| Name | L Flags | L Card. | L Type | L Description & Constraints | R Flags | R Card. | L Type | L Description & Constraints | Comments |
|---|
  Observation | I | 0..* | Observation | questionnaire observations
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..* | UsualWork | Usual Work
| - Elements differ in short: 'questionnaire observations' vs 'Usual Work'
- Elements differ in definition: 'For Observations derived from surveys/questionnaires.' vs 'Related data elements about the work a person reports having performed for the longest amount of time during his or her life, regardless of the person’s current job and regardless of whether or not the person performed this work for a continuous time. Knowledge of person’s Usual Work can potentially assist in diagnosis, treatment and/or prevention of chronic condition(s) or conditions with a long latency. The potential for exposure to Occupational Hazard(s) related to an Occupation and/or an Industry can change over time, and a person could have been in and out of their Usual Work over time, so additional data are helpful to fully evaluate the possible impact of the person’s Usual Work on their health and guide appropriate use of screening tests to detect early disease. Example: a person has worked for a total of 30 years as a building carpenter (Occupation), but in various industries, mostly hotel construction. Her Usual Occupation is ‘building carpenter’ and her Usual Industry is ‘hotel construction.’ Usual Work does not include work that was unpaid or voluntary.'
- Elements differ in comments: 'Used for simple observations such as education status, food insecurity observations, etc. This profile allows the representation of SDOH observations based on SDOH screening questionnaire responses (which can also be represented using SDC QuestionnaireResponse).' vs 'Used for simple observations such as device measurements, laboratory atomic results, vital signs, height, weight, smoking status, comments, etc. Other resources are used to provide context for observations such as laboratory reports, etc.'
|
 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 | Additional content defined by implementations
| |
 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(ServiceRequest) | The plan, proposal or order that is fulfilled in whole or in part by this observation
| - Elements differ in short: 'Fulfills plan, proposal or order' vs 'The plan, proposal or order that is fulfilled in whole or in part by this observation'
- Elements differ in definition: 'A plan, proposal or order that is fulfilled in whole or in part by this event. For example, a MedicationRequest may require a patient to have laboratory test performed before it is dispensed.' vs 'The plan, proposal or order that is fulfilled in whole or in part by this observation.'
- Type Mismatch: Reference([CanonicalType[http://hl7.org/fhir/StructureDefinition/CarePlan], CanonicalType[http://hl7.org/fhir/StructureDefinition/DeviceRequest], CanonicalType[http://hl7.org/fhir/StructureDefinition/ImmunizationRecommendation], CanonicalType[http://hl7.org/fhir/StructureDefinition/MedicationRequest], CanonicalType[http://hl7.org/fhir/StructureDefinition/NutritionOrder], CanonicalType[http://hl7.org/fhir/StructureDefinition/ServiceRequest]]) vs Reference([CanonicalType[http://hl7.org/fhir/StructureDefinition/ServiceRequest]])
|
| partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event
| Σ | 0..* | Reference(Procedure) | The larger procedure that this particular observation is a component or step
| - Elements differ in short: 'Part of referenced event' vs 'The larger procedure that this particular observation is a component or step'
- Elements differ in definition: 'A larger event of which this particular Observation is a component or step. For example, an observation as part of a procedure.' vs 'The larger procedure that this particular observation is a component or step.'
- Type Mismatch: Reference([CanonicalType[http://hl7.org/fhir/StructureDefinition/MedicationAdministration], CanonicalType[http://hl7.org/fhir/StructureDefinition/MedicationDispense], CanonicalType[http://hl7.org/fhir/StructureDefinition/MedicationStatement], CanonicalType[http://hl7.org/fhir/StructureDefinition/Procedure], CanonicalType[http://hl7.org/fhir/StructureDefinition/Immunization], CanonicalType[http://hl7.org/fhir/StructureDefinition/ImagingStudy]]) vs Reference([CanonicalType[http://hl7.org/fhir/StructureDefinition/Procedure]])
|
| status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.
| ?!Σ | 1..1 | code | registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.
| - 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..1 | CodeableConcept | Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
| - Elements differ in requirements: 'To identify that observation is derived from a questionnaire.' vs 'Used for filtering what observations are retrieved and displayed.'
- Elements differ in definition for mustSupport: 'true' vs 'false'
- Element minimum cardinalities differ: '1' vs '0'
- 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 | |
| Slices for extension | | 0..* | Extension | Additional content defined by implementations
Slice: Unordered, Open by value:url
| | 0..* | Extension | Additional content defined by implementations
Slice: Unordered, Open by value:url
| |
| coding | Σ | 0..* | Coding | Code defined by a terminology system
| Σ | 1..* | Coding | Code defined by a terminology system
Slice: Unordered, Open by value:code
| - Element minimum cardinalities differ: '0' vs '1'
|
 text | Σ | 0..1 | string | Plain text representation of the concept | Σ | 0..1 | string | Plain text representation of the concept | |
| code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type)
Binding: US Core Common SDOH Assessments ValueSet (preferred) | Σ | 1..1 | CodeableConcept | Type of observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.
| - Elements differ in definition for mustSupport: 'true' vs 'false'
- Example/preferred bindings differ at Observation.code using binding from USCoreObservationScreeningResponse
|
| id | | 0..1 | string | Unique id for inter-element referencing | | 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
| | 0..* | Extension | Additional content defined by implementations
Slice: Unordered, Open by value:url
| |
| coding | Σ | 0..* | Coding | Code defined by a terminology system
| Σ | 1..* | Coding | Code defined by a terminology system
Slice: Unordered, Open by value:code
| - Element minimum cardinalities differ: '0' vs '1'
|
| text | Σ | 0..1 | string | Plain text representation of the concept | Σ | 0..1 | string | Plain text representation of the concept | |
| subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who and/or what the observation is about | Σ | 1..1 | Reference(VRDR Decedent) | The subject of an observation | - Elements differ in short: 'Who and/or what the observation is about' vs 'The subject of an observation'
- Elements differ in definition: 'The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the `focus` element or the `code` itself specifies the actual focus of the observation.' vs 'The subject of an observation.'
- 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(RelatedPerson) | 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 | Period | Clinically relevant time/time-period for observation
Slice: Unordered, Closed by type:$this | - Elements differ in definition: '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".' 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 comments: 'At least a date should be present unless this observation is a historical report.' vs 'At least a date should be present unless this observation is a historical report. For recording imprecise or "fuzzy" times (For example, a blood glucose measurement taken "after breakfast") use the [Timing] datatype which allow the measurement to be tied to regular life events.'
- 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 | SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | PractitionerRole | US Core CareTeam Profile | US Core Related Person) | Who is responsible for the observation
| Σ | 0..* | Reference(Practitioner | Organization | US Core Patient Profile | RelatedPerson) | Who is responsible for the observation
| - Elements differ in definition for mustSupport: 'true' vs 'false'
|
| value[x] | SΣI | 0..1 | Quantity S, CodeableConcept S, string S, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual result
us-core-3: SHALL use UCUM for coded quantity units. | ΣI | 0..1 | CodeableConcept | Actual result
Slice: Unordered, Closed by type:$this | - Elements differ in comments: 'An observation may have; 1) a single value here, 2) both a value and a set of related or component values, or 3) only a set of related or component values. If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value.' vs 'An observation may have; 1) a single value here, 2) both a value and a set of related or component values, or 3) only a set of related or component values. If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the [Notes section] below.'
- Elements differ in definition for mustSupport: 'true' vs 'false'
|
| dataAbsentReason | SI | 0..1 | CodeableConcept | Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
| I | 0..0 | | | - Elements differ in comments: '"Null" or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. The alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For a given LOINC question, if the LOINC answer list includes concepts such as 'unknown' or 'not available', they should be used for Observation.value. Where these concepts are not part of the value set for Observation.value, the Observation.dataAbsentReason can be used if necessary and appropriate.' vs 'Null or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. For example, measurement values for a serology test could be "detected", "not detected", "inconclusive", or "specimen unsatisfactory".
The alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For example, the dataAbsentReason code "error" could be used when the measurement was not completed. Note that an observation may only be reported if there are values to report. For example differential cell counts values may be reported only when > 0. Because of these options, use-case agreements are required to interpret general observations for null or exceptional values.'
- Elements differ in definition for mustSupport: 'true' vs 'false'
- Element maximum cardinalities differ: '1' vs '0'
|
| interpretation | | 0..* | CodeableConcept | High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
| | 0..1 | CodeableConcept | High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
| - Element maximum cardinalities differ: '2147483647' vs '1'
|
| note | | 0..* | Annotation | Comments about the observation
| | 0..* | Annotation | Comments about the observation
| |
| bodySite | | 0..1 | CodeableConcept | Observed body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
| | 0..0 | | | - Element maximum cardinalities differ: '1' vs '0'
|
| method | | 0..1 | CodeableConcept | How it was done
Binding: ObservationMethods (example): Methods for simple observations.
| | 0..0 | | | - Element maximum cardinalities differ: '1' vs '0'
|
| specimen | | 0..1 | Reference(Specimen) | Specimen used for this observation | | 0..0 | | | - Element maximum cardinalities differ: '1' vs '0'
|
| device | | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | | 0..0 | | | - Element maximum cardinalities differ: '1' vs '0'
|
| referenceRange | I | 0..* | BackboneElement | Provides guide for interpretation
obs-3: Must have at least a low or a high or text
| I | 0..0 | | | - Element maximum cardinalities differ: '2147483647' vs '0'
|
| 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 (extensible): 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 (extensible): 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..0 | | | - Element maximum cardinalities differ: '2147483647' vs '0'
|
| derivedFrom | SΣ | 0..* | Reference(US Core Screening Response Observation Profile S | http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaireresponse S | US Core DocumentReference Profile | ImagingStudy | Media | MolecularSequence) | Related questionnaire responses or observations that the observation is made from
| Σ | 0..* | Reference(DocumentReference | Media | QuestionnaireResponse | Observation) | Related measurements the observation is made from
| - Elements differ in short: 'Related questionnaire responses or observations that the observation is made from' vs 'Related measurements the observation is made from'
- Elements differ in definition: 'Questionnaire responses or observations from which this observation value is derived.' vs 'The target resource that represents a measurement from which this observation value is derived. For example, a calculated anion gap or a fetal measurement based on an ultrasound image.'
- Elements differ in definition for mustSupport: 'true' vs 'false'
- Type Mismatch: Reference([CanonicalType[http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-screening-response], CanonicalType[http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaireresponse], CanonicalType[http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference], CanonicalType[http://hl7.org/fhir/StructureDefinition/ImagingStudy], CanonicalType[http://hl7.org/fhir/StructureDefinition/Media], CanonicalType[http://hl7.org/fhir/StructureDefinition/MolecularSequence]]) vs Reference([CanonicalType[http://hl7.org/fhir/StructureDefinition/DocumentReference], CanonicalType[http://hl7.org/fhir/StructureDefinition/Media], CanonicalType[http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse], CanonicalType[http://hl7.org/fhir/StructureDefinition/Observation]])
|
 component | SΣ | 0..* | BackboneElement | Component results
| Σ | 1..* | BackboneElement | Component results
Slice: Unordered, Open by value:code
| - Elements differ in definition: 'Some observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes. Examples: Individuals may be multiracial. Component is used to capture one or more races.' vs 'Some observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes. Examples include systolic and diastolic component observations for blood pressure measurement and multiple component observations for genetics observations.'
- Elements differ in comments: 'For questions represented in LOINC that specify “check all that apply”, the LOINC question should be used for Observation.code and for Observation.component.code. For “check all that apply” questions, the answers (regardless of whether one or more are selected) should only be represented using Observation.component.value and Observation.value should be empty.' vs 'For a discussion on the ways Observations can be assembled in groups together see [Notes] below.'
- Elements differ in definition for mustSupport: 'true' vs 'false'
- Element minimum cardinalities differ: '0' 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 | SΣ | 1..1 | CodeableConcept | Type of component observation (code / type)
Binding: LOINCCodes (extensible) | Σ | 1..1 | CodeableConcept | Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.
| - Elements differ in definition for mustSupport: 'true' vs 'false'
|
| value[x] | SΣI | 0..1 | Quantity S, CodeableConcept S, string S, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual component result
us-core-3: SHALL use UCUM for coded quantity units. | Σ | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual component result | - Elements differ in comments: 'see `Observation.value[x]` comments' vs 'Used when observation has a set of component observations. An observation may have both a value (e.g. an Apgar score) and component observations (the observations from which the Apgar score was derived). If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the [Notes section] below.'
- Elements differ in definition for mustSupport: 'true' vs 'false'
|
| dataAbsentReason | SI | 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.
| - Elements differ in comments: 'see `Observation.dataAbsentReason` comments' vs '"Null" or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. For example, measurement values for a serology test could be "detected", "not detected", "inconclusive", or "test not done".
The alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For example, the dataAbsentReason code "error" could be used when the measurement was not completed. Because of these options, use-case agreements are required to interpret general observations for exceptional values.'
- 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.
| |
 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 |