| Name | L Flags | L Card. | L Type | L Description & Constraints | R Flags | R Card. | L Type | L Description & Constraints | Comments |
|---|
  Observation | I | 0..* | Observation | Measurements and simple assertions
us-core-2: If there is no component or hasMember element then either a value[x] or a data absent reason must be present
| I | 0..* | Observation | Measurements and simple assertions
| - Elements differ in definition: 'This profile is created to meet the 2015 Edition Common Clinical Data Set 'Laboratory test(s) and Laboratory value(s)/result(s)' requirements.' vs 'Measurements and simple assertions made about a patient, device or other subject.'
|
 id | Σ | 0..1 | string | Logical id of this artifact | Σ | 0..1 | string | Logical id of this artifact | |
| meta | Σ | 0..1 | Meta | Metadata about the resource | Σ | 0..1 | Meta | Metadata about the resource | |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ?!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.
| | 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 | | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | | 0..* | Resource | Contained, inline Resources
| | 0..* | Resource | Contained, inline Resources
| |
 extension | | 0..* | Extension | Additional content defined by implementations
| | 0..* | Extension | Extension
Slice: Unordered, Open by value:Observation.extension.url
| - Elements differ in short: 'Additional content defined by implementations' vs 'Extension'
- Elements differ in definition: 'May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.' vs 'An Extension'
|
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
| ?! | 0..* | Extension | Extensions that cannot be ignored
| |
| identifier | Σ | 0..* | Identifier | Business Identifier for observation
| Σ | 0..* | Identifier | Business Identifier for observation
| |
| basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order
| 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
| 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) | ?!Σ | 1..1 | code | registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.
Fixed Value: final | - Elements differ in definition for mustSupport: 'true' vs 'false'
|
| Slices for category | S | 1..* | CodeableConcept | Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
| | 0..* | CodeableConcept | Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
| - Elements differ in definition for mustSupport: 'true' vs 'false'
- Element minimum cardinalities differ: '1' vs '0'
|
| code | SΣ | 1..1 | CodeableConcept | Laboratory Test Name
Binding: LOINCCodes (extensible): LOINC codes
| Σ | 1..1 | CodeableConcept | Type of observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.
Fixed Value: {"coding":[{"system":"http://loinc.org","code":"81956-5","display":"Date+time of death"}]} | - Elements differ in short: 'Laboratory Test Name' vs 'Type of observation (code / type)'
- Elements differ in definition: 'The test that was performed. A LOINC **SHALL** be used if the concept is present in LOINC.' vs 'Describes what was observed. Sometimes this is called the observation "name".'
- Elements differ in comments: 'The typical patterns for codes are: 1) a LOINC code either as a translation from a "local" code or as a primary code, or 2) a local code only if no suitable LOINC exists, or 3) both the local and the LOINC translation. Systems SHALL be capable of sending the local code if one exists. When using LOINC , Use either the SHORTNAME or LONG_COMMON_NAME field for the display.' vs '*All* code-value and, if present, component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.'
- Elements differ in definition for mustSupport: 'true' vs 'false'
- Elements differ in binding.description: 'LOINC codes' vs 'Codes identifying names of simple observations.'
|
| subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who and/or what the observation is about | Σ | 1..1 | Reference(VRDR Decedent) | Who and/or what the observation is about | - Elements differ in definition for mustSupport: 'true' vs 'false'
|
| focus | Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record
| 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 | Σ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made | |
| effective[x] | SΣI | 0..1 | dateTime S, Period, Timing, instant | Clinically relevant time/time-period for observation
us-core-1: Datetime must be at least to day. | Σ | 1..1 | dateTime | Clinically relevant time/time-period for observation | - Elements differ in definition: 'For lab tests this is the specimen collection date. For Ask at Order Entry Questions (AOE)'s this is the date the question was asked.' vs 'The time or time-period the observed value is asserted as being true. For biological subjects - e.g. human patients - this is usually called the "physiologically relevant time". This is usually either the time of the procedure or of specimen collection, but very often the source of the date/time is not known, only the date/time itself.'
- Elements differ in definition for mustSupport: 'true' vs 'false'
- Element minimum cardinalities differ: '0' vs '1'
|
| issued | Σ | 0..1 | instant | Date/Time this version was made available | 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
| Σ | 0..1 | Reference(VRDR Death Pronouncement Performer) | Who is responsible for the observation
| - Element maximum cardinalities differ: '2147483647' vs '1'
|
 value[x] | SΣI | 0..1 | Quantity S, CodeableConcept S, string S, boolean, integer, Range, Ratio, SampledData, 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. | ΣI | 0..1 | dateTime | Actual result | - Elements differ in short: 'Result Value' vs 'Actual result'
- Elements differ in definition: 'The Laboratory result value. If a coded value, the valueCodeableConcept.code **SHOULD** be selected from [SNOMED CT] if the concept exists. If a numeric value, valueQuantity.code **SHALL** be selected from [UCUM]. A FHIR [UCUM Codes value set] that defines all UCUM codes is in the FHIR specification.' vs 'The information determined as a result of making the observation, if the information has a simple value.'
- Elements differ in definition for mustSupport: 'true' vs 'false'
|
 id | | 0..1 | string | xml:id (or equivalent in JSON) | | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | | 0..* | Extension | Additional content defined by implementations
| | 0..* | Extension | Extension
Slice: Unordered, Open by value:url
| - Elements differ in short: 'Additional content defined by implementations' vs 'Extension'
- Elements differ in definition: 'May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.' vs 'An Extension'
|
 value | | 0..1 | dateTime | Primitive value for dateTime | | 0..1 | dateTime | Primitive value for dateTime | |
| dataAbsentReason | SI | 0..1 | CodeableConcept | Why the result is missing
Binding: DataAbsentReason (extensible) | I | 0..1 | CodeableConcept | Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
| - Elements differ in definition for mustSupport: 'true' vs 'false'
|
| interpretation | | 0..* | CodeableConcept | High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
| | 0..* | CodeableConcept | High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
| |
| note | | 0..* | Annotation | Comments about the observation
| | 0..1 | Annotation | Comments about the observation
| - Element maximum cardinalities differ: '2147483647' vs '1'
|
| bodySite | | 0..1 | CodeableConcept | Observed body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
| | 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.
| | 0..1 | CodeableConcept | How it was done
Binding: ObservationMethods (example): Methods for simple observations.
Fixed Value: {"coding":[{"system":"http://snomed.info/sct","code":"414135002","display":"Estimated"}]} | |
| specimen | | 0..1 | Reference(Specimen) | Specimen used for this observation | | 0..1 | Reference(Specimen) | Specimen used for this observation | |
| device | | 0..1 | Reference(Device | DeviceMetric) | (Measurement) 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
| I | 0..* | BackboneElement | Provides guide for interpretation
| |
| id | | 0..1 | string | Unique id for inter-element referencing | | 0..1 | string | Unique id for inter-element referencing | |
| extension | | 0..* | Extension | Additional content defined by implementations
| | 0..* | Extension | Additional content defined by implementations
| |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
| ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
| |
| low | I | 0..1 | SimpleQuantity | Low Range, if relevant | I | 0..1 | SimpleQuantity | Low Range, if relevant | |
| high | I | 0..1 | SimpleQuantity | High Range, if relevant | 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.
| | 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.
| | 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 | | 0..1 | Range | Applicable age range, if relevant | |
| text | | 0..1 | string | Text based reference range in an observation | | 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
| 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
| Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from
| |
 component | Σ | 0..* | BackboneElement | Component results
| Σ | 0..1 | BackboneElement | Component results
| - Element maximum cardinalities differ: '2147483647' vs '1'
|
 id | | 0..1 | string | Unique id for inter-element referencing | | 0..1 | string | Unique id for inter-element referencing | |
| extension | | 0..* | Extension | Additional content defined by implementations
| | 0..* | Extension | Additional content defined by implementations
| |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
| ?!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.
| Σ | 1..1 | CodeableConcept | Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.
Fixed Value: {"coding":[{"system":"http://loinc.org","code":"80616-6","display":"Date and time pronounced dead [US Standard Certificate of Death]"}]} | |
| value[x] | Σ | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual component result | Σ | 1..1 | dateTime | Actual component result | - Element minimum cardinalities differ: '0' vs '1'
|
| dataAbsentReason | I | 0..1 | CodeableConcept | Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
| 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.
| | 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
| | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result
| |
Documentation for this format |