NICE-LaboratoryTestResultObservation
Description
This profile is for sumbitting results of a laboratory test to the NICE.
Click here to go to the NICE-LaboratoryTestResultObservation Simplifier page
NICE data dictionary links
Source
This profile is used to submit laboratory test result related information to the Dutch National Intensive Care Evaluation (NICE). It was derived from the Nictiz Health and Care Information Model (HCIM; Dutch: Zorginformatiebouwsteen or ZIB) LaboratoryTestResultObservation, 2017 release version 3.1
Observation | I | Observation | Element idObservation LaboratoryTestResult Alternate namesVital Signs, Measurement, Results, Tests, LaboratoriumUitslag DefinitionA laboratory result describes the result of a laboratory analysis. These are specimen-oriented tests as performed in laboratories such as Clinical Chemistry, Serology, Microbiology, etc. In addition to the results of tests with a singular result, this concept can also contain the results of more complex tests with multiple results or a ‘panel’. This profile is used for two concepts of the HCIM LaboratoryTestResult at te same time: the root concept (NL-CM:13.1.1) and the LaboratoryTest concept (NL-CM:13.1.3). A LaboratoryTestResult can consist of just one LaboratoryTest or can be a panel of multiple LaboratoryTests. If there's just one LaboratoryTest, a single instance of this profile may be used to represent both concepts, but if there are multiple LaboratoryTests, there should be one parent instance representing the LaboratoryTestResult that uses Note that the The list below summarizes the different situations:
Also note that there is the additional profile zib-LaboratoryTestResult-DiagnosticReport, which is used for (textual) reports on individual (panels of) observations, like conclusions. The DiagnosticReport contains references to instances of this profile and can be used in all three the situations described above.
| |
id | Σ | 0..1 | id | There are no (further) constraints on this element Element idObservation.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 idObservation.meta Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.
|
implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idObservation.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. 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. This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.
|
language | 0..1 | codeBinding | There are no (further) constraints on this element Element idObservation.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. Common Languages (extensible)Constraints
| |
text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idObservation.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 may 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 in formation is added later.
|
contained | 0..* | Resource | There are no (further) constraints on this element Element idObservation.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.
| |
extension | I | 2..* | Extension | There are no (further) constraints on this element Element idObservation.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. In order 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. 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
|
Verified | S I | 1..1 | Extension(CodeableConcept) | Element idObservation.extension:Verified Is the instance validated by a medical professional? Alternate namesextensions, user content DefinitionExtension that is used to indicate whether the entire instance has been validated. Every instance shall be validated by a hospital member / datamanager. However, this is not always feasible in case of automated submission of NICE data elements. This extensions shall be used to indicate the validation status of the instance. 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. https://fhir.stichting-nice.nl/STU3/StructureDefinition/NICE-Verified-2022Q1 Constraints
|
ExtremeValueType | S ?! I | 0..1 | Extension(CodeableConcept) | Element idObservation.extension:ExtremeValueType Extension to indicate upper or lower bounds Alternate namesextensions, user content DefinitionExtension to indicate wether the element is the highest or the lowest value 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. https://fhir.stichting-nice.nl/STU3/StructureDefinition/NICE-ExtremeValueType-2022Q1 Constraints
|
ScoreDay | S I | 1..1 | Extension(Quantity) | Element idObservation.extension:ScoreDay ScoreDay Alternate namesextensions, user content DefinitionExtension that is used to indicate the day of scoring. The first 24 hours after admission count as day 1. The next day starts from the first morning shift and lasts 24 hours, so until the start of the next morning shift. Note: Score day 1 can overlap with score day 2, and 'the first morning shift' is specified locally can differ between hospitals. 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. https://fhir.stichting-nice.nl/STU3/StructureDefinition/NICE-ScoreDay-2022Q1 Constraints
|
modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.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. Usually modifier elements provide negation or qualification. In order 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. 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
|
identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idObservation.identifier Identifier Alternate namesIdentificatie DefinitionA unique identifier assigned to this observation. Allows observations to be distinguished and referenced.
|
basedOn | Σ I | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ProcedureRequest | ReferralRequest) | There are no (further) constraints on this element Element idObservation.basedOn Fulfills plan, proposal or order including requester information. Alternate namesFulfills, Aanvrager DefinitionA plan, proposal or order that is fulfilled in whole or in part by this event. Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon. Requester information should be captured and exchanged in the resource ProcedureRequest referenced by basedOn. Requester is the healthcare provider and/or organization where or by whom the LaboratoryTestResult was requested. There are a few required elements in ProcedureRequest - ProcedureRequest.status (use fixed value "active", unless you know what the actual value is) - ProcedureRequest.intent (use fixed value "order", unless you know what the actual value is) - ProcedureRequest.code (use extension http://hl7.org/fhir/STU3/extension-iso21090-nullflavor.html met valueCode UNK, unless you know what the actual value is) - ProcedureRequest.subject (equal to Observation.subject) - ProcedureRequest.requester.agent (contains the requesting HealthProfessional) Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ProcedureRequest | ReferralRequest) Constraints
|
status | S Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idObservation.status TestUitslagStatus Alternate namesTestUitslagStatus DefinitionThe status of the test result of this test. If the laboratory test is an panel/cluster, the overall status is given in the status of the panel/cluster. Need to track the status of individual results. Some results are finalized before the whole report is finalized. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. Codes providing the status of an observation. ObservationStatus (required)Constraints
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.status.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. In order 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. 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
|
TestResultStatus | I | 0..1 | Extension(CodeableConcept) | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus TestResultStatus Alternate namesextensions, user content, Bevat de specifieke code conform de zib, bij een FHIR-element die een verplichte koppeling heeft met een bepaalde FHIR waardelijst of een FHIR element die niet gecodeerd is gedefinieerd, terwijl de zib dit wel doet., TestUitslagStatus DefinitionProvides the specific HCIM code for TestResultStatus or ResultStatus. The status of the laboratory test result. If the laboratory test is an panel/cluster, this status reflects the status of the whole panel/cluster. If the status item per subtest is used too, this status must be in accordance with these status values. 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. http://nictiz.nl/fhir/StructureDefinition/code-specification Constraints
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.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. In order 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. 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
|
url | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.url identifies the meaning of the extension DefinitionSource of the definition for the extension code - a logical name or a URL. The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
http://nictiz.nl/fhir/StructureDefinition/code-specification
| |
valueCodeableConcept | 1..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept Value of extension DefinitionValue of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list). TestResultStatusCodelist TestResultStatusCodelijst (extensible)Constraints
| |
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.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. In order 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. 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
|
coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding.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. In order 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. 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
|
system | Σ | 0..1 | uri | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.
|
version | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
|
code | Σ | 0..1 | codeFixed Value | Element idObservation.status.extension:TestResultStatus.valueCodeableConcept:valueCodeableConcept.coding.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings may not exceed 1MB in size
final
|
display | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings may not exceed 1MB in size
|
userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
|
text | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
|
value | 0..1 | There are no (further) constraints on this element Element idObservation.status.value Primitive value for code DefinitionPrimitive value for code 1048576 | ||
category | 1..* | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.category Classification of type of observation DefinitionA code that classifies the general type of observation being made. Used for filtering what observations are retrieved and displayed. In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set. Unordered, Open, by $this(Value) BindingCodes for high level observation categories. Observation Category Codes (preferred)Constraints
| |
LaboratoryTestResultCode | 1..1 | CodeableConceptBindingPattern | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode LaboratoryTestResultCode DefinitionA code that classifies the general type of observation being made. Used for filtering what observations are retrieved and displayed. In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set. Codes for high level observation categories. Observation Category Codes (preferred)Constraints
{ "coding": [ { "system": "http://snomed.info/sct", "code": "49581000146104" } ] }
| |
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.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. In order 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. 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
|
coding | Σ | 0..* | CodingPattern | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
{ "system": "http://snomed.info/sct", "code": "49581000146104" }
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.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. In order 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. 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
|
system | Σ | 0..1 | uriFixed Value | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.
http://snomed.info/sct
|
version | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
|
code | Σ | 0..1 | codeFixed Value | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings may not exceed 1MB in size
49581000146104
|
display | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings may not exceed 1MB in size
Laboratory test finding (finding)
|
userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
|
text | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
|
ResultType | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.category:ResultType ResultType Alternate namesResultaatType DefinitionThe type of result defines the laboratory specialty under which the test is categorized. Used for filtering what observations are retrieved and displayed. In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set. ResultaatTypeCodelijst ResultaatTypeCodelijst (required)Constraints
| |
code | S Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idObservation.code TestCode or PanelOrBattery Alternate namesName, TestCode, Onderzoek DefinitionThe name and code of the executed test or for laboratory tests comprising multiple subtests and often requested together as a whole, this concept contains the name of the compound request (often indicated as a ‘panel’, ‘battery’ or ‘cluster’). Examples include: blood gases and EBV serology. Knowing what kind of observation is being made is essential to understanding the observation. This can either be the HCIM concept Test (NL-CM:13.1.4) or TestName (NL-CM:13.1.8) depending on the use case. See the documentation on the root of this profile for guidance on implementing the different uses cases. Codes identifying names of simple observations. LOINC Codes (example)Constraints
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.code.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.code.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. In order 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. 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
|
coding | Σ | 0..* | Coding | Element idObservation.code.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by system(Value) Constraints
|
NICELaboratoryTestResultCodeList | Σ | 1..* | CodingBinding | Element idObservation.code.coding:NICELaboratoryTestResultCodeList Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. The different LOINC codes describing the various types of laboratory results used by the NICE. NICE Laboratory Test Results (extensible)Constraints
|
text | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.code.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
|
subject | S Σ I | 1..1 | Reference(NICE-Patient) | Element idObservation.subject Patient Alternate namesPatiënt DefinitionThe patient, or group of patients, location, or device whose characteristics (direct or indirect) are described by the observation and into whose record the observation is placed. Comments: Indirect characteristics may be those of a specimen, fetus, donor, other observer (for example a relative or EMT), or any observation made about the subject. Observations have no value if you don't know who or what they're about. One would expect this element to be a cardinality of 1..1. The only circumstance in which the subject can be missing is when the observation is made by a device that does not know the patient. In this case, the observation SHALL be matched to a patient through some context/channel matching technique, and at this point, the observation should be updated. If the target of the observation is different than the subject, the general extension observation-focal-subject. may be used. However, the distinction between the patient's own value for an observation versus that of the fetus, or the donor or blood product unit, etc., are often specified in the observation code.
|
context | S I | 0..1 | Reference(NICE-Encounter) | Element idObservation.context Encounter during which this observation is made Alternate namesEncounter DefinitionThe encounter during which this journal entry was made. For some observations it may be important to know the link between an observation and a particular encounter. This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter or episode but still be tied to the context of the encounter or episode (e.g. pre-admission lab tests).
|
effectiveDateTime | Σ | 0..1 | dateTime | Element idObservation.effective[x]:effectiveDateTime TestDateTime Alternate namesOccurrence, TestDatumTijd DefinitionThe date and if possible the time at which the test was carried out. Knowing when an observation was deemed true is important to its relevance as well as determining trends. At least a date should be present unless this observation is a historical report.
|
issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element idObservation.issued Date/Time this was made available DefinitionThe date and time this observation was made available to providers, typically after the results have been reviewed and verified. Updated when the result is updated.
|
performer | Σ I | 0..* | Reference(nl-core-organization | nl-core-patient | nl-core-practitioner | nl-core-relatedperson) | There are no (further) constraints on this element Element idObservation.performer Who is responsible for the observation DefinitionWho was responsible for asserting the observed value as "true". May give a degree of confidence in the observation and also indicates where follow-up questions should be directed. 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. Reference(nl-core-organization | nl-core-patient | nl-core-practitioner | nl-core-relatedperson) Constraints
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.performer.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.performer.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. In order 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. 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
|
practitionerRole | I | 0..1 | Extension(Reference(nl-core-practitionerrole)) | There are no (further) constraints on this element Element idObservation.performer.extension:practitionerRole Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. Extension(Reference(nl-core-practitionerrole)) Extension URLhttp://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference Constraints
|
reference | Σ I | 0..1 | string | There are no (further) constraints on this element Element idObservation.performer.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
|
identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idObservation.performer.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.
|
display | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.performer.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
|
valueQuantity | S Σ I | 0..1 | Quantity | Element idObservation.value[x]:valueQuantity TestResult Alternate namesTestUitslag DefinitionThe test result. Depending on the type of test, the result will consist of a value with a unit or a coded value (ordinal or nominal). An observation exists to have a value, though it may not if it is in error, or if it represents a group of observations. Normally, an observation will have either a single value or a set of related observations. A few observations (e.g. Apgar score) may have both a value and related observations (for an Apgar score, the observations from which the measure is derived). If a value is present, the datatype for this element should be determined by Observation.code. This element has a variable name depending on the type as follows: valueQuantity, valueCodeableConcept, valueString, valueBoolean, valueRange, valueRatio, valueSampledData, valueAttachment, valueTime, valueDateTime, or valuePeriod. (The name format is "'value' + the type name" with a capital on the first letter of the type). If the data element is usually coded or if the type associated with the Observation.value defines a coded value, use CodeableConcept instead of string datatype even if the value is uncoded text. A value set is bound to the ValueCodeableConcept element. For further discussion and examples see the notes section below.
|
dataAbsentReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.dataAbsentReason Why the result is missing DefinitionProvides a reason why the expected value in the element Observation.value[x] is missing. For many results it is necessary to handle exceptional values in measurements. 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. Codes specifying why the result (Observation.value[x]) is missing. Observation Value Absent Reason (extensible)Constraints
|
interpretation | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.interpretation High, low, normal, etc. Alternate namesAbnormal Flag DefinitionThe assessment made based on the result of the observation. Intended as a simple compact code often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result. Otherwise known as abnormal flag. For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. 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. Codes identifying interpretations of observations. Observation Interpretation Codes (extensible)Constraints
| |
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.interpretation.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. In order 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. 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
|
coding | Σ I | 1..* | Coding | There are no (further) constraints on this element Element idObservation.interpretation.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by system(Value) Constraints
|
ObservationInterpretation | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Observation Interpretation Codes Observation Interpretation Codes (required)Permitted Values InterpretatieVlaggenCodelijst-To-Observation-Interpretation Constraints
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.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. In order 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. 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
|
system | Σ | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.
http://hl7.org/fhir/v2/0078
|
version | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
|
code | Σ | 1..1 | code | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings may not exceed 1MB in size
|
display | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings may not exceed 1MB in size
|
userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
|
InterpretatieVlaggenCodelijst | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst ResultFlags Alternate namesInterpretatieVlaggen DefinitionAttention codes indicating whether the result is above or below certain reference values or interpreting the result otherwise. (Resistent) Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. This slice binds the ValueSet from the HCIM, which overlaps the ValueSet from the core FHIR Observation. To satisfy the FHIR profiling rules, the code from the core FHIR ValueSet SHOULD be included as well if a code from this ValueSet is included. A ConceptMap (https://simplifier.net/resolve?canonical=http://nictiz.nl/fhir/ConceptMap/InterpretatieVlaggenCodelijst-to-observation-interpretation) is available that explains the relationship between the FHIR observation-interpretation value set and the HCIM ResultFlagsCodelist. InterpretatieVlaggenCodelijst InterpretatieVlaggenCodelijst (required)Constraints
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.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. In order 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. 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
|
system | Σ | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.
http://snomed.info/sct
|
version | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
|
code | Σ | 1..1 | code | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings may not exceed 1MB in size
|
display | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings may not exceed 1MB in size
|
userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
|
text | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
|
comment | 0..1 | string | There are no (further) constraints on this element Element idObservation.comment Comment or ResultInterpretation Alternate namesToelichting, UitslagInterpretatie DefinitionComments, such as a textual interpretation or advice accompanying the result, for example or a comment of the laboratory specialist regarding the interpretation of the results. Need to be able to provide free text additional information. Note that FHIR strings may not exceed 1MB in size
| |
bodySite | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idObservation.bodySite Observed body part DefinitionIndicates the site on the subject's body where the observation was made (i.e. the target site). Only used if not implicit in code found in Observation.code. In many systems, this may be represented as a related observation instead of an inline component. If the use case requires BodySite to be handled as a separate resource (e.g. to identify and track separately) then use the standard extension body-site-instance. Codes describing anatomical locations. May include laterality. SNOMED CT Body Structures (example)Constraints
| |
method | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.method TestMethod Alternate namesTestmethode DefinitionThe test method used to obtain the result. In some cases, method can impact results and is thus used for determining whether results can be compared or determining significance of results. Only used if not implicit in code for Observation.code. SNOMED CT (2.16.840.1.113883.6.96): All values TestmethodeCodelijst (extensible)Constraints
| |
specimen | S I | 0..1 | Reference(NICE-LaboratoryTestResultSpecimen) | Element idObservation.specimen Specimen Alternate namesMonster DefinitionTo find the dateTime of the test, we require information on the specimen that was used when this observation was made. Should only be used if not implicit in code found in Reference(NICE-LaboratoryTestResultSpecimen) Constraints
|
device | I | 0..1 | Reference(HCIM MedicalDevice Product) | There are no (further) constraints on this element Element idObservation.device (Measurement) Device DefinitionThe device used to generate the observation data. An extension should be used if further typing of the device is needed. Devices used to support obtaining an observation can be represented using either an extension or through the Observation.related element. Reference(HCIM MedicalDevice Product) Constraints
|
referenceRange | I | 0..* | BackboneElement | There are no (further) constraints on this element Element idObservation.referenceRange Reference Alternate namesReferentie DefinitionGuidance on how to interpret the value by comparison to a normal or recommended range. Knowing what values are considered "normal" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts. Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this may not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.referenceRange.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.referenceRange.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. In order 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. 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
|
modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.referenceRange.modifierExtension Extensions that cannot be ignored 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 that contains it. Usually modifier elements provide negation or qualification. In order 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. 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.
|
low | S I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idObservation.referenceRange.low ReferenceRangeLowerLimit Alternate namesReferentieOndergrens DefinitionThe lower reference limit for the patient of the value measured with the test. The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.
|
high | S I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idObservation.referenceRange.high ReferenceRangeUpperLimit Alternate namesReferentieBovengrens DefinitionThe upper reference limit for the patient of the value measured in the test. The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.
|
type | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.referenceRange.type Reference range qualifier DefinitionCodes to indicate the what part of the targeted reference population it applies to. For example, the normal or therapeutic range. Need to be able to say what kind of reference range this is - normal, recommended, therapeutic, etc, - for proper interpretation. This SHOULD be populated if there is more than one range. If this element is not present then the normal range is assumed. Code for the meaning of a reference range. Observation Reference Range Meaning Codes (extensible)Constraints
| |
appliesTo | 0..* | CodeableConcept | There are no (further) constraints on this element Element idObservation.referenceRange.appliesTo Reference range population DefinitionCodes to indicate the target population this reference range applies to. For example, a reference range may be based on the normal population or a particular sex or race. Need to be able to identify the target population for proper interpretation. This SHOULD be populated if there is more than one range. If this element is not present then the normal population is assumed. Codes identifying the population the reference range applies to. Observation Reference Range Applies To Codes (example)Constraints
| |
age | I | 0..1 | Range | There are no (further) constraints on this element Element idObservation.referenceRange.age Applicable age range, if relevant DefinitionThe age at which this reference range is applicable. This is a neonatal age (e.g. number of weeks at term) if the meaning says so. Some analytes vary greatly over age. The stated low and high value are assumed to have arbitrarily high precision when it comes to determining which values are in the range. I.e. 1.99 is not in the range 2 -> 3.
|
text | 0..1 | string | There are no (further) constraints on this element Element idObservation.referenceRange.text Text based reference range in an observation DefinitionText based reference range in an observation which may be used when a quantitative range is not appropriate for an observation. An example would be a reference value of "Negative" or a list or table of 'normals'. Note that FHIR strings may not exceed 1MB in size
| |
related | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idObservation.related RelatedResults Alternate namesGerelateerdeUitslag, LaboratoriumTest DefinitionReference to related LaboratoryTestResult instances, or to the LaboratoryTest concept if this is a grouping Observation. Normally, an observation will have either a value or a set of related observations. A few observations (e.g. Apgar score) may have both a value and a set of related observations or sometimes a QuestionnaireResponse from which the measure is derived. The
See the documentation on the root if this profile for guidance on implementing these use cases.
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.related.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.related.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. In order 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. 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
|
modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.related.modifierExtension Extensions that cannot be ignored 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 that contains it. Usually modifier elements provide negation or qualification. In order 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. 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.
|
type | 0..1 | codeBinding | There are no (further) constraints on this element Element idObservation.related.type has-member | derived-from | sequel-to | replaces | qualified-by | interfered-by DefinitionA code specifying the kind of relationship that exists with the target resource. A relationship type SHOULD be provided. The "derived-from" type is the only logical choice when referencing the QuestionnaireAnswer resource. Codes specifying how two observations are related. ObservationRelationshipType (required)Constraints
| |
target | I | 1..1 | Reference(QuestionnaireResponse | Sequence | HCIM LaboratoryTestResult Observation) | There are no (further) constraints on this element Element idObservation.related.target Resource that is related to this one DefinitionA reference to the observation or QuestionnaireResponse resource that is related to this observation. 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. Reference(QuestionnaireResponse | Sequence | HCIM LaboratoryTestResult Observation) Constraints
|
component | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idObservation.component LaboratoryTest Alternate namesLaboratoriumTest DefinitionContainer of the LaboratoryTest concept. This container contains all data elements of the LaboratoryTest concept. Component observations share the same attributes in the Observation resource as the primary observation and are always treated a part of a single observation (they are not separable). However, the reference range for the primary observation value is not inherited by the component values and is required when appropriate for each component observation. For a discussion on the ways Observations can be assembled in groups together see Notes below.
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.component.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.component.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. In order 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. 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
|
modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.component.modifierExtension Extensions that cannot be ignored 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 that contains it. Usually modifier elements provide negation or qualification. In order 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. 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.
|
code | Σ | 1..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.component.code TestCode Alternate namesTestCode DefinitionThe TestCode is the name of the executed test. Knowing what kind of observation is being made is essential to understanding the observation. 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. LOINC (2.16.840.1.113883.6.1): All values TestNaamCodelijst (extensible)Constraints
|
value[x] | Σ | 0..1 | There are no (further) constraints on this element Element idObservation.component.value[x] TestResult Alternate namesTestUitslag DefinitionThe test result. Depending on the type of test, the result will consist of a value with a unit or a coded value (ordinal or nominal). An observation exists to have a value, though it may not if it is in error, or if it represents a group of observations. Normally, an observation will have either a single value or a set of related observations. A few observations (e.g. Apgar score) may have both a value and related observations (for an Apgar score, the observations from which the measure is 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 boolean values use valueCodeableConcept and select codes from http://hl7.org/fhir/ValueSet/v2-0136 (these "yes/no" concepts can be mapped to the display name "true/false" or other mutually exclusive terms that may be needed"). The element, Observation.value[x], has a variable name depending on the type as follows: valueQuantity, valueCodeableConcept, valueRatio, valueChoice, valuePeriod, valueSampleData, or valueString (the name format is "'value' + the type name" with a capital on the first letter of the type).
| |
valueQuantity | Quantity | There are no (further) constraints on this element Data type | ||
valueCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data type | ||
valueString | string | There are no (further) constraints on this element Data type | ||
valueRange | Range | There are no (further) constraints on this element Data type | ||
valueRatio | Ratio | There are no (further) constraints on this element Data type | ||
valueSampledData | SampledData | There are no (further) constraints on this element Data type | ||
valueAttachment | Attachment | There are no (further) constraints on this element Data type | ||
valueTime | time | There are no (further) constraints on this element Data type | ||
valueDateTime | dateTime | There are no (further) constraints on this element Data type | ||
valuePeriod | Period | There are no (further) constraints on this element Data type | ||
dataAbsentReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.component.dataAbsentReason Why the component result is missing DefinitionProvides a reason why the expected value in the element Observation.value[x] is missing. For many results it is necessary to handle exceptional values in measurements. "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. Codes specifying why the result (Observation.value[x]) is missing. Observation Value Absent Reason (extensible)Constraints
|
interpretation | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.component.interpretation ResultFlags Alternate namesAbnormal Flag, InterpretatieVlaggen DefinitionAttention codes indicating whether the result is above or below certain reference values or interpreting the result otherwise. (Resistent) For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. A ConceptMap (https://simplifier.net/resolve?canonical=http://nictiz.nl/fhir/ConceptMap/InterpretatieVlaggenCodelijst-to-observation-interpretation) is available that maps ResultFlagsCodelist to the observation-interpretation valueset. InterpretatieVlaggenCodelijst InterpretatieVlaggenCodelijst (extensible)Permitted Values InterpretatieVlaggenCodelijst-To-Observation-Interpretation Constraints
| |
referenceRange | 0..* | see (referenceRange) | There are no (further) constraints on this element Element idObservation.component.referenceRange Provides guide for interpretation of component result DefinitionGuidance on how to interpret the value by comparison to a normal or recommended range. Knowing what values are considered "normal" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts. Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this may not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.
|
Observation | I | Observation | Element idObservation LaboratoryTestResult Alternate namesVital Signs, Measurement, Results, Tests, LaboratoriumUitslag DefinitionA laboratory result describes the result of a laboratory analysis. These are specimen-oriented tests as performed in laboratories such as Clinical Chemistry, Serology, Microbiology, etc. In addition to the results of tests with a singular result, this concept can also contain the results of more complex tests with multiple results or a ‘panel’. This profile is used for two concepts of the HCIM LaboratoryTestResult at te same time: the root concept (NL-CM:13.1.1) and the LaboratoryTest concept (NL-CM:13.1.3). A LaboratoryTestResult can consist of just one LaboratoryTest or can be a panel of multiple LaboratoryTests. If there's just one LaboratoryTest, a single instance of this profile may be used to represent both concepts, but if there are multiple LaboratoryTests, there should be one parent instance representing the LaboratoryTestResult that uses Note that the The list below summarizes the different situations:
Also note that there is the additional profile zib-LaboratoryTestResult-DiagnosticReport, which is used for (textual) reports on individual (panels of) observations, like conclusions. The DiagnosticReport contains references to instances of this profile and can be used in all three the situations described above.
| |
id | Σ | 0..1 | id | There are no (further) constraints on this element Element idObservation.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 idObservation.meta Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.
|
implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idObservation.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. 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. This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.
|
language | 0..1 | codeBinding | There are no (further) constraints on this element Element idObservation.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. Common Languages (extensible)Constraints
| |
text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idObservation.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 may 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 in formation is added later.
|
contained | 0..* | Resource | There are no (further) constraints on this element Element idObservation.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.
| |
extension | I | 2..* | Extension | There are no (further) constraints on this element Element idObservation.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. In order 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. 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
|
Verified | S I | 1..1 | Extension(CodeableConcept) | Element idObservation.extension:Verified Is the instance validated by a medical professional? Alternate namesextensions, user content DefinitionExtension that is used to indicate whether the entire instance has been validated. Every instance shall be validated by a hospital member / datamanager. However, this is not always feasible in case of automated submission of NICE data elements. This extensions shall be used to indicate the validation status of the instance. 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. https://fhir.stichting-nice.nl/STU3/StructureDefinition/NICE-Verified-2022Q1 Constraints
|
ExtremeValueType | S ?! I | 0..1 | Extension(CodeableConcept) | Element idObservation.extension:ExtremeValueType Extension to indicate upper or lower bounds Alternate namesextensions, user content DefinitionExtension to indicate wether the element is the highest or the lowest value 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. https://fhir.stichting-nice.nl/STU3/StructureDefinition/NICE-ExtremeValueType-2022Q1 Constraints
|
ScoreDay | S I | 1..1 | Extension(Quantity) | Element idObservation.extension:ScoreDay ScoreDay Alternate namesextensions, user content DefinitionExtension that is used to indicate the day of scoring. The first 24 hours after admission count as day 1. The next day starts from the first morning shift and lasts 24 hours, so until the start of the next morning shift. Note: Score day 1 can overlap with score day 2, and 'the first morning shift' is specified locally can differ between hospitals. 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. https://fhir.stichting-nice.nl/STU3/StructureDefinition/NICE-ScoreDay-2022Q1 Constraints
|
modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.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. Usually modifier elements provide negation or qualification. In order 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. 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
|
identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idObservation.identifier Identifier Alternate namesIdentificatie DefinitionA unique identifier assigned to this observation. Allows observations to be distinguished and referenced.
|
basedOn | Σ I | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ProcedureRequest | ReferralRequest) | There are no (further) constraints on this element Element idObservation.basedOn Fulfills plan, proposal or order including requester information. Alternate namesFulfills, Aanvrager DefinitionA plan, proposal or order that is fulfilled in whole or in part by this event. Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon. Requester information should be captured and exchanged in the resource ProcedureRequest referenced by basedOn. Requester is the healthcare provider and/or organization where or by whom the LaboratoryTestResult was requested. There are a few required elements in ProcedureRequest - ProcedureRequest.status (use fixed value "active", unless you know what the actual value is) - ProcedureRequest.intent (use fixed value "order", unless you know what the actual value is) - ProcedureRequest.code (use extension http://hl7.org/fhir/STU3/extension-iso21090-nullflavor.html met valueCode UNK, unless you know what the actual value is) - ProcedureRequest.subject (equal to Observation.subject) - ProcedureRequest.requester.agent (contains the requesting HealthProfessional) Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ProcedureRequest | ReferralRequest) Constraints
|
status | S Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idObservation.status TestUitslagStatus Alternate namesTestUitslagStatus DefinitionThe status of the test result of this test. If the laboratory test is an panel/cluster, the overall status is given in the status of the panel/cluster. Need to track the status of individual results. Some results are finalized before the whole report is finalized. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. Codes providing the status of an observation. ObservationStatus (required)Constraints
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.status.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. In order 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. 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
|
TestResultStatus | I | 0..1 | Extension(CodeableConcept) | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus TestResultStatus Alternate namesextensions, user content, Bevat de specifieke code conform de zib, bij een FHIR-element die een verplichte koppeling heeft met een bepaalde FHIR waardelijst of een FHIR element die niet gecodeerd is gedefinieerd, terwijl de zib dit wel doet., TestUitslagStatus DefinitionProvides the specific HCIM code for TestResultStatus or ResultStatus. The status of the laboratory test result. If the laboratory test is an panel/cluster, this status reflects the status of the whole panel/cluster. If the status item per subtest is used too, this status must be in accordance with these status values. 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. http://nictiz.nl/fhir/StructureDefinition/code-specification Constraints
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.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. In order 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. 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
|
url | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.url identifies the meaning of the extension DefinitionSource of the definition for the extension code - a logical name or a URL. The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
http://nictiz.nl/fhir/StructureDefinition/code-specification
| |
valueCodeableConcept | 1..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept Value of extension DefinitionValue of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list). TestResultStatusCodelist TestResultStatusCodelijst (extensible)Constraints
| |
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.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. In order 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. 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
|
coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding.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. In order 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. 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
|
system | Σ | 0..1 | uri | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.
|
version | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
|
code | Σ | 0..1 | codeFixed Value | Element idObservation.status.extension:TestResultStatus.valueCodeableConcept:valueCodeableConcept.coding.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings may not exceed 1MB in size
final
|
display | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings may not exceed 1MB in size
|
userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
|
text | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
|
value | 0..1 | There are no (further) constraints on this element Element idObservation.status.value Primitive value for code DefinitionPrimitive value for code 1048576 | ||
category | 1..* | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.category Classification of type of observation DefinitionA code that classifies the general type of observation being made. Used for filtering what observations are retrieved and displayed. In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set. Unordered, Open, by $this(Value) BindingCodes for high level observation categories. Observation Category Codes (preferred)Constraints
| |
LaboratoryTestResultCode | 1..1 | CodeableConceptBindingPattern | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode LaboratoryTestResultCode DefinitionA code that classifies the general type of observation being made. Used for filtering what observations are retrieved and displayed. In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set. Codes for high level observation categories. Observation Category Codes (preferred)Constraints
{ "coding": [ { "system": "http://snomed.info/sct", "code": "49581000146104" } ] }
| |
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.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. In order 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. 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
|
coding | Σ | 0..* | CodingPattern | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
{ "system": "http://snomed.info/sct", "code": "49581000146104" }
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.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. In order 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. 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
|
system | Σ | 0..1 | uriFixed Value | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.
http://snomed.info/sct
|
version | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
|
code | Σ | 0..1 | codeFixed Value | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings may not exceed 1MB in size
49581000146104
|
display | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings may not exceed 1MB in size
Laboratory test finding (finding)
|
userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
|
text | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
|
ResultType | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.category:ResultType ResultType Alternate namesResultaatType DefinitionThe type of result defines the laboratory specialty under which the test is categorized. Used for filtering what observations are retrieved and displayed. In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set. ResultaatTypeCodelijst ResultaatTypeCodelijst (required)Constraints
| |
code | S Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idObservation.code TestCode or PanelOrBattery Alternate namesName, TestCode, Onderzoek DefinitionThe name and code of the executed test or for laboratory tests comprising multiple subtests and often requested together as a whole, this concept contains the name of the compound request (often indicated as a ‘panel’, ‘battery’ or ‘cluster’). Examples include: blood gases and EBV serology. Knowing what kind of observation is being made is essential to understanding the observation. This can either be the HCIM concept Test (NL-CM:13.1.4) or TestName (NL-CM:13.1.8) depending on the use case. See the documentation on the root of this profile for guidance on implementing the different uses cases. Codes identifying names of simple observations. LOINC Codes (example)Constraints
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.code.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.code.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. In order 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. 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
|
coding | Σ | 0..* | Coding | Element idObservation.code.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by system(Value) Constraints
|
NICELaboratoryTestResultCodeList | Σ | 1..* | CodingBinding | Element idObservation.code.coding:NICELaboratoryTestResultCodeList Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. The different LOINC codes describing the various types of laboratory results used by the NICE. NICE Laboratory Test Results (extensible)Constraints
|
text | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.code.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
|
subject | S Σ I | 1..1 | Reference(NICE-Patient) | Element idObservation.subject Patient Alternate namesPatiënt DefinitionThe patient, or group of patients, location, or device whose characteristics (direct or indirect) are described by the observation and into whose record the observation is placed. Comments: Indirect characteristics may be those of a specimen, fetus, donor, other observer (for example a relative or EMT), or any observation made about the subject. Observations have no value if you don't know who or what they're about. One would expect this element to be a cardinality of 1..1. The only circumstance in which the subject can be missing is when the observation is made by a device that does not know the patient. In this case, the observation SHALL be matched to a patient through some context/channel matching technique, and at this point, the observation should be updated. If the target of the observation is different than the subject, the general extension observation-focal-subject. may be used. However, the distinction between the patient's own value for an observation versus that of the fetus, or the donor or blood product unit, etc., are often specified in the observation code.
|
context | S I | 0..1 | Reference(NICE-Encounter) | Element idObservation.context Encounter during which this observation is made Alternate namesEncounter DefinitionThe encounter during which this journal entry was made. For some observations it may be important to know the link between an observation and a particular encounter. This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter or episode but still be tied to the context of the encounter or episode (e.g. pre-admission lab tests).
|
effectiveDateTime | Σ | 0..1 | dateTime | Element idObservation.effective[x]:effectiveDateTime TestDateTime Alternate namesOccurrence, TestDatumTijd DefinitionThe date and if possible the time at which the test was carried out. Knowing when an observation was deemed true is important to its relevance as well as determining trends. At least a date should be present unless this observation is a historical report.
|
issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element idObservation.issued Date/Time this was made available DefinitionThe date and time this observation was made available to providers, typically after the results have been reviewed and verified. Updated when the result is updated.
|
performer | Σ I | 0..* | Reference(nl-core-organization | nl-core-patient | nl-core-practitioner | nl-core-relatedperson) | There are no (further) constraints on this element Element idObservation.performer Who is responsible for the observation DefinitionWho was responsible for asserting the observed value as "true". May give a degree of confidence in the observation and also indicates where follow-up questions should be directed. 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. Reference(nl-core-organization | nl-core-patient | nl-core-practitioner | nl-core-relatedperson) Constraints
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.performer.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.performer.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. In order 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. 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
|
practitionerRole | I | 0..1 | Extension(Reference(nl-core-practitionerrole)) | There are no (further) constraints on this element Element idObservation.performer.extension:practitionerRole Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. Extension(Reference(nl-core-practitionerrole)) Extension URLhttp://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference Constraints
|
reference | Σ I | 0..1 | string | There are no (further) constraints on this element Element idObservation.performer.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
|
identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idObservation.performer.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.
|
display | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.performer.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
|
valueQuantity | S Σ I | 0..1 | Quantity | Element idObservation.value[x]:valueQuantity TestResult Alternate namesTestUitslag DefinitionThe test result. Depending on the type of test, the result will consist of a value with a unit or a coded value (ordinal or nominal). An observation exists to have a value, though it may not if it is in error, or if it represents a group of observations. Normally, an observation will have either a single value or a set of related observations. A few observations (e.g. Apgar score) may have both a value and related observations (for an Apgar score, the observations from which the measure is derived). If a value is present, the datatype for this element should be determined by Observation.code. This element has a variable name depending on the type as follows: valueQuantity, valueCodeableConcept, valueString, valueBoolean, valueRange, valueRatio, valueSampledData, valueAttachment, valueTime, valueDateTime, or valuePeriod. (The name format is "'value' + the type name" with a capital on the first letter of the type). If the data element is usually coded or if the type associated with the Observation.value defines a coded value, use CodeableConcept instead of string datatype even if the value is uncoded text. A value set is bound to the ValueCodeableConcept element. For further discussion and examples see the notes section below.
|
dataAbsentReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.dataAbsentReason Why the result is missing DefinitionProvides a reason why the expected value in the element Observation.value[x] is missing. For many results it is necessary to handle exceptional values in measurements. 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. Codes specifying why the result (Observation.value[x]) is missing. Observation Value Absent Reason (extensible)Constraints
|
interpretation | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.interpretation High, low, normal, etc. Alternate namesAbnormal Flag DefinitionThe assessment made based on the result of the observation. Intended as a simple compact code often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result. Otherwise known as abnormal flag. For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. 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. Codes identifying interpretations of observations. Observation Interpretation Codes (extensible)Constraints
| |
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.interpretation.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. In order 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. 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
|
coding | Σ I | 1..* | Coding | There are no (further) constraints on this element Element idObservation.interpretation.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by system(Value) Constraints
|
ObservationInterpretation | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Observation Interpretation Codes Observation Interpretation Codes (required)Permitted Values InterpretatieVlaggenCodelijst-To-Observation-Interpretation Constraints
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.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. In order 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. 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
|
system | Σ | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.
http://hl7.org/fhir/v2/0078
|
version | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
|
code | Σ | 1..1 | code | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings may not exceed 1MB in size
|
display | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings may not exceed 1MB in size
|
userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
|
InterpretatieVlaggenCodelijst | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst ResultFlags Alternate namesInterpretatieVlaggen DefinitionAttention codes indicating whether the result is above or below certain reference values or interpreting the result otherwise. (Resistent) Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. This slice binds the ValueSet from the HCIM, which overlaps the ValueSet from the core FHIR Observation. To satisfy the FHIR profiling rules, the code from the core FHIR ValueSet SHOULD be included as well if a code from this ValueSet is included. A ConceptMap (https://simplifier.net/resolve?canonical=http://nictiz.nl/fhir/ConceptMap/InterpretatieVlaggenCodelijst-to-observation-interpretation) is available that explains the relationship between the FHIR observation-interpretation value set and the HCIM ResultFlagsCodelist. InterpretatieVlaggenCodelijst InterpretatieVlaggenCodelijst (required)Constraints
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.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. In order 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. 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
|
system | Σ | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.
http://snomed.info/sct
|
version | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
|
code | Σ | 1..1 | code | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings may not exceed 1MB in size
|
display | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings may not exceed 1MB in size
|
userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
|
text | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
|
comment | 0..1 | string | There are no (further) constraints on this element Element idObservation.comment Comment or ResultInterpretation Alternate namesToelichting, UitslagInterpretatie DefinitionComments, such as a textual interpretation or advice accompanying the result, for example or a comment of the laboratory specialist regarding the interpretation of the results. Need to be able to provide free text additional information. Note that FHIR strings may not exceed 1MB in size
| |
bodySite | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idObservation.bodySite Observed body part DefinitionIndicates the site on the subject's body where the observation was made (i.e. the target site). Only used if not implicit in code found in Observation.code. In many systems, this may be represented as a related observation instead of an inline component. If the use case requires BodySite to be handled as a separate resource (e.g. to identify and track separately) then use the standard extension body-site-instance. Codes describing anatomical locations. May include laterality. SNOMED CT Body Structures (example)Constraints
| |
method | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.method TestMethod Alternate namesTestmethode DefinitionThe test method used to obtain the result. In some cases, method can impact results and is thus used for determining whether results can be compared or determining significance of results. Only used if not implicit in code for Observation.code. SNOMED CT (2.16.840.1.113883.6.96): All values TestmethodeCodelijst (extensible)Constraints
| |
specimen | S I | 0..1 | Reference(NICE-LaboratoryTestResultSpecimen) | Element idObservation.specimen Specimen Alternate namesMonster DefinitionTo find the dateTime of the test, we require information on the specimen that was used when this observation was made. Should only be used if not implicit in code found in Reference(NICE-LaboratoryTestResultSpecimen) Constraints
|
device | I | 0..1 | Reference(HCIM MedicalDevice Product) | There are no (further) constraints on this element Element idObservation.device (Measurement) Device DefinitionThe device used to generate the observation data. An extension should be used if further typing of the device is needed. Devices used to support obtaining an observation can be represented using either an extension or through the Observation.related element. Reference(HCIM MedicalDevice Product) Constraints
|
referenceRange | I | 0..* | BackboneElement | There are no (further) constraints on this element Element idObservation.referenceRange Reference Alternate namesReferentie DefinitionGuidance on how to interpret the value by comparison to a normal or recommended range. Knowing what values are considered "normal" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts. Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this may not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.referenceRange.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.referenceRange.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. In order 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. 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
|
modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.referenceRange.modifierExtension Extensions that cannot be ignored 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 that contains it. Usually modifier elements provide negation or qualification. In order 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. 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.
|
low | S I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idObservation.referenceRange.low ReferenceRangeLowerLimit Alternate namesReferentieOndergrens DefinitionThe lower reference limit for the patient of the value measured with the test. The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.
|
high | S I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idObservation.referenceRange.high ReferenceRangeUpperLimit Alternate namesReferentieBovengrens DefinitionThe upper reference limit for the patient of the value measured in the test. The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.
|
type | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.referenceRange.type Reference range qualifier DefinitionCodes to indicate the what part of the targeted reference population it applies to. For example, the normal or therapeutic range. Need to be able to say what kind of reference range this is - normal, recommended, therapeutic, etc, - for proper interpretation. This SHOULD be populated if there is more than one range. If this element is not present then the normal range is assumed. Code for the meaning of a reference range. Observation Reference Range Meaning Codes (extensible)Constraints
| |
appliesTo | 0..* | CodeableConcept | There are no (further) constraints on this element Element idObservation.referenceRange.appliesTo Reference range population DefinitionCodes to indicate the target population this reference range applies to. For example, a reference range may be based on the normal population or a particular sex or race. Need to be able to identify the target population for proper interpretation. This SHOULD be populated if there is more than one range. If this element is not present then the normal population is assumed. Codes identifying the population the reference range applies to. Observation Reference Range Applies To Codes (example)Constraints
| |
age | I | 0..1 | Range | There are no (further) constraints on this element Element idObservation.referenceRange.age Applicable age range, if relevant DefinitionThe age at which this reference range is applicable. This is a neonatal age (e.g. number of weeks at term) if the meaning says so. Some analytes vary greatly over age. The stated low and high value are assumed to have arbitrarily high precision when it comes to determining which values are in the range. I.e. 1.99 is not in the range 2 -> 3.
|
text | 0..1 | string | There are no (further) constraints on this element Element idObservation.referenceRange.text Text based reference range in an observation DefinitionText based reference range in an observation which may be used when a quantitative range is not appropriate for an observation. An example would be a reference value of "Negative" or a list or table of 'normals'. Note that FHIR strings may not exceed 1MB in size
| |
related | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idObservation.related RelatedResults Alternate namesGerelateerdeUitslag, LaboratoriumTest DefinitionReference to related LaboratoryTestResult instances, or to the LaboratoryTest concept if this is a grouping Observation. Normally, an observation will have either a value or a set of related observations. A few observations (e.g. Apgar score) may have both a value and a set of related observations or sometimes a QuestionnaireResponse from which the measure is derived. The
See the documentation on the root if this profile for guidance on implementing these use cases.
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.related.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.related.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. In order 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. 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
|
modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.related.modifierExtension Extensions that cannot be ignored 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 that contains it. Usually modifier elements provide negation or qualification. In order 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. 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.
|
type | 0..1 | codeBinding | There are no (further) constraints on this element Element idObservation.related.type has-member | derived-from | sequel-to | replaces | qualified-by | interfered-by DefinitionA code specifying the kind of relationship that exists with the target resource. A relationship type SHOULD be provided. The "derived-from" type is the only logical choice when referencing the QuestionnaireAnswer resource. Codes specifying how two observations are related. ObservationRelationshipType (required)Constraints
| |
target | I | 1..1 | Reference(QuestionnaireResponse | Sequence | HCIM LaboratoryTestResult Observation) | There are no (further) constraints on this element Element idObservation.related.target Resource that is related to this one DefinitionA reference to the observation or QuestionnaireResponse resource that is related to this observation. 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. Reference(QuestionnaireResponse | Sequence | HCIM LaboratoryTestResult Observation) Constraints
|
component | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idObservation.component LaboratoryTest Alternate namesLaboratoriumTest DefinitionContainer of the LaboratoryTest concept. This container contains all data elements of the LaboratoryTest concept. Component observations share the same attributes in the Observation resource as the primary observation and are always treated a part of a single observation (they are not separable). However, the reference range for the primary observation value is not inherited by the component values and is required when appropriate for each component observation. For a discussion on the ways Observations can be assembled in groups together see Notes below.
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.component.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.component.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. In order 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. 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
|
modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.component.modifierExtension Extensions that cannot be ignored 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 that contains it. Usually modifier elements provide negation or qualification. In order 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. 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.
|
code | Σ | 1..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.component.code TestCode Alternate namesTestCode DefinitionThe TestCode is the name of the executed test. Knowing what kind of observation is being made is essential to understanding the observation. 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. LOINC (2.16.840.1.113883.6.1): All values TestNaamCodelijst (extensible)Constraints
|
value[x] | Σ | 0..1 | There are no (further) constraints on this element Element idObservation.component.value[x] TestResult Alternate namesTestUitslag DefinitionThe test result. Depending on the type of test, the result will consist of a value with a unit or a coded value (ordinal or nominal). An observation exists to have a value, though it may not if it is in error, or if it represents a group of observations. Normally, an observation will have either a single value or a set of related observations. A few observations (e.g. Apgar score) may have both a value and related observations (for an Apgar score, the observations from which the measure is 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 boolean values use valueCodeableConcept and select codes from http://hl7.org/fhir/ValueSet/v2-0136 (these "yes/no" concepts can be mapped to the display name "true/false" or other mutually exclusive terms that may be needed"). The element, Observation.value[x], has a variable name depending on the type as follows: valueQuantity, valueCodeableConcept, valueRatio, valueChoice, valuePeriod, valueSampleData, or valueString (the name format is "'value' + the type name" with a capital on the first letter of the type).
| |
valueQuantity | Quantity | There are no (further) constraints on this element Data type | ||
valueCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data type | ||
valueString | string | There are no (further) constraints on this element Data type | ||
valueRange | Range | There are no (further) constraints on this element Data type | ||
valueRatio | Ratio | There are no (further) constraints on this element Data type | ||
valueSampledData | SampledData | There are no (further) constraints on this element Data type | ||
valueAttachment | Attachment | There are no (further) constraints on this element Data type | ||
valueTime | time | There are no (further) constraints on this element Data type | ||
valueDateTime | dateTime | There are no (further) constraints on this element Data type | ||
valuePeriod | Period | There are no (further) constraints on this element Data type | ||
dataAbsentReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.component.dataAbsentReason Why the component result is missing DefinitionProvides a reason why the expected value in the element Observation.value[x] is missing. For many results it is necessary to handle exceptional values in measurements. "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. Codes specifying why the result (Observation.value[x]) is missing. Observation Value Absent Reason (extensible)Constraints
|
interpretation | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.component.interpretation ResultFlags Alternate namesAbnormal Flag, InterpretatieVlaggen DefinitionAttention codes indicating whether the result is above or below certain reference values or interpreting the result otherwise. (Resistent) For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. A ConceptMap (https://simplifier.net/resolve?canonical=http://nictiz.nl/fhir/ConceptMap/InterpretatieVlaggenCodelijst-to-observation-interpretation) is available that maps ResultFlagsCodelist to the observation-interpretation valueset. InterpretatieVlaggenCodelijst InterpretatieVlaggenCodelijst (extensible)Permitted Values InterpretatieVlaggenCodelijst-To-Observation-Interpretation Constraints
| |
referenceRange | 0..* | see (referenceRange) | There are no (further) constraints on this element Element idObservation.component.referenceRange Provides guide for interpretation of component result DefinitionGuidance on how to interpret the value by comparison to a normal or recommended range. Knowing what values are considered "normal" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts. Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this may not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.
|
Observation | I | Observation | Element idObservation LaboratoryTestResult Alternate namesVital Signs, Measurement, Results, Tests, LaboratoriumUitslag DefinitionA laboratory result describes the result of a laboratory analysis. These are specimen-oriented tests as performed in laboratories such as Clinical Chemistry, Serology, Microbiology, etc. In addition to the results of tests with a singular result, this concept can also contain the results of more complex tests with multiple results or a ‘panel’. This profile is used for two concepts of the HCIM LaboratoryTestResult at te same time: the root concept (NL-CM:13.1.1) and the LaboratoryTest concept (NL-CM:13.1.3). A LaboratoryTestResult can consist of just one LaboratoryTest or can be a panel of multiple LaboratoryTests. If there's just one LaboratoryTest, a single instance of this profile may be used to represent both concepts, but if there are multiple LaboratoryTests, there should be one parent instance representing the LaboratoryTestResult that uses Note that the The list below summarizes the different situations:
Also note that there is the additional profile zib-LaboratoryTestResult-DiagnosticReport, which is used for (textual) reports on individual (panels of) observations, like conclusions. The DiagnosticReport contains references to instances of this profile and can be used in all three the situations described above.
| |
id | Σ | 0..1 | id | There are no (further) constraints on this element Element idObservation.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 idObservation.meta Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.
|
implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idObservation.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. 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. This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.
|
language | 0..1 | codeBinding | There are no (further) constraints on this element Element idObservation.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. Common Languages (extensible)Constraints
| |
text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idObservation.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 may 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 in formation is added later.
|
contained | 0..* | Resource | There are no (further) constraints on this element Element idObservation.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.
| |
extension | I | 2..* | Extension | There are no (further) constraints on this element Element idObservation.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. In order 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. 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
|
Verified | S I | 1..1 | Extension(CodeableConcept) | Element idObservation.extension:Verified Is the instance validated by a medical professional? Alternate namesextensions, user content DefinitionExtension that is used to indicate whether the entire instance has been validated. Every instance shall be validated by a hospital member / datamanager. However, this is not always feasible in case of automated submission of NICE data elements. This extensions shall be used to indicate the validation status of the instance. 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. https://fhir.stichting-nice.nl/STU3/StructureDefinition/NICE-Verified-2022Q1 Constraints
|
ExtremeValueType | S ?! I | 0..1 | Extension(CodeableConcept) | Element idObservation.extension:ExtremeValueType Extension to indicate upper or lower bounds Alternate namesextensions, user content DefinitionExtension to indicate wether the element is the highest or the lowest value 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. https://fhir.stichting-nice.nl/STU3/StructureDefinition/NICE-ExtremeValueType-2022Q1 Constraints
|
ScoreDay | S I | 1..1 | Extension(Quantity) | Element idObservation.extension:ScoreDay ScoreDay Alternate namesextensions, user content DefinitionExtension that is used to indicate the day of scoring. The first 24 hours after admission count as day 1. The next day starts from the first morning shift and lasts 24 hours, so until the start of the next morning shift. Note: Score day 1 can overlap with score day 2, and 'the first morning shift' is specified locally can differ between hospitals. 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. https://fhir.stichting-nice.nl/STU3/StructureDefinition/NICE-ScoreDay-2022Q1 Constraints
|
modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.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. Usually modifier elements provide negation or qualification. In order 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. 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
|
identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idObservation.identifier Identifier Alternate namesIdentificatie DefinitionA unique identifier assigned to this observation. Allows observations to be distinguished and referenced.
|
basedOn | Σ I | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ProcedureRequest | ReferralRequest) | There are no (further) constraints on this element Element idObservation.basedOn Fulfills plan, proposal or order including requester information. Alternate namesFulfills, Aanvrager DefinitionA plan, proposal or order that is fulfilled in whole or in part by this event. Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon. Requester information should be captured and exchanged in the resource ProcedureRequest referenced by basedOn. Requester is the healthcare provider and/or organization where or by whom the LaboratoryTestResult was requested. There are a few required elements in ProcedureRequest - ProcedureRequest.status (use fixed value "active", unless you know what the actual value is) - ProcedureRequest.intent (use fixed value "order", unless you know what the actual value is) - ProcedureRequest.code (use extension http://hl7.org/fhir/STU3/extension-iso21090-nullflavor.html met valueCode UNK, unless you know what the actual value is) - ProcedureRequest.subject (equal to Observation.subject) - ProcedureRequest.requester.agent (contains the requesting HealthProfessional) Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ProcedureRequest | ReferralRequest) Constraints
|
status | S Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idObservation.status TestUitslagStatus Alternate namesTestUitslagStatus DefinitionThe status of the test result of this test. If the laboratory test is an panel/cluster, the overall status is given in the status of the panel/cluster. Need to track the status of individual results. Some results are finalized before the whole report is finalized. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. Codes providing the status of an observation. ObservationStatus (required)Constraints
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.status.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. In order 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. 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
|
TestResultStatus | I | 0..1 | Extension(CodeableConcept) | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus TestResultStatus Alternate namesextensions, user content, Bevat de specifieke code conform de zib, bij een FHIR-element die een verplichte koppeling heeft met een bepaalde FHIR waardelijst of een FHIR element die niet gecodeerd is gedefinieerd, terwijl de zib dit wel doet., TestUitslagStatus DefinitionProvides the specific HCIM code for TestResultStatus or ResultStatus. The status of the laboratory test result. If the laboratory test is an panel/cluster, this status reflects the status of the whole panel/cluster. If the status item per subtest is used too, this status must be in accordance with these status values. 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. http://nictiz.nl/fhir/StructureDefinition/code-specification Constraints
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.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. In order 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. 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
|
url | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.url identifies the meaning of the extension DefinitionSource of the definition for the extension code - a logical name or a URL. The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
http://nictiz.nl/fhir/StructureDefinition/code-specification
| |
valueCodeableConcept | 1..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept Value of extension DefinitionValue of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list). TestResultStatusCodelist TestResultStatusCodelijst (extensible)Constraints
| |
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.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. In order 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. 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
|
coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding.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. In order 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. 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
|
system | Σ | 0..1 | uri | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.
|
version | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
|
code | Σ | 0..1 | codeFixed Value | Element idObservation.status.extension:TestResultStatus.valueCodeableConcept:valueCodeableConcept.coding.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings may not exceed 1MB in size
final
|
display | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings may not exceed 1MB in size
|
userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.coding.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
|
text | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.status.extension:TestResultStatus.value[x]:valueCodeableConcept.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
|
value | 0..1 | There are no (further) constraints on this element Element idObservation.status.value Primitive value for code DefinitionPrimitive value for code 1048576 | ||
category | 1..* | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.category Classification of type of observation DefinitionA code that classifies the general type of observation being made. Used for filtering what observations are retrieved and displayed. In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set. Unordered, Open, by $this(Value) BindingCodes for high level observation categories. Observation Category Codes (preferred)Constraints
| |
LaboratoryTestResultCode | 1..1 | CodeableConceptBindingPattern | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode LaboratoryTestResultCode DefinitionA code that classifies the general type of observation being made. Used for filtering what observations are retrieved and displayed. In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set. Codes for high level observation categories. Observation Category Codes (preferred)Constraints
{ "coding": [ { "system": "http://snomed.info/sct", "code": "49581000146104" } ] }
| |
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.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. In order 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. 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
|
coding | Σ | 0..* | CodingPattern | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
{ "system": "http://snomed.info/sct", "code": "49581000146104" }
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.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. In order 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. 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
|
system | Σ | 0..1 | uriFixed Value | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.
http://snomed.info/sct
|
version | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
|
code | Σ | 0..1 | codeFixed Value | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings may not exceed 1MB in size
49581000146104
|
display | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings may not exceed 1MB in size
Laboratory test finding (finding)
|
userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.coding.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
|
text | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.category:LaboratoryTestResultCode.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
|
ResultType | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.category:ResultType ResultType Alternate namesResultaatType DefinitionThe type of result defines the laboratory specialty under which the test is categorized. Used for filtering what observations are retrieved and displayed. In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set. ResultaatTypeCodelijst ResultaatTypeCodelijst (required)Constraints
| |
code | S Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idObservation.code TestCode or PanelOrBattery Alternate namesName, TestCode, Onderzoek DefinitionThe name and code of the executed test or for laboratory tests comprising multiple subtests and often requested together as a whole, this concept contains the name of the compound request (often indicated as a ‘panel’, ‘battery’ or ‘cluster’). Examples include: blood gases and EBV serology. Knowing what kind of observation is being made is essential to understanding the observation. This can either be the HCIM concept Test (NL-CM:13.1.4) or TestName (NL-CM:13.1.8) depending on the use case. See the documentation on the root of this profile for guidance on implementing the different uses cases. Codes identifying names of simple observations. LOINC Codes (example)Constraints
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.code.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.code.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. In order 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. 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
|
coding | Σ | 0..* | Coding | Element idObservation.code.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by system(Value) Constraints
|
NICELaboratoryTestResultCodeList | Σ | 1..* | CodingBinding | Element idObservation.code.coding:NICELaboratoryTestResultCodeList Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. The different LOINC codes describing the various types of laboratory results used by the NICE. NICE Laboratory Test Results (extensible)Constraints
|
text | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.code.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
|
subject | S Σ I | 1..1 | Reference(NICE-Patient) | Element idObservation.subject Patient Alternate namesPatiënt DefinitionThe patient, or group of patients, location, or device whose characteristics (direct or indirect) are described by the observation and into whose record the observation is placed. Comments: Indirect characteristics may be those of a specimen, fetus, donor, other observer (for example a relative or EMT), or any observation made about the subject. Observations have no value if you don't know who or what they're about. One would expect this element to be a cardinality of 1..1. The only circumstance in which the subject can be missing is when the observation is made by a device that does not know the patient. In this case, the observation SHALL be matched to a patient through some context/channel matching technique, and at this point, the observation should be updated. If the target of the observation is different than the subject, the general extension observation-focal-subject. may be used. However, the distinction between the patient's own value for an observation versus that of the fetus, or the donor or blood product unit, etc., are often specified in the observation code.
|
context | S I | 0..1 | Reference(NICE-Encounter) | Element idObservation.context Encounter during which this observation is made Alternate namesEncounter DefinitionThe encounter during which this journal entry was made. For some observations it may be important to know the link between an observation and a particular encounter. This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter or episode but still be tied to the context of the encounter or episode (e.g. pre-admission lab tests).
|
effectiveDateTime | Σ | 0..1 | dateTime | Element idObservation.effective[x]:effectiveDateTime TestDateTime Alternate namesOccurrence, TestDatumTijd DefinitionThe date and if possible the time at which the test was carried out. Knowing when an observation was deemed true is important to its relevance as well as determining trends. At least a date should be present unless this observation is a historical report.
|
issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element idObservation.issued Date/Time this was made available DefinitionThe date and time this observation was made available to providers, typically after the results have been reviewed and verified. Updated when the result is updated.
|
performer | Σ I | 0..* | Reference(nl-core-organization | nl-core-patient | nl-core-practitioner | nl-core-relatedperson) | There are no (further) constraints on this element Element idObservation.performer Who is responsible for the observation DefinitionWho was responsible for asserting the observed value as "true". May give a degree of confidence in the observation and also indicates where follow-up questions should be directed. 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. Reference(nl-core-organization | nl-core-patient | nl-core-practitioner | nl-core-relatedperson) Constraints
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.performer.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.performer.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. In order 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. 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
|
practitionerRole | I | 0..1 | Extension(Reference(nl-core-practitionerrole)) | There are no (further) constraints on this element Element idObservation.performer.extension:practitionerRole Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. Extension(Reference(nl-core-practitionerrole)) Extension URLhttp://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference Constraints
|
reference | Σ I | 0..1 | string | There are no (further) constraints on this element Element idObservation.performer.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
|
identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idObservation.performer.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.
|
display | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.performer.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
|
valueQuantity | S Σ I | 0..1 | Quantity | Element idObservation.value[x]:valueQuantity TestResult Alternate namesTestUitslag DefinitionThe test result. Depending on the type of test, the result will consist of a value with a unit or a coded value (ordinal or nominal). An observation exists to have a value, though it may not if it is in error, or if it represents a group of observations. Normally, an observation will have either a single value or a set of related observations. A few observations (e.g. Apgar score) may have both a value and related observations (for an Apgar score, the observations from which the measure is derived). If a value is present, the datatype for this element should be determined by Observation.code. This element has a variable name depending on the type as follows: valueQuantity, valueCodeableConcept, valueString, valueBoolean, valueRange, valueRatio, valueSampledData, valueAttachment, valueTime, valueDateTime, or valuePeriod. (The name format is "'value' + the type name" with a capital on the first letter of the type). If the data element is usually coded or if the type associated with the Observation.value defines a coded value, use CodeableConcept instead of string datatype even if the value is uncoded text. A value set is bound to the ValueCodeableConcept element. For further discussion and examples see the notes section below.
|
dataAbsentReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.dataAbsentReason Why the result is missing DefinitionProvides a reason why the expected value in the element Observation.value[x] is missing. For many results it is necessary to handle exceptional values in measurements. 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. Codes specifying why the result (Observation.value[x]) is missing. Observation Value Absent Reason (extensible)Constraints
|
interpretation | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.interpretation High, low, normal, etc. Alternate namesAbnormal Flag DefinitionThe assessment made based on the result of the observation. Intended as a simple compact code often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result. Otherwise known as abnormal flag. For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. 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. Codes identifying interpretations of observations. Observation Interpretation Codes (extensible)Constraints
| |
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.interpretation.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. In order 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. 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
|
coding | Σ I | 1..* | Coding | There are no (further) constraints on this element Element idObservation.interpretation.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by system(Value) Constraints
|
ObservationInterpretation | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Observation Interpretation Codes Observation Interpretation Codes (required)Permitted Values InterpretatieVlaggenCodelijst-To-Observation-Interpretation Constraints
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.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. In order 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. 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
|
system | Σ | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.
http://hl7.org/fhir/v2/0078
|
version | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
|
code | Σ | 1..1 | code | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings may not exceed 1MB in size
|
display | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings may not exceed 1MB in size
|
userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idObservation.interpretation.coding:ObservationInterpretation.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
|
InterpretatieVlaggenCodelijst | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst ResultFlags Alternate namesInterpretatieVlaggen DefinitionAttention codes indicating whether the result is above or below certain reference values or interpreting the result otherwise. (Resistent) Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. This slice binds the ValueSet from the HCIM, which overlaps the ValueSet from the core FHIR Observation. To satisfy the FHIR profiling rules, the code from the core FHIR ValueSet SHOULD be included as well if a code from this ValueSet is included. A ConceptMap (https://simplifier.net/resolve?canonical=http://nictiz.nl/fhir/ConceptMap/InterpretatieVlaggenCodelijst-to-observation-interpretation) is available that explains the relationship between the FHIR observation-interpretation value set and the HCIM ResultFlagsCodelist. InterpretatieVlaggenCodelijst InterpretatieVlaggenCodelijst (required)Constraints
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.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. In order 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. 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
|
system | Σ | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.
http://snomed.info/sct
|
version | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
|
code | Σ | 1..1 | code | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings may not exceed 1MB in size
|
display | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings may not exceed 1MB in size
|
userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idObservation.interpretation.coding:InterpretatieVlaggenCodelijst.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
|
text | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
|
comment | 0..1 | string | There are no (further) constraints on this element Element idObservation.comment Comment or ResultInterpretation Alternate namesToelichting, UitslagInterpretatie DefinitionComments, such as a textual interpretation or advice accompanying the result, for example or a comment of the laboratory specialist regarding the interpretation of the results. Need to be able to provide free text additional information. Note that FHIR strings may not exceed 1MB in size
| |
bodySite | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idObservation.bodySite Observed body part DefinitionIndicates the site on the subject's body where the observation was made (i.e. the target site). Only used if not implicit in code found in Observation.code. In many systems, this may be represented as a related observation instead of an inline component. If the use case requires BodySite to be handled as a separate resource (e.g. to identify and track separately) then use the standard extension body-site-instance. Codes describing anatomical locations. May include laterality. SNOMED CT Body Structures (example)Constraints
| |
method | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.method TestMethod Alternate namesTestmethode DefinitionThe test method used to obtain the result. In some cases, method can impact results and is thus used for determining whether results can be compared or determining significance of results. Only used if not implicit in code for Observation.code. SNOMED CT (2.16.840.1.113883.6.96): All values TestmethodeCodelijst (extensible)Constraints
| |
specimen | S I | 0..1 | Reference(NICE-LaboratoryTestResultSpecimen) | Element idObservation.specimen Specimen Alternate namesMonster DefinitionTo find the dateTime of the test, we require information on the specimen that was used when this observation was made. Should only be used if not implicit in code found in Reference(NICE-LaboratoryTestResultSpecimen) Constraints
|
device | I | 0..1 | Reference(HCIM MedicalDevice Product) | There are no (further) constraints on this element Element idObservation.device (Measurement) Device DefinitionThe device used to generate the observation data. An extension should be used if further typing of the device is needed. Devices used to support obtaining an observation can be represented using either an extension or through the Observation.related element. Reference(HCIM MedicalDevice Product) Constraints
|
referenceRange | I | 0..* | BackboneElement | There are no (further) constraints on this element Element idObservation.referenceRange Reference Alternate namesReferentie DefinitionGuidance on how to interpret the value by comparison to a normal or recommended range. Knowing what values are considered "normal" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts. Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this may not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.referenceRange.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.referenceRange.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. In order 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. 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
|
modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.referenceRange.modifierExtension Extensions that cannot be ignored 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 that contains it. Usually modifier elements provide negation or qualification. In order 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. 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.
|
low | S I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idObservation.referenceRange.low ReferenceRangeLowerLimit Alternate namesReferentieOndergrens DefinitionThe lower reference limit for the patient of the value measured with the test. The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.
|
high | S I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idObservation.referenceRange.high ReferenceRangeUpperLimit Alternate namesReferentieBovengrens DefinitionThe upper reference limit for the patient of the value measured in the test. The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.
|
type | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.referenceRange.type Reference range qualifier DefinitionCodes to indicate the what part of the targeted reference population it applies to. For example, the normal or therapeutic range. Need to be able to say what kind of reference range this is - normal, recommended, therapeutic, etc, - for proper interpretation. This SHOULD be populated if there is more than one range. If this element is not present then the normal range is assumed. Code for the meaning of a reference range. Observation Reference Range Meaning Codes (extensible)Constraints
| |
appliesTo | 0..* | CodeableConcept | There are no (further) constraints on this element Element idObservation.referenceRange.appliesTo Reference range population DefinitionCodes to indicate the target population this reference range applies to. For example, a reference range may be based on the normal population or a particular sex or race. Need to be able to identify the target population for proper interpretation. This SHOULD be populated if there is more than one range. If this element is not present then the normal population is assumed. Codes identifying the population the reference range applies to. Observation Reference Range Applies To Codes (example)Constraints
| |
age | I | 0..1 | Range | There are no (further) constraints on this element Element idObservation.referenceRange.age Applicable age range, if relevant DefinitionThe age at which this reference range is applicable. This is a neonatal age (e.g. number of weeks at term) if the meaning says so. Some analytes vary greatly over age. The stated low and high value are assumed to have arbitrarily high precision when it comes to determining which values are in the range. I.e. 1.99 is not in the range 2 -> 3.
|
text | 0..1 | string | There are no (further) constraints on this element Element idObservation.referenceRange.text Text based reference range in an observation DefinitionText based reference range in an observation which may be used when a quantitative range is not appropriate for an observation. An example would be a reference value of "Negative" or a list or table of 'normals'. Note that FHIR strings may not exceed 1MB in size
| |
related | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idObservation.related RelatedResults Alternate namesGerelateerdeUitslag, LaboratoriumTest DefinitionReference to related LaboratoryTestResult instances, or to the LaboratoryTest concept if this is a grouping Observation. Normally, an observation will have either a value or a set of related observations. A few observations (e.g. Apgar score) may have both a value and a set of related observations or sometimes a QuestionnaireResponse from which the measure is derived. The
See the documentation on the root if this profile for guidance on implementing these use cases.
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.related.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.related.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. In order 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. 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
|
modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.related.modifierExtension Extensions that cannot be ignored 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 that contains it. Usually modifier elements provide negation or qualification. In order 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. 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.
|
type | 0..1 | codeBinding | There are no (further) constraints on this element Element idObservation.related.type has-member | derived-from | sequel-to | replaces | qualified-by | interfered-by DefinitionA code specifying the kind of relationship that exists with the target resource. A relationship type SHOULD be provided. The "derived-from" type is the only logical choice when referencing the QuestionnaireAnswer resource. Codes specifying how two observations are related. ObservationRelationshipType (required)Constraints
| |
target | I | 1..1 | Reference(QuestionnaireResponse | Sequence | HCIM LaboratoryTestResult Observation) | There are no (further) constraints on this element Element idObservation.related.target Resource that is related to this one DefinitionA reference to the observation or QuestionnaireResponse resource that is related to this observation. 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. Reference(QuestionnaireResponse | Sequence | HCIM LaboratoryTestResult Observation) Constraints
|
component | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idObservation.component LaboratoryTest Alternate namesLaboratoriumTest DefinitionContainer of the LaboratoryTest concept. This container contains all data elements of the LaboratoryTest concept. Component observations share the same attributes in the Observation resource as the primary observation and are always treated a part of a single observation (they are not separable). However, the reference range for the primary observation value is not inherited by the component values and is required when appropriate for each component observation. For a discussion on the ways Observations can be assembled in groups together see Notes below.
|
id | 0..1 | string | There are no (further) constraints on this element Element idObservation.component.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size
| |
extension | I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.component.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. In order 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. 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
|
modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idObservation.component.modifierExtension Extensions that cannot be ignored 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 that contains it. Usually modifier elements provide negation or qualification. In order 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. 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.
|
code | Σ | 1..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.component.code TestCode Alternate namesTestCode DefinitionThe TestCode is the name of the executed test. Knowing what kind of observation is being made is essential to understanding the observation. 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. LOINC (2.16.840.1.113883.6.1): All values TestNaamCodelijst (extensible)Constraints
|
value[x] | Σ | 0..1 | There are no (further) constraints on this element Element idObservation.component.value[x] TestResult Alternate namesTestUitslag DefinitionThe test result. Depending on the type of test, the result will consist of a value with a unit or a coded value (ordinal or nominal). An observation exists to have a value, though it may not if it is in error, or if it represents a group of observations. Normally, an observation will have either a single value or a set of related observations. A few observations (e.g. Apgar score) may have both a value and related observations (for an Apgar score, the observations from which the measure is 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 boolean values use valueCodeableConcept and select codes from http://hl7.org/fhir/ValueSet/v2-0136 (these "yes/no" concepts can be mapped to the display name "true/false" or other mutually exclusive terms that may be needed"). The element, Observation.value[x], has a variable name depending on the type as follows: valueQuantity, valueCodeableConcept, valueRatio, valueChoice, valuePeriod, valueSampleData, or valueString (the name format is "'value' + the type name" with a capital on the first letter of the type).
| |
valueQuantity | Quantity | There are no (further) constraints on this element Data type | ||
valueCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data type | ||
valueString | string | There are no (further) constraints on this element Data type | ||
valueRange | Range | There are no (further) constraints on this element Data type | ||
valueRatio | Ratio | There are no (further) constraints on this element Data type | ||
valueSampledData | SampledData | There are no (further) constraints on this element Data type | ||
valueAttachment | Attachment | There are no (further) constraints on this element Data type | ||
valueTime | time | There are no (further) constraints on this element Data type | ||
valueDateTime | dateTime | There are no (further) constraints on this element Data type | ||
valuePeriod | Period | There are no (further) constraints on this element Data type | ||
dataAbsentReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.component.dataAbsentReason Why the component result is missing DefinitionProvides a reason why the expected value in the element Observation.value[x] is missing. For many results it is necessary to handle exceptional values in measurements. "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. Codes specifying why the result (Observation.value[x]) is missing. Observation Value Absent Reason (extensible)Constraints
|
interpretation | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.component.interpretation ResultFlags Alternate namesAbnormal Flag, InterpretatieVlaggen DefinitionAttention codes indicating whether the result is above or below certain reference values or interpreting the result otherwise. (Resistent) For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. A ConceptMap (https://simplifier.net/resolve?canonical=http://nictiz.nl/fhir/ConceptMap/InterpretatieVlaggenCodelijst-to-observation-interpretation) is available that maps ResultFlagsCodelist to the observation-interpretation valueset. InterpretatieVlaggenCodelijst InterpretatieVlaggenCodelijst (extensible)Permitted Values InterpretatieVlaggenCodelijst-To-Observation-Interpretation Constraints
| |
referenceRange | 0..* | see (referenceRange) | There are no (further) constraints on this element Element idObservation.component.referenceRange Provides guide for interpretation of component result DefinitionGuidance on how to interpret the value by comparison to a normal or recommended range. Knowing what values are considered "normal" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts. Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this may not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.
|
Mapping FHIR profile NICE data dictionary
Path | identity | map | comment |
---|---|---|---|
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#233 | PaO2 |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#152 | Lowest hematocrit |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#40 | Lowest bicarbonate |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#410 | Lowest thrombocytes |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#338 | Lowest potassium |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#60 | Lowest creatinine |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#24 | Lowest albumin |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#382 | Lowest sodium |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#59 | Highest creatinine |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#151 | Highest hematocrit |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#41 | Highest bilirubin |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#337 | Highest potassium |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#381 | Highest sodium |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#438 | Lowest white bloodcells |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#437 | Highest white blood cells |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#23 | Highest albumin |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#231 | PaCO2 |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#239 | Arterial pH |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#133 | Lowest glucose during first 24 hours of IC admission |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#39 | Highest bicarbonate |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#132 | Highest glucose during first 24 hours of IC admission |
Observation | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#429 | Serum ureum |
Observation | NICE-Datadictionary-KIIC | https://www.stichting-nice.nl/dd/#131 | Glucose value |
Observation | NICE-Datadictionary-KIIC | https://www.stichting-nice.nl/dd/#798 | Glucose-target lower threshold |
Observation | NICE-Datadictionary-KIIC | https://www.stichting-nice.nl/dd/#797 | Glucose-target upper threshold |
Observation | NICE-Datadictionary-SOFA | https://www.stichting-nice.nl/dd/#391 | PaO2 |
Observation | NICE-Datadictionary-SOFA | https://www.stichting-nice.nl/dd/#387 | FiO2 |
Observation | NICE-Datadictionary-SOFA | https://www.stichting-nice.nl/dd/#392 | Thrombocytes |
Observation | NICE-Datadictionary-SOFA | https://www.stichting-nice.nl/dd/#383 | Bilirubin |
Observation | NICE-Datadictionary-SOFA | https://www.stichting-nice.nl/dd/#388 | Creatinine |
Observation | NICE-Datadictionary-Sepsis | https://www.stichting-nice.nl/dd/#681 | Value of lactate measurement |
Observation | NICE-Datadictionary-Sepsis | https://www.stichting-nice.nl/dd/#680 | Date of lactate measurement |
{ "resourceType": "Observation", "id": "NICE-LaboratoryTestResultObservation-Example-01", "meta": { "profile": [ "https://fhir.stichting-nice.nl/STU3/StructureDefinition/NICE-LaboratoryTestResultObservation-2022Q1" ] }, "text": { "status": "generated", --- We have skipped the narrative for better readability of the resource --- }, "extension": [ { "url": "https://fhir.stichting-nice.nl/STU3/StructureDefinition/NICE-Verified-2022Q1", "valueCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/ValueSet/v2-0532", "code": "Y", "display": "Yes" } ] } }, { "url": "https://fhir.stichting-nice.nl/STU3/StructureDefinition/NICE-ScoreDay-2022Q1", "valueQuantity": { "value": 1 } } ], "modifierExtension": [ { "url": "https://simplifier.net/nicefhirproject/nice-ExtremeValueType.structuredefinition", "valueCodeableConcept": { "coding": [ { "code": "L" } ] } } ], "_status": { "extension": [ { "url": "http://nictiz.nl/fhir/StructureDefinition/code-specification", "valueCodeableConcept": { "coding": [ { "code": "final" } ] } } ] }, "category": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "118246004", "display": "Laboratory test finding" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "20570-8", "display": "Hematocrit [Volume Fraction] of Blood" } ] }, "subject": { "reference": "Patient/NICE-Patient-01", "display": "P. Petersen" }, "context": { "reference": "Encounter/NICE-Encounter-01" }, "effectiveDateTime": "2022-01-08T08:43:00+02:00", "valueQuantity": { "value": 0.15, "unit": "ratio" } }
<Observation xmlns="http://hl7.org/fhir"> <id value="NICE-LaboratoryTestResultObservation-Example-01" /> <meta> <profile value="https://fhir.stichting-nice.nl/STU3/StructureDefinition/NICE-LaboratoryTestResultObservation-2022Q1" /> </meta> <text> <status value="generated" /> --- We have skipped the narrative for better readability of the resource --- </text> <extension url="https://fhir.stichting-nice.nl/STU3/StructureDefinition/NICE-Verified-2022Q1"> <valueCodeableConcept> <coding> <system value="http://terminology.hl7.org/ValueSet/v2-0532" /> <code value="Y" /> <display value="Yes" /> </coding> </valueCodeableConcept> </extension> <extension url="https://fhir.stichting-nice.nl/STU3/StructureDefinition/NICE-ScoreDay-2022Q1"> <valueQuantity> <value value="1" /> </valueQuantity> </extension> <modifierExtension url="https://simplifier.net/nicefhirproject/nice-ExtremeValueType.structuredefinition"> <valueCodeableConcept> <coding> <code value="L" /> </coding> </valueCodeableConcept> </modifierExtension> <status> <extension url="http://nictiz.nl/fhir/StructureDefinition/code-specification"> <valueCodeableConcept> <coding> <code value="final" /> </coding> </valueCodeableConcept> </extension> </status> <category> <coding> <system value="http://snomed.info/sct" /> <code value="118246004" /> <display value="Laboratory test finding" /> </coding> </category> <code> <coding> <system value="http://loinc.org" /> <code value="20570-8" /> <display value="Hematocrit [Volume Fraction] of Blood" /> </coding> </code> <subject> <reference value="Patient/NICE-Patient-01" /> <display value="P. Petersen" /> </subject> <context> <reference value="Encounter/NICE-Encounter-01" /> </context> <effectiveDateTime value="2022-01-08T08:43:00+02:00" /> <valueQuantity> <value value="0.15" /> <unit value="ratio" /> </valueQuantity> </Observation>