International Patient Summary Implementation Guide Implementation Guide: STU2 Ballot

This page is part of the International Patient Summary Implementation Guide (v0.2.0: STU 1 Ballot 2) based on FHIR v3.5.0. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

SD.17 StructureDefinition-observation-imaging-uv-ips

This profile represents the contraints applied to the Observation resource by the IPS project, which specifies an imaging observation for the international patient summary based on the FHIR standard R4.

This observation may represent the conclusions of a diagnostic procedure such a Chest RX, or it may group the set of results produced by that single or multi modality procedure.

In the latter case, the main observation (this one) carries the overall conclusion of the study and/or a global interpretation by the observer of the study as value of this observation; and may references the atomic results of the study as “child observations”.

It allows also to provide details about the related study using the event-partOf extension referring an ImagingStudy resource.

Conformance resource variables defined here

SD.17.1 Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: http://hl7.org/fhir/uv/ips/StructureDefinition/observation-imaging-uv-ips

Published on Tue Feb 06 18:53:52 AEST 2018 as a draft by .

This profile builds on Observation

Summary

Mandatory: 2 elements (1 nested mandatory element)
Must-Support: 22 elements
Fixed Value: 1 element
Prohibited: 5 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element Observation.component is sliced based on the values of value:code.binding.valueSet, type:value[x]

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*
... extension 0..*ExtensionSlice: Unordered, Open by value:url
... event-partOf S0..*Reference(Resource)Part of referenced event
URL: http://hl7.org/fhir/StructureDefinition/event-partOf
.... valueReference S0..1Reference()
..... identifier 0..0
... category S1..1CodeableConcept-uv-ipsFixed Value: {"coding":[{"system":"http://terminology.hl7.org/CodeSystem/observation-category","code":"imaging","display":"Imaging"}]}
... code S1..1CodeableConcept-uv-ipsBinding: IPS Results Observation Radiology (extensible)
... subject S1..1Reference(Patient-uv-ips)
.... reference 0..1string
.... identifier 0..0
... effective[x] S0..1dateTime, Period, Timing, instant
... performer S0..*Reference(Practitioner-uv-ips | Organization-observation-uv-ips)
.... identifier 0..0
... valueString S0..1string
... bodySite S0..1CodeableConcept-uv-ipsBinding: IPS Target Site (example)
... device S0..1Reference(Device-observer-uv-ips)
.... identifier 0..0
... hasMember SI0..*Reference(Observation-member-imaging-uv-ips)hasMemberOrComponent: component and hasMember are mutually exclusive
.... reference S0..1string
.... identifier 0..0
... component SIBackboneElementSlice: Unordered, Open by value:code.binding.valueSet, type:value[x]
hasMemberOrComponent: component and hasMember are mutually exclusive
... component S0..1BackboneElement
.... code 1..1CodeableConceptBinding: IPS Results Radiology Textual Observations (extensible)
.... valueString 0..1string
... component S0..1BackboneElement
.... code S1..1CodeableConceptBinding: IPS Results Observation Radiology (extensible)
.... valueCodeableConcept S1..1CodeableConcept
... component S0..*BackboneElement
.... code S1..1CodeableConceptBinding: IPS Results Observation Radiology (extensible)
.... value[x] 0..1Quantity, Range, Ratio
... component S0..*BackboneElement
.... code 1..1CodeableConceptBinding: IPS Results Radiology Linear Measurements Observations (extensible)
.... value[x] 0..1Quantity, Range, Ratio, SampledData
... component S0..*BackboneElement
.... code 1..1CodeableConceptBinding: IPS Results Radiology Area Measurements Observations (extensible)
.... value[x] 0..1Quantity, Range, Ratio
... component S0..*BackboneElement
.... code 1..1CodeableConceptBinding: IPS Results Radiology Volume Measurements Observations (extensible)
.... value[x] 0..1Quantity, Range, Ratio

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I0..*Measurements and simple assertions
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (preferred)
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... event-partOf SI0..*Reference(Resource)Extension
URL: http://hl7.org/fhir/StructureDefinition/event-partOf
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..0
.... url 1..1uri"http://hl7.org/fhir/StructureDefinition/event-partOf"
.... valueReference S0..1Reference()A set of images produced in single study (one or more series of references images)
..... id Σ0..1idLogical id of this artifact
..... meta Σ0..1MetaMetadata about the resource
..... implicitRules ?!Σ0..1uriA set of rules under which this content was created
..... language 0..1codeLanguage of the resource content
Binding: Common Languages (preferred)
..... text 0..1NarrativeText summary of the resource, for human interpretation
..... contained 0..*ResourceContained, inline Resources
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
..... status ?!Σ1..1coderegistered | available | cancelled | entered-in-error | unknown
Binding: ImagingStudyStatus (required)
..... modality Σ0..*CodingAll series modality if actual acquisition modalities
Binding: http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_29.html (extensible)
..... subject SΣ1..1Reference(Patient-uv-ips)Who or what is the subject of the study
...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣI0..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
...... display Σ0..1stringText alternative for the resource
..... context Σ0..1Reference(Encounter | EpisodeOfCare)Originating context
..... started SΣ0..1dateTimeWhen the study was started
Example General': 2011-01-01T11:01:20+03:00
..... basedOn Σ0..*Reference(CarePlan | ServiceRequest | Appointment | AppointmentResponse | Task)Request fulfilled
..... referrer Σ0..1Reference(Practitioner)Referring physician
..... interpreter Σ0..*Reference(Practitioner)Who interpreted images
..... endpoint Σ0..*Reference(Endpoint)Study access endpoint
..... numberOfSeries Σ0..1unsignedIntNumber of Study Related Series
..... numberOfInstances Σ0..1unsignedIntNumber of Study Related Instances
..... procedureReference Σ0..1Reference(Procedure)The performed Procedure reference
..... procedureCode SI0..*CodeableConcept-uv-ipsThe performed procedure code
Binding: http://www.rsna.org/RadLex_Playbook.aspx (extensible)
..... location Σ0..1Reference(Location)Where ImagingStudy occurred
..... reasonCode SΣ0..*CodeableConceptWhy the study was requested
Binding: ProcedureReasonCodes (example)
...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding Σ0..*CodingCode defined by a terminology system
...... text SΣ0..1stringPlain text representation of the concept
..... reasonReference Σ0..*Reference(Condition | Observation | Media | DiagnosticReport | DocumentReference)Why was study performed
..... note Σ0..*AnnotationUser-defined comments
..... description Σ0..1stringInstitution-generated description
..... series SΣI0..*BackboneElementEach study has one or more series of instances
...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored if unrecognized
...... identifier SΣ1..1IdentifierFormal DICOM identifier for this series
Example General': {"system":"urn:ietf:rfc:3986","value":"urn:oid:2.16.124.113543.6003.2588828330.45298.17418.2723805630"}
...... number Σ0..1unsignedIntNumeric identifier of this series
Example General': 3
...... modality SΣ1..1CodingThe modality of the instances in the series
Binding: http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_29.html (extensible)
...... description Σ0..1stringA short human readable summary of the series
Example General': CT Surview 180
...... numberOfInstances Σ0..1unsignedIntNumber of Series Related Instances
...... endpoint Σ0..*Reference(Endpoint)Series access endpoint
...... bodySite Σ0..1CodingBody part examined
Binding: SNOMEDCTBodyStructures (example)
...... laterality Σ0..1CodingBody part laterality
Binding: Laterality (example)
...... specimen Σ0..*Reference(Specimen)Specimen imaged
...... started Σ0..1dateTimeWhen the series started
...... performer ΣI0..*BackboneElementWho performed the series
....... id 0..1stringxml:id (or equivalent in JSON)
....... extension 0..*ExtensionAdditional content defined by implementations
....... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored if unrecognized
....... function Σ0..1CodeableConceptType of performance
Binding: ImagingStudySeriesPerformerFunction (required)
....... actor Σ1..1Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | Device | RelatedPerson)Who performed the series
...... instance SI0..*BackboneElementA single SOP instance from the series
....... id 0..1stringxml:id (or equivalent in JSON)
....... extension 0..*ExtensionAdditional content defined by implementations
....... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored if unrecognized
....... identifier S1..1IdentifierFormal DICOM identifier for this instance
Example General': {"system":"urn:ietf:rfc:3986","value":"urn:oid:2.16.124.113543.6003.189642796.63084.16748.2599092903"}
....... number 0..1unsignedIntThe number of this instance in the series
Example General': 1
....... sopClass 1..1CodingDICOM class type
Binding: http://dicom.nema.org/medical/dicom/current/output/chtml/part04/sect_B.5.html#table_B.5-1 (extensible)
....... title 0..1stringDescription of instance
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!Σ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required)
... category SI1..1CodeableConcept-uv-ipsClassification of type of observation
Binding: ObservationCategoryCodes (preferred)

Fixed Value: {"coding":[{"system":"http://terminology.hl7.org/CodeSystem/observation-category","code":"imaging","display":"Imaging"}]}
... code SI1..1CodeableConcept-uv-ipsType of observation (code / type)
Binding: IPS Results Observation Radiology (extensible)
... subject SΣ1..1Reference(Patient-uv-ips)Who and/or what the observation is about
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI0..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... display Σ0..1stringText alternative for the resource
... focus Σ0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter Σ0..1Reference(Encounter)Healthcare event during which this observation is made
... effective[x] SΣ0..1dateTime, Period, Timing, instantClinically relevant time/time-period for observation
... issued Σ0..1instantDate/Time this version was made available
... performer SΣ0..*Reference(Practitioner-uv-ips | Organization-observation-uv-ips)Who is responsible for the observation
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI0..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... display Σ0..1stringText alternative for the resource
... valueString SΣI0..1stringActual result
... dataAbsentReason I0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible)
... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
... comment 0..1stringComments about the test result value
... bodySite SI0..1CodeableConcept-uv-ipsObserved body part
Binding: IPS Target Site (example)
... method 0..1CodeableConceptHow it was done
Binding: ObservationMethods (example)
... specimen 0..1Reference(Specimen)Specimen used for this observation
... device S0..1Reference(Device-observer-uv-ips)(Measurement) Device
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI0..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... display Σ0..1stringText alternative for the resource
... referenceRange I0..*BackboneElementProvides guide for interpretation
obs-3: Must have at least a low or a high or text
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored if unrecognized
.... low I0..1SimpleQuantityLow Range, if relevant
.... high I0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred)
.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example)
.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember SΣI0..*Reference(Observation-member-imaging-uv-ips)Related resource that belongs to the Observation group
hasMemberOrComponent: component and hasMember are mutually exclusive
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣI0..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... display Σ0..1stringText alternative for the resource
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | Sequence)Related measurements the observation is made from
... component SΣIBackboneElementComponent results
Slice: Unordered, Open by value:code.binding.valueSet, type:value[x]
hasMemberOrComponent: component and hasMember are mutually exclusive
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored if unrecognized
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example)
.... value[x] Σ0..1Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, PeriodActual component result
.... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible)
.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
.... referenceRange 0..*Unknown reference to #Observation.referenceRange
Provides guide for interpretation of component result
... component SΣI0..1BackboneElementComponent results
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored if unrecognized
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: IPS Results Radiology Textual Observations (extensible)
.... valueString Σ0..1stringActual component result
.... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible)
.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
.... referenceRange 0..*Unknown reference to #Observation.referenceRange
Provides guide for interpretation of component result
... component SΣI0..1BackboneElementComponent results
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored if unrecognized
.... code SΣ1..1CodeableConceptType of component observation (code / type)
Binding: IPS Results Observation Radiology (extensible)
.... valueCodeableConcept SΣ1..1CodeableConceptActual component result
.... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible)
.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
.... referenceRange 0..*Unknown reference to #Observation.referenceRange
Provides guide for interpretation of component result
... component SΣI0..*BackboneElementComponent results
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored if unrecognized
.... code SΣ1..1CodeableConceptType of component observation (code / type)
Binding: IPS Results Observation Radiology (extensible)
.... value[x] Σ0..1Quantity, Range, RatioActual component result
.... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible)
.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
.... referenceRange 0..*Unknown reference to #Observation.referenceRange
Provides guide for interpretation of component result
... component SΣI0..*BackboneElementComponent results
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored if unrecognized
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: IPS Results Radiology Linear Measurements Observations (extensible)
.... value[x] Σ0..1Quantity, Range, Ratio, SampledDataActual component result
.... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible)
.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
.... referenceRange 0..*Unknown reference to #Observation.referenceRange
Provides guide for interpretation of component result
... component SΣI0..*BackboneElementComponent results
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored if unrecognized
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: IPS Results Radiology Area Measurements Observations (extensible)
.... value[x] Σ0..1Quantity, Range, RatioActual component result
.... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible)
.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
.... referenceRange 0..*Unknown reference to #Observation.referenceRange
Provides guide for interpretation of component result
... component SΣI0..*BackboneElementComponent results
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored if unrecognized
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: IPS Results Radiology Volume Measurements Observations (extensible)
.... value[x] Σ0..1Quantity, Range, RatioActual component result
.... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible)
.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
.... referenceRange 0..*Unknown reference to #Observation.referenceRange
Provides guide for interpretation of component result

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron