| 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..* | Observation | Measurements and simple assertions
| - Elements differ in short: 'questionnaire observations' vs 'Measurements and simple assertions'
- Elements differ in definition: 'For Observations derived from surveys/questionnaires.' vs 'Measurements and simple assertions made about a patient, device or other subject.'
- 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 | id | - Elements differ in short: 'Logical id of this artifact' vs 'id'
|
| 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(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): Codes providing the status of an observation.
| ?!Σ | 1..1 | code | status
Binding: ObservationStatus (required): Codes providing the status of an observation.
Fixed Value: final | - Elements differ in short: 'registered | preliminary | final | amended +' vs 'status'
- 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 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'
|
| code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type)
Binding: US Core Common SDOH Assessments ValueSet (preferred) | Σ | 1..1 | CodeableConcept | code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
Fixed Value: {"coding":[{"system":"http://loinc.org","code":"69449-7","display":"Manner of death"}]} | - Elements differ in short: 'Type of observation (code / type)' vs 'code'
- Elements differ in definition for mustSupport: 'true' vs 'false'
- Example/preferred bindings differ at Observation.code using binding from USCoreObservationScreeningResponse
|
| subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who and/or what the observation is about | Σ | 1..1 | Reference(Patient) | subject | - Elements differ in short: 'Who and/or what the observation is about' vs 'subject'
- 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 | 0..1 | dateTime, Period, Timing, instant | Clinically relevant time/time-period for observation | - 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'
|
| 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 | 1..1 | Reference(Practitioner) | performer
| - Elements differ in short: 'Who is responsible for the observation' vs 'performer'
- Elements differ in definition for mustSupport: 'true' vs 'false'
- Element minimum cardinalities differ: '0' vs '1'
- 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 | Actual result
us-core-3: SHALL use UCUM for coded quantity units. | ΣI | 1..1 | CodeableConcept | Actual result
Binding: Manner of Death (required): Manner of Death
| - 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'
- Element minimum cardinalities differ: '0' vs '1'
|
| 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..1 | CodeableConcept | Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
| - 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'
|
| 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..* | Annotation | Comments about the observation
| |
| 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.
| |
| 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 | 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 | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | 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/ImagingStudy], CanonicalType[http://hl7.org/fhir/StructureDefinition/Media], CanonicalType[http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse], CanonicalType[http://hl7.org/fhir/StructureDefinition/Observation], CanonicalType[http://hl7.org/fhir/StructureDefinition/MolecularSequence]])
|
 component | SΣ | 0..* | BackboneElement | Component results
| Σ | 0..* | BackboneElement | Component results
| - 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'
|
 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 |