group --></hasMember> <derivedFrom><!-- I 0..0 Reference(DocumentReference) Related resource from which the observation is made --></derivedFrom> <component> I 0..* BackboneElement <!-- I 0..* Component results --> <modifierExtension><!-- I 0..* Extension Extensions that cannot be ignored even if unrecognized --></modifierExtension> <code><!-- I 1..1 CodeableConcept Type of component observation (code / type) --></code> <value[x]><!-- I 0..1 Quantity|CodeableConcept|string| boolean|integer|Range|Ratio|SampledData|time|dateTime|Period|Attachment Actual component result --></value[x]> <dataAbsentReason><!-- I 0..1 CodeableConcept Why the component result is missing --></dataAbsentReason> <interpretation><!-- I 0..* CodeableConcept High, low, normal, etc. --></interpretation> <referenceRange><!-- See http://hl7.org/fhir/StructureDefinition/Observation#Observation.referenceRange Provides guide for interpretation of component result --></referenceRange> </component> </Observation>
{ // Example Lipid Profile // from Element: extension "meta" : { Meta }, // IMetadata about the resource "implicitRules" : "<uri>", // IA set of rules under which this content was created "language" : "<code>", // ILanguage of the resource content "text" : { Narrative }, // IText summary of the resource, for human interpretation "contained" : [{ Resource }], //Contained, inline Resources "modifierExtension" : [{ Extension }], // IExtensions that cannot be ignored "identifier" : [{ Identifier }], // IBusiness Identifier for observation // value[x]: Instantiates FHIR ObservationDefinition. One of these 2: "instantiatesCanonical" : "<canonical>", // IInstantiates FHIR ObservationDefinition "instantiatesReference" : { Reference(ObservationDefinition) }, // IInstantiates FHIR ObservationDefinition "basedOn" : [{ Reference(CarePlan) }], // IFulfills plan, proposal or order "triggeredBy" : [{ BackboneElement }], // ITriggering observation(s) "partOf" : [{ Reference(MedicationAdministration) }], // IPart of referenced event "status" : "<code>", // I R! registered | preliminary | final | amended + "category" : [{ CodeableConcept }], // IClassification of type of observation "code" : { CodeableConcept }, // I R! "subject" : { Reference(Patient) }, // IWho and/or what the observation is about "focus" : [{ Reference(Resource) }], // IWhat the observation is about, when it is not about the subject of record "encounter" : { Reference(Encounter) }, // IHealthcare event during which this observation is made // value[x]: Clinically relevant time/time-period for observation. One of these 4: "effectiveDateTime" : "<dateTime>", // IClinically relevant time/time-period for observation "effectivePeriod" : { Period }, // IClinically relevant time/time-period for observation "effectiveTiming" : { Timing }, // IClinically relevant time/time-period for observation "effectiveInstant" : "<instant>", // IClinically relevant time/time-period for observation "issued" : "<instant>", // IDate/Time this version was made available "performer" : [{ Reference(Practitioner) }], // IWho is responsible for the observation "valueQuantity" : [ // sliced by type:$this in the specified order, Closed { // Cholesterol value // I // from Element: extension "extension" : [ // sliced by value:url in the specified order, Open ] "value" : <decimal>, // IActual numerical value "unit" : "mmol/L", // I R! "system" : "http://unitsofmeasure.org", // I R! "code" : "mmol/L" // I R! } ], "dataAbsentReason" : { CodeableConcept }, // IWhy the result is missing "interpretation" : { CodeableConcept }, // I+ | ++ | +++ | - | -- | --- "note" : [{ Annotation }], // IComments about result "bodySite" : { CodeableConcept }, // IObserved body part "bodyStructure" : { Reference(BodyStructure) }, // IObserved body structure "method" : { CodeableConcept }, // IHow it was done "specimen" : { Reference(Specimen) }, // ISpecimen used for this observation "device" : { Reference(Device) }, // I(Measurement) Device "referenceRange" : { BackboneElement }, // I R! Provides guide for interpretation "component" : [{ BackboneElement }], // IComponent results }
This structure is derived from Observation.
Differential View
This indicates the differences between this profile and the base Observation structure.
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 1..1 | Observation | Measurements and simple assertions | |
code | S | 1..1 | CodeableConcept | Cholesterol 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://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 35200-5 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Cholesterol [Moles/volume] in Serum or Plasma | |
valueQuantity | S | 0..1 | Quantity | Cholesterol value |
value | S | 0..1 | decimal | Actual numerical value |
comparator | 0..0 | |||
unit | S | 1..1 | string | Unit representation Fixed Value: mmol/L |
system | S | 1..1 | uri | System that defines coded unit form Fixed Value: http://unitsofmeasure.org |
code | S | 1..1 | code | Coded form of the unit Fixed Value: mmol/L |
interpretation | S | 0..1 | CodeableConcept | + | ++ | +++ | - | -- | --- |
note | S | 0..* | Annotation | Comments about result |
referenceRange | S | 1..1 | BackboneElement | Provides guide for interpretation |
low | 0..0 | |||
high | 1..1 | SimpleQuantity | A fixed quantity (no comparator) Fixed Value: As shown | |
value | 1..1 | decimal | Numerical value (with implicit precision) Fixed Value: 4.5 | |
type | 0..0 | |||
appliesTo | 0..0 | |||
age | 0..0 | |||
hasMember | 0..0 | |||
derivedFrom | 0..0 | |||
Documentation for this format |
Snapshot View
This provides the consolidated view (aka snapshot) of the profile after applying the changes in this profile to the base Observation structure.
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 1..1 | Observation | Measurements and simple assertions | ||||
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: Common Languages (preferred): IETF language tag
| |||||
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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business Identifier for observation | ||||
instantiates[x] | Σ | 0..1 | canonical(ObservationDefinition), Reference(ObservationDefinition) | Instantiates FHIR ObservationDefinition | ||||
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | ||||
triggeredBy | 0..* | BackboneElement | Triggering observation(s) | |||||
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 | ||||
observation | Σ | 1..1 | Reference(Observation) | Triggering observation | ||||
type | Σ | 1..1 | code | reflex | repeat | re-run Binding: triggeredBytype (required): The type of TriggeredBy Observation. | ||||
reason | 0..1 | string | Reason that the observation was triggered | |||||
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationUsage | Procedure | Immunization | ImagingStudy | GenomicStudy) | Part of referenced event | ||||
status | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
category | 0..* | CodeableConcept | Classification of type of observation Binding: Observation Category Codes (preferred): Codes for high level observation categories. | |||||
code | SΣ | 1..1 | CodeableConcept | Cholesterol Binding: LOINC Codes (example): Codes identifying names of simple observations. Fixed Value: As shown | ||||
id | 0..0 | id | 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 | id | 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://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 35200-5 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Cholesterol [Moles/volume] in Serum or Plasma | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
subject | Σ | 0..1 | Reference(Patient | Group | Device | Location | Organization | Procedure | Practitioner | Medication | Substance | BiologicallyDerivedProduct | NutritionProduct) | Who and/or what the observation is about | ||||
focus | Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made | ||||
effective[x] | Σ | 0..1 | Clinically relevant time/time-period for observation | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
effectiveTiming | Timing | |||||||
effectiveInstant | instant | |||||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation | ||||
Slices for value[x] | ΣC | 0..1 | Quantity | Actual result Slice: Unordered, Closed by type:$this | ||||
value[x]:valueQuantity | SΣC | 0..1 | Quantity | Cholesterol value | ||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
value | SΣ | 0..1 | decimal | Actual numerical value | ||||
unit | SΣ | 1..1 | string | Unit representation Fixed Value: mmol/L | ||||
system | SΣC | 1..1 | uri | System that defines coded unit form Fixed Value: http://unitsofmeasure.org | ||||
code | SΣ | 1..1 | code | Coded form of the unit Fixed Value: mmol/L | ||||
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..1 | CodeableConcept | + | ++ | +++ | - | -- | --- Binding: Observation Interpretation Codes (extensible): Codes identifying interpretations of observations. | ||||
note | S | 0..* | Annotation | Comments about result | ||||
bodySite | 0..1 | CodeableConcept | Observed body part Binding: SNOMED CT Body Structures (example): SNOMED CT Body site concepts | |||||
bodyStructure | C | 0..1 | Reference(BodyStructure) | Observed body structure | ||||
method | 0..1 | CodeableConcept | How it was done Binding: Observation Methods (example): Methods for simple observations. | |||||
specimen | C | 0..1 | Reference(Specimen | Group) | Specimen used for this observation | ||||
device | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
referenceRange | SC | 1..1 | BackboneElement | Provides guide for interpretation | ||||
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 | ||||
high | C | 1..1 | SimpleQuantity | A fixed quantity (no comparator) Fixed Value: As shown | ||||
id | 0..0 | id | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
value | 1..1 | decimal | Numerical value (with implicit precision) Fixed Value: 4.5 | |||||
comparator | 0..0 | code | < | <= | >= | > | ad - how to understand the value | |||||
unit | 0..0 | string | Unit representation | |||||
system | 0..0 | uri | System that defines coded unit form | |||||
code | 0..0 | code | Coded form of the unit | |||||
normalValue | C | 0..1 | CodeableConcept | Normal value, if relevant Binding: Observation Reference Range Normal Value Codes (extensible): Codes identifying the normal value of the observation. | ||||
text | 0..1 | string | Text based reference range in an observation | |||||
component | Σ | 0..* | BackboneElement | Component results | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINC Codes (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 | |||||||
valueAttachment | Attachment | |||||||
dataAbsentReason | C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: Observation Interpretation Codes (extensible): Codes identifying interpretations of observations. | |||||
referenceRange | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |||||
Documentation for this format |
XML Template
<!-- Example Lipid Profile --> <Observation xmlns="http://hl7.org/fhir" > <!-- from Element: extension --> <id value="[id]"/><!-- 0..1 Logical id of this artifact --> <meta><!-- I 0..1 Meta Metadata about the resource --></meta> <implicitRules value="[uri]"/><!-- I 0..1 A set of rules under which this content was created --> <language value="[code]"/><!-- I 0..1 Language of the resource content --> <text><!-- I 0..1 Narrative Text summary of the resource, for human interpretation --></text> <contained><!-- 0..* Resource Contained, inline Resources --></contained> <modifierExtension><!-- I 0..* Extension Extensions that cannot be ignored --></modifierExtension> <identifier><!-- I 0..* Identifier Business Identifier for observation --></identifier> <instantiates[x]><!-- I 0..1 canonical|Reference(ObservationDefinition) Instantiates FHIR ObservationDefinition --></instantiates[x]> <basedOn><!-- I 0..* Reference(CarePlan) Fulfills plan, proposal or order --></basedOn> <triggeredBy> I 0..* BackboneElement <!-- I 0..* Triggering observation(s) --> <modifierExtension><!-- I 0..* Extension Extensions that cannot be ignored even if unrecognized --></modifierExtension> <observation><!-- I 1..1 Reference(Observation) Triggering observation --></observation> <type value="[code]"/><!-- I 1..1 reflex | repeat | re-run --> <reason value="[string]"/><!-- I 0..1 Reason that the observation was triggered --> </triggeredBy> <partOf><!-- I 0..* Reference(MedicationAdministration) Part of referenced event --></partOf> <status value="[code]"/><!-- I 1..1 registered | preliminary | final | amended + --> <category><!-- I 0..* CodeableConcept Classification of type of observation --></category> <code><!-- I 1..1 CodeableConcept Cholesterol --></code> <subject><!-- I 0..1 Reference(Patient) Who and/or what the observation is about --></subject> <focus><!-- I 0..* Reference(Resource) What the observation is about, when it is not about the subject of record --></focus> <encounter><!-- I 0..1 Reference(Encounter) Healthcare event during which this observation is made --></encounter> <effective[x]><!-- I 0..1 dateTime|Period|Timing|instant Clinically relevant time/time-period for observation --></effective[x]> <issued value="[instant]"/><!-- I 0..1 Date/Time this version was made available --> <performer><!-- I 0..* Reference(Practitioner) Who is responsible for the observation --></performer> <-- valueQuantity sliced by type:$this in the specified orderClosed--> <valueQuantity> I 0..1 Quantity <!-- I 0..1 Cholesterol value --> <value value="[decimal]"/><!-- I 0..1 Actual numerical value --> <comparator value="[code]"/><!-- I 0..0 < | <= | >= | > | ad - how to understand the value --> <unit value="[string]"/><!-- I 1..1 Unit representation --> <system value="[uri]"/><!-- I 1..1 System that defines coded unit form --> <code value="[code]"/><!-- I 1..1 Coded form of the unit --> </valueQuantity> <dataAbsentReason><!-- I 0..1 CodeableConcept Why the result is missing --></dataAbsentReason> <interpretation><!-- I 0..1 CodeableConcept + | ++ | +++ | - | -- | --- --></interpretation> <note><!-- I 0..* Annotation Comments about result --></note> <bodySite><!-- I 0..1 CodeableConcept Observed body part --></bodySite> <bodyStructure><!-- I 0..1 Reference(BodyStructure) Observed body structure --></bodyStructure> <method><!-- I 0..1 CodeableConcept How it was done --></method> <specimen><!-- I 0..1 Reference(Specimen) Specimen used for this observation --></specimen> <device><!-- I 0..1 Reference(Device) (Measurement) Device --></device> <referenceRange> I 1..1 BackboneElement <!-- I 1..1 Provides guide for interpretation --> <modifierExtension><!-- I 0..* Extension Extensions that cannot be ignored even if unrecognized --></modifierExtension> <low><!-- I 0..0 Quantity Low Range, if relevant --></low> <high><!-- I 1..1 Quantity A fixed quantity (no comparator) --></high> <normalValue><!-- I 0..1 CodeableConcept Normal value, if relevant --></normalValue> <type><!-- I 0..0 CodeableConcept Reference range qualifier --></type> <appliesTo><!-- I 0..0 CodeableConcept Reference range population --></appliesTo> <age><!-- I 0..0 Range Applicable age range, if relevant --></age> <text value="[string]"/><!-- I 0..1 Text based reference range in an observation --> </referenceRange> <hasMember><!-- I 0..0 Reference(Observation) Related resource that belongs to the Observation group --></hasMember> <derivedFrom><!-- I 0..0 Reference(DocumentReference) Related resource from which the observation is made --></derivedFrom> <component> I 0..* BackboneElement <!-- I 0..* Component results --> <modifierExtension><!-- I 0..* Extension Extensions that cannot be ignored even if unrecognized --></modifierExtension> <code><!-- I 1..1 CodeableConcept Type of component observation (code / type) --></code> <value[x]><!-- I 0..1 Quantity|CodeableConcept|string| boolean|integer|Range|Ratio|SampledData|time|dateTime|Period|Attachment Actual component result --></value[x]> <dataAbsentReason><!-- I 0..1 CodeableConcept Why the component result is missing --></dataAbsentReason> <interpretation><!-- I 0..* CodeableConcept High, low, normal, etc. --></interpretation> <referenceRange><!-- See http://hl7.org/fhir/StructureDefinition/Observation#Observation.referenceRange Provides guide for interpretation of component result --></referenceRange> </component> </Observation>
JSON Template
{ // Example Lipid Profile // from Element: extension "meta" : { Meta }, // IMetadata about the resource "implicitRules" : "<uri>", // IA set of rules under which this content was created "language" : "<code>", // ILanguage of the resource content "text" : { Narrative }, // IText summary of the resource, for human interpretation "contained" : [{ Resource }], //Contained, inline Resources "modifierExtension" : [{ Extension }], // IExtensions that cannot be ignored "identifier" : [{ Identifier }], // IBusiness Identifier for observation // value[x]: Instantiates FHIR ObservationDefinition. One of these 2: "instantiatesCanonical" : "<canonical>", // IInstantiates FHIR ObservationDefinition "instantiatesReference" : { Reference(ObservationDefinition) }, // IInstantiates FHIR ObservationDefinition "basedOn" : [{ Reference(CarePlan) }], // IFulfills plan, proposal or order "triggeredBy" : [{ BackboneElement }], // ITriggering observation(s) "partOf" : [{ Reference(MedicationAdministration) }], // IPart of referenced event "status" : "<code>", // I R! registered | preliminary | final | amended + "category" : [{ CodeableConcept }], // IClassification of type of observation "code" : { CodeableConcept }, // I R! "subject" : { Reference(Patient) }, // IWho and/or what the observation is about "focus" : [{ Reference(Resource) }], // IWhat the observation is about, when it is not about the subject of record "encounter" : { Reference(Encounter) }, // IHealthcare event during which this observation is made // value[x]: Clinically relevant time/time-period for observation. One of these 4: "effectiveDateTime" : "<dateTime>", // IClinically relevant time/time-period for observation "effectivePeriod" : { Period }, // IClinically relevant time/time-period for observation "effectiveTiming" : { Timing }, // IClinically relevant time/time-period for observation "effectiveInstant" : "<instant>", // IClinically relevant time/time-period for observation "issued" : "<instant>", // IDate/Time this version was made available "performer" : [{ Reference(Practitioner) }], // IWho is responsible for the observation "valueQuantity" : [ // sliced by type:$this in the specified order, Closed { // Cholesterol value // I // from Element: extension "extension" : [ // sliced by value:url in the specified order, Open ] "value" : <decimal>, // IActual numerical value "unit" : "mmol/L", // I R! "system" : "http://unitsofmeasure.org", // I R! "code" : "mmol/L" // I R! } ], "dataAbsentReason" : { CodeableConcept }, // IWhy the result is missing "interpretation" : { CodeableConcept }, // I+ | ++ | +++ | - | -- | --- "note" : [{ Annotation }], // IComments about result "bodySite" : { CodeableConcept }, // IObserved body part "bodyStructure" : { Reference(BodyStructure) }, // IObserved body structure "method" : { CodeableConcept }, // IHow it was done "specimen" : { Reference(Specimen) }, // ISpecimen used for this observation "device" : { Reference(Device) }, // I(Measurement) Device "referenceRange" : { BackboneElement }, // I R! Provides guide for interpretation "component" : [{ BackboneElement }], // IComponent results }
Alternate definitions: Master Definition (XML, JSON), Schematron
Path | Name | Conformance | ValueSet |
Observation.language | Common Languages | preferred | Common Languages |
Observation.triggeredBy.type | triggeredBytype | required | triggeredBytype |
Observation.status | ObservationStatus | required | ObservationStatus |
Observation.category | Observation Category Codes | preferred | Observation Category Codes |
Observation.code | LOINC Codes | example | LOINC Codes |
Observation.dataAbsentReason | DataAbsentReason | extensible | DataAbsentReason |
Observation.interpretation | Observation Interpretation Codes | extensible | Observation Interpretation Codes |
Observation.bodySite | SNOMED CT Body Structures | example | SNOMED CT Body Structures |
Observation.method | Observation Methods | example | Observation Methods |
Observation.referenceRange.normalValue | Observation Reference Range Normal Value Codes | extensible | Observation Reference Range Normal Value Codes |
Observation.component.code | LOINC Codes | example | LOINC Codes |
Observation.component.dataAbsentReason | DataAbsentReason | extensible | DataAbsentReason |
Observation.component.interpretation | Observation Interpretation Codes | extensible | Observation Interpretation Codes |