minimal Common Oncology Data Elements (mCODE) Implementation Guide
3.0.0-ballot - 2023May
minimal Common Oncology Data Elements (mCODE) Implementation Guide
3.0.0-ballot - 2023May
This page is part of the HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU1 (v3.0.0-ballot: STU 3 Ballot 1) based on FHIR R4. The current version which supercedes this version is 2.1.0. For a full list of available versions, see the Directory of published versions 
| Official URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-karnofsky-performance-status | Version: 3.0.0-ballot | |||
| Active as of 2023-03-28 | Maturity Level: 4 | Computable Name: KarnofskyPerformanceStatus | ||
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.
Observation resources associated with an in-scope patient with Observation.code LOINC 89243-0 MUST conform to this profile. Beyond this requirement, a producer of resources SHOULD ensure that any resource instance associated with an in-scope patient that would reasonably be expected to conform to this profile SHOULD be published in this form.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreObservationClinicalTestResultProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Observation | 0..* | USCoreObservationClinicalTestResultProfile | Measurements and simple assertions | |
  basedOn | 0..* | Reference(ServiceRequest | CarePlan) | Fulfills plan, proposal or order | |
| partOf | 0..* | Reference(Procedure) | Part of referenced event | |
  code | 1..1 | CodeableConcept | Clinical Test Name 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://loinc.org | |
 code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 89243-0 | |
| subject | 1..1 | Reference(Cancer Patient Profile) | Who and/or what the observation is about | |
 effective[x] | 0..1 | Clinically relevant time/time-period for observation | ||
 effectiveDateTime | dateTime | |||
 effectivePeriod | Period | |||
| value[x] | 0..1 | integer | Result Value | |
| interpretation | S | 0..* | CodeableConcept | High, low, normal, etc. Binding: LOINC Answer List LL4986-7 (required) |
| bodySite | 0..1 | CodeableConcept | Not used in this profile | |
| specimen | 0..1 | Reference(Specimen) | Not used in this profile | |
| device | 0..1 | Reference(Device | DeviceMetric) | Not used in this profile | |
| hasMember | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Not used in this profile | |
| component | 0..* | BackboneElement | Not used in this profile | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.interpretation | required | LOINC LL4986-7 |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | C | 0..* | USCoreObservationClinicalTestResultProfile | 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 |
| basedOn | Σ | 0..* | Reference(ServiceRequest | CarePlan) | Fulfills plan, proposal or order |
| partOf | Σ | 0..* | Reference(Procedure) | 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:clinical-test | S | 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://hl7.org/fhir/us/core/CodeSystem/us-core-observation-category | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: clinical-test | |
| code | SΣ | 1..1 | CodeableConcept | Clinical Test Name Binding: US Core Clinical Test Codes (extensible) 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 89243-0 | |
| subject | SΣ | 1..1 | Reference(Cancer Patient Profile) | Who and/or what the observation is about |
| effective[x] | SΣC | 0..1 | Clinically relevant time/time-period for observation | |
| effectiveDateTime | dateTime | |||
| value[x] | SΣC | 0..1 | integer | Result Value |
| dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
| interpretation | S | 0..* | CodeableConcept | High, low, normal, etc. Binding: LOINC Answer List LL4986-7 (required) |
| bodySite | 0..1 | CodeableConcept | Not used in this profile Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |
| specimen | 0..1 | Reference(Specimen) | Not used in this profile | |
| device | 0..1 | Reference(Device | DeviceMetric) | Not used in this profile | |
| hasMember | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Not used in this profile |
| component | Σ | 0..* | BackboneElement | Not used in this profile |
| 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. |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.status | required | ObservationStatus |
| Observation.category | preferred | ObservationCategoryCodes |
| Observation.category:clinical-test | preferred | Pattern: clinical-test |
| Observation.code | extensible | Pattern: LOINC code 89243-0 |
| Observation.dataAbsentReason | extensible | DataAbsentReason |
| Observation.interpretation | required | LOINC LL4986-7 |
| Observation.bodySite | example | SNOMEDCTBodyStructures |
| Observation.component.code | example | LOINCCodes (a valid code from LOINC) |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Observation | C | 0..* | USCoreObservationClinicalTestResultProfile | 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(ServiceRequest | CarePlan) | Fulfills plan, proposal or order | ||||
| partOf | Σ | 0..* | Reference(Procedure) | 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:clinical-test | 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://hl7.org/fhir/us/core/CodeSystem/us-core-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: clinical-test | |||||
| 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 | Clinical Test Name Binding: US Core Clinical Test Codes (extensible) 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://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 89243-0 | |||||
| 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 | |||||
| subject | SΣ | 1..1 | Reference(Cancer Patient Profile) | 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 | ||||
| effective[x] | SΣC | 0..1 | Clinically relevant time/time-period for observation | |||||
| effectiveDateTime | dateTime S | |||||||
| effectivePeriod | Period | |||||||
| 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 | 0..1 | integer | Result Value | ||||
| dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
| interpretation | S | 0..* | CodeableConcept | High, low, normal, etc. Binding: LOINC Answer List LL4986-7 (required) | ||||
| note | 0..* | Annotation | Comments about the observation | |||||
| bodySite | 0..1 | CodeableConcept | Not used in this profile 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) | Not used in this profile | |||||
| device | 0..1 | Reference(Device | DeviceMetric) | Not used in this profile | |||||
| 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) | Not used in this profile | ||||
| derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
| component | Σ | 0..* | BackboneElement | Not used in this profile | ||||
| 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 | ObservationStatus | ||||
| Observation.category | preferred | ObservationCategoryCodes | ||||
| Observation.category:clinical-test | preferred | Pattern: clinical-test | ||||
| Observation.code | extensible | Pattern: LOINC code 89243-0 | ||||
| Observation.dataAbsentReason | extensible | DataAbsentReason | ||||
| Observation.interpretation | required | LOINC LL4986-7 | ||||
| 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 |
This structure is derived from USCoreObservationClinicalTestResultProfile
Summary
Must-Support: 1 element
Structures
This structure refers to these other structures:
Maturity: 4
Differential View
This structure is derived from USCoreObservationClinicalTestResultProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 0..* | USCoreObservationClinicalTestResultProfile | Measurements and simple assertions | |
| basedOn | 0..* | Reference(ServiceRequest | CarePlan) | Fulfills plan, proposal or order | |
| partOf | 0..* | Reference(Procedure) | Part of referenced event | |
| code | 1..1 | CodeableConcept | Clinical Test Name 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 89243-0 | |
| subject | 1..1 | Reference(Cancer Patient Profile) | Who and/or what the observation is about | |
| effective[x] | 0..1 | Clinically relevant time/time-period for observation | ||
| effectiveDateTime | dateTime | |||
| effectivePeriod | Period | |||
| value[x] | 0..1 | integer | Result Value | |
| interpretation | S | 0..* | CodeableConcept | High, low, normal, etc. Binding: LOINC Answer List LL4986-7 (required) |
| bodySite | 0..1 | CodeableConcept | Not used in this profile | |
| specimen | 0..1 | Reference(Specimen) | Not used in this profile | |
| device | 0..1 | Reference(Device | DeviceMetric) | Not used in this profile | |
| hasMember | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Not used in this profile | |
| component | 0..* | BackboneElement | Not used in this profile | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.interpretation | required | LOINC LL4986-7 |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | C | 0..* | USCoreObservationClinicalTestResultProfile | 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 |
| basedOn | Σ | 0..* | Reference(ServiceRequest | CarePlan) | Fulfills plan, proposal or order |
| partOf | Σ | 0..* | Reference(Procedure) | 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:clinical-test | S | 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://hl7.org/fhir/us/core/CodeSystem/us-core-observation-category | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: clinical-test | |
| code | SΣ | 1..1 | CodeableConcept | Clinical Test Name Binding: US Core Clinical Test Codes (extensible) 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 89243-0 | |
| subject | SΣ | 1..1 | Reference(Cancer Patient Profile) | Who and/or what the observation is about |
| effective[x] | SΣC | 0..1 | Clinically relevant time/time-period for observation | |
| effectiveDateTime | dateTime | |||
| value[x] | SΣC | 0..1 | integer | Result Value |
| dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
| interpretation | S | 0..* | CodeableConcept | High, low, normal, etc. Binding: LOINC Answer List LL4986-7 (required) |
| bodySite | 0..1 | CodeableConcept | Not used in this profile Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |
| specimen | 0..1 | Reference(Specimen) | Not used in this profile | |
| device | 0..1 | Reference(Device | DeviceMetric) | Not used in this profile | |
| hasMember | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Not used in this profile |
| component | Σ | 0..* | BackboneElement | Not used in this profile |
| 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. |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Observation.status | required | ObservationStatus |
| Observation.category | preferred | ObservationCategoryCodes |
| Observation.category:clinical-test | preferred | Pattern: clinical-test |
| Observation.code | extensible | Pattern: LOINC code 89243-0 |
| Observation.dataAbsentReason | extensible | DataAbsentReason |
| Observation.interpretation | required | LOINC LL4986-7 |
| Observation.bodySite | example | SNOMEDCTBodyStructures |
| Observation.component.code | example | LOINCCodes (a valid code from LOINC) |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Observation | C | 0..* | USCoreObservationClinicalTestResultProfile | 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(ServiceRequest | CarePlan) | Fulfills plan, proposal or order | ||||
| partOf | Σ | 0..* | Reference(Procedure) | 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:clinical-test | 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://hl7.org/fhir/us/core/CodeSystem/us-core-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: clinical-test | |||||
| 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 | Clinical Test Name Binding: US Core Clinical Test Codes (extensible) 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://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 89243-0 | |||||
| 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 | |||||
| subject | SΣ | 1..1 | Reference(Cancer Patient Profile) | 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 | ||||
| effective[x] | SΣC | 0..1 | Clinically relevant time/time-period for observation | |||||
| effectiveDateTime | dateTime S | |||||||
| effectivePeriod | Period | |||||||
| 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 | 0..1 | integer | Result Value | ||||
| dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
| interpretation | S | 0..* | CodeableConcept | High, low, normal, etc. Binding: LOINC Answer List LL4986-7 (required) | ||||
| note | 0..* | Annotation | Comments about the observation | |||||
| bodySite | 0..1 | CodeableConcept | Not used in this profile 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) | Not used in this profile | |||||
| device | 0..1 | Reference(Device | DeviceMetric) | Not used in this profile | |||||
| 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) | Not used in this profile | ||||
| derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
| component | Σ | 0..* | BackboneElement | Not used in this profile | ||||
| 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 | ObservationStatus | ||||
| Observation.category | preferred | ObservationCategoryCodes | ||||
| Observation.category:clinical-test | preferred | Pattern: clinical-test | ||||
| Observation.code | extensible | Pattern: LOINC code 89243-0 | ||||
| Observation.dataAbsentReason | extensible | DataAbsentReason | ||||
| Observation.interpretation | required | LOINC LL4986-7 | ||||
| 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 |
This structure is derived from USCoreObservationClinicalTestResultProfile
Summary
Must-Support: 1 element
Structures
This structure refers to these other structures:
Maturity: 4
Other representations of profile: CSV, Excel, Schematron
IG © 2019+ HL7 International Clinical Interoperability Council. Package hl7.fhir.us.mcode#3.0.0-ballot based on FHIR 4.0.1. Generated 2023-03-28
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