Base Profile for Lab Observations

EHRtoRegistryLaboratoryResultObservationProfile

This profile definition contains the formal specification requirements for representing laboratory observations (derived from the U.S. Core Implementation Guide).

To summarize (for human readers), the following data elements are mandatory (i.e data SHALL be present) or must be supported if the data is present in the sending system:

Each Observation must have:

  1. a status
  2. a category code of laboratory
  3. a LOINC code, if available, which tells you what is being measured
  4. a patient

Each Observation must support:

  1. a time indicating when the measurement was taken
  2. a result value or a reason why the data is absent
    • if the result value is a numeric quantity, a standard UCUM unit

Other implementation guidance:

  • Additional codes that translate or map to the Observation code or category codes are allowed. For example:
    • providing both a local code and LOINC code
    • providing a more specific category codes such as chemistry, or system specific codes in addition to the laboratory category code.
  • An Observation without a value SHALL include a reason why the data is absent unless there are component observations, or references to other observations that are grouped within it.
  • See the definition of Must Support for clarification on its meaning in this context.

Profile Specification

identifierΣ0..*Identifier
basedOnΣ I0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)
partOfΣ I0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)
statusS Σ ?!1..1codeBinding
LaboratoryS1..1CodeableConceptBinding
codeS Σ1..1CodeableConceptBinding
subjectS Σ I1..1Reference(US Core Patient Profile)
focusΣ I0..*Reference(Resource)
encounterΣ I0..1Reference(Encounter)
effectiveDateTimedateTime
effectivePeriodPeriod
issuedΣ0..1instant
performerΣ I0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)
valueQuantityQuantity
valueCodeableConceptCodeableConcept
valueStringstring
valueBooleanboolean
valueIntegerinteger
valueRangeRange
valueRatioRatio
valueSampledDataSampledData
valueTimetime
valueDateTimedateTime
valuePeriodPeriod
dataAbsentReasonS I0..1CodeableConceptBinding
interpretation0..*CodeableConceptBinding
note0..*Annotation
bodySite0..1CodeableConcept
method0..1CodeableConcept
specimenI0..1Reference(Specimen)
deviceI0..1Reference(Device | DeviceMetric)
lowI0..1SimpleQuantity
highI0..1SimpleQuantity
type0..1CodeableConceptBinding
appliesTo0..*CodeableConcept
ageI0..1Range
text0..1string
hasMemberΣ I0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)
derivedFromΣ I0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)
codeΣ1..1CodeableConcept
valueQuantityQuantity
valueCodeableConceptCodeableConcept
valueStringstring
valueBooleanboolean
valueIntegerinteger
valueRangeRange
valueRatioRatio
valueSampledDataSampledData
valueTimetime
valueDateTimedateTime
valuePeriodPeriod
dataAbsentReasonI0..1CodeableConceptBinding
interpretation0..*CodeableConceptBinding
referenceRange0..*see (referenceRange)