Records blood pressure measurements, defined as the force of circulating blood on the walls of the arteries.

Conformance note: The blood pressure profile is based on the FHIR profile for blood pressure, and adds a set of optional elements that can help clinicians interpret the result. Because these additional elements are optional, any BloodPressure that conforms to the current profile also will conform to the FHIR profile, and vice versa.

Records the body height, defined as the distance from the sole to the crown of the head.

Records the body weight, defined as the mass or quantity of heaviness of the individual.

Complete blood count (CBC) with auto differential panel. Includes various measures of red blood cells, platelets, and various types of white blood cells and other related measures, such as hemoglobin. The components of this panel are not entirely standardized, so the definition of the CBC includes tests that are optional, or performed by certain laboratories but not others. Instances typically will include a subset of the listed panel members.

A clinician’s qualitative judgment on the current trend of the cancer, e.g., whether it is stable, worsening (progressing), or improving (responding). The judgment may be based a single type or multiple kinds of evidence, such as imaging data, assessment of symptoms, tumor markers, laboratory data, etc.

A radiological treatment addressing a cancer condition. The scope of this profile has been narrowed to cancer-related procedures by constraining the ReasonReference and ReasonCode to cancer conditions.

Conformance note: If an ICD-10-PCS code is used in the code attribute, and there is a semantically equivalent SNOMED CT or CPT code, the resulting Procedure instance will not be compliant with US Core Profiles

A surgical action addressing a cancer condition.

Conformance note: If an ICD-10-PCS code is used in the code attribute, and there is a semantically equivalent SNOMED CT or CPT code, the resulting Procedure instance will not be compliant with US Core Profiles.

A comorbidity refers to one or more diseases or conditions that occur along with another condition in the same person at the same time. Conditions considered comorbidities are often long-term or chronic conditions. Comorbidities are defined relative to an index disease and may be categorical, rather than described in full detail. The comorbid condition class provides comorbidity codes corresponding the Elixhauser Comorbidity Index.

Conformance note: If an ICD-10-CM code is used for the code attribute, and a semantically equivalent SNOMED code is available, the resulting instance will not be compliant with US Core Profiles.

Represents a comprehensive metabolic 2000 panel (CMP) from serum or plasma, which measures various components such as glucose, electrolytes, kidney function, and liver function. The components of this panel are not entirely standardized, so the definition of the CMP includes tests that are optional, or performed by certain laboratories but not others. Therefore, instances typically will include a subset of the listed panel members.

The Eastern Cooperative Oncology Group (ECOG) Performance Status represents the patient’s functional status and is used to determine their ability to tolerate therapies in serious illness, specifically for chemotherapy. Source: LOINC

Records an alteration in the most common DNA nucleotide sequence. The term variant can be used to describe an alteration that may be benign, pathogenic, or of unknown significance. The term variant is increasingly being used in place of the term mutation. When reporting ‘Genetic Variant Found’, at least one element out of the following must be reported: ‘Variant Found Identifier’, ‘Variant Found HGVS Name’, and ‘Variant Found Description’.

A test for a specific mutation on a particular gene. This profile is used to record whether a single discrete variant tested is present or absent (denoted as positive or negative respectively).

Genetic analysis summary report. The report may include one or more tests, with two distinct test types. The first type is a targeted mutation test, where a specific mutation on a specific gene is tested for. The result is either positive or negative for that mutation. The second type is a more general test for variants. This type of test returns the identity of variants found in a certain region of the genome.

The identity of non-genomic laboratory tests is typically represented by a LOINC code. However, many genetic tests and panels do not have LOINC codes, although some might have an identifier in NCBI Genetic Testing Registry (GTR), a central location for voluntary submission of genetic test information by providers. To identify the diagnostic report, the name of the report must be in the text sub-field of the code structure. If there is a coded identifier from GTR, LOINC, or other source, then it should be included into the the code sub-field of the code structure. If there is no suitable code, the code can be omitted.

Conformance note: To be conformant to US Core, the code attribute must be a LOINC code, if available. If there is no suitable code in LOINC, then a code from an alternative code system (such as GTR) can be used.

Implementation note: The performer of the test (organization or practitioner) should be included in the FHIR profile as the performer.actor.

Conformance note: The category for this profile is set to GE (Genetics), a code from http://hl7.org/fhir/ValueSet/diagnostic-service-sections. This is contrary to the Argonaut and US Core specifications, which require the category ‘LAB’ in diagnostic reports containing laboratory results. This is assumed to be an oversight in the US Core and Argonaut specifications.

The Karnofsky Performance Status (KPS) is a tool used to measure a patient’s functional status. It can be used to compare the effectiveness of different therapies and to help assess the prognosis of certain patients, such as those with certain cancers. The KPS score ranges from 0 to 100 in intervals of 10. Higher scores are associated with better functional status, with 100 representing no symptoms or evidence of disease, and 0 representing death.

A record of the use of a medication (individual administration or entire course). The use may be reported by the patient or clinician and adminstration does not have to be directly observed.

Implementation note: Although FHIR supports the asserter (information source) and date asserted, it does not have a place for the author (who created and is responsible for the statement) and recorder (who entered the statement). Extensions are provided.

Conformance note: The treatment of ‘not taken’ has changed from DSTU2 and STU3 to R4. In R4, status and statusReason are used to indicate medications not taken. For upward compatibility, the ‘not taken’ attributes are profiled out. ReasonCode is a choice of CodeableConcept or ref(Condition) in DSTU2, and limited to one reason (pick a type). In STU3 and R4, there can be multiple reason codes, and multiple reason references, simultaneously.

Implementation note: Preference is given to using the National Library of Medicine (NLM) RxNorm terminology for medications. RxNorm is a coding standard established by the Office of the National Coordinator (ONC). However, RxNorm is restricted to FDA-approved drugs and does not include clinical trial drugs. MedicationStatement allows for the inclusion of other coding systems like the NCI Thesaurus (NCIT) to represent clinical trial oncology drugs.

A person in the role of a patient. Sometimes, the patient is not the subject of information in a clinical statement where the Patient is the SubjectOfRecord.

Compatibility: Lies at the intersection of Argonaut and US Core Patient. MaritalStatus has a required binding in Argonaut, but an extensible binding in US-Core. To be feasible under both DSTU2 Argonaut and STU3 US-Core, the required binding strength is adopted.

Records the history of the primary cancer condition, the original or first tumor in the body (reference https://www.cancer.gov/publications/dictionaries/cancer-terms/def/primary-tumor). Cancers that are not clearly secondary (i.e., of uncertain origin or behavior) should be documented as primary.

Cancer staging information summarized in this profile should reflect the most recent staging assessment on the patient, and should be updated if and when there is a new staging assessment. Past staging assessments will be preserved in instances of the TNMClinicalStageGroup and/or TNMPathologicalStageGroup, which refer back to PrimaryCancerCondition.

Conformance note: For the code attribute, to be compliant with US Core Profiles, SNOMED CT must be used unless there is no suitable code, in which case ICD-10-CM can be used.

Records the history of secondary neoplasms, including location(s) and the date of onset of metastases. A secondary cancer results from the spread (metastasization) of cancer from its original site (reference: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/secondary-tumor).

Conformance note: For the code attribute, to be compliant with US Core Profiles, SNOMED CT must be used unless there is no suitable code, in which case ICD-10-CM can be used.

Category describing the presence or absence of metastases in remote anatomical locations, assessed using tests that are done before surgery. These include physical exams, imaging tests, laboratory tests (such as blood tests), and biopsies (definition adapted from NCI Dictionary of Cancer Terms).

Category of the primary tumor, based on its size and extent, assessed prior to surgery, based on evidence such as physical examination, imaging, and/or biopsy.

Category of the presence or absence of metastases in regional lymph nodes, assessed using tests that are done before surgery. These include physical exams, imaging tests, laboratory tests (such as blood tests), and biopsies (definition adapted from NCI Dictionary of Cancer Terms).

The extent of the cancer in the body, according to the TNM classification system, based on information obtained prior to neoadjuvant treatment and surgery, e.g. based on evidence such as physical examination, imaging, and/or biopsy.

Category describing the presence or absence of metastases in remote anatomical locations, assessed through pathologic analysis of a specimen.

Category describing the primary tumor, based on its size and extent, assessed through pathologic analysis of a tumor specimen.

Category describing the presence or absence of metastases in regional lymph nodes, assessed through pathologic analysis of a specimen.

The extent of the cancer in the body, according to the TNM classification system, based on examination of tissue samples removed during surgery, in addition to physical examination and imaging and potentially, other prognostic factors.

The result of a tumor marker test. Tumor marker tests are generally used to guide cancer treatment decisions and monitor treatment, as well as to predict the chance of recovery and cancer recurrence. A tumor marker is a substance found in tissue or blood or other body fluids that may be a sign of cancer or certain benign (noncancer) conditions. Most tumor markers are made by both normal cells and cancer cells, but they are made in larger amounts by cancer cells. A tumor marker may help to diagnose cancer, plan treatment, or find out how well treatment is working or if cancer has come back. Examples of tumor markers include CA-125 (in ovarian cancer), CA 15-3 (in breast cancer), CEA (in colon cancer), and PSA (in prostate cancer). Tumor markers differ from genetic markers in that they are measured at the levels of the protein and substance post-RNA protein synthesis. (Source: Adapted from NCI Dictionary of Cancer Terms and Cancer.net)

Implementation note: The data value for TumorMarkerTest has cardinality is 0..1 (required if known) because when the test result is indeterminate, no quantitative data value will be reported. Instead, the reason for the null value will be reported in the DataAbsentReason field.

A body structure such as wound or tumor, observed to be present in a patient. The body structure is a condition that persists over time. The Code represents the body structure itself (the morphology), while the BodyLocation is the location of that structure. This corresponds to FHIR R4, where the BodyStructure resource has morphology (corresponding to Code) and a location. For example, the Code could be blunt force injury (SCT 3821009) and location left knee.

Abstract class representing an event occurrence or performance of any type of action.

Abstract class representing a request for any type of action to be performed.

Abstract class representing any type of action or event.

Alanine aminotransferase [Enzymatic activity/​volume] in Serum or Plasma

Albumin/​Globulin [Mass Ratio] in Serum or Plasma

Albumin [Mass/​volume] in Serum or Plasma

Alkaline phosphatase [Enzymatic activity/​volume] in Serum or Plasma

Anion gap in Serum or Plasma. Units are optional but if provided, must be in mmol/L.

Aspartate aminotransferase [Enzymatic activity/​volume] in Serum or Plasma

Basophils/​100 leukocytes in Blood by Automated count

Basophils [#/​volume] in Blood by Automated count

Bicarbonate [Moles/​volume] in Serum or Plasma

Bilirubin.direct [Mass/​volume] in Serum or Plasma

Bilirubin.total [Mass/​volume] in Serum or Plasma

Blasts/100 leukocytes in Blood by Manual count

Blasts [#/volume] in Blood. Units not required by LOINC but are strongly recommended.

Calcium [Mass/​volume] in Serum or Plasma

Abstract class for describing a primary or secondary metastatic neoplastic diseases.

Abstract parent class for members of cancer staging panels. Cancer panel members must include a timing element and staging system, and focus on a cancer disorder. Specific realizations will have value sets specific to certain staging systems.

A panel that contains cancer staging information. This class is the parent of classes containing information related to clinical and pathologic staging, including TNMClinicalStageGroup and TNMPathologicStageGroup.

Carbon dioxide, total [Moles/​volume] in Serum or Plasma

Chloride [Moles/​volume] in Serum or Plasma

This abstract class provides properties and behaviors common to entries in a medical record. Patient and Encounter are ubiquitous in clinical statements. This class also allows for common representation of simple data provenance elements asserter, recorder, and creation date.

The result of evaluations (measurements, tests, or questions) whose answer is expressed as a code.

A condition that is or may be present in a subject. ‘Condition’ is interpreted broadly and could be a disorder, abnormality, problem, injury, complaint, functionality, illness, disease, ailment, sickness, affliction, upset, difficulty, disorder, symptom, worry, or trouble. The Observation-based class, ConditionAbsent, should be used to describe conditions that are not present or negative findings. This profiled Condition uses the BodyLocation structure that includes not only a code, but optional laterality, direction, and relation to landmark(s).

Creatinine [Mass/​volume] in Serum or Plasma

The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports.

Parent class for any item in clinical or administrative health-related system. A DomainResource can belong to a single person’s health record, or represent an entity that surfaces in multiple records, such as organizations, providers, payments, decision support artifacts, etc.

Note to FHIR implementers: Objective FHIR includes Status and Identifier fields on DomainResource because these two attributes occur in almost every FHIR resource. The most significant exception are 3 or 4 resources that use an ‘active’ flag instead of coded status value. There is no apparent pattern to this inconsistency. FHIR resources that use a coded status have active and inactive as status values. In the spirit of providing a consistent object-oriented logical model for FHIR, Objective FHIR uses status across all domain resources.

Abstract element representing a group of services delivered to a patient.

Root class for entities such as people, organizations, and devices that have a separately identifiable existence.

Abstract parent class for both Entity and Role.

Eosinophils/​100 leukocytes in Blood by Automated count

Eosinophils [#/​volume] in Blood by Automated count

Erythrocyte distribution width [Entitic volume] by Automated count

Erythrocyte distribution width [Ratio] by Automated count

MCHC [Mass/​volume] by Automated count

MCH [Entitic mass] by Automated count

Erythrocytes [#/​volume] in Blood by Automated count.

Nucleated erythrocytes/100 leukocytes [Ratio] in Blood by Automated count. Units not required by LOINC but are strongly recommended.

Nucleated erythrocytes/100 leukocytes [Ratio] in Blood. Units are required.

Nucleated erythrocytes [#/volume] in Blood. Units not required by LOINC but are strongly recommended.

Glomerular filtration rate/​1.73 sq M.predicted [Volume Rate/​Area] in Serum or Plasma by Creatinine-based formula (MDRD). Units are optional.

Glomerular filtration rate/​1.73 sq M predicted among blacks [Volume Rate/​Area] in Serum, Plasma or Blood by Creatinine-based formula (MDRD). Units are optional.

Glomerular filtration rate/​1.73 sq M predicted among females [Volume Rate/​Area] in Serum, Plasma or Blood by Creatinine-based formula (MDRD). Units are optional.

Glomerular filtration rate/​1.73 sq M predicted among non-blacks [Volume Rate/​Area] in Serum, Plasma or Blood by Creatinine-based formula (MDRD). Units are optional.

Globulin [Mass/​volume] in Serum by calculation

Glucose [Mass/​volume] in Serum or Plasma

Granulocytes/​100 leukocytes in Blood by Automated count

Immature granulocytes/100 leukocytes in Blood by Automated count. LOINC does not specify that units are required.

Immature granulocytes [#/volume] in Blood by Automated count. Units are not required

Hematocrit [Volume Fraction] of Blood by Automated count

Hemoglobin [Mass/​volume] in Blood

An abstract class representing items such as administrative records, knowledge artifacts, definitional items, and entities such as organizations and entities. These items are often independent of a single patient, and do not represent clinical judgements or observations about a patient.

A coded finding based on a specimen, usually collected from a patient (but possibly from a location).

A grouping or summarization of laboratory results, where individual results are typically Observations or nested Observations (panels). This class aligns with US Core DiagnosticReport Profile for Laboratory Results Reporting.

Leukocytes [#/​volume] in Blood by Automated count

Leukocytes other [#/​volume] in Blood by Automated count. Units not required by LOINC but are strongly recommended.

Lymphocytes/​100 leukocytes in Blood by Automated count

Lymphocytes [#/​volume] in Blood by Automated count

Variant lymphocytes/​100 leukocytes in Blood by Automated count. Units not required by LOINC but are strongly recommended.

Variant lymphocytes/100 leukocytes in Blood

Variant lymphocytes [#/​volume] in Blood by Automated count. Units not required by LOINC but are strongly recommended.

MCV [Entitic volume] by Automated count

Abstract class representing medication exposure, independent of whether reported in a medication statement or medication administration. Does not include medication requests (prescriptions).

Indicates that a medication product has been dispensed for a named person/patient. This includes a description of the medication product (supply) provided and the instructions for administering the medication. The medication dispense is the result of a pharmacy system responding to a medication order.

Metamyelocytes/100 leukocytes in Blood by Manual count

Metamyelocytes [#/volume] in Blood

Monocytes/​100 leukocytes in Blood by Automated count

Monocytes [#/​volume] in Blood by Automated count

Morphology [Interpretation] in Blood Narrative.

Myelocytes/100 leukocytes in Blood by Manual count

Myelocytes [#/volume] in Blood. Units not required by LOINC but are strongly recommended.

Neutrophils/​100 leukocytes in Blood by Automated count

Band form neutrophils/​100 leukocytes in Blood by Automated count. Units not required by LOINC but are strongly recommended.

Band form neutrophils/100 leukocytes in Blood by Manual count

Band form neutrophils [#/​volume] in Blood by Automated count

Band form neutrophils [#/volume] in Blood

Neutrophils [#/​volume] in Blood by Automated count

An observation that is not based on a specimen.

Represents the result of evaluations (measurements, tests, or questions) that have been performed. Observation has a value representing the result (answer), or an DataAbsentReason indicating why the value is not present. Things observed about the subject can include social and behavioral factors, subjective and objective observations, and assessments. For an Observation, the Code describes the aspect or property of the subject being observed or measured. The Code is the ‘question code’ that pairs to the ‘answer’ contained in the Value.

Other cells/​100 leukocytes in Blood by Automated count. Units not required by LOINC but are strongly recommended.

Other cells [#/​volume] in Blood by Automated count. Units not required by LOINC but are strongly recommended.

Platelet distribution width [Entitic volume] in Blood by Automated count. Units not required by LOINC but are strongly recommended.

Platelet mean volume [Entitic volume] in Blood by Automated count. Units not required by LOINC but are strongly recommended.

Platelet mean volume [Entitic volume] in Blood by Rees-Ecker.

Platelets [#/​volume] in Blood by Automated count

Potassium [Moles/​volume] in Serum or Plasma

An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy.

Promyelocytes/100 leukocytes in Blood by Manual count

Promyelocytes [#/volume] in Blood

Protein [Mass/​volume] in Serum or Plasma

A quantiative result from a laboratory test.

The result of evaluations (measurements, tests, or questions) whose answer is expressed as a code.

A radiation oncology procedure. The procedure might represent a complete course of treatment, or a single session that is part of a series of treatments. If the treatment is part of a larger course of treatment, the PartOf attribute should indicate that. If the procedure represents the entire course of therapy, the RadiationFractionsDelivered should indicate the number of sessions. If the procedure represents one session, then the RadiationFractionsDelivered would be 1, and the TotalRadiationDoseDelivered will be the same as the RadiationDosePerFraction.

Capacity in which an actor is involved in an activity. For instance, ‘attending physician’. Note that attributes of the actor (an entity) that remain constant regardless of the role the actor plays should be part of the entity and not the role. For instance, a person may be a practitioner and a patient. In both cases their date of birth will be the same and thus such information should not be part of the role.

An observation whose result is a code, and also having no components or panel members

A result from a laboratory test without panel members or components.

Laboratory tests that must be reported with units, following the LOINC UNITSREQUIRED field, a Y/N field that indicates that units are required when this LOINC is included as an OBX segment in a HIPAA attachment

An observation whose result is a quantity, with no components or panel members

An assertion, determination, opinion, evaluation, result, observation, or measurement made by a person or device.

Sodium [Moles/​volume] in Serum or Plasma

A procedure that involves a physical intervention on tissues.

Conformance note: If an ICD-10-PCS code is used in the code attribute, and an equivalent SNOMED CT is available, the resulting Procedure instance will not be compliant with US Core Profiles.

The presence of an abnormal mass of tissue (neoplasm) that results when cells divide more than they should or do not die when they should. Tumors may be benign (not cancer), or malignant (cancer). (source: NCI Dictionary).

Conformance note: For the HistologyMorphologyBehavior attribute, to be compliant with US Core Profiles, SNOMED CT must be used unless there is no suitable code, in which case ICD-O-3 can be used.

Urea nitrogen/​Creatinine [Mass Ratio] in Serum or Plasma

Urea nitrogen [Mass/​volume] in Serum or Plasma

Abstract class parent for all vital sign profiles.