QI-Core Implementation Guide
6.0.0 - STU6
QI-Core Implementation Guide
6.0.0 - STU6
This page is part of the Quality Improvement Core Framework (v6.0.0: STU6 (v6.0.0)) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
| Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observationcancelled | Version: 6.0.0 | |||
| Active as of 2018-08-22 | Computable Name: QICoreObservationCancelled | |||
Profile of ObservationCancelled for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.
The Simple Observation and ObservationCancelled profiles represent the positive and negative statements for an observation. To ensure instances retrieved meet negative intent, applications should check the status element as illustrated in this example:
define "Pap Test Refused":
["ObservationCancelled": "Pap Test"] PapTest
where PapTest.notDoneReason in "Patient Refusal"
Note that when a more specific observation, such as a Blood Pressure, is negated, the resource instance should conform to both the specific observation profile AND the general negation profile.
| Negation Example with valueset | Observation not indicated; indicates that none of the observations in the given not done value set were performed. |
| Negation Example with code | Observation not indicate; indicates that a specific observation, by code, was not done. |
For a more complete discussion of representation of negation within QI-Core and quality improvement artifacts, see the Negation in QI-Core topic.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Observation | C | 0..* | Observation | Measurements and simple assertions ond-1: to indicate what observation was not recorded, either at least one coding in the code or a notDoneValueSet extension shall be provided |
  notDoneReason | 1..1 | CodeableConcept | (QI-Core) Extension URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneReason Binding: QICore Negation Reason Codes (extensible): The reason the event did not occur or was not performed | |
 status | 1..1 | code | (QI-Core) registered | preliminary | final | amended + Fixed Value: cancelled | |
 category | 1..* | CodeableConcept | (QI-Core) Classification of type of observation | |
 code | 1..1 | CodeableConcept | (QI-Core) Type of observation (code / type) | |
  notDoneValueSet | 0..1 | canonical(ValueSet) | (QI-Core) What was not done URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet | |
 subject | 1..1 | Reference(QICore Patient) | (QI-Core) Who and/or what the observation is about | |
| issued | 1..1 | instant | (QI-Core) Date/Time this version was made available | |
| performer | 0..* | Reference(QICore Practitioner | QICore Organization | QICore Patient | QICore RelatedPerson) | Who is responsible for the observation | |
 Slices for value[x] | Σ | 0..1 | (QI-Core) Actual result Slice: Unordered, Open by type:$this | |
  valueQuantity | Quantity | |||
| valueCodeableConcept | CodeableConcept | |||
| valueString | string | |||
| valueBoolean | boolean | |||
| valueInteger | integer | |||
| valueRange | Range | |||
| valueRatio | Ratio | |||
| valueSampledData | SampledData | |||
| valueTime | time | |||
| valueDateTime | dateTime | |||
| valuePeriod | Period | |||
 value[x]:valueCodeableConcept | 0..1 | CodeableConcept | (QI-Core) Actual result Binding: US Core Observation Value Codes (SNOMED-CT) (preferred): SNOMED CT for coded results | |
| interpretation | 0..* | CodeableConcept | (QI-Core) High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |
| derivedFrom | 0..* | Reference(QICore Simple Observation | QICore QuestionnaireResponse | US Core DocumentReference Profile | ImagingStudy | Media | MolecularSequence) | Related measurements the observation is made from | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Observation.value[x]:valueCodeableConcept | preferred | USCoreObservationValueCodes (a valid code from SNOMED CT)http://hl7.org/fhir/us/core/ValueSet/us-core-observation-value-codes | |
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| ond-1 | error | Observation | to indicate what observation was not recorded, either at least one coding in the code or a notDoneValueSet extension shall be provided : code.extension('http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists() xor code.coding.exists() |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | C | 0..* | Observation | Measurements and simple assertions 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 ond-1: to indicate what observation was not recorded, either at least one coding in the code or a notDoneValueSet extension shall be provided |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
| notDoneReason | 1..1 | CodeableConcept | (QI-Core) Extension URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneReason Binding: QICore Negation Reason Codes (extensible): The reason the event did not occur or was not performed | |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!Σ | 1..1 | code | (QI-Core) registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: cancelled |
| category | 1..* | CodeableConcept | (QI-Core) Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |
| code | Σ | 1..1 | CodeableConcept | (QI-Core) Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. |
| notDoneValueSet | 0..1 | canonical(ValueSet) | (QI-Core) What was not done URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet | |
| subject | Σ | 1..1 | Reference(QICore Patient) | (QI-Core) Who and/or what the observation is about |
| issued | Σ | 1..1 | instant | (QI-Core) Date/Time this version was made available |
| performer | Σ | 0..* | Reference(QICore Practitioner | QICore Organization | QICore Patient | QICore RelatedPerson) | Who is responsible for the observation |
| Slices for value[x] | ΣC | 0..1 | (QI-Core) Actual result Slice: Unordered, Open by type:$this | |
| valueQuantity | Quantity | |||
| valueCodeableConcept | CodeableConcept | |||
| valueString | string | |||
| valueBoolean | boolean | |||
| valueInteger | integer | |||
| valueRange | Range | |||
| valueRatio | Ratio | |||
| valueSampledData | SampledData | |||
| valueTime | time | |||
| valueDateTime | dateTime | |||
| valuePeriod | Period | |||
| value[x]:valueCodeableConcept | ΣC | 0..1 | CodeableConcept | (QI-Core) Actual result Binding: US Core Observation Value Codes (SNOMED-CT) (preferred): SNOMED CT for coded results |
| interpretation | 0..* | CodeableConcept | (QI-Core) High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |
| derivedFrom | Σ | 0..* | Reference(QICore Simple Observation | QICore QuestionnaireResponse | US Core DocumentReference Profile | ImagingStudy | Media | MolecularSequence) | Related measurements the observation is made from |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.status | required | Fixed Value: cancelledhttp://hl7.org/fhir/ValueSet/observation-status|4.0.1from the FHIR Standard | |
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | |
| Observation.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | |
| Observation.value[x]:valueCodeableConcept | preferred | USCoreObservationValueCodes (a valid code from SNOMED CT)http://hl7.org/fhir/us/core/ValueSet/us-core-observation-value-codes | |
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Observation | 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 : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
| ond-1 | error | Observation | to indicate what observation was not recorded, either at least one coding in the code or a notDoneValueSet extension shall be provided : code.extension('http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists() xor code.coding.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Observation | C | 0..* | Observation | Measurements and simple assertions 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 ond-1: to indicate what observation was not recorded, either at least one coding in the code or a notDoneValueSet extension shall be provided | ||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| notDoneReason | 1..1 | CodeableConcept | (QI-Core) Extension URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneReason Binding: QICore Negation Reason Codes (extensible): The reason the event did not occur or was not performed | |||||
| 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 | ?!Σ | 1..1 | code | (QI-Core) registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: cancelled | ||||
| category | 1..* | CodeableConcept | (QI-Core) Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||
| code | Σ | 1..1 | CodeableConcept | (QI-Core) Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| notDoneValueSet | 0..1 | canonical(ValueSet) | (QI-Core) What was not done URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet | |||||
| coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| subject | Σ | 1..1 | Reference(QICore Patient) | (QI-Core) 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] | Σ | 0..1 | Clinically relevant time/time-period for observation | |||||
| effectiveDateTime | dateTime | |||||||
| effectivePeriod | Period | |||||||
| effectiveTiming | Timing | |||||||
| effectiveInstant | instant | |||||||
| issued | Σ | 1..1 | instant | (QI-Core) Date/Time this version was made available | ||||
| performer | Σ | 0..* | Reference(QICore Practitioner | QICore Organization | QICore Patient | QICore RelatedPerson) | Who is responsible for the observation | ||||
| Slices for value[x] | ΣC | 0..1 | (QI-Core) Actual result Slice: Unordered, Open by type:$this | |||||
| valueQuantity | Quantity | |||||||
| valueCodeableConcept | CodeableConcept | |||||||
| valueString | string | |||||||
| valueBoolean | boolean | |||||||
| valueInteger | integer | |||||||
| valueRange | Range | |||||||
| valueRatio | Ratio | |||||||
| valueSampledData | SampledData | |||||||
| valueTime | time | |||||||
| valueDateTime | dateTime | |||||||
| valuePeriod | Period | |||||||
| value[x]:valueCodeableConcept | ΣC | 0..1 | CodeableConcept | (QI-Core) Actual result Binding: US Core Observation Value Codes (SNOMED-CT) (preferred): SNOMED CT for coded results | ||||
| 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 | (QI-Core) 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 | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
| derivedFrom | Σ | 0..* | Reference(QICore Simple Observation | QICore QuestionnaireResponse | US Core DocumentReference Profile | ImagingStudy | Media | MolecularSequence) | Related measurements 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 | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Observation.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Observation.status | required | Fixed Value: cancelledhttp://hl7.org/fhir/ValueSet/observation-status|4.0.1from the FHIR Standard | ||||
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | ||||
| Observation.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.value[x]:valueCodeableConcept | preferred | USCoreObservationValueCodes (a valid code from SNOMED CT)http://hl7.org/fhir/us/core/ValueSet/us-core-observation-value-codes | ||||
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard | ||||
| Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methodsfrom the FHIR Standard | ||||
| Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaningfrom the FHIR Standard | ||||
| Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliestofrom the FHIR Standard | ||||
| Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Observation | 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 : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
| ond-1 | error | Observation | to indicate what observation was not recorded, either at least one coding in the code or a notDoneValueSet extension shall be provided : code.extension('http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists() xor code.coding.exists() |
This structure is derived from Observation
Summary
Mandatory: 6 elements
Fixed Value: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Observation
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | C | 0..* | Observation | Measurements and simple assertions ond-1: to indicate what observation was not recorded, either at least one coding in the code or a notDoneValueSet extension shall be provided |
| notDoneReason | 1..1 | CodeableConcept | (QI-Core) Extension URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneReason Binding: QICore Negation Reason Codes (extensible): The reason the event did not occur or was not performed | |
| status | 1..1 | code | (QI-Core) registered | preliminary | final | amended + Fixed Value: cancelled | |
| category | 1..* | CodeableConcept | (QI-Core) Classification of type of observation | |
| code | 1..1 | CodeableConcept | (QI-Core) Type of observation (code / type) | |
| notDoneValueSet | 0..1 | canonical(ValueSet) | (QI-Core) What was not done URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet | |
| subject | 1..1 | Reference(QICore Patient) | (QI-Core) Who and/or what the observation is about | |
| issued | 1..1 | instant | (QI-Core) Date/Time this version was made available | |
| performer | 0..* | Reference(QICore Practitioner | QICore Organization | QICore Patient | QICore RelatedPerson) | Who is responsible for the observation | |
| Slices for value[x] | Σ | 0..1 | (QI-Core) Actual result Slice: Unordered, Open by type:$this | |
| valueQuantity | Quantity | |||
| valueCodeableConcept | CodeableConcept | |||
| valueString | string | |||
| valueBoolean | boolean | |||
| valueInteger | integer | |||
| valueRange | Range | |||
| valueRatio | Ratio | |||
| valueSampledData | SampledData | |||
| valueTime | time | |||
| valueDateTime | dateTime | |||
| valuePeriod | Period | |||
| value[x]:valueCodeableConcept | 0..1 | CodeableConcept | (QI-Core) Actual result Binding: US Core Observation Value Codes (SNOMED-CT) (preferred): SNOMED CT for coded results | |
| interpretation | 0..* | CodeableConcept | (QI-Core) High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |
| derivedFrom | 0..* | Reference(QICore Simple Observation | QICore QuestionnaireResponse | US Core DocumentReference Profile | ImagingStudy | Media | MolecularSequence) | Related measurements the observation is made from | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Observation.value[x]:valueCodeableConcept | preferred | USCoreObservationValueCodes (a valid code from SNOMED CT)http://hl7.org/fhir/us/core/ValueSet/us-core-observation-value-codes | |
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| ond-1 | error | Observation | to indicate what observation was not recorded, either at least one coding in the code or a notDoneValueSet extension shall be provided : code.extension('http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists() xor code.coding.exists() |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | C | 0..* | Observation | Measurements and simple assertions 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 ond-1: to indicate what observation was not recorded, either at least one coding in the code or a notDoneValueSet extension shall be provided |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
| notDoneReason | 1..1 | CodeableConcept | (QI-Core) Extension URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneReason Binding: QICore Negation Reason Codes (extensible): The reason the event did not occur or was not performed | |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!Σ | 1..1 | code | (QI-Core) registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: cancelled |
| category | 1..* | CodeableConcept | (QI-Core) Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |
| code | Σ | 1..1 | CodeableConcept | (QI-Core) Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. |
| notDoneValueSet | 0..1 | canonical(ValueSet) | (QI-Core) What was not done URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet | |
| subject | Σ | 1..1 | Reference(QICore Patient) | (QI-Core) Who and/or what the observation is about |
| issued | Σ | 1..1 | instant | (QI-Core) Date/Time this version was made available |
| performer | Σ | 0..* | Reference(QICore Practitioner | QICore Organization | QICore Patient | QICore RelatedPerson) | Who is responsible for the observation |
| Slices for value[x] | ΣC | 0..1 | (QI-Core) Actual result Slice: Unordered, Open by type:$this | |
| valueQuantity | Quantity | |||
| valueCodeableConcept | CodeableConcept | |||
| valueString | string | |||
| valueBoolean | boolean | |||
| valueInteger | integer | |||
| valueRange | Range | |||
| valueRatio | Ratio | |||
| valueSampledData | SampledData | |||
| valueTime | time | |||
| valueDateTime | dateTime | |||
| valuePeriod | Period | |||
| value[x]:valueCodeableConcept | ΣC | 0..1 | CodeableConcept | (QI-Core) Actual result Binding: US Core Observation Value Codes (SNOMED-CT) (preferred): SNOMED CT for coded results |
| interpretation | 0..* | CodeableConcept | (QI-Core) High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |
| derivedFrom | Σ | 0..* | Reference(QICore Simple Observation | QICore QuestionnaireResponse | US Core DocumentReference Profile | ImagingStudy | Media | MolecularSequence) | Related measurements the observation is made from |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.status | required | Fixed Value: cancelledhttp://hl7.org/fhir/ValueSet/observation-status|4.0.1from the FHIR Standard | |
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | |
| Observation.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | |
| Observation.value[x]:valueCodeableConcept | preferred | USCoreObservationValueCodes (a valid code from SNOMED CT)http://hl7.org/fhir/us/core/ValueSet/us-core-observation-value-codes | |
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Observation | 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 : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
| ond-1 | error | Observation | to indicate what observation was not recorded, either at least one coding in the code or a notDoneValueSet extension shall be provided : code.extension('http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists() xor code.coding.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Observation | C | 0..* | Observation | Measurements and simple assertions 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 ond-1: to indicate what observation was not recorded, either at least one coding in the code or a notDoneValueSet extension shall be provided | ||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| notDoneReason | 1..1 | CodeableConcept | (QI-Core) Extension URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneReason Binding: QICore Negation Reason Codes (extensible): The reason the event did not occur or was not performed | |||||
| 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 | ?!Σ | 1..1 | code | (QI-Core) registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: cancelled | ||||
| category | 1..* | CodeableConcept | (QI-Core) Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||
| code | Σ | 1..1 | CodeableConcept | (QI-Core) Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| notDoneValueSet | 0..1 | canonical(ValueSet) | (QI-Core) What was not done URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet | |||||
| coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| subject | Σ | 1..1 | Reference(QICore Patient) | (QI-Core) 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] | Σ | 0..1 | Clinically relevant time/time-period for observation | |||||
| effectiveDateTime | dateTime | |||||||
| effectivePeriod | Period | |||||||
| effectiveTiming | Timing | |||||||
| effectiveInstant | instant | |||||||
| issued | Σ | 1..1 | instant | (QI-Core) Date/Time this version was made available | ||||
| performer | Σ | 0..* | Reference(QICore Practitioner | QICore Organization | QICore Patient | QICore RelatedPerson) | Who is responsible for the observation | ||||
| Slices for value[x] | ΣC | 0..1 | (QI-Core) Actual result Slice: Unordered, Open by type:$this | |||||
| valueQuantity | Quantity | |||||||
| valueCodeableConcept | CodeableConcept | |||||||
| valueString | string | |||||||
| valueBoolean | boolean | |||||||
| valueInteger | integer | |||||||
| valueRange | Range | |||||||
| valueRatio | Ratio | |||||||
| valueSampledData | SampledData | |||||||
| valueTime | time | |||||||
| valueDateTime | dateTime | |||||||
| valuePeriod | Period | |||||||
| value[x]:valueCodeableConcept | ΣC | 0..1 | CodeableConcept | (QI-Core) Actual result Binding: US Core Observation Value Codes (SNOMED-CT) (preferred): SNOMED CT for coded results | ||||
| 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 | (QI-Core) 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 | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
| derivedFrom | Σ | 0..* | Reference(QICore Simple Observation | QICore QuestionnaireResponse | US Core DocumentReference Profile | ImagingStudy | Media | MolecularSequence) | Related measurements 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 | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Observation.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Observation.status | required | Fixed Value: cancelledhttp://hl7.org/fhir/ValueSet/observation-status|4.0.1from the FHIR Standard | ||||
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | ||||
| Observation.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.value[x]:valueCodeableConcept | preferred | USCoreObservationValueCodes (a valid code from SNOMED CT)http://hl7.org/fhir/us/core/ValueSet/us-core-observation-value-codes | ||||
| Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard | ||||
| Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methodsfrom the FHIR Standard | ||||
| Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaningfrom the FHIR Standard | ||||
| Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliestofrom the FHIR Standard | ||||
| Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | ||||
| Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonfrom the FHIR Standard | ||||
| Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Observation | 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 : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
| ond-1 | error | Observation | to indicate what observation was not recorded, either at least one coding in the code or a notDoneValueSet extension shall be provided : code.extension('http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists() xor code.coding.exists() |
This structure is derived from Observation
Summary
Mandatory: 6 elements
Fixed Value: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2019+ HL7 International / Clinical Quality Information. Package hl7.fhir.us.qicore#6.0.0 based on FHIR 4.0.1. Generated 2024-03-01
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