This page is part of the US Core (v6.0.0: STU6) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
Official URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus | Version: 6.0.0 | |||
Active as of 2022-04-20 | Computable Name: USCoreSmokingStatusProfile | |||
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License |
The US Core Smoking Status Observation Profile is based upon the core FHIR Observation Resource and implements the U.S. Core Data for Interoperability (USCDI) v2 Smoking status’ requirements. This profile sets minimum expectations for the Observation resource to record, search, and fetch smoking status data associated with a patient to promote interoperability and adoption through common implementation. It identifies which core elements, extensions, vocabularies, and value sets SHALL be present in the resource and constrains the way the elements are used when using this profile. It provides the floor for standards development for specific use cases.
Example Usage Scenarios:
The following are example usage scenarios for the US Core-SmokingStatus 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 Views below provides the formal summary, definitions, and terminology requirements.
Each Observation Must Have:
* see guidance below
Profile Specific Implementation Guidance:
Observation.code
is extensible, and all Observation.value[x]
data types are available to encourage the use of this profile for other smoking questions such as the code - 67741-9 Smoking tobacco use duration.Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | 0..* | Observation | Measurements and simple assertions | |||||
status | S | 1..1 | code | (USCDI) registered | preliminary | final | amended + Binding: US Core Status for Smoking Status Observation (required) | ||||
Slices for category | S | 1..* | CodeableConcept | (USCDI) Classification of type of observation Slice: Unordered, Open by pattern:$this | ||||
category:SocialHistory | S | 1..1 | CodeableConcept | (USCDI) 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: social-history | |||||
code | S | 1..1 | CodeableConcept | (USCDI) Smoking Status Binding: US Core Smoking Status Observation Codes (extensible) | ||||
subject | S | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who and/or what the observation is about | ||||
effectiveDateTime | S | 1..1 | dateTime | (USCDI) Clinically relevant time/time-period for observation | ||||
value[x] | SC | 1..1 | (USCDI) Typically Coded Responses from Smoking Status Value Set Binding: Smoking Status (preferred): This value set enumerates codes SNOMED CT codes historically used for the current smoking status of a patient with a maximum required binding to Snomed CT codes.
us-core-3: SHALL use UCUM for coded quantity units. | |||||
valueCodeableConcept | CodeableConcept S | |||||||
valueQuantity | Quantity | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
Observation.status | required | USCoreObservationSmokingStatusStatus | ||||
Observation.code | extensible | USCoreSmokingStatusObservationCodes | ||||
Observation.value[x] | preferred | Smoking Status
|
Id | Grade | Path(s) | Details | Requirements |
us-core-3 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : valueQuantity.system.empty() or valueQuantity.system = 'http://unitsofmeasure.org' |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | Measurements and simple assertions | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
status | ?!SΣ | 1..1 | code | (USCDI) registered | preliminary | final | amended + Binding: US Core Status for Smoking Status Observation (required) | ||||
Slices for category | S | 1..* | CodeableConcept | (USCDI) Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
category:SocialHistory | S | 1..1 | CodeableConcept | (USCDI) 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: social-history | |||||
code | SΣ | 1..1 | CodeableConcept | (USCDI) Smoking Status Binding: US Core Smoking Status Observation Codes (extensible) | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who and/or what the observation is about | ||||
Slices for effective[x] | Σ | 1..1 | dateTime | Clinically relevant time/time-period for observation Slice: Unordered, Closed by type:$this | ||||
effective[x]:effectiveDateTime | SΣ | 1..1 | dateTime | (USCDI) Clinically relevant time/time-period for observation | ||||
value[x] | SΣC | 1..1 | (USCDI) Typically Coded Responses from Smoking Status Value Set Binding: Smoking Status (preferred): This value set enumerates codes SNOMED CT codes historically used for the current smoking status of a patient with a maximum required binding to Snomed CT codes.
us-core-3: SHALL use UCUM for coded quantity units. | |||||
valueCodeableConcept | CodeableConcept | |||||||
Documentation for this format |
Path | Conformance | ValueSet / Code | ||||
Observation.status | required | USCoreObservationSmokingStatusStatus | ||||
Observation.category | preferred | ObservationCategoryCodes | ||||
Observation.category:SocialHistory | preferred | Pattern: social-history | ||||
Observation.code | extensible | USCoreSmokingStatusObservationCodes | ||||
Observation.value[x] | preferred | Smoking Status
|
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
us-core-3 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : valueQuantity.system.empty() or valueQuantity.system = 'http://unitsofmeasure.org' |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | 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: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | 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 | (USCDI) registered | preliminary | final | amended + Binding: US Core Status for Smoking Status Observation (required) | ||||
Slices for category | S | 1..* | CodeableConcept | (USCDI) Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
category:SocialHistory | S | 1..1 | CodeableConcept | (USCDI) 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: social-history | |||||
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 | (USCDI) Smoking Status Binding: US Core Smoking Status Observation Codes (extensible) | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who and/or what the observation is about | ||||
focus | ΣTU | 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 | ||||
Slices for effective[x] | Σ | 1..1 | dateTime | Clinically relevant time/time-period for observation Slice: Unordered, Closed by type:$this | ||||
effective[x]:effectiveDateTime | SΣ | 1..1 | dateTime | (USCDI) Clinically relevant time/time-period for observation | ||||
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 | ||||
value[x] | SΣC | 1..1 | (USCDI) Typically Coded Responses from Smoking Status Value Set Binding: Smoking Status (preferred): This value set enumerates codes SNOMED CT codes historically used for the current smoking status of a patient with a maximum required binding to Snomed CT codes.
us-core-3: SHALL use UCUM for coded quantity units. | |||||
valueCodeableConcept | CodeableConcept S | |||||||
valueQuantity | Quantity | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | C | 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 | C | 0..* | 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 | ||||
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 | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
component | 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: 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 | 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: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
referenceRange | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |||||
Documentation for this format |
Id | Grade | Path(s) | Details | Requirements |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
us-core-3 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : valueQuantity.system.empty() or valueQuantity.system = 'http://unitsofmeasure.org' |
This structure is derived from Observation
Summary
Mandatory: 5 elements
Must-Support: 7 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 | 0..* | Observation | Measurements and simple assertions | |||||
status | S | 1..1 | code | (USCDI) registered | preliminary | final | amended + Binding: US Core Status for Smoking Status Observation (required) | ||||
Slices for category | S | 1..* | CodeableConcept | (USCDI) Classification of type of observation Slice: Unordered, Open by pattern:$this | ||||
category:SocialHistory | S | 1..1 | CodeableConcept | (USCDI) 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: social-history | |||||
code | S | 1..1 | CodeableConcept | (USCDI) Smoking Status Binding: US Core Smoking Status Observation Codes (extensible) | ||||
subject | S | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who and/or what the observation is about | ||||
effectiveDateTime | S | 1..1 | dateTime | (USCDI) Clinically relevant time/time-period for observation | ||||
value[x] | SC | 1..1 | (USCDI) Typically Coded Responses from Smoking Status Value Set Binding: Smoking Status (preferred): This value set enumerates codes SNOMED CT codes historically used for the current smoking status of a patient with a maximum required binding to Snomed CT codes.
us-core-3: SHALL use UCUM for coded quantity units. | |||||
valueCodeableConcept | CodeableConcept S | |||||||
valueQuantity | Quantity | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
Observation.status | required | USCoreObservationSmokingStatusStatus | ||||
Observation.code | extensible | USCoreSmokingStatusObservationCodes | ||||
Observation.value[x] | preferred | Smoking Status
|
Id | Grade | Path(s) | Details | Requirements |
us-core-3 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : valueQuantity.system.empty() or valueQuantity.system = 'http://unitsofmeasure.org' |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | Measurements and simple assertions | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
status | ?!SΣ | 1..1 | code | (USCDI) registered | preliminary | final | amended + Binding: US Core Status for Smoking Status Observation (required) | ||||
Slices for category | S | 1..* | CodeableConcept | (USCDI) Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
category:SocialHistory | S | 1..1 | CodeableConcept | (USCDI) Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following | ||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: social-history | |||||
code | SΣ | 1..1 | CodeableConcept | (USCDI) Smoking Status Binding: US Core Smoking Status Observation Codes (extensible) | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who and/or what the observation is about | ||||
Slices for effective[x] | Σ | 1..1 | dateTime | Clinically relevant time/time-period for observation Slice: Unordered, Closed by type:$this | ||||
effective[x]:effectiveDateTime | SΣ | 1..1 | dateTime | (USCDI) Clinically relevant time/time-period for observation | ||||
value[x] | SΣC | 1..1 | (USCDI) Typically Coded Responses from Smoking Status Value Set Binding: Smoking Status (preferred): This value set enumerates codes SNOMED CT codes historically used for the current smoking status of a patient with a maximum required binding to Snomed CT codes.
us-core-3: SHALL use UCUM for coded quantity units. | |||||
valueCodeableConcept | CodeableConcept | |||||||
Documentation for this format |
Path | Conformance | ValueSet / Code | ||||
Observation.status | required | USCoreObservationSmokingStatusStatus | ||||
Observation.category | preferred | ObservationCategoryCodes | ||||
Observation.category:SocialHistory | preferred | Pattern: social-history | ||||
Observation.code | extensible | USCoreSmokingStatusObservationCodes | ||||
Observation.value[x] | preferred | Smoking Status
|
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
us-core-3 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : valueQuantity.system.empty() or valueQuantity.system = 'http://unitsofmeasure.org' |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | 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: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | 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 | (USCDI) registered | preliminary | final | amended + Binding: US Core Status for Smoking Status Observation (required) | ||||
Slices for category | S | 1..* | CodeableConcept | (USCDI) Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
category:SocialHistory | S | 1..1 | CodeableConcept | (USCDI) Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: social-history | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
code | SΣ | 1..1 | CodeableConcept | (USCDI) Smoking Status Binding: US Core Smoking Status Observation Codes (extensible) | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who and/or what the observation is about | ||||
focus | ΣTU | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made | ||||
Slices for effective[x] | Σ | 1..1 | dateTime | Clinically relevant time/time-period for observation Slice: Unordered, Closed by type:$this | ||||
effective[x]:effectiveDateTime | SΣ | 1..1 | dateTime | (USCDI) Clinically relevant time/time-period for observation | ||||
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 | ||||
value[x] | SΣC | 1..1 | (USCDI) Typically Coded Responses from Smoking Status Value Set Binding: Smoking Status (preferred): This value set enumerates codes SNOMED CT codes historically used for the current smoking status of a patient with a maximum required binding to Snomed CT codes.
us-core-3: SHALL use UCUM for coded quantity units. | |||||
valueCodeableConcept | CodeableConcept S | |||||||
valueQuantity | Quantity | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | C | 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 | C | 0..* | 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 | ||||
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 | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
component | 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: 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 | 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: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
referenceRange | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | ||||
Observation.language | preferred | CommonLanguages
| ||||
Observation.status | required | USCoreObservationSmokingStatusStatus | ||||
Observation.category | preferred | ObservationCategoryCodes | ||||
Observation.category:SocialHistory | preferred | Pattern: social-history | ||||
Observation.code | extensible | USCoreSmokingStatusObservationCodes | ||||
Observation.value[x] | preferred | Smoking Status
| ||||
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 | example | LOINCCodes (a valid code from LOINC) | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReason | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodes |
Id | Grade | Path(s) | Details | Requirements |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
us-core-3 | error | Observation.value[x] | SHALL use UCUM for coded quantity units. : valueQuantity.system.empty() or valueQuantity.system = 'http://unitsofmeasure.org' |
This structure is derived from Observation
Summary
Mandatory: 5 elements
Must-Support: 7 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
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 syntax used to describe the interactions is described here.
patient/Observation.rs
)patient.Observation.rs?category=http://terminology.hl7.org/3.1.0/CodeSystem-observation-category.html|social-history
).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|}social-history
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and a category code = social-history
(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|}social-history&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 = social-history
(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|}social-history&status={system|}[code]{,{system|}[code],...}
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and category = social-history
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)