Presurgery Observation
FHIR Profile
Observations for the DBIR registry are defined in ... categories:
- pre-surgery observations
The profile is accessible via Observation and presented below.
| Practitioner | I | Practitioner | There are no (further) constraints on this element Element idPractitioner A person with a formal responsibility in the provisioning of healthcare or related services DefinitionA person who is directly or indirectly involved in the provisioning of healthcare.
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| id | Σ | 0..1 | string | There are no (further) constraints on this element Element idPractitioner.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idPractitioner.meta Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
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| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idPractitioner.implicitRules A set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
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| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idPractitioner.language Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). A human language.
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| text | 0..1 | Narrative | There are no (further) constraints on this element Element idPractitioner.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
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| contained | 0..* | Resource | There are no (further) constraints on this element Element idPractitioner.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idPractitioner.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idPractitioner.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| identifier | Σ | 1..* | Identifier | There are no (further) constraints on this element Element idPractitioner.identifier An identifier for the person as this agent DefinitionAn identifier that applies to this person in this role. Often, specific identities are assigned for the agent.
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| id | 0..1 | string | There are no (further) constraints on this element Element idPractitioner.identifier.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idPractitioner.identifier.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idPractitioner.identifier.use usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idPractitioner.identifier.type Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
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| system | Σ | 0..1 | uriFixed Value | Element idPractitioner.identifier.system The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
http://mrdm.nl/profiles/fhir/R4/dbir/CodeSystem/code-system
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| value | Σ | 1..1 | stringBinding | Element idPractitioner.identifier.value The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
General 123456 Mappings
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| period | Σ I | 0..1 | Period | There are no (further) constraints on this element Element idPractitioner.identifier.period Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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| assigner | Σ I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idPractitioner.identifier.assigner Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| active | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idPractitioner.active Whether this practitioner's record is in active use DefinitionWhether this practitioner's record is in active use. Need to be able to mark a practitioner record as not to be used because it was created in error. If the practitioner is not in use by one organization, then it should mark the period on the PractitonerRole with an end date (even if they are active) as they may be active in another role. This resource is generally assumed to be active if no value is provided for the active element
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| name | Σ | 0..* | HumanName | There are no (further) constraints on this element Element idPractitioner.name The name(s) associated with the practitioner DefinitionThe name(s) associated with the practitioner. The name(s) that a Practitioner is known by. Where there are multiple, the name that the practitioner is usually known as should be used in the display. The selection of the use property should ensure that there is a single usual name specified, and others use the nickname (alias), old, or other values as appropriate. In general, select the value to be used in the ResourceReference.display based on this:
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| telecom | Σ I | 0..* | ContactPoint | There are no (further) constraints on this element Element idPractitioner.telecom A contact detail for the practitioner (that apply to all roles) DefinitionA contact detail for the practitioner, e.g. a telephone number or an email address. Need to know how to reach a practitioner independent to any roles the practitioner may have. Person may have multiple ways to be contacted with different uses or applicable periods. May need to have options for contacting the person urgently and to help with identification. These typically will have home numbers, or mobile numbers that are not role specific.
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| address | Σ | 0..* | Address | There are no (further) constraints on this element Element idPractitioner.address Address(es) of the practitioner that are not role specific (typically home address) DefinitionAddress(es) of the practitioner that are not role specific (typically home address). Work addresses are not typically entered in this property as they are usually role dependent. The home/mailing address of the practitioner is often required for employee administration purposes, and also for some rostering services where the start point (practitioners home) can be used in calculations. The PractitionerRole does not have an address value on it, as it is expected that the location property be used for this purpose (which has an address).
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| gender | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element idPractitioner.gender male | female | other | unknown DefinitionAdministrative Gender - the gender that the person is considered to have for administration and record keeping purposes. Needed to address the person correctly. Note that FHIR strings SHALL NOT exceed 1MB in size The gender of a person used for administrative purposes.
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| birthDate | Σ | 0..1 | date | There are no (further) constraints on this element Element idPractitioner.birthDate The date on which the practitioner was born DefinitionThe date of birth for the practitioner. Needed for identification.
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| photo | I | 0..* | Attachment | There are no (further) constraints on this element Element idPractitioner.photo Image of the person DefinitionImage of the person. Many EHR systems have the capability to capture an image of patients and personnel. Fits with newer social media usage too. When providing a summary view (for example with Observation.value[x]) Attachment should be represented with a brief display text such as "Signed Procedure Consent".
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| qualification | 0..* | BackboneElement | There are no (further) constraints on this element Element idPractitioner.qualification Certification, licenses, or training pertaining to the provision of care DefinitionThe official certifications, training, and licenses that authorize or otherwise pertain to the provision of care by the practitioner. For example, a medical license issued by a medical board authorizing the practitioner to practice medicine within a certian locality.
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| id | 0..1 | string | There are no (further) constraints on this element Element idPractitioner.qualification.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idPractitioner.qualification.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idPractitioner.qualification.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| identifier | 0..* | Identifier | There are no (further) constraints on this element Element idPractitioner.qualification.identifier An identifier for this qualification for the practitioner DefinitionAn identifier that applies to this person's qualification in this role. Often, specific identities are assigned for the qualification.
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| code | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idPractitioner.qualification.code Coded representation of the qualification DefinitionCoded representation of the qualification. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Specific qualification the practitioner has to provide a service.
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| period | I | 0..1 | Period | There are no (further) constraints on this element Element idPractitioner.qualification.period Period during which the qualification is valid DefinitionPeriod during which the qualification is valid. Qualifications are often for a limited period of time, and can be revoked. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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| issuer | I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idPractitioner.qualification.issuer Organization that regulates and issues the qualification DefinitionOrganization that regulates and issues the qualification. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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| communication | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element idPractitioner.communication A language the practitioner can use in patient communication DefinitionA language the practitioner can use in patient communication. Knowing which language a practitioner speaks can help in facilitating communication with patients. The structure aa-BB with this exact casing is one the most widely used notations for locale. However not all systems code this but instead have it as free text. Hence CodeableConcept instead of code as the data type. A human language.
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