This page is part of the HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU1 (v3.0.0: STU 3) 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/mcode/StructureDefinition/mcode-comorbidities | Version: 3.0.0 | |||
Draft as of 2023-10-25 | Maturity Level: 1 | Computable Name: Comorbidities |
General structure for capturing comorbid conditions with respect to a primary (‘index’) condition. The user can use this profile in three ways: (1) free-form, listing any conditions they wish to highlight as significant comorbidities, (2) following a formal paradigm such as the Charlson Comorbidity Index or the NCI Comorbidity Index, or (3) use disease categories defined for registry reporting purposes, such as those defined by Center for International Blood and Marrow Transplant Research (CIBMTR).
“Comorbidity” speaks to the presence of more than one distinct condition in an individual. Typically, the term refers to additional disorders relative to a current “index” disease (Valderas, et al.).
Co-occurring disorders are typically treated as high-level categories, for example, “liver disease, mild”, “dementia”, or “renal disease”. Comorbidity categories are not universal, but rather, selected because of their clinical significance to the diagnosis, prognosis, or treatment of the index disease. The comorbidities significant in COVID-19 treatment are different than those for congestive heart failure.
There are several general models used to note the presence of multiple disease categories in one individual, typically used to calculate a morbidity burden or risk score. The Charlson Comorbidity Index is one of the most widely used. The NCI Comorbidity Index is similar, however, the NCI comorbidities exclude solid tumors, leukemias, and lymphomas, given that the index was developed from a cohort of cancer patients. However, there is no uniform way to record comorbidities, and therefore mCODE does not impose any particular framework.
The user can use this profile in three ways: (1) free-form, listing any conditions they wish to highlight as significant comorbidities, (2) by following a formal paradigm, such as Charlson or Elixhauser, or (3) use codes defined for registry reporting purposes, such as codes defined by Center for International Blood and Marrow Transplant Research (CIBMTR). This profile contains two extensions, representing comorbidities that are present and those asserted to be absent.
Record the “index” condition (the condition the comorbidities are relevant to) in Observation.focus
. Reference the patient’s primary cancer condition.
Comorbidities that are present are reported in the array Observation.extension:comorbidConditionPresent
as a valueReference
or valueCodeableConcept
. The use of valueReference
is optional and applicable only if there is an existing Condition resource representing the comorbid condition. In other cases, a diagnosis code or a comorbid condition category code appears in valueCodeableConcept
.
Typically, a cancer condition would not be considered a comorbidity in a cancer patient, but it is possible that there could be a pre-existing or concurrent cancer condition included in the list of comorbidities.
Usually, only comorbidities that are present are recorded. However, assertions of absent comorbidities are useful when calculating comorbid risk indices. To assert a comorbidity is not present, the array Observation.extension:comorbidConditionAbsent
is populated with either a diagnosis code or comorbid condition category code.
To represent no comorbidities, there should be only one entry in Observation.extension:comorbidConditionAbsent
with the valueCodeableConcept
of SNOMED CT ID 64572001 (Disease).
If a formal methodology is used to assess comorbidities (e.g., Charlson, NCI, Elixhauser, CIMBTR, ACE-27), it should be identified in Observation.method
. The comorbidity score (Observation.value
) cannot be interpreted without knowing the method. The method may also provide the comorbidity categories used in present and absent comorbidities.
At present, only Charlson has a specific SNOMED CT code, so in other cases, a plain text can be specified in Observation.method.text
.
A comorbid condition risk index, if it exists, is reported in Observation.value[x]
. In several frameworks the index is an integer, so the value would appear as Observation.valueInteger
.
Observation resources associated with an in-scope patient with Observation.code
of SCT#398192003 “Co-morbid conditions (finding)” SHALL 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 Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | Observation | Measurements and simple assertions | |
Slices for extension | S | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
comorbidConditionPresent | S | 0..* | CodeableConcept, Reference(Condition) | Related Condition Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-related-condition |
comorbidConditionAbsent | S | 0..* | CodeableConcept | Related Condition Absent Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-related-condition-absent |
status | S | 1..1 | code | registered | preliminary | final | amended + |
code | S | 1..1 | CodeableConcept | Type of observation (code / type) 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://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 398192003 | |
subject | S | 0..1 | Reference(Cancer Patient Profile) | Who and/or what the observation is about |
focus | S | 0..* | Reference(Primary Cancer Condition Profile) | The Index Condition |
effective[x] | S | 0..1 | dateTime, Period, Timing, instant | Clinically relevant time/time-period for observation |
value[x] | 0..1 | Actual result | ||
valueQuantity | Quantity | |||
valueInteger | integer | |||
bodySite | 0..1 | CodeableConcept | Not used in this profile | |
method | 0..1 | CodeableConcept | Comorbidity framework used. | |
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 |
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 |
Slices for extension | S | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
comorbidConditionPresent | S | 0..* | CodeableConcept, Reference(Condition) | Related Condition Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-related-condition |
comorbidConditionAbsent | S | 0..* | CodeableConcept | Related Condition Absent Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-related-condition-absent |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. 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://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 398192003 | |
subject | SΣ | 0..1 | Reference(Cancer Patient Profile) | Who and/or what the observation is about |
focus | SΣ | 0..* | Reference(Primary Cancer Condition Profile) | The Index Condition |
effective[x] | SΣ | 0..1 | Clinically relevant time/time-period for observation | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
effectiveTiming | Timing | |||
effectiveInstant | instant | |||
value[x] | ΣC | 0..1 | Actual result | |
valueQuantity | Quantity | |||
valueInteger | integer | |||
bodySite | 0..1 | CodeableConcept | Not used in this profile Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |
method | 0..1 | CodeableConcept | Comorbidity framework used. 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 | |
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.code | example | Pattern: SNOMED CT code 398192003 |
Observation.bodySite | example | SNOMEDCTBodyStructures |
Observation.method | example | ObservationMethods |
Observation.component.code | example | LOINCCodes (a valid code from LOINC) |
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 | |||||
Slices for extension | S | 0..* | Extension | Extension Slice: Unordered, Open by value:url | ||||
comorbidConditionPresent | S | 0..* | CodeableConcept, Reference(Condition) | Related Condition Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-related-condition | ||||
comorbidConditionAbsent | S | 0..* | CodeableConcept | Related Condition Absent Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-related-condition-absent | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business Identifier for observation | ||||
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | ||||
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
category | 0..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. 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://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 398192003 | |||||
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 | 0..1 | Reference(Cancer Patient Profile) | Who and/or what the observation is about | ||||
focus | SΣ | 0..* | Reference(Primary Cancer Condition Profile) | The Index Condition | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made | ||||
effective[x] | SΣ | 0..1 | Clinically relevant time/time-period for observation | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
effectiveTiming | Timing | |||||||
effectiveInstant | instant | |||||||
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] | ΣC | 0..1 | Actual result | |||||
valueQuantity | Quantity | |||||||
valueInteger | integer | |||||||
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 | Not used in this profile Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
method | 0..1 | CodeableConcept | Comorbidity framework used. 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.code | example | Pattern: SNOMED CT code 398192003 | ||||
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 |
This structure is derived from Observation
Summary
Must-Support: 8 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 1
Differential View
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | Observation | Measurements and simple assertions | |
Slices for extension | S | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
comorbidConditionPresent | S | 0..* | CodeableConcept, Reference(Condition) | Related Condition Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-related-condition |
comorbidConditionAbsent | S | 0..* | CodeableConcept | Related Condition Absent Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-related-condition-absent |
status | S | 1..1 | code | registered | preliminary | final | amended + |
code | S | 1..1 | CodeableConcept | Type of observation (code / type) 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://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 398192003 | |
subject | S | 0..1 | Reference(Cancer Patient Profile) | Who and/or what the observation is about |
focus | S | 0..* | Reference(Primary Cancer Condition Profile) | The Index Condition |
effective[x] | S | 0..1 | dateTime, Period, Timing, instant | Clinically relevant time/time-period for observation |
value[x] | 0..1 | Actual result | ||
valueQuantity | Quantity | |||
valueInteger | integer | |||
bodySite | 0..1 | CodeableConcept | Not used in this profile | |
method | 0..1 | CodeableConcept | Comorbidity framework used. | |
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 |
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 |
Slices for extension | S | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
comorbidConditionPresent | S | 0..* | CodeableConcept, Reference(Condition) | Related Condition Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-related-condition |
comorbidConditionAbsent | S | 0..* | CodeableConcept | Related Condition Absent Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-related-condition-absent |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. 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://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 398192003 | |
subject | SΣ | 0..1 | Reference(Cancer Patient Profile) | Who and/or what the observation is about |
focus | SΣ | 0..* | Reference(Primary Cancer Condition Profile) | The Index Condition |
effective[x] | SΣ | 0..1 | Clinically relevant time/time-period for observation | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
effectiveTiming | Timing | |||
effectiveInstant | instant | |||
value[x] | ΣC | 0..1 | Actual result | |
valueQuantity | Quantity | |||
valueInteger | integer | |||
bodySite | 0..1 | CodeableConcept | Not used in this profile Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |
method | 0..1 | CodeableConcept | Comorbidity framework used. 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 | |
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.code | example | Pattern: SNOMED CT code 398192003 |
Observation.bodySite | example | SNOMEDCTBodyStructures |
Observation.method | example | ObservationMethods |
Observation.component.code | example | LOINCCodes (a valid code from LOINC) |
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 | |||||
Slices for extension | S | 0..* | Extension | Extension Slice: Unordered, Open by value:url | ||||
comorbidConditionPresent | S | 0..* | CodeableConcept, Reference(Condition) | Related Condition Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-related-condition | ||||
comorbidConditionAbsent | S | 0..* | CodeableConcept | Related Condition Absent Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-related-condition-absent | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business Identifier for observation | ||||
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | ||||
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
category | 0..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. 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://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 398192003 | |||||
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 | 0..1 | Reference(Cancer Patient Profile) | Who and/or what the observation is about | ||||
focus | SΣ | 0..* | Reference(Primary Cancer Condition Profile) | The Index Condition | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made | ||||
effective[x] | SΣ | 0..1 | Clinically relevant time/time-period for observation | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
effectiveTiming | Timing | |||||||
effectiveInstant | instant | |||||||
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] | ΣC | 0..1 | Actual result | |||||
valueQuantity | Quantity | |||||||
valueInteger | integer | |||||||
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 | Not used in this profile Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
method | 0..1 | CodeableConcept | Comorbidity framework used. 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.code | example | Pattern: SNOMED CT code 398192003 | ||||
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 |
This structure is derived from Observation
Summary
Must-Support: 8 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 1
Other representations of profile: CSV, Excel, Schematron