This page is part of the US Core (v4.1.0: STU5 Ballot 1) based on FHIR R4. The current version which supercedes this version is 5.0.1. For a full list of available versions, see the Directory of published versions
Defining URL: | http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-screening-response |
Version: | 4.1.0 |
Name: | USCoreObservationScreeningResponse |
Title: | US Core Screening Response Observation Profile |
Status: | Active as of 11/12/21 |
Definition: | Profile for observations that represent question and answer pairs from from surveys/questionnaires such as Social Determinants of Health (SDOH) screening instruments. |
Publisher: | HL7 International - Cross-Group Projects |
Copyright: | Used by permission of HL7 International, all rights reserved Creative Commons License |
Source Resource: | XML / JSON / Turtle |
The official URL for this profile is:
http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-screening-response
This profile sets minimum expectations for the Observation resource to record, search, and fetch retrieve observations that represent the questions and responses to form/survey and assessment tools such as the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) Survey. This profile encompasses single, multipart, and derived responses. It identifies which core elements, extensions, vocabularies and value sets SHALL be present in the resource when using this profile. These observations are distinct from observations representing individual clinical assessments made by an individual about a patient’s social history and not derived from an assessment tool or survey. These types of observations should use the US Core Social History Assessment Observation Profile instead.
Example Usage Scenarios:
The following are example usage scenarios for the US Core-Results profile:
The following data-elements must always be present (Mandatory definition]) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.
Each Observation must have:
Each Observation must support:
We are seeking feedback on the inclusion of Observation.component as a Must Support element for systems to record multiple answers for a screening question in a single Observation. Based on how broadly this is supported in current implementations, we may remove the constraint on Observation.component and recommend multiple Observations.
Profile specific implementation guidance:
Observation.code
(e.g., LOINC) that specify “check all that apply”, the question should be used for Observation.code
and for Observation.component.code
. For “check all that apply” questions, the answers (regardless of whether one or more are selected) should only be represented using Observation.component.value
and Observation.value
should be empty.Observation.hasMember
.
Observation.dataAbsentReason
.Observation.component
without a value, SHALL include a reason why the data is absent.
Observation.component.dataAbsentReason
.Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
Summary
Mandatory: 3 elements
Must-Support: 14 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | I | 0..* | Observation | questionnaire observations us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present |
status | S | 1..1 | code | registered | preliminary | final | amended + |
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this |
category:survey | S | 1..1 | CodeableConcept | Classification of type of observation Required Pattern: At least the following |
coding | 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: survey | |
code | S | 1..1 | CodeableConcept | Type of observation (code / type) Binding: US Core Common SDOH Assessments ValueSet (preferred) |
subject | S | 1..1 | Reference(US Core Patient Profile) | Who and/or what the observation is about |
effective[x] | SI | 0..1 | Clinically relevant time/time-period for observation us-core-1: Datetime must be at least to day. | |
effectiveDateTime | dateTime S | |||
effectivePeriod | Period | |||
effectiveTiming | Timing | |||
effectiveInstant | instant | |||
performer | S | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core Related Person) | Who is responsible for the observation |
value[x] | SI | 0..1 | Actual result us-core-3: SHALL use UCUM for coded quantity units. | |
valueQuantity | Quantity S | |||
valueCodeableConcept | CodeableConcept S | |||
valueString | string S | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
dataAbsentReason | SI | 0..1 | CodeableConcept | Why the result is missing |
derivedFrom | S | 0..* | Reference(US Core Screening Response Observation Profile S | SDC Questionnaire Response S | US Core DocumentReference Profile | ImagingStudy | Media | MolecularSequence) | Related questionnaire responses or observations that the observation is made from |
component | S | 0..* | BackboneElement | Component results |
code | S | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (extensible) |
value[x] | SI | 0..1 | Actual component result us-core-3: SHALL use UCUM for coded quantity units. | |
valueQuantity | Quantity S | |||
valueCodeableConcept | CodeableConcept S | |||
valueString | string S | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
dataAbsentReason | S | 0..1 | CodeableConcept | Why the component result is missing |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | I | 0..* | Observation | questionnaire observations us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present |
id | Σ | 0..1 | string | 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) Max Binding: AllLanguages: A human language. | |
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
contained | 0..* | Resource | Contained, inline Resources | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | Σ | 0..* | Identifier | Business Identifier for observation |
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order |
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event |
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
category:survey | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: survey | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: US Core Common SDOH Assessments ValueSet (preferred) |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | 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] | SΣI | 0..1 | Clinically relevant time/time-period for observation us-core-1: Datetime must be at least to day. | |
effectiveDateTime | dateTime S | |||
effectivePeriod | Period | |||
effectiveTiming | Timing | |||
effectiveInstant | instant | |||
issued | Σ | 0..1 | instant | Date/Time this version was made available |
performer | SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core Related Person) | Who is responsible for the observation |
value[x] | SΣI | 0..1 | Actual result us-core-3: SHALL use UCUM for coded quantity units. | |
valueQuantity | Quantity S | |||
valueCodeableConcept | CodeableConcept S | |||
valueString | string S | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
dataAbsentReason | SI | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |
note | 0..* | Annotation | Comments about the observation | |
bodySite | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |
method | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |
specimen | 0..1 | Reference(Specimen) | Specimen used for this observation | |
device | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |
referenceRange | I | 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 | I | 0..1 | SimpleQuantity | Low Range, if relevant |
high | I | 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 | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group |
derivedFrom | SΣ | 0..* | Reference(US Core Screening Response Observation Profile S | SDC Questionnaire Response S | US Core DocumentReference Profile | ImagingStudy | Media | MolecularSequence) | Related questionnaire responses or observations that the observation is made from |
component | SΣ | 0..* | BackboneElement | Component results |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | SΣ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (extensible) |
value[x] | SΣI | 0..1 | Actual component result us-core-3: SHALL use UCUM for coded quantity units. | |
valueQuantity | Quantity S | |||
valueCodeableConcept | CodeableConcept S | |||
valueString | string S | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
dataAbsentReason | SI | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |
referenceRange | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | I | 0..* | Observation | questionnaire observations us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present |
status | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
Slices for category | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |
category:survey | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following | |
coding | 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: survey | |
code | Σ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: US Core Common SDOH Assessments ValueSet (preferred) |
subject | Σ | 1..1 | Reference(US Core Patient Profile) | Who and/or what the observation is about |
effective[x] | ΣI | 0..1 | Clinically relevant time/time-period for observation us-core-1: Datetime must be at least to day. | |
effectiveDateTime | dateTime | |||
performer | Σ | 0..* | Reference(US Core Practitioner Profile) | Who is responsible for the observation |
value[x] | ΣI | 0..1 | Actual result us-core-3: SHALL use UCUM for coded quantity units. | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
dataAbsentReason | I | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
derivedFrom | Σ | 0..* | Reference(US Core Screening Response Observation Profile | SDC Questionnaire Response) | Related questionnaire responses or observations that the observation is made from |
component | Σ | 0..* | BackboneElement | Component results |
code | Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (extensible) |
value[x] | ΣI | 0..1 | Actual component result us-core-3: SHALL use UCUM for coded quantity units. | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
dataAbsentReason | I | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
Documentation for this format |
This structure is derived from Observation
Summary
Mandatory: 3 elements
Must-Support: 14 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | I | 0..* | Observation | questionnaire observations us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present |
status | S | 1..1 | code | registered | preliminary | final | amended + |
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this |
category:survey | S | 1..1 | CodeableConcept | Classification of type of observation Required Pattern: At least the following |
coding | 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: survey | |
code | S | 1..1 | CodeableConcept | Type of observation (code / type) Binding: US Core Common SDOH Assessments ValueSet (preferred) |
subject | S | 1..1 | Reference(US Core Patient Profile) | Who and/or what the observation is about |
effective[x] | SI | 0..1 | Clinically relevant time/time-period for observation us-core-1: Datetime must be at least to day. | |
effectiveDateTime | dateTime S | |||
effectivePeriod | Period | |||
effectiveTiming | Timing | |||
effectiveInstant | instant | |||
performer | S | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core Related Person) | Who is responsible for the observation |
value[x] | SI | 0..1 | Actual result us-core-3: SHALL use UCUM for coded quantity units. | |
valueQuantity | Quantity S | |||
valueCodeableConcept | CodeableConcept S | |||
valueString | string S | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
dataAbsentReason | SI | 0..1 | CodeableConcept | Why the result is missing |
derivedFrom | S | 0..* | Reference(US Core Screening Response Observation Profile S | SDC Questionnaire Response S | US Core DocumentReference Profile | ImagingStudy | Media | MolecularSequence) | Related questionnaire responses or observations that the observation is made from |
component | S | 0..* | BackboneElement | Component results |
code | S | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (extensible) |
value[x] | SI | 0..1 | Actual component result us-core-3: SHALL use UCUM for coded quantity units. | |
valueQuantity | Quantity S | |||
valueCodeableConcept | CodeableConcept S | |||
valueString | string S | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
dataAbsentReason | S | 0..1 | CodeableConcept | Why the component result is missing |
Documentation for this format |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | I | 0..* | Observation | questionnaire observations us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present |
id | Σ | 0..1 | string | 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) Max Binding: AllLanguages: A human language. | |
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
contained | 0..* | Resource | Contained, inline Resources | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | Σ | 0..* | Identifier | Business Identifier for observation |
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order |
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event |
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
category:survey | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: survey | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: US Core Common SDOH Assessments ValueSet (preferred) |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | 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] | SΣI | 0..1 | Clinically relevant time/time-period for observation us-core-1: Datetime must be at least to day. | |
effectiveDateTime | dateTime S | |||
effectivePeriod | Period | |||
effectiveTiming | Timing | |||
effectiveInstant | instant | |||
issued | Σ | 0..1 | instant | Date/Time this version was made available |
performer | SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core Related Person) | Who is responsible for the observation |
value[x] | SΣI | 0..1 | Actual result us-core-3: SHALL use UCUM for coded quantity units. | |
valueQuantity | Quantity S | |||
valueCodeableConcept | CodeableConcept S | |||
valueString | string S | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
dataAbsentReason | SI | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |
note | 0..* | Annotation | Comments about the observation | |
bodySite | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |
method | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |
specimen | 0..1 | Reference(Specimen) | Specimen used for this observation | |
device | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |
referenceRange | I | 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 | I | 0..1 | SimpleQuantity | Low Range, if relevant |
high | I | 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 | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group |
derivedFrom | SΣ | 0..* | Reference(US Core Screening Response Observation Profile S | SDC Questionnaire Response S | US Core DocumentReference Profile | ImagingStudy | Media | MolecularSequence) | Related questionnaire responses or observations that the observation is made from |
component | SΣ | 0..* | BackboneElement | Component results |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | SΣ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (extensible) |
value[x] | SΣI | 0..1 | Actual component result us-core-3: SHALL use UCUM for coded quantity units. | |
valueQuantity | Quantity S | |||
valueCodeableConcept | CodeableConcept S | |||
valueString | string S | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
dataAbsentReason | SI | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |
referenceRange | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |
Documentation for this format |
Other representations of profile: CSV, Excel, Schematron
Path | Conformance | ValueSet / Code |
Observation.language | preferred | CommonLanguages Max Binding: AllLanguages |
Observation.status | required | ObservationStatus |
Observation.category | preferred | ObservationCategoryCodes |
Observation.category:survey | preferred | Pattern: survey |
Observation.code | preferred | USCoreCommonSDOHAssessments |
Observation.dataAbsentReason | extensible | DataAbsentReason |
Observation.interpretation | extensible | ObservationInterpretationCodes |
Observation.bodySite | example | SNOMEDCTBodyStructures |
Observation.method | example | ObservationMethods |
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes |
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes |
Observation.component.code | extensible | LOINCCodes |
Observation.component.dataAbsentReason | extensible | DataAbsentReason |
Observation.component.interpretation | extensible | ObservationInterpretationCodes |
Id | Path | Details | Requirements |
us-core-2 | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) | |
us-core-1 | Observation.effective[x] | Datetime must be at least to day. : $this is DateTime implies $this.toString().length() >= 10 | |
us-core-3 | Observation.value[x] | SHALL use UCUM for coded quantity units. : valueQuantity.system.empty() or valueQuantity.system = 'http://unitsofmeasure.org' | |
obs-3 | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
us-core-3 | Observation.component.value[x] | SHALL use UCUM for coded quantity units. : valueQuantity.system.empty() or valueQuantity.system = 'http://unitsofmeasure.org' |
Below is an overview of the required Server RESTful FHIR interactions for this profile - for example, search and read operations - when supporting the US Core interactions to access this profile’s information (Profile Support + Interaction Support). Note that systems that support only US Core Profiles (Profile Only Support) are not required to support these interactions. See the US Core Server CapabilityStatement for a complete list of supported RESTful interactions for this IG.
The following search parameters and search parameter combinations SHALL be supported:
SHALL support searching using the combination of the patient
and category
search parameters:
GET [base]/Observation?patient={Type/}[id]&category=http://terminology.hl7.org/CodeSystem/observation-category|survey
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and a category code = survey
(how to search by reference and how to search by token)
patient
and code
search parameters:
code
(e.g.code={system|}[code],{system|}[code],...
)GET [base]/Observation?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and observation code(s). SHOULD support search by multiple report codes. The Observation code
parameter searches `Observation.code only. (how to search by reference and how to search by token)
patient
and category
and date
search parameters:
date
comparators: gt,lt,ge,le
date
(e.g.date=[date]&date=[date]]&...
)GET [base]/Observation?patient={Type/}[id]&category=http://terminology.hl7.org/CodeSystem/observation-category|survey&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and date and a category code = survey
(how to search by reference and how to search by token and how to search by date)
The following search parameter combinations SHOULD be supported:
patient
and category
and status
search parameters:
status
(e.g.status={system|}[code],{system|}[code],...
)GET [base]/Observation?patient={Type/}[id]&category=http://terminology.hl7.org/CodeSystem/observation-category|survey&status={system|}[code]{,{system|}[code],...}
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and category = survey
and status (how to search by reference and how to search by token)
patient
and code
and date
search parameters:
code
(e.g.code={system|}[code],{system|}[code],...
)date
comparators: gt,lt,ge,le
date
(e.g.date=[date]&date=[date]]&...
)GET [base]/Observation?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and date and report code(s). SHOULD support search by multiple report codes. (how to search by reference and how to search by token and how to search by date)