This page is part of the Clinical Guidelines (v1.0.0: STU 1) based on FHIR R4. This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
The official URL for this profile is:
http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-observation
Documents a specific observation as an activity within the context of a computable clinical practice guideline
This profile builds on Observation.
This profile was published on Thu Jun 06 00:00:00 UTC 2019 as a draft by Health Level Seven, Inc. - CDS WG.
Description of Profiles, Differentials, and Snapshots.
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | I | 0..* | Observation | Measurements and simple assertions |
id | Σ | 0..1 | string | 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) Max Binding: AllLanguages: A human language. | |
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
contained | 0..* | Resource | Contained, inline Resources | |
extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
cpg-instantiatesCaseFeature | S | 0..1 | canonical(StructureDefinition) | Definition of this case feature URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-instantiatesCaseFeature |
cpg-caseFeatureType | S | 0..1 | code | asserted | inferred URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeatureType Binding: CPG Case Feature Type (required): Whether the case feature is asserted or inferred |
cpg-caseFeaturePertinence | S | 0..1 | code | weakly-positive | weakly-negative | strongly-positive | strongly-negative | pathognomonic URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeaturePertinence Binding: CPG Case Feature Pertinence (required): Describes the pertinence of a case feature |
cpg-pertinent | S | 0..* | Reference() | Pertinent information URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-pertinent |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | SΣ | 0..* | Identifier | Business Identifier for observation |
basedOn | SΣ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order |
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event |
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
category | S | 0..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. |
subject | SΣ | 0..1 | Reference(Patient | Group | Device | Location) | 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 | SΣ | 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 | 0..1 | instant | Date/Time this version was made available |
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation |
value[x] | ΣI | 0..1 | Actual result | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
dataAbsentReason | I | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |
note | 0..* | Annotation | Comments about the observation | |
bodySite | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |
method | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |
specimen | 0..1 | Reference(Specimen) | Specimen used for this observation | |
device | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |
referenceRange | I | 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 | I | 0..1 | SimpleQuantity | Low Range, if relevant |
high | I | 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(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | 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 | I | 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 |
Differential View
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | I | 0..* | Observation | Measurements and simple assertions |
id | Σ | 0..1 | string | 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) Max Binding: AllLanguages: A human language. | |
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
contained | 0..* | Resource | Contained, inline Resources | |
extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
cpg-instantiatesCaseFeature | S | 0..1 | canonical(StructureDefinition) | Definition of this case feature URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-instantiatesCaseFeature |
cpg-caseFeatureType | S | 0..1 | code | asserted | inferred URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeatureType Binding: CPG Case Feature Type (required): Whether the case feature is asserted or inferred |
cpg-caseFeaturePertinence | S | 0..1 | code | weakly-positive | weakly-negative | strongly-positive | strongly-negative | pathognomonic URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeaturePertinence Binding: CPG Case Feature Pertinence (required): Describes the pertinence of a case feature |
cpg-pertinent | S | 0..* | Reference() | Pertinent information URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-pertinent |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | SΣ | 0..* | Identifier | Business Identifier for observation |
basedOn | SΣ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order |
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event |
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
category | S | 0..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. |
subject | SΣ | 0..1 | Reference(Patient | Group | Device | Location) | 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 | SΣ | 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 | 0..1 | instant | Date/Time this version was made available |
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation |
value[x] | ΣI | 0..1 | Actual result | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
dataAbsentReason | I | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |
note | 0..* | Annotation | Comments about the observation | |
bodySite | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |
method | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |
specimen | 0..1 | Reference(Specimen) | Specimen used for this observation | |
device | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |
referenceRange | I | 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 | I | 0..1 | SimpleQuantity | Low Range, if relevant |
high | I | 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(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | 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 | I | 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 |
Observation.language | preferred | CommonLanguages Max Binding: AllLanguages |
Observation.status | required | ObservationStatus |
Observation.category | preferred | ObservationCategoryCodes |
Observation.code | example | LOINCCodes |
Observation.dataAbsentReason | extensible | DataAbsentReason |
Observation.interpretation | extensible | ObservationInterpretationCodes |
Observation.bodySite | example | SNOMEDCTBodyStructures |
Observation.method | example | ObservationMethods |
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes |
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes |
Observation.component.code | example | LOINCCodes |
Observation.component.dataAbsentReason | extensible | DataAbsentReason |
Observation.component.interpretation | extensible | ObservationInterpretationCodes |
Id | Path | Details | Requirements |
dom-2 | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | 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 | 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 | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
obs-6 | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
obs-7 | 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() | |
ele-1 | Observation.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | Observation.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | Observation.extension:instantiatesCaseFeature | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | Observation.extension:instantiatesCaseFeature | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | Observation.extension:caseFeatureType | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | Observation.extension:caseFeatureType | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | Observation.extension:caseFeaturePertinence | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | Observation.extension:caseFeaturePertinence | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | Observation.extension:pertinent | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | Observation.extension:pertinent | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | Observation.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | Observation.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | Observation.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.basedOn | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.partOf | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.category | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.subject | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.encounter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.effective[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.issued | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.performer | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.value[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.dataAbsentReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.interpretation | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.note | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.bodySite | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.method | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.specimen | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.device | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.referenceRange | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
obs-3 | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
ele-1 | Observation.referenceRange.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | Observation.referenceRange.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | Observation.referenceRange.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | Observation.referenceRange.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | Observation.referenceRange.low | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.referenceRange.high | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.referenceRange.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.referenceRange.appliesTo | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.referenceRange.age | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.referenceRange.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.hasMember | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.derivedFrom | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.component | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.component.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | Observation.component.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | Observation.component.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | Observation.component.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | Observation.component.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.component.value[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.component.dataAbsentReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.component.interpretation | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | Observation.component.referenceRange | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |