HL7.FHIR.US.DENTAL-DATA-EXCHANGE\Dental Findings Profile

This page is part of the Dental Data Exchange (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

Resource Profile: DentalFindings

This profile is used to convey oral findings including findings of an Odontogram, Peridontal (overall assessment and tooth-specific observations), Intra and Extra Oral Soft Tissue, TMJ, TMD, and Occlusion. Note - findings in this profile often support associated diagnoses (FHIR Conditions).

The official URL for this profile is:

http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-findings

Formal Views of Profile Content

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

Text Summary
Differential Table
Snapshot Table
Snapshot Table (Must Support)
All

This structure is derived from Observation

Summary

Structures

This structure refers to these other structures:

This structure is derived from Observation

Name	Card.	Type	Description & Constraints
Observation	0..*	Observation	Measurements and simple assertions
code	1..1	CodeableConcept	Type of observation (code / type) Binding: Dental Observation Codes (extensible)
subject	0..1	Reference(US Core Patient Profile)	Who and/or what the observation is about
encounter	0..1	Reference(US Core Encounter Profile)	Healthcare event during which this observation is made
performer	0..*	Reference(US Core Practitioner Profile)	Who is responsible for the observation
bodySite	0..1	CodeableConcept	Observed body part Binding: Dental Anatomy (preferred)
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Observation	I	0..*	Observation	Measurements and simple assertions
id	Σ	0..1	string	Logical id of this artifact
meta	ΣI	0..1	Meta	Metadata about the resource
implicitRules	?!ΣI	0..1	uri	A set of rules under which this content was created
language	I	0..1	code	Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages
text	I	0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!I	0..*	Extension	Extensions that cannot be ignored
identifier	ΣI	0..*	Identifier	Business Identifier for observation
basedOn	ΣI	0..*	Reference(CarePlan \| DeviceRequest \| ImmunizationRecommendation \| MedicationRequest \| NutritionOrder \| ServiceRequest)	Fulfills plan, proposal or order
partOf	ΣI	0..*	Reference(MedicationAdministration \| MedicationDispense \| MedicationStatement \| Procedure \| Immunization \| ImagingStudy)	Part of referenced event
status	?!ΣI	1..1	code	registered \| preliminary \| final \| amended + Binding: ObservationStatus (required)
category	I	0..*	CodeableConcept	Classification of type of observation Binding: ObservationCategoryCodes (preferred)
code	ΣI	1..1	CodeableConcept	Type of observation (code / type) Binding: Dental Observation Codes (extensible)
subject	ΣI	0..1	Reference(US Core Patient Profile)	Who and/or what the observation is about
focus	ΣI	0..*	Reference(Resource)	What the observation is about, when it is not about the subject of record
encounter	ΣI	0..1	Reference(US Core Encounter Profile)	Healthcare event during which this observation is made
effective[x]	ΣI	0..1		Clinically relevant time/time-period for observation
effectiveDateTime			dateTime
effectivePeriod			Period
effectiveTiming			Timing
effectiveInstant			instant
issued	ΣI	0..1	instant	Date/Time this version was made available
performer	ΣI	0..*	Reference(US Core Practitioner Profile)	Who is responsible for the observation
value[x]	ΣI	0..1		Actual result
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	I	0..1	CodeableConcept	Why the result is missing Binding: DataAbsentReason (extensible)
interpretation	I	0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible)
note	I	0..*	Annotation	Comments about the observation
bodySite	I	0..1	CodeableConcept	Observed body part Binding: Dental Anatomy (preferred)
method	I	0..1	CodeableConcept	How it was done Binding: ObservationMethods (example)
specimen	I	0..1	Reference(Specimen)	Specimen used for this observation
device	I	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	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	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	I	0..1	CodeableConcept	Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred)
appliesTo	I	0..*	CodeableConcept	Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example)
age	I	0..1	Range	Applicable age range, if relevant
text	I	0..1	string	Text based reference range in an observation
hasMember	ΣI	0..*	Reference(Observation \| QuestionnaireResponse \| MolecularSequence)	Related resource that belongs to the Observation group
derivedFrom	ΣI	0..*	Reference(DocumentReference \| ImagingStudy \| Media \| QuestionnaireResponse \| Observation \| MolecularSequence)	Related measurements the observation is made from
component	ΣI	0..*	BackboneElement	Component results
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	ΣI	1..1	CodeableConcept	Type of component observation (code / type) Binding: LOINCCodes (example)
value[x]	ΣI	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	I	0..1	CodeableConcept	Why the component result is missing Binding: DataAbsentReason (extensible)
interpretation	I	0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible)
referenceRange	I	0..*	See referenceRange	Provides guide for interpretation of component result
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Observation	I	0..*	Observation	Measurements and simple assertions
Documentation for this format

This structure is derived from Observation

Summary

Structures

This structure refers to these other structures:

Differential View

This structure is derived from Observation

Name	Card.	Type	Description & Constraints
Observation	0..*	Observation	Measurements and simple assertions
code	1..1	CodeableConcept	Type of observation (code / type) Binding: Dental Observation Codes (extensible)
subject	0..1	Reference(US Core Patient Profile)	Who and/or what the observation is about
encounter	0..1	Reference(US Core Encounter Profile)	Healthcare event during which this observation is made
performer	0..*	Reference(US Core Practitioner Profile)	Who is responsible for the observation
bodySite	0..1	CodeableConcept	Observed body part Binding: Dental Anatomy (preferred)
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Observation	I	0..*	Observation	Measurements and simple assertions
id	Σ	0..1	string	Logical id of this artifact
meta	ΣI	0..1	Meta	Metadata about the resource
implicitRules	?!ΣI	0..1	uri	A set of rules under which this content was created
language	I	0..1	code	Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages
text	I	0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!I	0..*	Extension	Extensions that cannot be ignored
identifier	ΣI	0..*	Identifier	Business Identifier for observation
basedOn	ΣI	0..*	Reference(CarePlan \| DeviceRequest \| ImmunizationRecommendation \| MedicationRequest \| NutritionOrder \| ServiceRequest)	Fulfills plan, proposal or order
partOf	ΣI	0..*	Reference(MedicationAdministration \| MedicationDispense \| MedicationStatement \| Procedure \| Immunization \| ImagingStudy)	Part of referenced event
status	?!ΣI	1..1	code	registered \| preliminary \| final \| amended + Binding: ObservationStatus (required)
category	I	0..*	CodeableConcept	Classification of type of observation Binding: ObservationCategoryCodes (preferred)
code	ΣI	1..1	CodeableConcept	Type of observation (code / type) Binding: Dental Observation Codes (extensible)
subject	ΣI	0..1	Reference(US Core Patient Profile)	Who and/or what the observation is about
focus	ΣI	0..*	Reference(Resource)	What the observation is about, when it is not about the subject of record
encounter	ΣI	0..1	Reference(US Core Encounter Profile)	Healthcare event during which this observation is made
effective[x]	ΣI	0..1		Clinically relevant time/time-period for observation
effectiveDateTime			dateTime
effectivePeriod			Period
effectiveTiming			Timing
effectiveInstant			instant
issued	ΣI	0..1	instant	Date/Time this version was made available
performer	ΣI	0..*	Reference(US Core Practitioner Profile)	Who is responsible for the observation
value[x]	ΣI	0..1		Actual result
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	I	0..1	CodeableConcept	Why the result is missing Binding: DataAbsentReason (extensible)
interpretation	I	0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible)
note	I	0..*	Annotation	Comments about the observation
bodySite	I	0..1	CodeableConcept	Observed body part Binding: Dental Anatomy (preferred)
method	I	0..1	CodeableConcept	How it was done Binding: ObservationMethods (example)
specimen	I	0..1	Reference(Specimen)	Specimen used for this observation
device	I	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	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	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	I	0..1	CodeableConcept	Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred)
appliesTo	I	0..*	CodeableConcept	Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example)
age	I	0..1	Range	Applicable age range, if relevant
text	I	0..1	string	Text based reference range in an observation
hasMember	ΣI	0..*	Reference(Observation \| QuestionnaireResponse \| MolecularSequence)	Related resource that belongs to the Observation group
derivedFrom	ΣI	0..*	Reference(DocumentReference \| ImagingStudy \| Media \| QuestionnaireResponse \| Observation \| MolecularSequence)	Related measurements the observation is made from
component	ΣI	0..*	BackboneElement	Component results
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	ΣI	1..1	CodeableConcept	Type of component observation (code / type) Binding: LOINCCodes (example)
value[x]	ΣI	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	I	0..1	CodeableConcept	Why the component result is missing Binding: DataAbsentReason (extensible)
interpretation	I	0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible)
referenceRange	I	0..*	See referenceRange	Provides guide for interpretation of component result
Documentation for this format

Other representations of profile: Schematron

Terminology Bindings

Path	Conformance	ValueSet
Observation.language	preferred	CommonLanguages Max Binding: AllLanguages
Observation.status	required	ObservationStatus
Observation.category	preferred	ObservationCategoryCodes
Observation.code	extensible	DentalObservationCodes
Observation.dataAbsentReason	extensible	DataAbsentReason
Observation.interpretation	extensible	ObservationInterpretationCodes
Observation.bodySite	preferred	DentalAnatomy
Observation.method	example	ObservationMethods
Observation.referenceRange.type	preferred	ObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesTo	example	ObservationReferenceRangeAppliesToCodes
Observation.component.code	example	LOINCCodes
Observation.component.dataAbsentReason	extensible	DataAbsentReason
Observation.component.interpretation	extensible	ObservationInterpretationCodes

Constraints

Id	Path	Details	Requirements
dom-2	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	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	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	Observation	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	Observation	A resource should have narrative for robust management : text.`div`.exists()
obs-6	Observation	dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty()
obs-7	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()
ele-1	Observation.meta	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.implicitRules	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.language	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.text	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Observation.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Observation.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Observation.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Observation.identifier	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.basedOn	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.partOf	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.status	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.category	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.code	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.subject	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.focus	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.encounter	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.effective[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.issued	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.performer	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.value[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.dataAbsentReason	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.interpretation	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.note	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.bodySite	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.method	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.specimen	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.device	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.referenceRange	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
obs-3	Observation.referenceRange	Must have at least a low or a high or text : low.exists() or high.exists() or text.exists()
ele-1	Observation.referenceRange.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Observation.referenceRange.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Observation.referenceRange.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Observation.referenceRange.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Observation.referenceRange.low	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.referenceRange.high	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.referenceRange.type	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.referenceRange.appliesTo	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.referenceRange.age	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.referenceRange.text	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.hasMember	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.derivedFrom	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.component	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.component.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Observation.component.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Observation.component.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Observation.component.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Observation.component.code	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.component.value[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.component.dataAbsentReason	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.component.interpretation	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Observation.component.referenceRange	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())