HL7 FHIR® Implementation Guide: Breast Cancer Data, Release 1 - US Realm (Draft for Comment)
This page is part of the Breast Cancer Data Logical Models and FHIR Profiles (v0.1.0: STU 1 Draft) based on FHIR R3. . For a full list of available versions, see the Directory of published versions 
The official URL for this profile is:
http://hl7.org/fhir/us/breastcancer/StructureDefinition/cimi-statement-EvaluationResultRecorded
Represents the result of evaluations (measurements, tests, or questions) that have been performed.
EvaluationResultRecorded has a value representing the result (answer), or an ExceptionValue indicating why the value is not present. The subject of a finding can be the entire patient, or an entity such as a location body structure, intervention, or condition. Things observed about the subject can include social and behavioral factors, subjective and objective observations, and assessments.
This profile builds on US Core Results Profile.
This profile was published on Sun Apr 01 00:00:00 AEDT 2018 as a draft by The HL7 Cancer Interoperability Group sponsored by Clinical Interoperability Council Work Group (CIC).
View the corresponding EvaluationResultRecordedModel logical model.
Summary
Fixed Value: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
BC Mapping Source
This structure represents the following BC mapping definition:
cimi.statement.EvaluationResultRecorded maps to http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults: EvaluationResultTopic.Category maps to category EvaluationResultTopic.FindingMethod maps to method EvaluationResultTopic.Quantity maps to value[x] EvaluationResultTopic.CodeableConcept maps to value[x] EvaluationResultTopic.string maps to value[x] EvaluationResultTopic.boolean maps to value[x] EvaluationResultTopic.Range maps to value[x] EvaluationResultTopic.Ratio maps to value[x] EvaluationResultTopic.time maps to value[x] EvaluationResultTopic.dateTime maps to value[x] EvaluationResultTopic.TimePeriod maps to value[x] EvaluationResultTopic.TopicCode maps to code EvaluationResultTopic.AnatomicalLocation maps to bodySite EvaluationResultTopic.Specimen maps to specimen EvaluationResultTopic.Interpretation maps to interpretation RecordedContext.RelevantTime maps to effective[x] RecordedContext.FindingStatus maps to status RecordedContext.ExceptionValue maps to dataAbsentReason EvaluationResultTopic.ReferenceRange maps to referenceRange EvaluationResultTopic.ReferenceRange.Range.LowerBound maps to referenceRange.low EvaluationResultTopic.ReferenceRange.Range.UpperBound maps to referenceRange.high EvaluationResultTopic.ReferenceRange.Type maps to referenceRange.type EvaluationResultTopic.ReferenceRange.ApplicableSubpopulation maps to referenceRange.appliesTo EvaluationResultTopic.ReferenceRange.ApplicableAgeRange maps to referenceRange.age fix related.type to #has-member EvaluationResultTopic.EvaluationComponent maps to component (slice on = coding.code; slice strategy = includes) EvaluationResultTopic.EvaluationComponent._Concept maps to component.code EvaluationResultTopic.EvaluationComponent.Quantity maps to component.value[x] EvaluationResultTopic.EvaluationComponent.CodeableConcept maps to component.value[x] EvaluationResultTopic.EvaluationComponent.string maps to component.value[x] EvaluationResultTopic.EvaluationComponent.Range maps to component.value[x] EvaluationResultTopic.EvaluationComponent.Ratio maps to component.value[x] EvaluationResultTopic.EvaluationComponent.time maps to component.value[x] EvaluationResultTopic.EvaluationComponent.dateTime maps to component.value[x] EvaluationResultTopic.EvaluationComponent.TimePeriod maps to component.value[x] EvaluationResultTopic.EvaluationComponent.ExceptionValue maps to component.dataAbsentReason EvaluationResultTopic.EvaluationComponent.Interpretation maps to component.interpretation EvaluationResultTopic.EvaluationComponent.ReferenceRange maps to component.referenceRange Members.EvaluationResultRecorded maps to related.target (slice at = related; slice on = target.reference.resolve(); slice on type = profile; slice strategy = includes)
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Observation | I | 0..* | BC EvaluationResultRecorded Profile us-core-2: If there is no component or related element then either a value[x] or a data absent reason must be present | |
  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: Common Languages (extensible) | |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
 contained | 0..* | Resource | Contained, inline Resources | |
 cimi-Encounter-extension | 0..1 | (Complex) | BC Encounter Extension URL: http://hl7.org/fhir/us/breastcancer/StructureDefinition/cimi-Encounter-extension | |
 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 | ProcedureRequest | ReferralRequest) | Fulfills plan, proposal or order |
| status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required) |
| category | SI | 1..* | CodeableConcept | Classification of type of observation Binding: Observation Category Codes (extensible) us-core-5: Must have a category of 'laboratory' and a code system 'http://hl7.org/fhir/observation-category' |
| code | SΣ | 1..1 | CodeableConcept | Laboratory Test Name Binding: LOINC Codes (extensible) |
| subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who and/or what this is about |
| context | 0..1 | Reference(Encounter | EpisodeOfCare) | Healthcare event during which this observation is made | |
 effective[x] | SΣI | 0..1 | dateTime, Period | Clinically relevant time/time-period for observation us-core-1: Datetime must be at least to day. |
| issued | Σ | 0..1 | instant | Date/Time this was made available |
| performer | Σ | 0..* | Reference(Practitioner | Organization | Patient | RelatedPerson) | Who is responsible for the observation |
| value[x] | SΣI | 0..1 | Quantity, CodeableConcept, string, boolean, RangeProfile, RatioProfile, time, dateTime, Period | Result Value us-core-4: SHOULD use Snomed CT for coded Results us-core-3: SHALL use UCUM for coded quantity units. |
| dataAbsentReason | SI | 0..1 | CodeableConcept | Why the result is missing Binding: ExceptionValueVS (required) |
| interpretation | 0..1 | CodeableConcept | High, low, normal, etc. Binding: Observation Interpretation Codes (extensible) | |
| comment | 0..1 | string | Comments about result | |
| bodySite | 0..1 | CodeableConcept | Observed body part Binding: AnatomicalLocationVS (required) | |
| method | 0..1 | CodeableConcept | How it was done Binding: LOINC Codes (preferred) | |
| specimen | 0..1 | Reference(BC Specimen Profile) | 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 | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| 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: Observation Reference Range Meaning Codes (extensible) | |
| appliesTo | 0..* | CodeableConcept | Reference range population Binding: Observation Reference Range Applies To Codes (extensible) | |
| age | 0..1 | RangeProfile | Applicable age range, if relevant | |
 text | 0..1 | string | Text based reference range in an observation | |
| related | ΣI | 0..* | BackboneElement | Resource related to this observation |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| type | 0..1 | code | has-member | derived-from | sequel-to | replaces | qualified-by | interfered-by Binding: ObservationRelationshipType (required) Fixed Value: has-member | |
| target | 1..1 | Reference(BC EvaluationResultRecorded Profile) | Resource that is related to this one | |
| component | ΣI | 0..* | BackboneElement | Component results |
 id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| code | Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINC Codes (example) |
| value[x] | Σ | 0..1 | Quantity, CodeableConcept, string, RangeProfile, RatioProfile, time, dateTime, Period | Actual component result |
| dataAbsentReason | I | 0..1 | CodeableConcept | Why the component result is missing Binding: ExceptionValueVS (required) |
| interpretation | 0..1 | CodeableConcept | High, low, normal, etc. Binding: Observation Interpretation Codes (extensible) | |
| referenceRange | 0..* | BackboneElement | Provides guide for interpretation of component result | |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| 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: Observation Reference Range Meaning Codes (extensible) | |
| appliesTo | 0..* | CodeableConcept | Reference range population Binding: Observation Reference Range Applies To Codes (example) | |
| age | 0..1 | Range | Applicable age range, if relevant | |
| text | 0..1 | string | Text based reference range in an observation | |
| Documentation for this format | ||||
Summary
Fixed Value: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
BC Mapping Source
This structure represents the following BC mapping definition:
cimi.statement.EvaluationResultRecorded maps to http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults: EvaluationResultTopic.Category maps to category EvaluationResultTopic.FindingMethod maps to method EvaluationResultTopic.Quantity maps to value[x] EvaluationResultTopic.CodeableConcept maps to value[x] EvaluationResultTopic.string maps to value[x] EvaluationResultTopic.boolean maps to value[x] EvaluationResultTopic.Range maps to value[x] EvaluationResultTopic.Ratio maps to value[x] EvaluationResultTopic.time maps to value[x] EvaluationResultTopic.dateTime maps to value[x] EvaluationResultTopic.TimePeriod maps to value[x] EvaluationResultTopic.TopicCode maps to code EvaluationResultTopic.AnatomicalLocation maps to bodySite EvaluationResultTopic.Specimen maps to specimen EvaluationResultTopic.Interpretation maps to interpretation RecordedContext.RelevantTime maps to effective[x] RecordedContext.FindingStatus maps to status RecordedContext.ExceptionValue maps to dataAbsentReason EvaluationResultTopic.ReferenceRange maps to referenceRange EvaluationResultTopic.ReferenceRange.Range.LowerBound maps to referenceRange.low EvaluationResultTopic.ReferenceRange.Range.UpperBound maps to referenceRange.high EvaluationResultTopic.ReferenceRange.Type maps to referenceRange.type EvaluationResultTopic.ReferenceRange.ApplicableSubpopulation maps to referenceRange.appliesTo EvaluationResultTopic.ReferenceRange.ApplicableAgeRange maps to referenceRange.age fix related.type to #has-member EvaluationResultTopic.EvaluationComponent maps to component (slice on = coding.code; slice strategy = includes) EvaluationResultTopic.EvaluationComponent._Concept maps to component.code EvaluationResultTopic.EvaluationComponent.Quantity maps to component.value[x] EvaluationResultTopic.EvaluationComponent.CodeableConcept maps to component.value[x] EvaluationResultTopic.EvaluationComponent.string maps to component.value[x] EvaluationResultTopic.EvaluationComponent.Range maps to component.value[x] EvaluationResultTopic.EvaluationComponent.Ratio maps to component.value[x] EvaluationResultTopic.EvaluationComponent.time maps to component.value[x] EvaluationResultTopic.EvaluationComponent.dateTime maps to component.value[x] EvaluationResultTopic.EvaluationComponent.TimePeriod maps to component.value[x] EvaluationResultTopic.EvaluationComponent.ExceptionValue maps to component.dataAbsentReason EvaluationResultTopic.EvaluationComponent.Interpretation maps to component.interpretation EvaluationResultTopic.EvaluationComponent.ReferenceRange maps to component.referenceRange Members.EvaluationResultRecorded maps to related.target (slice at = related; slice on = target.reference.resolve(); slice on type = profile; slice strategy = includes)
Differential View
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | I | 0..* | BC EvaluationResultRecorded Profile us-core-2: If there is no component or related element then either a value[x] or a data absent reason must be present | |
| 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: Common Languages (extensible) | |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
| cimi-Encounter-extension | 0..1 | (Complex) | BC Encounter Extension URL: http://hl7.org/fhir/us/breastcancer/StructureDefinition/cimi-Encounter-extension | |
| 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 | ProcedureRequest | ReferralRequest) | Fulfills plan, proposal or order |
| status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required) |
| category | SI | 1..* | CodeableConcept | Classification of type of observation Binding: Observation Category Codes (extensible) us-core-5: Must have a category of 'laboratory' and a code system 'http://hl7.org/fhir/observation-category' |
| code | SΣ | 1..1 | CodeableConcept | Laboratory Test Name Binding: LOINC Codes (extensible) |
| subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who and/or what this is about |
| context | 0..1 | Reference(Encounter | EpisodeOfCare) | Healthcare event during which this observation is made | |
| effective[x] | SΣI | 0..1 | dateTime, Period | Clinically relevant time/time-period for observation us-core-1: Datetime must be at least to day. |
| issued | Σ | 0..1 | instant | Date/Time this was made available |
| performer | Σ | 0..* | Reference(Practitioner | Organization | Patient | RelatedPerson) | Who is responsible for the observation |
| value[x] | SΣI | 0..1 | Quantity, CodeableConcept, string, boolean, RangeProfile, RatioProfile, time, dateTime, Period | Result Value us-core-4: SHOULD use Snomed CT for coded Results us-core-3: SHALL use UCUM for coded quantity units. |
| dataAbsentReason | SI | 0..1 | CodeableConcept | Why the result is missing Binding: ExceptionValueVS (required) |
| interpretation | 0..1 | CodeableConcept | High, low, normal, etc. Binding: Observation Interpretation Codes (extensible) | |
| comment | 0..1 | string | Comments about result | |
| bodySite | 0..1 | CodeableConcept | Observed body part Binding: AnatomicalLocationVS (required) | |
| method | 0..1 | CodeableConcept | How it was done Binding: LOINC Codes (preferred) | |
| specimen | 0..1 | Reference(BC Specimen Profile) | 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 | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| 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: Observation Reference Range Meaning Codes (extensible) | |
| appliesTo | 0..* | CodeableConcept | Reference range population Binding: Observation Reference Range Applies To Codes (extensible) | |
| age | 0..1 | RangeProfile | Applicable age range, if relevant | |
| text | 0..1 | string | Text based reference range in an observation | |
| related | ΣI | 0..* | BackboneElement | Resource related to this observation |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| type | 0..1 | code | has-member | derived-from | sequel-to | replaces | qualified-by | interfered-by Binding: ObservationRelationshipType (required) Fixed Value: has-member | |
| target | 1..1 | Reference(BC EvaluationResultRecorded Profile) | Resource that is related to this one | |
| component | ΣI | 0..* | BackboneElement | Component results |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| code | Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINC Codes (example) |
| value[x] | Σ | 0..1 | Quantity, CodeableConcept, string, RangeProfile, RatioProfile, time, dateTime, Period | Actual component result |
| dataAbsentReason | I | 0..1 | CodeableConcept | Why the component result is missing Binding: ExceptionValueVS (required) |
| interpretation | 0..1 | CodeableConcept | High, low, normal, etc. Binding: Observation Interpretation Codes (extensible) | |
| referenceRange | 0..* | BackboneElement | Provides guide for interpretation of component result | |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| 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: Observation Reference Range Meaning Codes (extensible) | |
| appliesTo | 0..* | CodeableConcept | Reference range population Binding: Observation Reference Range Applies To Codes (example) | |
| age | 0..1 | Range | Applicable age range, if relevant | |
| text | 0..1 | string | Text based reference range in an observation | |
| Documentation for this format | ||||
Downloads: StructureDefinition: (XML, JSON, TTL), Schema: XML Schematron
| Path | Name | Conformance | ValueSet |
| Observation.language | Common Languages | extensible | Common Languages |
| Observation.status | ObservationStatus | required | ObservationStatus |
| Observation.category | Observation Category Codes | extensible | Observation Category Codes |
| Observation.code | LOINC Codes | extensible | LOINC Codes |
| Observation.dataAbsentReason | ExceptionValueVS | required | ExceptionValueVS |
| Observation.interpretation | Observation Interpretation Codes | extensible | Observation Interpretation Codes |
| Observation.bodySite | AnatomicalLocationVS | required | AnatomicalLocationVS |
| Observation.method | LOINC Codes | preferred | LOINC Codes |
| Observation.referenceRange.type | Observation Reference Range Meaning Codes | extensible | Observation Reference Range Meaning Codes |
| Observation.referenceRange.appliesTo | Observation Reference Range Applies To Codes | extensible | Observation Reference Range Applies To Codes |
| Observation.related.type | ObservationRelationshipType | required | ObservationRelationshipType |
| Observation.component.code | LOINC Codes | example | LOINC Codes |
| Observation.component.dataAbsentReason | ExceptionValueVS | required | ExceptionValueVS |
| Observation.component.interpretation | Observation Interpretation Codes | extensible | Observation Interpretation Codes |
| Observation.component.referenceRange.type | Observation Reference Range Meaning Codes | extensible | Observation Reference Range Meaning Codes |
| Observation.component.referenceRange.appliesTo | Observation Reference Range Applies To Codes | example | Observation Reference Range Applies To Codes |
| 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-1 | Observation | If the resource is contained in another resource, it SHALL NOT contain any narrative : contained.text.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-3 | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource : contained.where(('#'+id in %resource.descendants().reference).not()).empty() | |
| obs-7 | Observation | If code is the same as a component code then the value element associated with the code SHALL NOT be present : value.empty() or code!=component.code | |
| obs-6 | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
| us-core-2 | Observation | If there is no component or related element then either a value[x] or a data absent reason must be present : (component.empty() and related.empty()) implies (dataAbsentReason or value) | |
| us-core-5 | Observation.category | Must have a category of 'laboratory' and a code system 'http://hl7.org/fhir/observation-category' : where(coding.system='http://hl7.org/fhir/observation-category' and coding.code='laboratory').exists() | |
| us-core-1 | Observation.effective[x] | Datetime must be at least to day. : ($this as dateTime).toString().length() >= 8 | |
| us-core-4 | Observation.value[x] | SHOULD use Snomed CT for coded Results : valueCodeableConcept.coding.system.empty() or valueCodeableConcept.coding.system = 'http://snomed.info/sct' | |
| us-core-3 | Observation.value[x] | SHALL use UCUM for coded quantity units. : valueQuantity.system.empty() or valueQuantity.system = 'http://unitsofmeasure.org' | |
| ele-1 | Observation.referenceRange | All FHIR elements must have a @value or children : hasValue() | (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.related | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
| ele-1 | Observation.component | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) |