Person-Centered Outcomes (PCO) Implementation Guide
1.0.0-ballot - STU 1 Ballot United States of America flag

This page is part of the Person-Centered Outcomes (PCO) Implementation Guide (v1.0.0-ballot: STU 1 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. No current official version has been published yet. For a full list of available versions, see the Directory of published versions

Resource Profile: Readiness Assessment

Official URL: http://hl7.org/fhir/us/pco/StructureDefinition/pco-readiness-assessment Version: 1.0.0-ballot
Standards status: Draft Maturity Level: 2 Computable Name: PCOReadinessAssessmentProfile

Assessment of a person's readiness for change including importance and confidence for making that change.

The Readiness Assessment Observation records a person's responses to questions about their readiness to make a change, e.g. to achieve a person-centered goal. Assessing a person's readiness for change typically consists of asking two questions:

  • "On a scale of 1 to 10, how important is it for you to… (your goal)?"
  • "On a scale of 1 to 10, how confident are you that you will be able to… (your goal)?".

The Readiness Assessment Observation inherits from the US Core Observation Screening Assessment Profile; refer to it for scope and usage guidance. The US Core profile meets the requirements of the U.S. Core Data for Interoperability (USCDI) Health Status Assessments Data Class. It sets the minimum expectations for the Observation Resource to record, search, and fetch observations representing the questions and responses to surveys and screening and assessment tools.

Example Usage Scenarios:

The following are example usage scenarios for this Profile:

  • Record or update observations related to a person's assessment of readiness for change. These observations may be extracted from a QuestionnaireResponse that inludes panel(s) of question/answer responses about importance or confidence, or observations created from a dedicated assessment application without use of a Questionnaire.
  • Query for observations representing a patient's assessment of readiness for change focused on a specified goal.

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 Readiness Assessment Observation must have:

  1. a status
  2. a category code of "survey"
  3. a code identifying the type of readiness assessment
  4. a patient

Each Readiness Assessment Observation must support:

  1. additional categories that further specify the assessment or screening
  2. a time indicating when the assessment was taken
  3. who answered the questions
  4. a focus referring to a Goal or Observation that was assessed for readiness to change
  5. a value containing either:
    • a codeable concept containing a scale value from 0 to 10 from the LOINC Answer List
    • or hasMember referencing Observations within a panel of questions.

Usage:

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* USCoreObservationScreeningAssessmentProfile Survey Observation
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
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
us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present
us-core-3: SHALL use UCUM for coded quantity units.
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... status ?!SΣ 1..1 code (USCDI) registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.


ele-1: All FHIR elements must have a @value or children
.... category:survey S 1..1 CodeableConcept (USCDI) Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


ele-1: All FHIR elements must have a @value or children

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://terminology.hl7.org/CodeSystem/observation-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: survey
.... category:screening-assessment S 0..* CodeableConcept (USCDI) Classification of type of observation
Binding: US Core Screening Assessment Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


ele-1: All FHIR elements must have a @value or children
... code SΣ 1..1 CodeableConcept (USCDI) Type of observation (code / type)
Binding: Readiness Assessment Codes (extensible): Type of readiness being assessed


ele-1: All FHIR elements must have a @value or children
... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) Who and/or what the observation is about
ele-1: All FHIR elements must have a @value or children
... focus SΣ 0..1 Reference(Goal | Observation) The goal or observation that is assessed
ele-1: All FHIR elements must have a @value or children
... effective[x] SΣC 0..1 (USCDI) Clinically relevant time/time-period for observation
ele-1: All FHIR elements must have a @value or children
us-core-1: Datetime must be at least to day.
.... effectiveDateTime dateTime
... performer SΣ 0..* Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) (USCDI) Who is responsible for the observation
ele-1: All FHIR elements must have a @value or children
... value[x] SΣC 0..1 CodeableConcept A scale value ranging from 0 to 10
Binding: LOINC Answer List LL2335-9 (required)
ele-1: All FHIR elements must have a @value or children
... dataAbsentReason SC 0..1 CodeableConcept (USCDI) Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.


ele-1: All FHIR elements must have a @value or children
... hasMember SΣ 0..* Reference(Readiness Assessment) Reference to panel members
ele-1: All FHIR elements must have a @value or children
... derivedFrom SΣ 0..* Reference(US Core Observation Screening Assessment Profile | US Core QuestionnaireResponse Profile) Related Observation(s) or other resource the observation is made from
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
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:surveypreferredPattern: survey
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:screening-assessmentrequiredUSCoreScreeningAssessmentObservationCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-category
Observation.codeextensibleReadinessAssessmentType (a valid code from Readiness Assessment Concepts)
http://hl7.org/fhir/us/pco/ValueSet/readiness-assessment-codes
from this IG
Observation.value[x]requiredLOINC LL2335-9
http://loinc.org/vs/LL2335-9
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard

This structure is derived from USCoreObservationScreeningAssessmentProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..* USCoreObservationScreeningAssessmentProfile Survey Observation
... code 1..1 CodeableConcept (USCDI) Type of observation (code / type)
Binding: Readiness Assessment Codes (extensible): Type of readiness being assessed

... focus S 0..1 Reference(Goal | Observation) The goal or observation that is assessed
... value[x] 0..1 CodeableConcept A scale value ranging from 0 to 10
Binding: LOINC Answer List LL2335-9 (required)
... derivedFrom 0..* Reference(US Core Observation Screening Assessment Profile | US Core QuestionnaireResponse Profile) Related Observation(s) or other resource the observation is made from

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.codeextensibleReadinessAssessmentType (a valid code from Readiness Assessment Concepts)
http://hl7.org/fhir/us/pco/ValueSet/readiness-assessment-codes
from this IG
Observation.value[x]requiredLOINC LL2335-9
http://loinc.org/vs/LL2335-9
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* USCoreObservationScreeningAssessmentProfile Survey 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
us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present
us-core-3: SHALL use UCUM for coded quantity units.
... 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
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business Identifier for observation
... basedOn Σ 0..* Reference(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 (USCDI) registered | preliminary | final | amended +
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:survey S 1..1 CodeableConcept (USCDI) Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: survey
...... 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
.... category:screening-assessment S 0..* CodeableConcept (USCDI) Classification of type of observation
Binding: US Core Screening Assessment Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code SΣ 1..1 CodeableConcept (USCDI) Type of observation (code / type)
Binding: Readiness Assessment Codes (extensible): Type of readiness being assessed

... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) Who and/or what the observation is about
... focus SΣ 0..1 Reference(Goal | Observation) The goal or observation that is assessed
... encounter Σ 0..1 Reference(Encounter) Healthcare event during which this observation is made
... effective[x] SΣC 0..1 (USCDI) Clinically relevant time/time-period for observation
us-core-1: Datetime must be at least to day.
.... effectiveDateTime dateTime S
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... issued Σ 0..1 instant Date/Time this version was made available
... performer SΣ 0..* Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) (USCDI) Who is responsible for the observation
... value[x] SΣC 0..1 CodeableConcept S A scale value ranging from 0 to 10
Binding: LOINC Answer List LL2335-9 (required)
... dataAbsentReason SC 0..1 CodeableConcept (USCDI) 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(Readiness Assessment) Reference to panel members
... derivedFrom SΣ 0..* Reference(US Core Observation Screening Assessment Profile S | US Core QuestionnaireResponse Profile S) Related Observation(s) or other resource the observation is made from
... component Σ 0..* BackboneElement Component results
.... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Observation.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
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:surveypreferredPattern: survey
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:screening-assessmentrequiredUSCoreScreeningAssessmentObservationCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-category
Observation.codeextensibleReadinessAssessmentType (a valid code from Readiness Assessment Concepts)
http://hl7.org/fhir/us/pco/ValueSet/readiness-assessment-codes
from this IG
Observation.value[x]requiredLOINC LL2335-9
http://loinc.org/vs/LL2335-9
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

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* USCoreObservationScreeningAssessmentProfile Survey Observation
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
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
us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present
us-core-3: SHALL use UCUM for coded quantity units.
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... status ?!SΣ 1..1 code (USCDI) registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.


ele-1: All FHIR elements must have a @value or children
.... category:survey S 1..1 CodeableConcept (USCDI) Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


ele-1: All FHIR elements must have a @value or children

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://terminology.hl7.org/CodeSystem/observation-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: survey
.... category:screening-assessment S 0..* CodeableConcept (USCDI) Classification of type of observation
Binding: US Core Screening Assessment Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


ele-1: All FHIR elements must have a @value or children
... code SΣ 1..1 CodeableConcept (USCDI) Type of observation (code / type)
Binding: Readiness Assessment Codes (extensible): Type of readiness being assessed


ele-1: All FHIR elements must have a @value or children
... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) Who and/or what the observation is about
ele-1: All FHIR elements must have a @value or children
... focus SΣ 0..1 Reference(Goal | Observation) The goal or observation that is assessed
ele-1: All FHIR elements must have a @value or children
... effective[x] SΣC 0..1 (USCDI) Clinically relevant time/time-period for observation
ele-1: All FHIR elements must have a @value or children
us-core-1: Datetime must be at least to day.
.... effectiveDateTime dateTime
... performer SΣ 0..* Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) (USCDI) Who is responsible for the observation
ele-1: All FHIR elements must have a @value or children
... value[x] SΣC 0..1 CodeableConcept A scale value ranging from 0 to 10
Binding: LOINC Answer List LL2335-9 (required)
ele-1: All FHIR elements must have a @value or children
... dataAbsentReason SC 0..1 CodeableConcept (USCDI) Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.


ele-1: All FHIR elements must have a @value or children
... hasMember SΣ 0..* Reference(Readiness Assessment) Reference to panel members
ele-1: All FHIR elements must have a @value or children
... derivedFrom SΣ 0..* Reference(US Core Observation Screening Assessment Profile | US Core QuestionnaireResponse Profile) Related Observation(s) or other resource the observation is made from
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
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:surveypreferredPattern: survey
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:screening-assessmentrequiredUSCoreScreeningAssessmentObservationCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-category
Observation.codeextensibleReadinessAssessmentType (a valid code from Readiness Assessment Concepts)
http://hl7.org/fhir/us/pco/ValueSet/readiness-assessment-codes
from this IG
Observation.value[x]requiredLOINC LL2335-9
http://loinc.org/vs/LL2335-9
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard

Differential View

This structure is derived from USCoreObservationScreeningAssessmentProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..* USCoreObservationScreeningAssessmentProfile Survey Observation
... code 1..1 CodeableConcept (USCDI) Type of observation (code / type)
Binding: Readiness Assessment Codes (extensible): Type of readiness being assessed

... focus S 0..1 Reference(Goal | Observation) The goal or observation that is assessed
... value[x] 0..1 CodeableConcept A scale value ranging from 0 to 10
Binding: LOINC Answer List LL2335-9 (required)
... derivedFrom 0..* Reference(US Core Observation Screening Assessment Profile | US Core QuestionnaireResponse Profile) Related Observation(s) or other resource the observation is made from

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.codeextensibleReadinessAssessmentType (a valid code from Readiness Assessment Concepts)
http://hl7.org/fhir/us/pco/ValueSet/readiness-assessment-codes
from this IG
Observation.value[x]requiredLOINC LL2335-9
http://loinc.org/vs/LL2335-9

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* USCoreObservationScreeningAssessmentProfile Survey 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
us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present
us-core-3: SHALL use UCUM for coded quantity units.
... 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
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business Identifier for observation
... basedOn Σ 0..* Reference(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 (USCDI) registered | preliminary | final | amended +
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:survey S 1..1 CodeableConcept (USCDI) Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: survey
...... 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
.... category:screening-assessment S 0..* CodeableConcept (USCDI) Classification of type of observation
Binding: US Core Screening Assessment Observation Category (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code SΣ 1..1 CodeableConcept (USCDI) Type of observation (code / type)
Binding: Readiness Assessment Codes (extensible): Type of readiness being assessed

... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) Who and/or what the observation is about
... focus SΣ 0..1 Reference(Goal | Observation) The goal or observation that is assessed
... encounter Σ 0..1 Reference(Encounter) Healthcare event during which this observation is made
... effective[x] SΣC 0..1 (USCDI) Clinically relevant time/time-period for observation
us-core-1: Datetime must be at least to day.
.... effectiveDateTime dateTime S
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... issued Σ 0..1 instant Date/Time this version was made available
... performer SΣ 0..* Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core RelatedPerson Profile) (USCDI) Who is responsible for the observation
... value[x] SΣC 0..1 CodeableConcept S A scale value ranging from 0 to 10
Binding: LOINC Answer List LL2335-9 (required)
... dataAbsentReason SC 0..1 CodeableConcept (USCDI) 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(Readiness Assessment) Reference to panel members
... derivedFrom SΣ 0..* Reference(US Core Observation Screening Assessment Profile S | US Core QuestionnaireResponse Profile S) Related Observation(s) or other resource the observation is made from
... component Σ 0..* BackboneElement Component results
.... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Observation.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
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:surveypreferredPattern: survey
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:screening-assessmentrequiredUSCoreScreeningAssessmentObservationCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-screening-assessment-observation-category
Observation.codeextensibleReadinessAssessmentType (a valid code from Readiness Assessment Concepts)
http://hl7.org/fhir/us/pco/ValueSet/readiness-assessment-codes
from this IG
Observation.value[x]requiredLOINC LL2335-9
http://loinc.org/vs/LL2335-9
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

 

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