PACIO Personal Functioning and Engagement Implementation Guide
2.0.0-ballot - STU2 Ballot United States of America flag

This page is part of the PACIO Personal Functioning and Engagement Implementation Guide (v2.0.0-ballot: STU 2 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

Resource Profile: Personal Functioning and Engagement Collection

Official URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/pfe-collection Version: 2.0.0-ballot
Active as of 2024-08-13 Computable Name: PFECollection

A point in time collection of post-acute care observations for a patient. This profile is used for exchanging a set of observation data collected through the use of a structured resource (e.g., assessment tool, instrument, or screen) with multiple questions.

Example Usage Scenarios:

The following are example usage scenarios for this Profile:

  • Query for the documentation of a formal panel of assessment questions related to a patient's functioning and engagement.
  • Record or update observations related to collections of assessment questions for a Patient.

Mandatory and Must Support Data Elements

The following data elements must always be present or must be supported if the data is present in the sending system (Must Support definition). They are presented below with a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.

Each Personal Functioning and Engagement Collection must have:

  1. a status
  2. a category code of "survey" and "functioning"
  3. a code representing the specific panel
  4. a patient
  5. the point in time or period when the observation was made
  6. who made the observation

Each Personal Functioning and Engagement Collection must support:

  1. the location the observation was made
  2. any devices the patient used
  3. an additional category value or values specifying the specific health or health-related domain that this observation is related to***
  4. related questionnaire responses that this observation is made from
  5. references to nested collections or single questions that represent the answers within the panel* or a reason why the data is absent**

* ** *** see guidance below

Profile specific implementation guidance:

  • *These collection observations represent structured instruments and panels with multiple questions. The hasMember element SHALL be used to point to child Observation instances that contain the specific questions and answers, represented by Single Observations or nested panels represented by this profile. The Observation.value and Observation.component elements SHALL be empty.
  • **An Observation without a value, SHALL include a reason why the data is absent unless there are 1) component observations, or 2) reporting panel observations using Observation.hasMember. Systems that never provide an observation without a value are not required to support Observation.dataAbsentReason.
  • ***When a health or health-related domain is specified as an additional category value, Observation.code SHOULD be drawn from the corresponding domain-based value set as discussed below and on the domains page.

***Panel codes are not in scope for inclusion within domain-based value sets within STU1 of the PFE IG while the PACIO community determines how best to apply domains to panels that may have specific observations from multiple domains as descendents. In the meantime, the recommendation is not to include domain categories within Collection observation instances.

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreSimpleObservationProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..* USCoreSimpleObservationProfile assessment observation
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
.... device-use S 0..* Reference(Personal Functioning and Engagement Use of Device) An extension to indicate a record of assistive device usage by a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/device-patient-used
... status 1..1 code Should have the value 'final' when all the observatons are complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
... category 1..* CodeableConcept (USCDI) Classification of type of observation
.... category:us-core 0..* CodeableConcept (USCDI) Classification of type of observation
Binding: Personal Functioning and Engagement US Core Value Set (required)
... Slices for category Content/Rules for all slices
.... category:survey S 0..1 CodeableConcept (USCDI) Classification of type of observation
Binding: Personal Functioning and Engagement Survey Value Set (required)
... Slices for category Content/Rules for all slices
.... category:PFEDomain S 0..* CodeableConcept (USCDI) Classification of type of observation
Binding: Personal Functioning and Engagement Category Value Set (required)
... code 1..1 CodeableConcept For a Post-Acute Care structured assessment resource such as an instrument or screen, use a LOINC code to identify the instrument/screen name or panel/section title to indicate the kind of assessment.
... effective[x] 1..1 Clinical relevant time for an assessment such as post-acute care observations performed with structured evaluation tools is the time the evaluation occurs, i.e., when the clinician obtains the answers entered in the tool. However, the only timing available may be when then tool is completed by the clinician. That timing is generally documented as a point in time (dateTime).
.... effectiveDateTime dateTime
.... effectivePeriod Period
... performer 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... value[x] 0..0
... hasMember S 0..* Reference(Personal Functioning and Engagement Single Observation) Each post-acute care observation in the collection. May also be another collection to support nested sections.
... derivedFrom S 0..* Reference(US Core QuestionnaireResponse Profile | US Core Simple Observation Profile) Should point back to the QuestionnaireResponse that this resource is derived from.
... component 0..0

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.category:us-corerequiredPFEUSCoreCategoryVS
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-us-core-category-vs
from this IG
Observation.category:surveyrequiredPFESurveyCategoryVS
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-survey-category-vs
from this IG
Observation.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* USCoreSimpleObservationProfile assessment observation
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
.... device-use S 0..* Reference(Personal Functioning and Engagement Use of Device) An extension to indicate a record of assistive device usage by a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/device-patient-used
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for category S 1..* CodeableConcept (USCDI) Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:us-core S 0..* CodeableConcept (USCDI) Classification of type of observation
Binding: Personal Functioning and Engagement US Core Value Set (required)
.... category:survey S 0..1 CodeableConcept (USCDI) Classification of type of observation
Binding: Personal Functioning and Engagement Survey Value Set (required)
.... category:PFEDomain S 0..* CodeableConcept (USCDI) Classification of type of observation
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ 1..1 CodeableConcept For a Post-Acute Care structured assessment resource such as an instrument or screen, use a LOINC code to identify the instrument/screen name or panel/section title to indicate the kind of assessment.
Binding: LOINCCodes (preferred)
... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) Who and/or what the observation is about
... effective[x] SΣ 1..1 Clinical relevant time for an assessment such as post-acute care observations performed with structured evaluation tools is the time the evaluation occurs, i.e., when the clinician obtains the answers entered in the tool. However, the only timing available may be when then tool is completed by the clinician. That timing is generally documented as a point in time (dateTime).
.... effectiveDateTime dateTime
... performer SΣ 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... hasMember SΣ 0..* Reference(Personal Functioning and Engagement Single Observation) Each post-acute care observation in the collection. May also be another collection to support nested sections.
... derivedFrom SΣ 0..* Reference(US Core QuestionnaireResponse Profile | US Core Simple Observation Profile) Should point back to the QuestionnaireResponse that this resource is derived from.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:us-corerequiredPFEUSCoreCategoryVS
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-us-core-category-vs
from this IG
Observation.category:surveyrequiredPFESurveyCategoryVS
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-survey-category-vs
from this IG
Observation.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs
from this IG
Observation.codepreferredLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* USCoreSimpleObservationProfile assessment observation
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
... 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.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
.... device-use S 0..* Reference(Personal Functioning and Engagement Use of Device) An extension to indicate a record of assistive device usage by a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/device-patient-used
... 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 Should have the value 'final' when all the observatons are complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category S 1..* CodeableConcept (USCDI) Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:us-core S 0..* CodeableConcept (USCDI) Classification of type of observation
Binding: Personal Functioning and Engagement US Core Value Set (required)
.... category:survey S 0..1 CodeableConcept (USCDI) Classification of type of observation
Binding: Personal Functioning and Engagement Survey Value Set (required)
.... category:PFEDomain S 0..* CodeableConcept (USCDI) Classification of type of observation
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ 1..1 CodeableConcept For a Post-Acute Care structured assessment resource such as an instrument or screen, use a LOINC code to identify the instrument/screen name or panel/section title to indicate the kind of assessment.
Binding: LOINCCodes (preferred)
... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) Who and/or what the observation is about
... focus Σ 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] SΣ 1..1 Clinical relevant time for an assessment such as post-acute care observations performed with structured evaluation tools is the time the evaluation occurs, i.e., when the clinician obtains the answers entered in the tool. However, the only timing available may be when then tool is completed by the clinician. That timing is generally documented as a point in time (dateTime).
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued Σ 0..1 instant Date/Time this version was made available
... performer SΣ 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..* Annotation Comments about the observation
... bodySite 0..1 CodeableConcept Observed body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1 CodeableConcept How it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1 Reference(Specimen) Specimen used for this observation
... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... referenceRange C 0..* BackboneElement Provides guide for interpretation
obs-3: Must have at least a low or a high or text
.... 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 SΣ 0..* Reference(Personal Functioning and Engagement Single Observation) Each post-acute care observation in the collection. May also be another collection to support nested sections.
... derivedFrom SΣ 0..* Reference(US Core QuestionnaireResponse Profile | US Core Simple Observation Profile) Should point back to the QuestionnaireResponse that this resource is derived from.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:us-corerequiredPFEUSCoreCategoryVS
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-us-core-category-vs
from this IG
Observation.category:surveyrequiredPFESurveyCategoryVS
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-survey-category-vs
from this IG
Observation.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs
from this IG
Observation.codepreferredLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Observation.methodexampleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
http://hl7.org/fhir/ValueSet/referencerange-meaning
from the FHIR Standard
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
http://hl7.org/fhir/ValueSet/referencerange-appliesto
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard

Differential View

This structure is derived from USCoreSimpleObservationProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..* USCoreSimpleObservationProfile assessment observation
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
.... device-use S 0..* Reference(Personal Functioning and Engagement Use of Device) An extension to indicate a record of assistive device usage by a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/device-patient-used
... status 1..1 code Should have the value 'final' when all the observatons are complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
... category 1..* CodeableConcept (USCDI) Classification of type of observation
.... category:us-core 0..* CodeableConcept (USCDI) Classification of type of observation
Binding: Personal Functioning and Engagement US Core Value Set (required)
... Slices for category Content/Rules for all slices
.... category:survey S 0..1 CodeableConcept (USCDI) Classification of type of observation
Binding: Personal Functioning and Engagement Survey Value Set (required)
... Slices for category Content/Rules for all slices
.... category:PFEDomain S 0..* CodeableConcept (USCDI) Classification of type of observation
Binding: Personal Functioning and Engagement Category Value Set (required)
... code 1..1 CodeableConcept For a Post-Acute Care structured assessment resource such as an instrument or screen, use a LOINC code to identify the instrument/screen name or panel/section title to indicate the kind of assessment.
... effective[x] 1..1 Clinical relevant time for an assessment such as post-acute care observations performed with structured evaluation tools is the time the evaluation occurs, i.e., when the clinician obtains the answers entered in the tool. However, the only timing available may be when then tool is completed by the clinician. That timing is generally documented as a point in time (dateTime).
.... effectiveDateTime dateTime
.... effectivePeriod Period
... performer 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... value[x] 0..0
... hasMember S 0..* Reference(Personal Functioning and Engagement Single Observation) Each post-acute care observation in the collection. May also be another collection to support nested sections.
... derivedFrom S 0..* Reference(US Core QuestionnaireResponse Profile | US Core Simple Observation Profile) Should point back to the QuestionnaireResponse that this resource is derived from.
... component 0..0

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.category:us-corerequiredPFEUSCoreCategoryVS
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-us-core-category-vs
from this IG
Observation.category:surveyrequiredPFESurveyCategoryVS
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-survey-category-vs
from this IG
Observation.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs
from this IG

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* USCoreSimpleObservationProfile assessment observation
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
.... device-use S 0..* Reference(Personal Functioning and Engagement Use of Device) An extension to indicate a record of assistive device usage by a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/device-patient-used
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for category S 1..* CodeableConcept (USCDI) Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:us-core S 0..* CodeableConcept (USCDI) Classification of type of observation
Binding: Personal Functioning and Engagement US Core Value Set (required)
.... category:survey S 0..1 CodeableConcept (USCDI) Classification of type of observation
Binding: Personal Functioning and Engagement Survey Value Set (required)
.... category:PFEDomain S 0..* CodeableConcept (USCDI) Classification of type of observation
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ 1..1 CodeableConcept For a Post-Acute Care structured assessment resource such as an instrument or screen, use a LOINC code to identify the instrument/screen name or panel/section title to indicate the kind of assessment.
Binding: LOINCCodes (preferred)
... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) Who and/or what the observation is about
... effective[x] SΣ 1..1 Clinical relevant time for an assessment such as post-acute care observations performed with structured evaluation tools is the time the evaluation occurs, i.e., when the clinician obtains the answers entered in the tool. However, the only timing available may be when then tool is completed by the clinician. That timing is generally documented as a point in time (dateTime).
.... effectiveDateTime dateTime
... performer SΣ 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... hasMember SΣ 0..* Reference(Personal Functioning and Engagement Single Observation) Each post-acute care observation in the collection. May also be another collection to support nested sections.
... derivedFrom SΣ 0..* Reference(US Core QuestionnaireResponse Profile | US Core Simple Observation Profile) Should point back to the QuestionnaireResponse that this resource is derived from.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:us-corerequiredPFEUSCoreCategoryVS
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-us-core-category-vs
from this IG
Observation.category:surveyrequiredPFESurveyCategoryVS
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-survey-category-vs
from this IG
Observation.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs
from this IG
Observation.codepreferredLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* USCoreSimpleObservationProfile assessment observation
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
... 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.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
.... device-use S 0..* Reference(Personal Functioning and Engagement Use of Device) An extension to indicate a record of assistive device usage by a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/device-patient-used
... 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 Should have the value 'final' when all the observatons are complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category S 1..* CodeableConcept (USCDI) Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:us-core S 0..* CodeableConcept (USCDI) Classification of type of observation
Binding: Personal Functioning and Engagement US Core Value Set (required)
.... category:survey S 0..1 CodeableConcept (USCDI) Classification of type of observation
Binding: Personal Functioning and Engagement Survey Value Set (required)
.... category:PFEDomain S 0..* CodeableConcept (USCDI) Classification of type of observation
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ 1..1 CodeableConcept For a Post-Acute Care structured assessment resource such as an instrument or screen, use a LOINC code to identify the instrument/screen name or panel/section title to indicate the kind of assessment.
Binding: LOINCCodes (preferred)
... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) Who and/or what the observation is about
... focus Σ 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] SΣ 1..1 Clinical relevant time for an assessment such as post-acute care observations performed with structured evaluation tools is the time the evaluation occurs, i.e., when the clinician obtains the answers entered in the tool. However, the only timing available may be when then tool is completed by the clinician. That timing is generally documented as a point in time (dateTime).
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued Σ 0..1 instant Date/Time this version was made available
... performer SΣ 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..* Annotation Comments about the observation
... bodySite 0..1 CodeableConcept Observed body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1 CodeableConcept How it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1 Reference(Specimen) Specimen used for this observation
... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... referenceRange C 0..* BackboneElement Provides guide for interpretation
obs-3: Must have at least a low or a high or text
.... 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 SΣ 0..* Reference(Personal Functioning and Engagement Single Observation) Each post-acute care observation in the collection. May also be another collection to support nested sections.
... derivedFrom SΣ 0..* Reference(US Core QuestionnaireResponse Profile | US Core Simple Observation Profile) Should point back to the QuestionnaireResponse that this resource is derived from.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:us-corerequiredPFEUSCoreCategoryVS
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-us-core-category-vs
from this IG
Observation.category:surveyrequiredPFESurveyCategoryVS
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-survey-category-vs
from this IG
Observation.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs
from this IG
Observation.codepreferredLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Observation.methodexampleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
http://hl7.org/fhir/ValueSet/referencerange-meaning
from the FHIR Standard
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
http://hl7.org/fhir/ValueSet/referencerange-appliesto
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard

 

Other representations of profile: CSV, Excel, Schematron

Notes:

The syntax used to describe the interactions below is described here.

Mandatory Search Parameters:

The following search parameters and search parameter combinations SHALL be supported:

  1. SHALL support searching using the combination of the patient and category search parameters:

    GET [base]/Observation?patient={Type/}[id]&category={system|}[code]

    Example:

    1. GET [base]/Observation?patient=1134281&category=http://terminology.hl7.org/CodeSystem/observation-category|survey
    2. GET [base]/Observation?patient=1134281&category=http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-category-cs|mental_functions

    Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and a category code = survey or mental_functions respectively (how to search by reference and how to search by token)

  2. SHALL support searching using the combination of the patient and code search parameters:
    • including optional support for OR search on code (e.g.code={system|}[code],{system|}[code],...)

    GET [base]/Observation?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}

    Example:

    1. GET [base]/Observation?patient=1134281&code=http://loinc.org|72133-2
    2. GET [base]/Observation?patient=1134281&code=http://loinc.org|72133-2,http://loinc.org|72107-6,http://loinc.org|54635-8

    Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and observation code(s). SHOULD support search by multiple report codes. The Observation code parameter searches `Observation.code only. (how to search by reference and how to search by token)

  3. SHALL support searching using the combination of the patient and category and date search parameters:
    • including support for these date comparators: gt,lt,ge,le
    • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)

    GET [base]/Observation?patient={Type/}[id]&category={system|}[code]&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]Observation?patient=555580&category=http://terminology.hl7.org/CodeSystem/observation-category|survey&date=ge2018-03-14T00:00:00Z
    2. GET [base]Observation?patient=555580&category=http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-category-cs|mental_functions&date=ge2018-03-14T00:00:00Z

    Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and date and a category code = survey or mental_functions respectively (how to search by reference and how to search by token and how to search by date)

Optional Search Parameters:

The following search parameter combinations SHOULD be supported:

  1. SHOULD support searching using the combination of the patient and category and status search parameters:
    • including support for OR search on status (e.g.status={system|}[code],{system|}[code],...)

    GET [base]/Observation?patient={Type/}[id]&category={system|}[code]&status={system|}[code]{,{system|}[code],...}

    Example:

    1. GET [base]/Observation?patient=1134281&category=http://terminology.hl7.org/CodeSystem/observation-category|survey&status=final
    2. GET [base]/Observation?patient=1134281&category=http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-category-cs|mental_functions&status=final

    Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and category = survey or mental_functions respectively and status final (how to search by reference and how to search by token)

  2. SHOULD support searching using the combination of the patient and code and date search parameters:
    • including optional support for OR search on code (e.g.code={system|}[code],{system|}[code],...)
    • including support for these date comparators: gt,lt,ge,le
    • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)

    GET [base]/Observation?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]Observation?patient=555580&code=http://loinc.org|72133-2&date=ge2019-01-01T00:00:00Z

    Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and date and report code(s). SHOULD support search by multiple report codes. (how to search by reference and how to search by token and how to search by date)