PACIO Personal Functioning and Engagement Implementation Guide
1.0.0 - STU1 United States of America flag

This page is part of the PACIO Personal Functioning and Engagement Implementation Guide (v1.0.0: STU 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. 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: 1.0.0
Draft as of 2024-01-05 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 USCoreObservationSurveyProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*USCoreObservationSurveyProfileSurvey Observation
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... event-location S0..1Reference(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 S0..*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
... category 2..*CodeableConceptClassification of type of observation
... category:functioning S1..1CodeableConceptClassification of type of observation
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: functioning
..... display1..1stringRepresentation defined by the system
Fixed Value: Functioning
... category:PFEDomain S0..*CodeableConceptClassification of type of observation
Binding: Personal Functioning and Engagement Category Value Set (required)
... code 1..1CodeableConceptFor 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..1Clinical 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).
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... 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 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 0..*Reference(US Core QuestionnaireResponse Profile | US Core Observation Survey Profile)Should point back to the QuestionnaireResponse that this resource is derived from.
... component 0..0

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*USCoreObservationSurveyProfileSurvey Observation
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... event-location S0..1Reference(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
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣ1..1codeShould 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 S2..*CodeableConceptClassification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:survey S1..1CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: survey
.... category:functioning S1..1CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: functioning
...... display1..1stringRepresentation defined by the system
Fixed Value: Functioning
.... category:PFEDomain S0..*CodeableConceptClassification of type of observation
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ1..1CodeableConceptFor 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: US Core Survey Codes (preferred)
... subject SΣ1..1Reference(US Core Patient Profile)Who and/or what the observation is about
... effective[x] SΣC1..1Clinical 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).
.... effectiveDateTimedateTime
... performer SΣ1..*Reference(US Core Practitioner 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 SC0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... hasMember SΣ0..*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 SΣ0..*Reference(US Core QuestionnaireResponse Profile | US Core Observation Survey Profile)Should point back to the QuestionnaireResponse that this resource is derived from.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.statusrequiredObservationStatus
Observation.categorypreferredObservationCategoryCodes
Observation.category:surveypreferredPattern: survey
Observation.category:functioningpreferredPattern: functioning("Functioning")
Observation.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
Observation.codepreferredUSCoreSurveyCodes
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*USCoreObservationSurveyProfileSurvey Observation
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... event-location S0..1Reference(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 S0..*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..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!SΣ1..1codeShould 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 S2..*CodeableConceptClassification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:survey S1..1CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: survey
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
.... category:functioning S1..1CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: functioning
...... display1..1stringRepresentation defined by the system
Fixed Value: Functioning
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
.... category:PFEDomain S0..*CodeableConceptClassification of type of observation
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ1..1CodeableConceptFor 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: US Core Survey Codes (preferred)
... subject SΣ1..1Reference(US Core Patient Profile)Who and/or what the observation is about
... focus Σ0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter Σ0..1Reference(Encounter)Healthcare event during which this observation is made
... effective[x] SΣC1..1Clinical 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).
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod
... issued Σ0..1instantDate/Time this version was made available
... performer SΣ1..*Reference(US Core Practitioner Profile S | 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 SC0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

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


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

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

... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange C0..*BackboneElementProvides guide for interpretation
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low C0..1SimpleQuantityLow Range, if relevant
.... high C0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember SΣ0..*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 SΣ0..*Reference(US Core QuestionnaireResponse Profile S | US Core Observation Survey Profile S)Should point back to the QuestionnaireResponse that this resource is derived from.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Observation.statusrequiredObservationStatus
Observation.categorypreferredObservationCategoryCodes
Observation.category:surveypreferredPattern: survey
Observation.category:functioningpreferredPattern: functioning("Functioning")
Observation.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
Observation.codepreferredUSCoreSurveyCodes
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySiteexampleSNOMEDCTBodyStructures
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes

Differential View

This structure is derived from USCoreObservationSurveyProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*USCoreObservationSurveyProfileSurvey Observation
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... event-location S0..1Reference(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 S0..*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
... category 2..*CodeableConceptClassification of type of observation
... category:functioning S1..1CodeableConceptClassification of type of observation
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: functioning
..... display1..1stringRepresentation defined by the system
Fixed Value: Functioning
... category:PFEDomain S0..*CodeableConceptClassification of type of observation
Binding: Personal Functioning and Engagement Category Value Set (required)
... code 1..1CodeableConceptFor 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..1Clinical 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).
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... 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 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 0..*Reference(US Core QuestionnaireResponse Profile | US Core Observation Survey Profile)Should point back to the QuestionnaireResponse that this resource is derived from.
... component 0..0

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*USCoreObservationSurveyProfileSurvey Observation
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... event-location S0..1Reference(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
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣ1..1codeShould 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 S2..*CodeableConceptClassification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:survey S1..1CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: survey
.... category:functioning S1..1CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: functioning
...... display1..1stringRepresentation defined by the system
Fixed Value: Functioning
.... category:PFEDomain S0..*CodeableConceptClassification of type of observation
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ1..1CodeableConceptFor 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: US Core Survey Codes (preferred)
... subject SΣ1..1Reference(US Core Patient Profile)Who and/or what the observation is about
... effective[x] SΣC1..1Clinical 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).
.... effectiveDateTimedateTime
... performer SΣ1..*Reference(US Core Practitioner 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 SC0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... hasMember SΣ0..*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 SΣ0..*Reference(US Core QuestionnaireResponse Profile | US Core Observation Survey Profile)Should point back to the QuestionnaireResponse that this resource is derived from.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.statusrequiredObservationStatus
Observation.categorypreferredObservationCategoryCodes
Observation.category:surveypreferredPattern: survey
Observation.category:functioningpreferredPattern: functioning("Functioning")
Observation.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
Observation.codepreferredUSCoreSurveyCodes
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*USCoreObservationSurveyProfileSurvey Observation
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... event-location S0..1Reference(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 S0..*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..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!SΣ1..1codeShould 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 S2..*CodeableConceptClassification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:survey S1..1CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: survey
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
.... category:functioning S1..1CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: functioning
...... display1..1stringRepresentation defined by the system
Fixed Value: Functioning
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
.... category:PFEDomain S0..*CodeableConceptClassification of type of observation
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ1..1CodeableConceptFor 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: US Core Survey Codes (preferred)
... subject SΣ1..1Reference(US Core Patient Profile)Who and/or what the observation is about
... focus Σ0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter Σ0..1Reference(Encounter)Healthcare event during which this observation is made
... effective[x] SΣC1..1Clinical 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).
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod
... issued Σ0..1instantDate/Time this version was made available
... performer SΣ1..*Reference(US Core Practitioner Profile S | 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 SC0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

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


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

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

... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange C0..*BackboneElementProvides guide for interpretation
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low C0..1SimpleQuantityLow Range, if relevant
.... high C0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember SΣ0..*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 SΣ0..*Reference(US Core QuestionnaireResponse Profile S | US Core Observation Survey Profile S)Should point back to the QuestionnaireResponse that this resource is derived from.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Observation.statusrequiredObservationStatus
Observation.categorypreferredObservationCategoryCodes
Observation.category:surveypreferredPattern: survey
Observation.category:functioningpreferredPattern: functioning("Functioning")
Observation.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
Observation.codepreferredUSCoreSurveyCodes
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySiteexampleSNOMEDCTBodyStructures
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes

 

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)