HdBe-LaboratoryTestResult
Profile | Description | Status | URL |
---|---|---|---|
HdBe-LaboratoryTestResult | A 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’. | draft | https://fhir.healthdata.be/StructureDefinition/HdBe-LaboratoryTestResult |
HdBe-LaboratoryTestResult.Requester | This is a minimal defined profile on ServiceRequest to capture the requester information of the CBB LaboratoryTestResult. Although the concept Requester is not implemented in the zib profile because it is deemed unimplementable as-is, it has been implemented by this profile using a light profile on ServiceRequest. The profile does not contain enough guidance to implement a requesting service fully. It merely allows capturing the requester information in a native FHIR element. | draft | https://fhir.healthdata.be/StructureDefinition/HdBe-LaboratoryTestResult.Requester |
HdBe-LaboratoryTestResult.Specimen | Obtained specimen material or a microbial isolate that is used in a laboratory analysis. | draft | https://fhir.healthdata.be/StructureDefinition/HdBe-LaboratoryTestResult.Specimen |
UML overview profiles
HdBe-LaboratoryTestResult
Instructions |
---|
1. Guidance on use for singular tests and panels The CBB LaboratoryTestResult captures both singular laboratory tests and panels/clusters of multiple related tests requested together (e.g., blood gases and EBV serology)*. This profile should be used slightly different in these two situations:
Note 1: The CBB also recognizes the RelatedResult concept. This is unrelated to the use of panels/clusters. This concept is represented either using 2. Unmapped CBB concept
3. Unmapped zib concept
|
ReTaM |
---|
At least the below stated rules need to be followed.
Note that the FHIR CodeableConcept data type allows multiple codes (if they represent the same concept) because |
Observation | I | Observation | Element IdObservation LaboratoryTestResult / LaboratoryTest Alternate namesVital Signs, Measurement, Results, Tests, LaboratoriumUitslag, LaboratoriumTest DefinitionAn instance of CBB LaboratoryTestResult or of a single LaboratoryTest within this CBB. 1. Guidance on use for singular tests and panels The CBB LaboratoryTestResult captures both singular laboratory tests and panels/clusters of multiple related tests requested together (e.g., blood gases and EBV serology)*. This profile should be used slightly different in these two situations:
Note 1: The CBB also recognizes the RelatedResult concept. This is unrelated to the use of panels/clusters. This concept is represented either using 2. Unmapped CBB concept
3. Unmapped zib concept
| |
extension | I | 0..* | Extension | 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. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Constraints
|
sequelTo | I | 0..* | Extension(Reference(Observation)) | Element IdObservation.extension:sequelTo Sequel to referenced Observation Alternate namesextensions, user content DefinitionThis observation follows the target observation (e.g. timed tests such as Glucose Tolerance Test). 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(Observation)) Extension URLhttp://hl7.org/fhir/StructureDefinition/observation-sequelTo Constraints
|
url | 1..1 | System.StringFixed Value | There are no (further) constraints on this element Element IdObservation.extension:sequelTo.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. System.String Fixed Valuehttp://hl7.org/fhir/StructureDefinition/observation-sequelTo
| |
value[x] | 1..1 | Element IdObservation.extension:sequelTo.value[x] RelatedResult Alternate namesGerelateerdeUitslag DefinitionThis is one of the two mechanisms to represent concept RelatedResult. The other mechanism is
| ||
valueReference | Reference(Observation | HdBe LaboratoryTestResult) | Data Type | ||
identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdObservation.identifier Business Identifier for observation DefinitionA unique identifier assigned to this observation. Allows observations to be distinguished and referenced.
|
basedOn | Σ I | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | HdBe LaboratoryTestResult Requester) | Element IdObservation.basedOn Fulfills plan, proposal or order Alternate namesFulfills DefinitionA plan, proposal or order that is fulfilled in whole or in part by this event. For example, a MedicationRequest may require a patient to have laboratory test performed before it is dispensed. Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon. The ServiceRequest.requester holds the information on who requested the laboratory test. This ServiceRequest is linked through this element. Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | HdBe LaboratoryTestResult Requester) Constraints
|
partOf | Σ I | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | There are no (further) constraints on this element Element IdObservation.partOf Part of referenced event Alternate namesContainer DefinitionA larger event of which this particular Observation is a component or step. For example, an observation as part of a procedure. To link an Observation to an Encounter use Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Constraints
|
status | Σ ?! | 1..1 | codeBinding | Element IdObservation.status ResultStatus / TestResultStatus Alternate namesTestUitslagStatus DefinitionThe status of the laboratory test result or test result panel/cluster. Need to track the status of individual results. Some results are finalized before the whole report is finalized. If this resource represents a singular test result or a single test in a cluster/panel, this will be the status of this particular test result. However, if it represents the overall result of a panel/cluster, this status should represent the status of the panel/cluster and should be in accordance with the test result statuses of the individual tests. Codes providing the status of an observation. TestResultStatus (required)Constraints
|
category | 0..* | CodeableConceptBinding | 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. ObservationCategoryCodes (preferred)Constraints
| |
resultType | 0..1 | CodeableConceptBinding | Element IdObservation.category:resultType 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. Codes for high level observation categories. ResultType (required)Constraints
| |
code | Σ | 1..1 | CodeableConcept | Element IdObservation.code PanelOrBattery / TestCode Alternate namesName, Onderzoek, TestCode DefinitionThe name and code of the executed test. For laboratory tests comprising multiple subtests and often requested together as a whole, this concept contains the name and code 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.
At least the below stated rules need to be followed.
Note that the FHIR CodeableConcept data type allows multiple codes (if they represent the same concept) because Codes identifying names of simple observations. LOINCCodes (example)Constraints
|
subject | Σ I | 0..1 | Reference(Patient | Group | Device | Location | HdBe Patient) | Element IdObservation.subject Who and/or what the observation is about DefinitionThe patient, or group of patients, location, or device this observation is about and into whose record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the 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. Reference(Patient | Group | Device | Location | HdBe Patient) Constraints
|
focus | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdObservation.focus What the observation is about, when it is not about the subject of record DefinitionThe actual focus of an observation when it is not the patient of record representing something or someone associated with the patient such as a spouse, parent, fetus, or donor. For example, fetus observations in a mother's record. The focus of an observation could also be an existing condition, an intervention, the subject's diet, another observation of the subject, or a body structure such as tumor or implanted device. An example use case would be using the Observation resource to capture whether the mother is trained to change her child's tracheostomy tube. In this example, the child is the patient of record and the mother is the focus. Typically, an observation is made about the subject - a patient, or group of patients, location, or device - and the distinction between the subject and what is directly measured for an observation is specified in the observation code itself ( e.g., "Blood Glucose") and does not need to be represented separately using this element. Use
|
encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdObservation.encounter Healthcare event during which this observation is made Alternate namesContext DefinitionThe healthcare event (e.g. a patient and healthcare provider interaction) during which this observation is 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 but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
|
effective[x] | Σ | 0..1 | Element IdObservation.effective[x] Clinically relevant time/time-period for observation Alternate namesOccurrence DefinitionThe time or time-period the observed value is asserted as being true. For biological subjects - e.g. human patients - this is usually called the "physiologically relevant time". This is usually either the time of the procedure or of specimen collection, but very often the source of the date/time is not known, only the date/time itself. 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. For recording imprecise or "fuzzy" times (For example, a blood glucose measurement taken "after breakfast") use the Timing datatype which allow the measurement to be tied to regular life events. Unordered, Open, by $this(Type) Constraints
| |
effectivePeriod | Period | There are no (further) constraints on this element Data Type | ||
effectiveTiming | Timing | There are no (further) constraints on this element Data Type | ||
effectiveInstant | instant | There are no (further) constraints on this element Data Type | ||
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. For recording imprecise or "fuzzy" times (For example, a blood glucose measurement taken "after breakfast") use the Timing datatype which allow the measurement to be tied to regular life events.
|
issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element IdObservation.issued Date/Time this version was made available DefinitionThe date and time this version of the observation was made available to providers, typically after the results have been reviewed and verified. For Observations that don’t require review and verification, it may be the same as the
|
performer | Σ I | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | 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(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Sliced:Unordered, Open, by resolve()(Profile) Constraints
|
performer | Σ I | 0..1 | Reference(HdBe HealthcareOrganization Organization) | Element IdObservation.performer:performer Performer Alternate namesUitvoerder DefinitionThe healthcare provider and/or organization where or by whom the LaboratoryTestResult was performed. 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(HdBe HealthcareOrganization Organization) Constraints
|
value[x] | Σ I | 0..1 | Element IdObservation.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 might not if it is in error, or if it represents a group of observations. An observation may have; 1) a single value here, 2) both a value and a set of related or component values, or 3) only a set of related or component values. If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For quantitative results, it is mandatory to provide an unit. For additional guidance, see the Notes section below.
| |
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 | ||
valueBoolean | boolean | There are no (further) constraints on this element Data Type | ||
valueInteger | integer | 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 | ||
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.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. DataAbsentReason (extensible)Constraints
|
interpretation | 0..* | CodeableConceptBinding | Element IdObservation.interpretation High, low, normal, etc. Alternate namesAbnormal Flag DefinitionA categorical assessment of an observation value. For example, high, low, normal. For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result. Unordered, Open, by coding(Exists) BindingCodes identifying interpretations of observations. ObservationInterpretationCodes (extensible)Constraints
| |
resultFlags | 0..* | CodeableConceptBinding | Element IdObservation.interpretation:resultFlags ResultFlags Alternate namesAbnormal Flag, InterpretatieVlaggen DefinitionAttention codes indicating whether the result of a quantitative test is above or below certain reference values or interpreting the result otherwise.(Resistent). The values Resistant, Intermediate en Susceptible are used with microbiological test results. For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result. Use ConceptMap 'ResultFlags-to-ObservationInterpretation' to translate CBB terminology to profile terminology in ValueSet 'Observation-interpretation' ObservationInterpretationCodes (extensible)Permitted Values ResultFlags_to_ObservationInterpretationCodes Constraints
| |
coding | Σ | 1..* | Coding | There are no (further) constraints on this element Element IdObservation.interpretation:resultFlags.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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.
|
text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdObservation.interpretation:resultFlags.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.
|
resultInterpretation | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdObservation.interpretation:resultInterpretation High, low, normal, etc. Alternate namesAbnormal Flag DefinitionA categorical assessment of an observation value. For example, high, low, normal. For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result. Codes identifying interpretations of observations. ObservationInterpretationCodes (extensible)Constraints
| |
coding | Σ | 0..0 | Coding | There are no (further) constraints on this element Element IdObservation.interpretation:resultInterpretation.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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.
|
text | Σ | 0..1 | string | Element IdObservation.interpretation:resultInterpretation.text ResultInterpretation Alternate namesUitslagInterpretatie DefinitionComment of the laboratory specialist regarding the interpretation of the results 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.
|
note | 0..1 | Annotation | There are no (further) constraints on this element Element IdObservation.note Comments about the observation DefinitionComments about the observation or the results. Need to be able to provide free text additional information. May include general statements about the observation, or statements about significant, unexpected or unreliable results values, or information about its source when relevant to its interpretation.
| |
author[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdObservation.note.author[x] Individual responsible for the annotation DefinitionThe individual responsible for making the annotation. Organization is used when there's no need for specific attribution as to who made the comment.
| |
authorString | string | There are no (further) constraints on this element Data Type | ||
authorReference | Reference(Practitioner | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Data Type Reference(Practitioner | Patient | RelatedPerson | Organization) | ||
time | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdObservation.note.time When the annotation was made DefinitionIndicates when this particular annotation was made.
|
text | Σ | 1..1 | markdown | Element IdObservation.note.text Comment Alternate namesToelichting DefinitionComments, such as a textual interpretation or advice accompanying the result, for example. Systems are not required to have markdown support, so the text should be readable without markdown processing. The markdown syntax is GFM - see https://github.github.com/gfm/
|
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 bodySite. Codes describing anatomical locations. May include laterality. SNOMEDCTBodyStructures (example)Constraints
| |
method | 0..1 | CodeableConceptBinding | 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. Methods for simple observations. TestMethod (required)Constraints
| |
specimen | I | 0..1 | Reference(Specimen | HdBe LaboratoryTestResult.Specimen) | Element IdObservation.specimen Specimen used for this observation DefinitionThe specimen that was used when this observation was made. The Specimen concept of the CCB defines either the collected source material without further processing, or a microorganism, optionally including the source material from which it whas isolated.
Reference(Specimen | HdBe LaboratoryTestResult.Specimen) Constraints
|
device | I | 0..1 | Reference(Device | DeviceMetric) | There are no (further) constraints on this element Element IdObservation.device (Measurement) Device DefinitionThe device used to generate the observation data. Note that this is not meant to represent a device involved in the transmission of the result, e.g., a gateway. Such devices may be documented using the Provenance resource where relevant. Reference(Device | DeviceMetric) Constraints
|
referenceRange | I | 0..* | BackboneElement | There are no (further) constraints on this element Element IdObservation.referenceRange Provides guide for interpretation DefinitionGuidance on how to interpret the value by comparison to a normal or recommended range. Multiple reference ranges are interpreted as an "OR". In other words, to represent two distinct target populations, two 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 might 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.
|
low | I | 0..1 | SimpleQuantity | 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 | I | 0..1 | SimpleQuantity | 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. ObservationReferenceRangeMeaningCodes (preferred)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. Multiple 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. ObservationReferenceRangeAppliesToCodes (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 | 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". Text based reference ranges is only used when the ReferenceRangeLowerLimit and/or ReferenceRangeUpperLimit cannot be expressed as quantity in
| |
hasMember | Σ I | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence | HdBe LaboratoryTestResult) | Element IdObservation.hasMember Related resource that belongs to the Observation group DefinitionThis observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group. When this resource is used to represent the overall result of a panel/cluster of laboratory tests, the individual test results SHOULD be referenced here. See the root of this profile for guidance. Reference(Observation | QuestionnaireResponse | MolecularSequence | HdBe LaboratoryTestResult) Constraints
|
derivedFrom | Σ I | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence | HdBe LaboratoryTestResult) | Element IdObservation.derivedFrom RelatedResult Alternate namesGerelateerdeUitslag DefinitionThe target resource that represents a measurement from which this observation value is derived. For example, a calculated anion gap or a fetal measurement based on an ultrasound image. This is one of the two mechanisms to represent concept RelatedResult. The other mechanism is All the reference choices that are listed in this element can represent clinical observations and other measurements that may be the source for a derived value. The most common reference will be another Observation. For a discussion on the ways Observations can assembled in groups together, see Notes below. Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence | HdBe LaboratoryTestResult) Constraints
|
component | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdObservation.component Component results DefinitionSome observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes. Examples include systolic and diastolic component observations for blood pressure measurement and multiple component observations for genetics observations. 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.
|
code | Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element IdObservation.component.code Type of component observation (code / type) DefinitionDescribes what was observed. Sometimes this is called the observation "code". Knowing what kind of observation is being made is essential to understanding the observation. All code-value and component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation. Codes identifying names of simple observations. LOINCCodes (example)Constraints
|
value[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdObservation.component.value[x] Actual component result DefinitionThe information determined as a result of making the observation, if the information has a simple value. An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations. Used when observation has a set of component observations. An observation may have both a value (e.g. an Apgar score) and component observations (the observations from which the Apgar score was derived). If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the Notes section below.
| |
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 | ||
valueBoolean | boolean | There are no (further) constraints on this element Data Type | ||
valueInteger | integer | 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 | ||
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.component.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. DataAbsentReason (extensible)Constraints
|
interpretation | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdObservation.component.interpretation High, low, normal, etc. Alternate namesAbnormal Flag DefinitionA categorical assessment of an observation value. For example, high, low, normal. For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result. Codes identifying interpretations of observations. ObservationInterpretationCodes (extensible)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 might 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 / LaboratoryTest Alternate namesVital Signs, Measurement, Results, Tests, LaboratoriumUitslag, LaboratoriumTest DefinitionAn instance of CBB LaboratoryTestResult or of a single LaboratoryTest within this CBB. 1. Guidance on use for singular tests and panels The CBB LaboratoryTestResult captures both singular laboratory tests and panels/clusters of multiple related tests requested together (e.g., blood gases and EBV serology)*. This profile should be used slightly different in these two situations:
Note 1: The CBB also recognizes the RelatedResult concept. This is unrelated to the use of panels/clusters. This concept is represented either using 2. Unmapped CBB concept
3. Unmapped zib concept
| |
extension | I | 0..* | Extension | 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. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Constraints
|
sequelTo | I | 0..* | Extension(Reference(Observation)) | Element IdObservation.extension:sequelTo Sequel to referenced Observation Alternate namesextensions, user content DefinitionThis observation follows the target observation (e.g. timed tests such as Glucose Tolerance Test). 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(Observation)) Extension URLhttp://hl7.org/fhir/StructureDefinition/observation-sequelTo Constraints
|
url | 1..1 | System.StringFixed Value | There are no (further) constraints on this element Element IdObservation.extension:sequelTo.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. System.String Fixed Valuehttp://hl7.org/fhir/StructureDefinition/observation-sequelTo
| |
value[x] | 1..1 | Element IdObservation.extension:sequelTo.value[x] RelatedResult Alternate namesGerelateerdeUitslag DefinitionThis is one of the two mechanisms to represent concept RelatedResult. The other mechanism is
| ||
valueReference | Reference(Observation | HdBe LaboratoryTestResult) | Data Type | ||
identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdObservation.identifier Business Identifier for observation DefinitionA unique identifier assigned to this observation. Allows observations to be distinguished and referenced.
|
basedOn | Σ I | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | HdBe LaboratoryTestResult Requester) | Element IdObservation.basedOn Fulfills plan, proposal or order Alternate namesFulfills DefinitionA plan, proposal or order that is fulfilled in whole or in part by this event. For example, a MedicationRequest may require a patient to have laboratory test performed before it is dispensed. Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon. The ServiceRequest.requester holds the information on who requested the laboratory test. This ServiceRequest is linked through this element. Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | HdBe LaboratoryTestResult Requester) Constraints
|
partOf | Σ I | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | There are no (further) constraints on this element Element IdObservation.partOf Part of referenced event Alternate namesContainer DefinitionA larger event of which this particular Observation is a component or step. For example, an observation as part of a procedure. To link an Observation to an Encounter use Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Constraints
|
status | Σ ?! | 1..1 | codeBinding | Element IdObservation.status ResultStatus / TestResultStatus Alternate namesTestUitslagStatus DefinitionThe status of the laboratory test result or test result panel/cluster. Need to track the status of individual results. Some results are finalized before the whole report is finalized. If this resource represents a singular test result or a single test in a cluster/panel, this will be the status of this particular test result. However, if it represents the overall result of a panel/cluster, this status should represent the status of the panel/cluster and should be in accordance with the test result statuses of the individual tests. Codes providing the status of an observation. TestResultStatus (required)Constraints
|
category | 0..* | CodeableConceptBinding | 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. ObservationCategoryCodes (preferred)Constraints
| |
resultType | 0..1 | CodeableConceptBinding | Element IdObservation.category:resultType 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. Codes for high level observation categories. ResultType (required)Constraints
| |
code | Σ | 1..1 | CodeableConcept | Element IdObservation.code PanelOrBattery / TestCode Alternate namesName, Onderzoek, TestCode DefinitionThe name and code of the executed test. For laboratory tests comprising multiple subtests and often requested together as a whole, this concept contains the name and code 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.
At least the below stated rules need to be followed.
Note that the FHIR CodeableConcept data type allows multiple codes (if they represent the same concept) because Codes identifying names of simple observations. LOINCCodes (example)Constraints
|
subject | Σ I | 0..1 | Reference(Patient | Group | Device | Location | HdBe Patient) | Element IdObservation.subject Who and/or what the observation is about DefinitionThe patient, or group of patients, location, or device this observation is about and into whose record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the 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. Reference(Patient | Group | Device | Location | HdBe Patient) Constraints
|
focus | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdObservation.focus What the observation is about, when it is not about the subject of record DefinitionThe actual focus of an observation when it is not the patient of record representing something or someone associated with the patient such as a spouse, parent, fetus, or donor. For example, fetus observations in a mother's record. The focus of an observation could also be an existing condition, an intervention, the subject's diet, another observation of the subject, or a body structure such as tumor or implanted device. An example use case would be using the Observation resource to capture whether the mother is trained to change her child's tracheostomy tube. In this example, the child is the patient of record and the mother is the focus. Typically, an observation is made about the subject - a patient, or group of patients, location, or device - and the distinction between the subject and what is directly measured for an observation is specified in the observation code itself ( e.g., "Blood Glucose") and does not need to be represented separately using this element. Use
|
encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdObservation.encounter Healthcare event during which this observation is made Alternate namesContext DefinitionThe healthcare event (e.g. a patient and healthcare provider interaction) during which this observation is 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 but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
|
effective[x] | Σ | 0..1 | Element IdObservation.effective[x] Clinically relevant time/time-period for observation Alternate namesOccurrence DefinitionThe time or time-period the observed value is asserted as being true. For biological subjects - e.g. human patients - this is usually called the "physiologically relevant time". This is usually either the time of the procedure or of specimen collection, but very often the source of the date/time is not known, only the date/time itself. 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. For recording imprecise or "fuzzy" times (For example, a blood glucose measurement taken "after breakfast") use the Timing datatype which allow the measurement to be tied to regular life events. Unordered, Open, by $this(Type) Constraints
| |
effectivePeriod | Period | There are no (further) constraints on this element Data Type | ||
effectiveTiming | Timing | There are no (further) constraints on this element Data Type | ||
effectiveInstant | instant | There are no (further) constraints on this element Data Type | ||
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. For recording imprecise or "fuzzy" times (For example, a blood glucose measurement taken "after breakfast") use the Timing datatype which allow the measurement to be tied to regular life events.
|
issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element IdObservation.issued Date/Time this version was made available DefinitionThe date and time this version of the observation was made available to providers, typically after the results have been reviewed and verified. For Observations that don’t require review and verification, it may be the same as the
|
performer | Σ I | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | 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(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Sliced:Unordered, Open, by resolve()(Profile) Constraints
|
performer | Σ I | 0..1 | Reference(HdBe HealthcareOrganization Organization) | Element IdObservation.performer:performer Performer Alternate namesUitvoerder DefinitionThe healthcare provider and/or organization where or by whom the LaboratoryTestResult was performed. 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(HdBe HealthcareOrganization Organization) Constraints
|
value[x] | Σ I | 0..1 | Element IdObservation.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 might not if it is in error, or if it represents a group of observations. An observation may have; 1) a single value here, 2) both a value and a set of related or component values, or 3) only a set of related or component values. If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For quantitative results, it is mandatory to provide an unit. For additional guidance, see the Notes section below.
| |
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 | ||
valueBoolean | boolean | There are no (further) constraints on this element Data Type | ||
valueInteger | integer | 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 | ||
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.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. DataAbsentReason (extensible)Constraints
|
interpretation | 0..* | CodeableConceptBinding | Element IdObservation.interpretation High, low, normal, etc. Alternate namesAbnormal Flag DefinitionA categorical assessment of an observation value. For example, high, low, normal. For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result. Unordered, Open, by coding(Exists) BindingCodes identifying interpretations of observations. ObservationInterpretationCodes (extensible)Constraints
| |
resultFlags | 0..* | CodeableConceptBinding | Element IdObservation.interpretation:resultFlags ResultFlags Alternate namesAbnormal Flag, InterpretatieVlaggen DefinitionAttention codes indicating whether the result of a quantitative test is above or below certain reference values or interpreting the result otherwise.(Resistent). The values Resistant, Intermediate en Susceptible are used with microbiological test results. For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result. Use ConceptMap 'ResultFlags-to-ObservationInterpretation' to translate CBB terminology to profile terminology in ValueSet 'Observation-interpretation' ObservationInterpretationCodes (extensible)Permitted Values ResultFlags_to_ObservationInterpretationCodes Constraints
| |
coding | Σ | 1..* | Coding | There are no (further) constraints on this element Element IdObservation.interpretation:resultFlags.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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.
|
text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdObservation.interpretation:resultFlags.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.
|
resultInterpretation | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdObservation.interpretation:resultInterpretation High, low, normal, etc. Alternate namesAbnormal Flag DefinitionA categorical assessment of an observation value. For example, high, low, normal. For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result. Codes identifying interpretations of observations. ObservationInterpretationCodes (extensible)Constraints
| |
coding | Σ | 0..0 | Coding | There are no (further) constraints on this element Element IdObservation.interpretation:resultInterpretation.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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.
|
text | Σ | 0..1 | string | Element IdObservation.interpretation:resultInterpretation.text ResultInterpretation Alternate namesUitslagInterpretatie DefinitionComment of the laboratory specialist regarding the interpretation of the results 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.
|
note | 0..1 | Annotation | There are no (further) constraints on this element Element IdObservation.note Comments about the observation DefinitionComments about the observation or the results. Need to be able to provide free text additional information. May include general statements about the observation, or statements about significant, unexpected or unreliable results values, or information about its source when relevant to its interpretation.
| |
author[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdObservation.note.author[x] Individual responsible for the annotation DefinitionThe individual responsible for making the annotation. Organization is used when there's no need for specific attribution as to who made the comment.
| |
authorString | string | There are no (further) constraints on this element Data Type | ||
authorReference | Reference(Practitioner | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Data Type Reference(Practitioner | Patient | RelatedPerson | Organization) | ||
time | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdObservation.note.time When the annotation was made DefinitionIndicates when this particular annotation was made.
|
text | Σ | 1..1 | markdown | Element IdObservation.note.text Comment Alternate namesToelichting DefinitionComments, such as a textual interpretation or advice accompanying the result, for example. Systems are not required to have markdown support, so the text should be readable without markdown processing. The markdown syntax is GFM - see https://github.github.com/gfm/
|
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 bodySite. Codes describing anatomical locations. May include laterality. SNOMEDCTBodyStructures (example)Constraints
| |
method | 0..1 | CodeableConceptBinding | 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. Methods for simple observations. TestMethod (required)Constraints
| |
specimen | I | 0..1 | Reference(Specimen | HdBe LaboratoryTestResult.Specimen) | Element IdObservation.specimen Specimen used for this observation DefinitionThe specimen that was used when this observation was made. The Specimen concept of the CCB defines either the collected source material without further processing, or a microorganism, optionally including the source material from which it whas isolated.
Reference(Specimen | HdBe LaboratoryTestResult.Specimen) Constraints
|
device | I | 0..1 | Reference(Device | DeviceMetric) | There are no (further) constraints on this element Element IdObservation.device (Measurement) Device DefinitionThe device used to generate the observation data. Note that this is not meant to represent a device involved in the transmission of the result, e.g., a gateway. Such devices may be documented using the Provenance resource where relevant. Reference(Device | DeviceMetric) Constraints
|
referenceRange | I | 0..* | BackboneElement | There are no (further) constraints on this element Element IdObservation.referenceRange Provides guide for interpretation DefinitionGuidance on how to interpret the value by comparison to a normal or recommended range. Multiple reference ranges are interpreted as an "OR". In other words, to represent two distinct target populations, two 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 might 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.
|
low | I | 0..1 | SimpleQuantity | 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 | I | 0..1 | SimpleQuantity | 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. ObservationReferenceRangeMeaningCodes (preferred)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. Multiple 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. ObservationReferenceRangeAppliesToCodes (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 | 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". Text based reference ranges is only used when the ReferenceRangeLowerLimit and/or ReferenceRangeUpperLimit cannot be expressed as quantity in
| |
hasMember | Σ I | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence | HdBe LaboratoryTestResult) | Element IdObservation.hasMember Related resource that belongs to the Observation group DefinitionThis observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group. When this resource is used to represent the overall result of a panel/cluster of laboratory tests, the individual test results SHOULD be referenced here. See the root of this profile for guidance. Reference(Observation | QuestionnaireResponse | MolecularSequence | HdBe LaboratoryTestResult) Constraints
|
derivedFrom | Σ I | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence | HdBe LaboratoryTestResult) | Element IdObservation.derivedFrom RelatedResult Alternate namesGerelateerdeUitslag DefinitionThe target resource that represents a measurement from which this observation value is derived. For example, a calculated anion gap or a fetal measurement based on an ultrasound image. This is one of the two mechanisms to represent concept RelatedResult. The other mechanism is All the reference choices that are listed in this element can represent clinical observations and other measurements that may be the source for a derived value. The most common reference will be another Observation. For a discussion on the ways Observations can assembled in groups together, see Notes below. Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence | HdBe LaboratoryTestResult) Constraints
|
component | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdObservation.component Component results DefinitionSome observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes. Examples include systolic and diastolic component observations for blood pressure measurement and multiple component observations for genetics observations. 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.
|
code | Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element IdObservation.component.code Type of component observation (code / type) DefinitionDescribes what was observed. Sometimes this is called the observation "code". Knowing what kind of observation is being made is essential to understanding the observation. All code-value and component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation. Codes identifying names of simple observations. LOINCCodes (example)Constraints
|
value[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdObservation.component.value[x] Actual component result DefinitionThe information determined as a result of making the observation, if the information has a simple value. An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations. Used when observation has a set of component observations. An observation may have both a value (e.g. an Apgar score) and component observations (the observations from which the Apgar score was derived). If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the Notes section below.
| |
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 | ||
valueBoolean | boolean | There are no (further) constraints on this element Data Type | ||
valueInteger | integer | 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 | ||
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.component.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. DataAbsentReason (extensible)Constraints
|
interpretation | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdObservation.component.interpretation High, low, normal, etc. Alternate namesAbnormal Flag DefinitionA categorical assessment of an observation value. For example, high, low, normal. For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result. Codes identifying interpretations of observations. ObservationInterpretationCodes (extensible)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 might 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 / LaboratoryTest Alternate namesVital Signs, Measurement, Results, Tests, LaboratoriumUitslag, LaboratoriumTest DefinitionAn instance of CBB LaboratoryTestResult or of a single LaboratoryTest within this CBB. 1. Guidance on use for singular tests and panels The CBB LaboratoryTestResult captures both singular laboratory tests and panels/clusters of multiple related tests requested together (e.g., blood gases and EBV serology)*. This profile should be used slightly different in these two situations:
Note 1: The CBB also recognizes the RelatedResult concept. This is unrelated to the use of panels/clusters. This concept is represented either using 2. Unmapped CBB concept
3. Unmapped zib concept
| |
extension | I | 0..* | Extension | 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. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Constraints
|
sequelTo | I | 0..* | Extension(Reference(Observation)) | Element IdObservation.extension:sequelTo Sequel to referenced Observation Alternate namesextensions, user content DefinitionThis observation follows the target observation (e.g. timed tests such as Glucose Tolerance Test). 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(Observation)) Extension URLhttp://hl7.org/fhir/StructureDefinition/observation-sequelTo Constraints
|
url | 1..1 | System.StringFixed Value | There are no (further) constraints on this element Element IdObservation.extension:sequelTo.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. System.String Fixed Valuehttp://hl7.org/fhir/StructureDefinition/observation-sequelTo
| |
value[x] | 1..1 | Element IdObservation.extension:sequelTo.value[x] RelatedResult Alternate namesGerelateerdeUitslag DefinitionThis is one of the two mechanisms to represent concept RelatedResult. The other mechanism is
| ||
valueReference | Reference(Observation | HdBe LaboratoryTestResult) | Data Type | ||
identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdObservation.identifier Business Identifier for observation DefinitionA unique identifier assigned to this observation. Allows observations to be distinguished and referenced.
|
basedOn | Σ I | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | HdBe LaboratoryTestResult Requester) | Element IdObservation.basedOn Fulfills plan, proposal or order Alternate namesFulfills DefinitionA plan, proposal or order that is fulfilled in whole or in part by this event. For example, a MedicationRequest may require a patient to have laboratory test performed before it is dispensed. Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon. The ServiceRequest.requester holds the information on who requested the laboratory test. This ServiceRequest is linked through this element. Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | HdBe LaboratoryTestResult Requester) Constraints
|
partOf | Σ I | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | There are no (further) constraints on this element Element IdObservation.partOf Part of referenced event Alternate namesContainer DefinitionA larger event of which this particular Observation is a component or step. For example, an observation as part of a procedure. To link an Observation to an Encounter use Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Constraints
|
status | Σ ?! | 1..1 | codeBinding | Element IdObservation.status ResultStatus / TestResultStatus Alternate namesTestUitslagStatus DefinitionThe status of the laboratory test result or test result panel/cluster. Need to track the status of individual results. Some results are finalized before the whole report is finalized. If this resource represents a singular test result or a single test in a cluster/panel, this will be the status of this particular test result. However, if it represents the overall result of a panel/cluster, this status should represent the status of the panel/cluster and should be in accordance with the test result statuses of the individual tests. Codes providing the status of an observation. TestResultStatus (required)Constraints
|
category | 0..* | CodeableConceptBinding | 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. ObservationCategoryCodes (preferred)Constraints
| |
resultType | 0..1 | CodeableConceptBinding | Element IdObservation.category:resultType 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. Codes for high level observation categories. ResultType (required)Constraints
| |
code | Σ | 1..1 | CodeableConcept | Element IdObservation.code PanelOrBattery / TestCode Alternate namesName, Onderzoek, TestCode DefinitionThe name and code of the executed test. For laboratory tests comprising multiple subtests and often requested together as a whole, this concept contains the name and code 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.
At least the below stated rules need to be followed.
Note that the FHIR CodeableConcept data type allows multiple codes (if they represent the same concept) because Codes identifying names of simple observations. LOINCCodes (example)Constraints
|
subject | Σ I | 0..1 | Reference(Patient | Group | Device | Location | HdBe Patient) | Element IdObservation.subject Who and/or what the observation is about DefinitionThe patient, or group of patients, location, or device this observation is about and into whose record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the 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. Reference(Patient | Group | Device | Location | HdBe Patient) Constraints
|
focus | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdObservation.focus What the observation is about, when it is not about the subject of record DefinitionThe actual focus of an observation when it is not the patient of record representing something or someone associated with the patient such as a spouse, parent, fetus, or donor. For example, fetus observations in a mother's record. The focus of an observation could also be an existing condition, an intervention, the subject's diet, another observation of the subject, or a body structure such as tumor or implanted device. An example use case would be using the Observation resource to capture whether the mother is trained to change her child's tracheostomy tube. In this example, the child is the patient of record and the mother is the focus. Typically, an observation is made about the subject - a patient, or group of patients, location, or device - and the distinction between the subject and what is directly measured for an observation is specified in the observation code itself ( e.g., "Blood Glucose") and does not need to be represented separately using this element. Use
|
encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdObservation.encounter Healthcare event during which this observation is made Alternate namesContext DefinitionThe healthcare event (e.g. a patient and healthcare provider interaction) during which this observation is 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 but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
|
effective[x] | Σ | 0..1 | Element IdObservation.effective[x] Clinically relevant time/time-period for observation Alternate namesOccurrence DefinitionThe time or time-period the observed value is asserted as being true. For biological subjects - e.g. human patients - this is usually called the "physiologically relevant time". This is usually either the time of the procedure or of specimen collection, but very often the source of the date/time is not known, only the date/time itself. 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. For recording imprecise or "fuzzy" times (For example, a blood glucose measurement taken "after breakfast") use the Timing datatype which allow the measurement to be tied to regular life events. Unordered, Open, by $this(Type) Constraints
| |
effectivePeriod | Period | There are no (further) constraints on this element Data Type | ||
effectiveTiming | Timing | There are no (further) constraints on this element Data Type | ||
effectiveInstant | instant | There are no (further) constraints on this element Data Type | ||
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. For recording imprecise or "fuzzy" times (For example, a blood glucose measurement taken "after breakfast") use the Timing datatype which allow the measurement to be tied to regular life events.
|
issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element IdObservation.issued Date/Time this version was made available DefinitionThe date and time this version of the observation was made available to providers, typically after the results have been reviewed and verified. For Observations that don’t require review and verification, it may be the same as the
|
performer | Σ I | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | 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(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Sliced:Unordered, Open, by resolve()(Profile) Constraints
|
performer | Σ I | 0..1 | Reference(HdBe HealthcareOrganization Organization) | Element IdObservation.performer:performer Performer Alternate namesUitvoerder DefinitionThe healthcare provider and/or organization where or by whom the LaboratoryTestResult was performed. 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(HdBe HealthcareOrganization Organization) Constraints
|
value[x] | Σ I | 0..1 | Element IdObservation.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 might not if it is in error, or if it represents a group of observations. An observation may have; 1) a single value here, 2) both a value and a set of related or component values, or 3) only a set of related or component values. If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For quantitative results, it is mandatory to provide an unit. For additional guidance, see the Notes section below.
| |
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 | ||
valueBoolean | boolean | There are no (further) constraints on this element Data Type | ||
valueInteger | integer | 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 | ||
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.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. DataAbsentReason (extensible)Constraints
|
interpretation | 0..* | CodeableConceptBinding | Element IdObservation.interpretation High, low, normal, etc. Alternate namesAbnormal Flag DefinitionA categorical assessment of an observation value. For example, high, low, normal. For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result. Unordered, Open, by coding(Exists) BindingCodes identifying interpretations of observations. ObservationInterpretationCodes (extensible)Constraints
| |
resultFlags | 0..* | CodeableConceptBinding | Element IdObservation.interpretation:resultFlags ResultFlags Alternate namesAbnormal Flag, InterpretatieVlaggen DefinitionAttention codes indicating whether the result of a quantitative test is above or below certain reference values or interpreting the result otherwise.(Resistent). The values Resistant, Intermediate en Susceptible are used with microbiological test results. For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result. Use ConceptMap 'ResultFlags-to-ObservationInterpretation' to translate CBB terminology to profile terminology in ValueSet 'Observation-interpretation' ObservationInterpretationCodes (extensible)Permitted Values ResultFlags_to_ObservationInterpretationCodes Constraints
| |
coding | Σ | 1..* | Coding | There are no (further) constraints on this element Element IdObservation.interpretation:resultFlags.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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.
|
text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdObservation.interpretation:resultFlags.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.
|
resultInterpretation | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdObservation.interpretation:resultInterpretation High, low, normal, etc. Alternate namesAbnormal Flag DefinitionA categorical assessment of an observation value. For example, high, low, normal. For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result. Codes identifying interpretations of observations. ObservationInterpretationCodes (extensible)Constraints
| |
coding | Σ | 0..0 | Coding | There are no (further) constraints on this element Element IdObservation.interpretation:resultInterpretation.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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.
|
text | Σ | 0..1 | string | Element IdObservation.interpretation:resultInterpretation.text ResultInterpretation Alternate namesUitslagInterpretatie DefinitionComment of the laboratory specialist regarding the interpretation of the results 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.
|
note | 0..1 | Annotation | There are no (further) constraints on this element Element IdObservation.note Comments about the observation DefinitionComments about the observation or the results. Need to be able to provide free text additional information. May include general statements about the observation, or statements about significant, unexpected or unreliable results values, or information about its source when relevant to its interpretation.
| |
author[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdObservation.note.author[x] Individual responsible for the annotation DefinitionThe individual responsible for making the annotation. Organization is used when there's no need for specific attribution as to who made the comment.
| |
authorString | string | There are no (further) constraints on this element Data Type | ||
authorReference | Reference(Practitioner | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Data Type Reference(Practitioner | Patient | RelatedPerson | Organization) | ||
time | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdObservation.note.time When the annotation was made DefinitionIndicates when this particular annotation was made.
|
text | Σ | 1..1 | markdown | Element IdObservation.note.text Comment Alternate namesToelichting DefinitionComments, such as a textual interpretation or advice accompanying the result, for example. Systems are not required to have markdown support, so the text should be readable without markdown processing. The markdown syntax is GFM - see https://github.github.com/gfm/
|
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 bodySite. Codes describing anatomical locations. May include laterality. SNOMEDCTBodyStructures (example)Constraints
| |
method | 0..1 | CodeableConceptBinding | 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. Methods for simple observations. TestMethod (required)Constraints
| |
specimen | I | 0..1 | Reference(Specimen | HdBe LaboratoryTestResult.Specimen) | Element IdObservation.specimen Specimen used for this observation DefinitionThe specimen that was used when this observation was made. The Specimen concept of the CCB defines either the collected source material without further processing, or a microorganism, optionally including the source material from which it whas isolated.
Reference(Specimen | HdBe LaboratoryTestResult.Specimen) Constraints
|
device | I | 0..1 | Reference(Device | DeviceMetric) | There are no (further) constraints on this element Element IdObservation.device (Measurement) Device DefinitionThe device used to generate the observation data. Note that this is not meant to represent a device involved in the transmission of the result, e.g., a gateway. Such devices may be documented using the Provenance resource where relevant. Reference(Device | DeviceMetric) Constraints
|
referenceRange | I | 0..* | BackboneElement | There are no (further) constraints on this element Element IdObservation.referenceRange Provides guide for interpretation DefinitionGuidance on how to interpret the value by comparison to a normal or recommended range. Multiple reference ranges are interpreted as an "OR". In other words, to represent two distinct target populations, two 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 might 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.
|
low | I | 0..1 | SimpleQuantity | 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 | I | 0..1 | SimpleQuantity | 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. ObservationReferenceRangeMeaningCodes (preferred)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. Multiple 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. ObservationReferenceRangeAppliesToCodes (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 | 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". Text based reference ranges is only used when the ReferenceRangeLowerLimit and/or ReferenceRangeUpperLimit cannot be expressed as quantity in
| |
hasMember | Σ I | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence | HdBe LaboratoryTestResult) | Element IdObservation.hasMember Related resource that belongs to the Observation group DefinitionThis observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group. When this resource is used to represent the overall result of a panel/cluster of laboratory tests, the individual test results SHOULD be referenced here. See the root of this profile for guidance. Reference(Observation | QuestionnaireResponse | MolecularSequence | HdBe LaboratoryTestResult) Constraints
|
derivedFrom | Σ I | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence | HdBe LaboratoryTestResult) | Element IdObservation.derivedFrom RelatedResult Alternate namesGerelateerdeUitslag DefinitionThe target resource that represents a measurement from which this observation value is derived. For example, a calculated anion gap or a fetal measurement based on an ultrasound image. This is one of the two mechanisms to represent concept RelatedResult. The other mechanism is All the reference choices that are listed in this element can represent clinical observations and other measurements that may be the source for a derived value. The most common reference will be another Observation. For a discussion on the ways Observations can assembled in groups together, see Notes below. Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence | HdBe LaboratoryTestResult) Constraints
|
component | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdObservation.component Component results DefinitionSome observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes. Examples include systolic and diastolic component observations for blood pressure measurement and multiple component observations for genetics observations. 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.
|
code | Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element IdObservation.component.code Type of component observation (code / type) DefinitionDescribes what was observed. Sometimes this is called the observation "code". Knowing what kind of observation is being made is essential to understanding the observation. All code-value and component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation. Codes identifying names of simple observations. LOINCCodes (example)Constraints
|
value[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdObservation.component.value[x] Actual component result DefinitionThe information determined as a result of making the observation, if the information has a simple value. An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations. Used when observation has a set of component observations. An observation may have both a value (e.g. an Apgar score) and component observations (the observations from which the Apgar score was derived). If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the Notes section below.
| |
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 | ||
valueBoolean | boolean | There are no (further) constraints on this element Data Type | ||
valueInteger | integer | 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 | ||
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.component.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. DataAbsentReason (extensible)Constraints
|
interpretation | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdObservation.component.interpretation High, low, normal, etc. Alternate namesAbnormal Flag DefinitionA categorical assessment of an observation value. For example, high, low, normal. For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result. Codes identifying interpretations of observations. ObservationInterpretationCodes (extensible)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 might 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 to CBB
Path | map | CBB | comment |
---|---|---|---|
Observation | LaboratoryTestResult | HdBe-LaboratoryTestResult | |
Observation | LaboratoryTest | HdBe-LaboratoryTestResult | |
Observation.extension:sequelTo.value[x] | LaboratoryTestResult.RelatedResult | HdBe-LaboratoryTestResult | |
Observation.basedOn | LaboratoryTestResult.Requester | HdBe-LaboratoryTestResult | implicit (main mapping on the referenced ServiceRequest.requester) |
Observation.status | LaboratoryTestResult.ResultStatus | HdBe-LaboratoryTestResult | |
Observation.status | LaboratoryTestResult.LaboratoryTest.TestResultStatus | HdBe-LaboratoryTestResult | |
Observation.category:resultType | LaboratoryTestResult.ResultType | HdBe-LaboratoryTestResult | |
Observation.code | LaboratoryTestResult.PanelOrBattery | HdBe-LaboratoryTestResult | |
Observation.code | LaboratoryTestResult.LaboratoryTest.TestCode | HdBe-LaboratoryTestResult | |
Observation.effective[x]:effectiveDateTime | LaboratoryTestResult.LaboratoryTest.TestDateTime | HdBe-LaboratoryTestResult | |
Observation.performer:performer | LaboratoryTestResult.Performer.HealthcareOrganization | HdBe-LaboratoryTestResult | |
Observation.value[x] | LaboratoryTestResult.LaboratoryTest.TestResult | HdBe-LaboratoryTestResult | |
Observation.interpretation:resultFlags | LaboratoryTestResult.LaboratoryTest.ResultFlags | HdBe-LaboratoryTestResult | |
Observation.interpretation:resultInterpretation.text | LaboratoryTestResult.LaboratoryTest.ResultInterpretation | HdBe-LaboratoryTestResult | |
Observation.note.text | LaboratoryTestResult.LaboratoryTest.Comment | HdBe-LaboratoryTestResult | |
Observation.method | LaboratoryTestResult.LaboratoryTest.TestMethod | HdBe-LaboratoryTestResult | |
Observation.specimen | LaboratoryTestResult.Specimen | HdBe-LaboratoryTestResult | |
Observation.referenceRange.low | LaboratoryTestResult.LaboratoryTest.ReferenceRangeLowerLimit | HdBe-LaboratoryTestResult | |
Observation.referenceRange.high | LaboratoryTestResult.LaboratoryTest.ReferenceRangeUpperLimit | HdBe-LaboratoryTestResult | |
Observation.referenceRange.text | LaboratoryTestResult.LaboratoryTest.ReferenceRangeLowerLimit | HdBe-LaboratoryTestResult | |
Observation.referenceRange.text | LaboratoryTestResult.LaboratoryTest.ReferenceRangeUpperLimit | HdBe-LaboratoryTestResult | |
Observation.derivedFrom | LaboratoryTestResult.RelatedResult | HdBe-LaboratoryTestResult |
zib LaboratoryTestResult difference
Concept | Category | Description |
---|---|---|
status |
terminology | Replaced FHIR ValueSet with ValueSet-TestResultStatus as this is a subset of the FHIR valueset. |
status |
terminology | Removed ConceptMap as we replaced the ValueSet values to the FHIR ValueSet. |
status |
terminology | Replaced zib CodeSystem values to corresponding values from the FHIR ObservationStatus CodeSystem because these are more widely adopted and can be mapped to zib status terminology. The new ValueSet contains a subset of the ObservationStatus CodeSystem to maintain compatibility with the zib. |
code |
terminology | Removed ValueSet binding and described in the comment the use of Loinc and Albert codes as per the subset defined by the FPS Health (ReTaM). Added a reference to the subset on the website of the FPS Health. The ReTaM codes are not duplicated in a FHIR ValueSet because this would require extensive maintenance in keeping the ValueSet up-to-date. |
performer |
reference | Added reference to HdBe-HealthcareOrganization-Organization (seems missing in the current zib profile implementation). |
performer |
reference | Removed reference to HdBe-HealthcareProfessional-Practitioner in slice as this is incorporated by the pattern. |
value[x] |
textual | Added textual guidance to include the unit for quantitative results. |
interpretation.resultFlags |
terminology | Added ConceptMap ResultFlagsCodelist-to-ObservationInterpretation (seems missing in the current zib profile implementation). |
interpretation.resultFlags |
terminology | Removed concepts 'Resistent', 'Intermediate' and 'Susceptible' from the ValueSet. These codes are seen as a quantitative result. (zib ticket #1555) |
interpretation.resultFlags |
textual | Removed notion of 'Resistent', 'Intermediate' and 'Susceptible' codes in definition. |
derivedFrom |
reference | Added reference to HdBe-LaboratoryTestResult (seems missing in the current zib profile implementation). |
referenceRange.text |
mapping | Added mapping to ReferenceRangeLowerLimit and ReferenceRangeUpperLimit for when the quantaty datatype does not suffice. |
basedOn |
mapping | Added mapping to a new profile on ServiceRequest to implement the requester element of the CBB/zib. Although this element does not provide enough information to create a profile that describes a full ordering service, it will provide details on capturing a requester in FHIR. |
HdBe-LaboratoryTestResult.Specimen
Instructions |
---|
The Specimen concept from the CBB HdBe-LaboratoryTestResult contains a concept for SpecimenMaterial and for Microorganism. These two concepts cannot be represented in the same Specimen resources; if there's a need to communicate both the microorganism and the sample material from which it was isolated, two instances need to be used. The instance representing the microorganism should refer to the instance respresenting the sample material using |
Specimen | I | Specimen | Element IdSpecimen Specimen Alternate namesMonster DefinitionThe Specimen concept from the CBB HdBe-LaboratoryTestResult contains a concept for SpecimenMaterial and for Microorganism. These two concepts cannot be represented in the same Specimen resources; if there's a need to communicate both the microorganism and the sample material from which it was isolated, two instances need to be used. The instance representing the microorganism should refer to the instance respresenting the sample material using
| |
identifier | Σ | 0..* | Identifier | Element IdSpecimen.identifier SpecimenId Alternate namesMonsternummer DefinitionIdentification number of the material obtained, as a reference for inquiries to the source organization. In a transmural setting, this number will consist of a specimen number including the identification of the issuing organization, to be unique outside of the borders of an organization.
|
accessionIdentifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element IdSpecimen.accessionIdentifier Identifier assigned by the lab DefinitionThe identifier assigned by the lab when accessioning specimen(s). This is not necessarily the same as the specimen identifier, depending on local lab procedures.
|
status | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element IdSpecimen.status available | unavailable | unsatisfactory | entered-in-error DefinitionThe availability of the specimen. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. Codes providing the status/availability of a specimen. SpecimenStatus (required)Constraints
|
type | Σ | 0..1 | CodeableConceptBinding | Element IdSpecimen.type SpecimenMaterial / Microorganism Alternate namesMicroorganisme Definition
The Specimen concept from the CBB LaboratoryTestResult contains a concept for SpecimenMaterial and for Microorganism (isolated from the specimen material). These two concepts cannot be represented in the same Specimen resources; this If there's a need to communicate both the microorganism and the sample material from which it was isolated, two instances need to be used. The instance representing the microorganism should refer in this case to the instance respresenting the sample material using If this resource represents material and is carried out on derived material (such as plasma), this element will still contain the material drawn (in this case, blood). In this case, the LOINC code will generally refer to plasma. The type of the specimen. SpecimenMaterial-and-Microorganism (required)Constraints
|
subject | Σ I | 0..1 | Reference(Patient | Group | Device | Substance | Location) | There are no (further) constraints on this element Element IdSpecimen.subject Where the specimen came from. This may be from patient(s), from a location (e.g., the source of an environmental sample), or a sampling of a substance or a device DefinitionWhere the specimen came from. This may be from patient(s), from a location (e.g., the source of an environmental sample), or a sampling of a substance or a device. Must know the subject context. 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(Patient | Group | Device | Substance | Location) Constraints
|
receivedTime | Σ | 0..1 | dateTime | Element IdSpecimen.receivedTime ReceivedDateTime Alternate namesAannameDatumTijd DefinitionDate and time that the material is handed over at the laboratory or specimen collection center. This is the issue with material that is collected by the patient himself.
|
parent | I | 0..* | Reference(Specimen | HdBe LaboratoryTestResult.Specimen) | Element IdSpecimen.parent Specimen from which this specimen originated DefinitionReference to the parent (source) specimen which is used when the specimen was either derived from or a component of another specimen. When this resource represents a microorganism (that is, Reference(Specimen | HdBe LaboratoryTestResult.Specimen) Constraints
|
request | I | 0..* | Reference(ServiceRequest) | There are no (further) constraints on this element Element IdSpecimen.request Why the specimen was collected DefinitionDetails concerning a service request that required a specimen to be collected. The request may be explicit or implied such with a ServiceRequest that requires a blood draw.
|
collection | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdSpecimen.collection Collection details DefinitionDetails concerning the specimen collection.
| |
collector | Σ I | 0..1 | Reference(Practitioner | PractitionerRole) | There are no (further) constraints on this element Element IdSpecimen.collection.collector Who collected the specimen DefinitionPerson who collected the specimen. 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(Practitioner | PractitionerRole) Constraints
|
collected[x] | Σ | 0..1 | Element IdSpecimen.collection.collected[x] Collection time DefinitionTime when specimen was collected from subject - the physiologically relevant time. Unordered, Open, by $this(Type) Constraints
| |
collectedDateTime | Σ | 0..1 | dateTime | Element IdSpecimen.collection.collected[x]:collectedDateTime CollectionDateTime Alternate namesAfnameDatumTijd DefinitionDate and time at which the material was collected.
|
collectedPeriod | Σ | 0..1 | Period | Element IdSpecimen.collection.collected[x]:collectedPeriod CollectionPeriod Alternate namesVerzamelperiode DefinitionIf the material has not been collected at a single point in time but over a certain period, this period can be captured in this concept. An example is 24 hour urine.
|
duration | Σ I | 0..1 | DurationBinding | Element IdSpecimen.collection.duration CollectionPeriod Alternate namesVerzamelperiode DefinitionIf the material has not been collected at a single point in time but over a certain period, this period can be captured in this concept. An example is 24 hour urine. 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. Appropriate units for Duration. CommonUCUMCodesForDuration (extensible)Constraints
|
quantity | I | 0..1 | SimpleQuantity | Element IdSpecimen.collection.quantity CollectedVolume Alternate namesVerzamelvolume DefinitionTotal volume of the collected material. If it is necessary to determine the absolute amount of a particular substance in the collected material, the volume thereof must be given. 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.
|
method | 0..1 | CodeableConceptBinding | Element IdSpecimen.collection.method CollectionMethod Alternate namesAfnameprocedure DefinitionIf relevant for the results, the method of obtaining the specimen can be entered as well. 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. The technique that is used to perform the procedure. CollectionMethod (required)Constraints
| |
bodySite | 0..1 | HdBe AnatomicalLocationBinding | Element IdSpecimen.collection.bodySite AnatomicalLocation Alternate namesLocatie, AnatomischeLocatie DefinitionAnatomic location where the material is collected, e.g. elbow 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 describing anatomical locations. May include laterality. Location (required)Constraints
| |
extension | I | 0..* | Extension | Element IdSpecimen.collection.bodySite.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Constraints
|
laterality | I | 0..1 | Extension(CodeableConcept) | There are no (further) constraints on this element Element IdSpecimen.collection.bodySite.extension:laterality 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. https://fhir.healthdata.be/StructureDefinition/ext-AnatomicalLocation.Laterality Constraints
|
url | 1..1 | System.StringFixed Value | There are no (further) constraints on this element Element IdSpecimen.collection.bodySite.extension:laterality.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. System.String Fixed Valuehttps://fhir.healthdata.be/StructureDefinition/ext-AnatomicalLocation.Laterality
| |
value[x] | 0..1 | Binding | There are no (further) constraints on this element Element IdSpecimen.collection.bodySite.extension:laterality.value[x] Laterality Alternate namesLateraliteit DefinitionLaterality adds information about body site to the anatomic location, e.g. left.
| |
valueCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data Type | ||
morphology | I | 0..1 | Extension(CodeableConcept) | Element IdSpecimen.collection.bodySite.extension:morphology 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. https://fhir.healthdata.be/StructureDefinition/ext-LaboratoryTestResult.Specimen.Morphology Constraints
|
coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element IdSpecimen.collection.bodySite.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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.
|
text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdSpecimen.collection.bodySite.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.
|
fastingStatus[x] | Σ | 0..1 | Binding | There are no (further) constraints on this element Element IdSpecimen.collection.fastingStatus[x] Whether or how long patient abstained from food and/or drink DefinitionAbstinence or reduction from some or all food, drink, or both, for a period of time prior to sample collection. Many diagnostic tests require fasting to facilitate accurate interpretation. Representing fasting status using this element is preferred to representing it with an observation using a 'pre-coordinated code' such as LOINC 2005-7 (Calcium [Moles/time] in 2 hour Urine --12 hours fasting), or using a component observation Codes describing the fasting status of the patient. v2.0916 (extensible)Constraints
|
fastingStatusCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data Type | ||
fastingStatusDuration | Duration | There are no (further) constraints on this element Data Type | ||
processing | 0..* | BackboneElement | There are no (further) constraints on this element Element IdSpecimen.processing Processing and processing step details DefinitionDetails concerning processing and processing steps for the specimen.
| |
description | 0..1 | string | There are no (further) constraints on this element Element IdSpecimen.processing.description Textual description of procedure DefinitionTextual description of procedure. Note that FHIR strings SHALL NOT exceed 1MB in size
| |
procedure | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdSpecimen.processing.procedure Indicates the treatment step applied to the specimen DefinitionA coded value specifying the procedure used to process the specimen. 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. Type indicating the technique used to process the specimen. SpecimenProcessingProcedure (example)Constraints
| |
additive | I | 0..* | Reference(Substance) | There are no (further) constraints on this element Element IdSpecimen.processing.additive Material used in the processing step DefinitionMaterial used in the processing step. 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.
|
time[x] | 0..1 | There are no (further) constraints on this element Element IdSpecimen.processing.time[x] Date and time of specimen processing DefinitionA record of the time or period when the specimen processing occurred. For example the time of sample fixation or the period of time the sample was in formalin.
| ||
timeDateTime | dateTime | There are no (further) constraints on this element Data Type | ||
timePeriod | Period | There are no (further) constraints on this element Data Type | ||
container | 0..* | BackboneElement | There are no (further) constraints on this element Element IdSpecimen.container Direct container of specimen (tube/slide, etc.) DefinitionThe container holding the specimen. The recursive nature of containers; i.e. blood in tube in tray in rack is not addressed here.
| |
extension | I | 0..* | Extension | Element IdSpecimen.container.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Constraints
|
specimenNumberExtension | I | 0..1 | Extension(integer) | Element IdSpecimen.container.extension:specimenNumberExtension The sequence number of the sample Alternate namesextensions, user content DefinitionAn assigned number on the specimen denoting the order of collection. 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://hl7.org/fhir/StructureDefinition/specimen-sequenceNumber Constraints
|
url | 1..1 | System.StringFixed Value | There are no (further) constraints on this element Element IdSpecimen.container.extension:specimenNumberExtension.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. System.String Fixed Valuehttp://hl7.org/fhir/StructureDefinition/specimen-sequenceNumber
| |
value[x] | 1..1 | Element IdSpecimen.container.extension:specimenNumberExtension.value[x] SpecimenNumberExtension Alternate namesMonstervolgnummer DefinitionThe specimen number extension is used when the collected material is distributed from the original tube or container across multiple tubes. In combination with the specimen Id the extension yield a unique identification of the tube or container.
| ||
valueInteger | integer | There are no (further) constraints on this element Data Type | ||
identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdSpecimen.container.identifier Id for the container DefinitionId for container. There may be multiple; a manufacturer's bar code, lab assigned identifier, etc. The container ID may differ from the specimen id in some circumstances.
|
description | 0..1 | string | There are no (further) constraints on this element Element IdSpecimen.container.description Textual description of the container DefinitionTextual description of the container. Note that FHIR strings SHALL NOT exceed 1MB in size
| |
type | 0..1 | CodeableConceptBinding | Element IdSpecimen.container.type ContainerType Alternate namesContainertype DefinitionContainer type describes the envelope in which the material is collected or sent. Examples include blood tubes, transport container, possibly including culture medium. 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. Type of specimen container. ContainerType (preferred)Constraints
| |
capacity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element IdSpecimen.container.capacity Container volume or size DefinitionThe capacity (volume or other measure) the container may contain. 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.
|
specimenQuantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element IdSpecimen.container.specimenQuantity Quantity of specimen within container DefinitionThe quantity of specimen in the container; may be volume, dimensions, or other appropriate measurements, depending on the specimen type. 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.
|
additive[x] | 0..1 | There are no (further) constraints on this element Element IdSpecimen.container.additive[x] Additive associated with container DefinitionIntroduced substance to preserve, maintain or enhance the specimen. Examples: Formalin, Citrate, EDTA. Substance added to specimen container. v2.0371 (example)Constraints
| ||
additiveCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data Type | ||
additiveReference | Reference(Substance) | There are no (further) constraints on this element Data Type | ||
condition | Σ | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdSpecimen.condition State of the specimen DefinitionA mode or state of being that describes the nature of the specimen. The specimen condition can be used to assess its quality or appropriateness for a specific test. Specimen condition is an observation made about the specimen. It's a point-in-time assessment. It can be used to assess its quality or appropriateness for a specific test. Codes describing the state of the specimen. v2.0493 (extensible)Constraints
|
note | 0..* | Annotation | There are no (further) constraints on this element Element IdSpecimen.note Comments DefinitionTo communicate any details or issues about the specimen or during the specimen collection. (for example: broken vial, sent with patient, frozen). For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
| |
author[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdSpecimen.note.author[x] Individual responsible for the annotation DefinitionThe individual responsible for making the annotation. Organization is used when there's no need for specific attribution as to who made the comment.
| |
authorString | string | There are no (further) constraints on this element Data Type | ||
authorReference | Reference(Practitioner | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Data Type Reference(Practitioner | Patient | RelatedPerson | Organization) | ||
time | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdSpecimen.note.time When the annotation was made DefinitionIndicates when this particular annotation was made.
|
text | Σ | 1..1 | markdown | Element IdSpecimen.note.text Comment Alternate namesToelichting DefinitionComments on the specimen , such as drawing material after a (glucose) stimulus or taking medicine. Systems are not required to have markdown support, so the text should be readable without markdown processing. The markdown syntax is GFM - see https://github.github.com/gfm/
|
Specimen | I | Specimen | Element IdSpecimen Specimen Alternate namesMonster DefinitionThe Specimen concept from the CBB HdBe-LaboratoryTestResult contains a concept for SpecimenMaterial and for Microorganism. These two concepts cannot be represented in the same Specimen resources; if there's a need to communicate both the microorganism and the sample material from which it was isolated, two instances need to be used. The instance representing the microorganism should refer to the instance respresenting the sample material using
| |
identifier | Σ | 0..* | Identifier | Element IdSpecimen.identifier SpecimenId Alternate namesMonsternummer DefinitionIdentification number of the material obtained, as a reference for inquiries to the source organization. In a transmural setting, this number will consist of a specimen number including the identification of the issuing organization, to be unique outside of the borders of an organization.
|
accessionIdentifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element IdSpecimen.accessionIdentifier Identifier assigned by the lab DefinitionThe identifier assigned by the lab when accessioning specimen(s). This is not necessarily the same as the specimen identifier, depending on local lab procedures.
|
status | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element IdSpecimen.status available | unavailable | unsatisfactory | entered-in-error DefinitionThe availability of the specimen. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. Codes providing the status/availability of a specimen. SpecimenStatus (required)Constraints
|
type | Σ | 0..1 | CodeableConceptBinding | Element IdSpecimen.type SpecimenMaterial / Microorganism Alternate namesMicroorganisme Definition
The Specimen concept from the CBB LaboratoryTestResult contains a concept for SpecimenMaterial and for Microorganism (isolated from the specimen material). These two concepts cannot be represented in the same Specimen resources; this If there's a need to communicate both the microorganism and the sample material from which it was isolated, two instances need to be used. The instance representing the microorganism should refer in this case to the instance respresenting the sample material using If this resource represents material and is carried out on derived material (such as plasma), this element will still contain the material drawn (in this case, blood). In this case, the LOINC code will generally refer to plasma. The type of the specimen. SpecimenMaterial-and-Microorganism (required)Constraints
|
subject | Σ I | 0..1 | Reference(Patient | Group | Device | Substance | Location) | There are no (further) constraints on this element Element IdSpecimen.subject Where the specimen came from. This may be from patient(s), from a location (e.g., the source of an environmental sample), or a sampling of a substance or a device DefinitionWhere the specimen came from. This may be from patient(s), from a location (e.g., the source of an environmental sample), or a sampling of a substance or a device. Must know the subject context. 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(Patient | Group | Device | Substance | Location) Constraints
|
receivedTime | Σ | 0..1 | dateTime | Element IdSpecimen.receivedTime ReceivedDateTime Alternate namesAannameDatumTijd DefinitionDate and time that the material is handed over at the laboratory or specimen collection center. This is the issue with material that is collected by the patient himself.
|
parent | I | 0..* | Reference(Specimen | HdBe LaboratoryTestResult.Specimen) | Element IdSpecimen.parent Specimen from which this specimen originated DefinitionReference to the parent (source) specimen which is used when the specimen was either derived from or a component of another specimen. When this resource represents a microorganism (that is, Reference(Specimen | HdBe LaboratoryTestResult.Specimen) Constraints
|
request | I | 0..* | Reference(ServiceRequest) | There are no (further) constraints on this element Element IdSpecimen.request Why the specimen was collected DefinitionDetails concerning a service request that required a specimen to be collected. The request may be explicit or implied such with a ServiceRequest that requires a blood draw.
|
collection | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdSpecimen.collection Collection details DefinitionDetails concerning the specimen collection.
| |
collector | Σ I | 0..1 | Reference(Practitioner | PractitionerRole) | There are no (further) constraints on this element Element IdSpecimen.collection.collector Who collected the specimen DefinitionPerson who collected the specimen. 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(Practitioner | PractitionerRole) Constraints
|
collected[x] | Σ | 0..1 | Element IdSpecimen.collection.collected[x] Collection time DefinitionTime when specimen was collected from subject - the physiologically relevant time. Unordered, Open, by $this(Type) Constraints
| |
collectedDateTime | Σ | 0..1 | dateTime | Element IdSpecimen.collection.collected[x]:collectedDateTime CollectionDateTime Alternate namesAfnameDatumTijd DefinitionDate and time at which the material was collected.
|
collectedPeriod | Σ | 0..1 | Period | Element IdSpecimen.collection.collected[x]:collectedPeriod CollectionPeriod Alternate namesVerzamelperiode DefinitionIf the material has not been collected at a single point in time but over a certain period, this period can be captured in this concept. An example is 24 hour urine.
|
duration | Σ I | 0..1 | DurationBinding | Element IdSpecimen.collection.duration CollectionPeriod Alternate namesVerzamelperiode DefinitionIf the material has not been collected at a single point in time but over a certain period, this period can be captured in this concept. An example is 24 hour urine. 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. Appropriate units for Duration. CommonUCUMCodesForDuration (extensible)Constraints
|
quantity | I | 0..1 | SimpleQuantity | Element IdSpecimen.collection.quantity CollectedVolume Alternate namesVerzamelvolume DefinitionTotal volume of the collected material. If it is necessary to determine the absolute amount of a particular substance in the collected material, the volume thereof must be given. 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.
|
method | 0..1 | CodeableConceptBinding | Element IdSpecimen.collection.method CollectionMethod Alternate namesAfnameprocedure DefinitionIf relevant for the results, the method of obtaining the specimen can be entered as well. 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. The technique that is used to perform the procedure. CollectionMethod (required)Constraints
| |
bodySite | 0..1 | HdBe AnatomicalLocationBinding | Element IdSpecimen.collection.bodySite AnatomicalLocation Alternate namesLocatie, AnatomischeLocatie DefinitionAnatomic location where the material is collected, e.g. elbow 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 describing anatomical locations. May include laterality. Location (required)Constraints
| |
extension | I | 0..* | Extension | Element IdSpecimen.collection.bodySite.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Constraints
|
laterality | I | 0..1 | Extension(CodeableConcept) | There are no (further) constraints on this element Element IdSpecimen.collection.bodySite.extension:laterality 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. https://fhir.healthdata.be/StructureDefinition/ext-AnatomicalLocation.Laterality Constraints
|
url | 1..1 | System.StringFixed Value | There are no (further) constraints on this element Element IdSpecimen.collection.bodySite.extension:laterality.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. System.String Fixed Valuehttps://fhir.healthdata.be/StructureDefinition/ext-AnatomicalLocation.Laterality
| |
value[x] | 0..1 | Binding | There are no (further) constraints on this element Element IdSpecimen.collection.bodySite.extension:laterality.value[x] Laterality Alternate namesLateraliteit DefinitionLaterality adds information about body site to the anatomic location, e.g. left.
| |
valueCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data Type | ||
morphology | I | 0..1 | Extension(CodeableConcept) | Element IdSpecimen.collection.bodySite.extension:morphology 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. https://fhir.healthdata.be/StructureDefinition/ext-LaboratoryTestResult.Specimen.Morphology Constraints
|
coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element IdSpecimen.collection.bodySite.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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.
|
text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdSpecimen.collection.bodySite.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.
|
fastingStatus[x] | Σ | 0..1 | Binding | There are no (further) constraints on this element Element IdSpecimen.collection.fastingStatus[x] Whether or how long patient abstained from food and/or drink DefinitionAbstinence or reduction from some or all food, drink, or both, for a period of time prior to sample collection. Many diagnostic tests require fasting to facilitate accurate interpretation. Representing fasting status using this element is preferred to representing it with an observation using a 'pre-coordinated code' such as LOINC 2005-7 (Calcium [Moles/time] in 2 hour Urine --12 hours fasting), or using a component observation Codes describing the fasting status of the patient. v2.0916 (extensible)Constraints
|
fastingStatusCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data Type | ||
fastingStatusDuration | Duration | There are no (further) constraints on this element Data Type | ||
processing | 0..* | BackboneElement | There are no (further) constraints on this element Element IdSpecimen.processing Processing and processing step details DefinitionDetails concerning processing and processing steps for the specimen.
| |
description | 0..1 | string | There are no (further) constraints on this element Element IdSpecimen.processing.description Textual description of procedure DefinitionTextual description of procedure. Note that FHIR strings SHALL NOT exceed 1MB in size
| |
procedure | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdSpecimen.processing.procedure Indicates the treatment step applied to the specimen DefinitionA coded value specifying the procedure used to process the specimen. 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. Type indicating the technique used to process the specimen. SpecimenProcessingProcedure (example)Constraints
| |
additive | I | 0..* | Reference(Substance) | There are no (further) constraints on this element Element IdSpecimen.processing.additive Material used in the processing step DefinitionMaterial used in the processing step. 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.
|
time[x] | 0..1 | There are no (further) constraints on this element Element IdSpecimen.processing.time[x] Date and time of specimen processing DefinitionA record of the time or period when the specimen processing occurred. For example the time of sample fixation or the period of time the sample was in formalin.
| ||
timeDateTime | dateTime | There are no (further) constraints on this element Data Type | ||
timePeriod | Period | There are no (further) constraints on this element Data Type | ||
container | 0..* | BackboneElement | There are no (further) constraints on this element Element IdSpecimen.container Direct container of specimen (tube/slide, etc.) DefinitionThe container holding the specimen. The recursive nature of containers; i.e. blood in tube in tray in rack is not addressed here.
| |
extension | I | 0..* | Extension | Element IdSpecimen.container.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Constraints
|
specimenNumberExtension | I | 0..1 | Extension(integer) | Element IdSpecimen.container.extension:specimenNumberExtension The sequence number of the sample Alternate namesextensions, user content DefinitionAn assigned number on the specimen denoting the order of collection. 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://hl7.org/fhir/StructureDefinition/specimen-sequenceNumber Constraints
|
url | 1..1 | System.StringFixed Value | There are no (further) constraints on this element Element IdSpecimen.container.extension:specimenNumberExtension.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. System.String Fixed Valuehttp://hl7.org/fhir/StructureDefinition/specimen-sequenceNumber
| |
value[x] | 1..1 | Element IdSpecimen.container.extension:specimenNumberExtension.value[x] SpecimenNumberExtension Alternate namesMonstervolgnummer DefinitionThe specimen number extension is used when the collected material is distributed from the original tube or container across multiple tubes. In combination with the specimen Id the extension yield a unique identification of the tube or container.
| ||
valueInteger | integer | There are no (further) constraints on this element Data Type | ||
identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdSpecimen.container.identifier Id for the container DefinitionId for container. There may be multiple; a manufacturer's bar code, lab assigned identifier, etc. The container ID may differ from the specimen id in some circumstances.
|
description | 0..1 | string | There are no (further) constraints on this element Element IdSpecimen.container.description Textual description of the container DefinitionTextual description of the container. Note that FHIR strings SHALL NOT exceed 1MB in size
| |
type | 0..1 | CodeableConceptBinding | Element IdSpecimen.container.type ContainerType Alternate namesContainertype DefinitionContainer type describes the envelope in which the material is collected or sent. Examples include blood tubes, transport container, possibly including culture medium. 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. Type of specimen container. ContainerType (preferred)Constraints
| |
capacity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element IdSpecimen.container.capacity Container volume or size DefinitionThe capacity (volume or other measure) the container may contain. 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.
|
specimenQuantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element IdSpecimen.container.specimenQuantity Quantity of specimen within container DefinitionThe quantity of specimen in the container; may be volume, dimensions, or other appropriate measurements, depending on the specimen type. 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.
|
additive[x] | 0..1 | There are no (further) constraints on this element Element IdSpecimen.container.additive[x] Additive associated with container DefinitionIntroduced substance to preserve, maintain or enhance the specimen. Examples: Formalin, Citrate, EDTA. Substance added to specimen container. v2.0371 (example)Constraints
| ||
additiveCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data Type | ||
additiveReference | Reference(Substance) | There are no (further) constraints on this element Data Type | ||
condition | Σ | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdSpecimen.condition State of the specimen DefinitionA mode or state of being that describes the nature of the specimen. The specimen condition can be used to assess its quality or appropriateness for a specific test. Specimen condition is an observation made about the specimen. It's a point-in-time assessment. It can be used to assess its quality or appropriateness for a specific test. Codes describing the state of the specimen. v2.0493 (extensible)Constraints
|
note | 0..* | Annotation | There are no (further) constraints on this element Element IdSpecimen.note Comments DefinitionTo communicate any details or issues about the specimen or during the specimen collection. (for example: broken vial, sent with patient, frozen). For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
| |
author[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdSpecimen.note.author[x] Individual responsible for the annotation DefinitionThe individual responsible for making the annotation. Organization is used when there's no need for specific attribution as to who made the comment.
| |
authorString | string | There are no (further) constraints on this element Data Type | ||
authorReference | Reference(Practitioner | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Data Type Reference(Practitioner | Patient | RelatedPerson | Organization) | ||
time | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdSpecimen.note.time When the annotation was made DefinitionIndicates when this particular annotation was made.
|
text | Σ | 1..1 | markdown | Element IdSpecimen.note.text Comment Alternate namesToelichting DefinitionComments on the specimen , such as drawing material after a (glucose) stimulus or taking medicine. Systems are not required to have markdown support, so the text should be readable without markdown processing. The markdown syntax is GFM - see https://github.github.com/gfm/
|
Specimen | I | Specimen | Element IdSpecimen Specimen Alternate namesMonster DefinitionThe Specimen concept from the CBB HdBe-LaboratoryTestResult contains a concept for SpecimenMaterial and for Microorganism. These two concepts cannot be represented in the same Specimen resources; if there's a need to communicate both the microorganism and the sample material from which it was isolated, two instances need to be used. The instance representing the microorganism should refer to the instance respresenting the sample material using
| |
identifier | Σ | 0..* | Identifier | Element IdSpecimen.identifier SpecimenId Alternate namesMonsternummer DefinitionIdentification number of the material obtained, as a reference for inquiries to the source organization. In a transmural setting, this number will consist of a specimen number including the identification of the issuing organization, to be unique outside of the borders of an organization.
|
accessionIdentifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element IdSpecimen.accessionIdentifier Identifier assigned by the lab DefinitionThe identifier assigned by the lab when accessioning specimen(s). This is not necessarily the same as the specimen identifier, depending on local lab procedures.
|
status | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element IdSpecimen.status available | unavailable | unsatisfactory | entered-in-error DefinitionThe availability of the specimen. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. Codes providing the status/availability of a specimen. SpecimenStatus (required)Constraints
|
type | Σ | 0..1 | CodeableConceptBinding | Element IdSpecimen.type SpecimenMaterial / Microorganism Alternate namesMicroorganisme Definition
The Specimen concept from the CBB LaboratoryTestResult contains a concept for SpecimenMaterial and for Microorganism (isolated from the specimen material). These two concepts cannot be represented in the same Specimen resources; this If there's a need to communicate both the microorganism and the sample material from which it was isolated, two instances need to be used. The instance representing the microorganism should refer in this case to the instance respresenting the sample material using If this resource represents material and is carried out on derived material (such as plasma), this element will still contain the material drawn (in this case, blood). In this case, the LOINC code will generally refer to plasma. The type of the specimen. SpecimenMaterial-and-Microorganism (required)Constraints
|
subject | Σ I | 0..1 | Reference(Patient | Group | Device | Substance | Location) | There are no (further) constraints on this element Element IdSpecimen.subject Where the specimen came from. This may be from patient(s), from a location (e.g., the source of an environmental sample), or a sampling of a substance or a device DefinitionWhere the specimen came from. This may be from patient(s), from a location (e.g., the source of an environmental sample), or a sampling of a substance or a device. Must know the subject context. 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(Patient | Group | Device | Substance | Location) Constraints
|
receivedTime | Σ | 0..1 | dateTime | Element IdSpecimen.receivedTime ReceivedDateTime Alternate namesAannameDatumTijd DefinitionDate and time that the material is handed over at the laboratory or specimen collection center. This is the issue with material that is collected by the patient himself.
|
parent | I | 0..* | Reference(Specimen | HdBe LaboratoryTestResult.Specimen) | Element IdSpecimen.parent Specimen from which this specimen originated DefinitionReference to the parent (source) specimen which is used when the specimen was either derived from or a component of another specimen. When this resource represents a microorganism (that is, Reference(Specimen | HdBe LaboratoryTestResult.Specimen) Constraints
|
request | I | 0..* | Reference(ServiceRequest) | There are no (further) constraints on this element Element IdSpecimen.request Why the specimen was collected DefinitionDetails concerning a service request that required a specimen to be collected. The request may be explicit or implied such with a ServiceRequest that requires a blood draw.
|
collection | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdSpecimen.collection Collection details DefinitionDetails concerning the specimen collection.
| |
collector | Σ I | 0..1 | Reference(Practitioner | PractitionerRole) | There are no (further) constraints on this element Element IdSpecimen.collection.collector Who collected the specimen DefinitionPerson who collected the specimen. 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(Practitioner | PractitionerRole) Constraints
|
collected[x] | Σ | 0..1 | Element IdSpecimen.collection.collected[x] Collection time DefinitionTime when specimen was collected from subject - the physiologically relevant time. Unordered, Open, by $this(Type) Constraints
| |
collectedDateTime | Σ | 0..1 | dateTime | Element IdSpecimen.collection.collected[x]:collectedDateTime CollectionDateTime Alternate namesAfnameDatumTijd DefinitionDate and time at which the material was collected.
|
collectedPeriod | Σ | 0..1 | Period | Element IdSpecimen.collection.collected[x]:collectedPeriod CollectionPeriod Alternate namesVerzamelperiode DefinitionIf the material has not been collected at a single point in time but over a certain period, this period can be captured in this concept. An example is 24 hour urine.
|
duration | Σ I | 0..1 | DurationBinding | Element IdSpecimen.collection.duration CollectionPeriod Alternate namesVerzamelperiode DefinitionIf the material has not been collected at a single point in time but over a certain period, this period can be captured in this concept. An example is 24 hour urine. 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. Appropriate units for Duration. CommonUCUMCodesForDuration (extensible)Constraints
|
quantity | I | 0..1 | SimpleQuantity | Element IdSpecimen.collection.quantity CollectedVolume Alternate namesVerzamelvolume DefinitionTotal volume of the collected material. If it is necessary to determine the absolute amount of a particular substance in the collected material, the volume thereof must be given. 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.
|
method | 0..1 | CodeableConceptBinding | Element IdSpecimen.collection.method CollectionMethod Alternate namesAfnameprocedure DefinitionIf relevant for the results, the method of obtaining the specimen can be entered as well. 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. The technique that is used to perform the procedure. CollectionMethod (required)Constraints
| |
bodySite | 0..1 | HdBe AnatomicalLocationBinding | Element IdSpecimen.collection.bodySite AnatomicalLocation Alternate namesLocatie, AnatomischeLocatie DefinitionAnatomic location where the material is collected, e.g. elbow 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 describing anatomical locations. May include laterality. Location (required)Constraints
| |
extension | I | 0..* | Extension | Element IdSpecimen.collection.bodySite.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Constraints
|
laterality | I | 0..1 | Extension(CodeableConcept) | There are no (further) constraints on this element Element IdSpecimen.collection.bodySite.extension:laterality 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. https://fhir.healthdata.be/StructureDefinition/ext-AnatomicalLocation.Laterality Constraints
|
url | 1..1 | System.StringFixed Value | There are no (further) constraints on this element Element IdSpecimen.collection.bodySite.extension:laterality.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. System.String Fixed Valuehttps://fhir.healthdata.be/StructureDefinition/ext-AnatomicalLocation.Laterality
| |
value[x] | 0..1 | Binding | There are no (further) constraints on this element Element IdSpecimen.collection.bodySite.extension:laterality.value[x] Laterality Alternate namesLateraliteit DefinitionLaterality adds information about body site to the anatomic location, e.g. left.
| |
valueCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data Type | ||
morphology | I | 0..1 | Extension(CodeableConcept) | Element IdSpecimen.collection.bodySite.extension:morphology 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. https://fhir.healthdata.be/StructureDefinition/ext-LaboratoryTestResult.Specimen.Morphology Constraints
|
coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element IdSpecimen.collection.bodySite.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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.
|
text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdSpecimen.collection.bodySite.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.
|
fastingStatus[x] | Σ | 0..1 | Binding | There are no (further) constraints on this element Element IdSpecimen.collection.fastingStatus[x] Whether or how long patient abstained from food and/or drink DefinitionAbstinence or reduction from some or all food, drink, or both, for a period of time prior to sample collection. Many diagnostic tests require fasting to facilitate accurate interpretation. Representing fasting status using this element is preferred to representing it with an observation using a 'pre-coordinated code' such as LOINC 2005-7 (Calcium [Moles/time] in 2 hour Urine --12 hours fasting), or using a component observation Codes describing the fasting status of the patient. v2.0916 (extensible)Constraints
|
fastingStatusCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data Type | ||
fastingStatusDuration | Duration | There are no (further) constraints on this element Data Type | ||
processing | 0..* | BackboneElement | There are no (further) constraints on this element Element IdSpecimen.processing Processing and processing step details DefinitionDetails concerning processing and processing steps for the specimen.
| |
description | 0..1 | string | There are no (further) constraints on this element Element IdSpecimen.processing.description Textual description of procedure DefinitionTextual description of procedure. Note that FHIR strings SHALL NOT exceed 1MB in size
| |
procedure | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdSpecimen.processing.procedure Indicates the treatment step applied to the specimen DefinitionA coded value specifying the procedure used to process the specimen. 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. Type indicating the technique used to process the specimen. SpecimenProcessingProcedure (example)Constraints
| |
additive | I | 0..* | Reference(Substance) | There are no (further) constraints on this element Element IdSpecimen.processing.additive Material used in the processing step DefinitionMaterial used in the processing step. 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.
|
time[x] | 0..1 | There are no (further) constraints on this element Element IdSpecimen.processing.time[x] Date and time of specimen processing DefinitionA record of the time or period when the specimen processing occurred. For example the time of sample fixation or the period of time the sample was in formalin.
| ||
timeDateTime | dateTime | There are no (further) constraints on this element Data Type | ||
timePeriod | Period | There are no (further) constraints on this element Data Type | ||
container | 0..* | BackboneElement | There are no (further) constraints on this element Element IdSpecimen.container Direct container of specimen (tube/slide, etc.) DefinitionThe container holding the specimen. The recursive nature of containers; i.e. blood in tube in tray in rack is not addressed here.
| |
extension | I | 0..* | Extension | Element IdSpecimen.container.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Constraints
|
specimenNumberExtension | I | 0..1 | Extension(integer) | Element IdSpecimen.container.extension:specimenNumberExtension The sequence number of the sample Alternate namesextensions, user content DefinitionAn assigned number on the specimen denoting the order of collection. 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://hl7.org/fhir/StructureDefinition/specimen-sequenceNumber Constraints
|
url | 1..1 | System.StringFixed Value | There are no (further) constraints on this element Element IdSpecimen.container.extension:specimenNumberExtension.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. System.String Fixed Valuehttp://hl7.org/fhir/StructureDefinition/specimen-sequenceNumber
| |
value[x] | 1..1 | Element IdSpecimen.container.extension:specimenNumberExtension.value[x] SpecimenNumberExtension Alternate namesMonstervolgnummer DefinitionThe specimen number extension is used when the collected material is distributed from the original tube or container across multiple tubes. In combination with the specimen Id the extension yield a unique identification of the tube or container.
| ||
valueInteger | integer | There are no (further) constraints on this element Data Type | ||
identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdSpecimen.container.identifier Id for the container DefinitionId for container. There may be multiple; a manufacturer's bar code, lab assigned identifier, etc. The container ID may differ from the specimen id in some circumstances.
|
description | 0..1 | string | There are no (further) constraints on this element Element IdSpecimen.container.description Textual description of the container DefinitionTextual description of the container. Note that FHIR strings SHALL NOT exceed 1MB in size
| |
type | 0..1 | CodeableConceptBinding | Element IdSpecimen.container.type ContainerType Alternate namesContainertype DefinitionContainer type describes the envelope in which the material is collected or sent. Examples include blood tubes, transport container, possibly including culture medium. 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. Type of specimen container. ContainerType (preferred)Constraints
| |
capacity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element IdSpecimen.container.capacity Container volume or size DefinitionThe capacity (volume or other measure) the container may contain. 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.
|
specimenQuantity | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element IdSpecimen.container.specimenQuantity Quantity of specimen within container DefinitionThe quantity of specimen in the container; may be volume, dimensions, or other appropriate measurements, depending on the specimen type. 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.
|
additive[x] | 0..1 | There are no (further) constraints on this element Element IdSpecimen.container.additive[x] Additive associated with container DefinitionIntroduced substance to preserve, maintain or enhance the specimen. Examples: Formalin, Citrate, EDTA. Substance added to specimen container. v2.0371 (example)Constraints
| ||
additiveCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data Type | ||
additiveReference | Reference(Substance) | There are no (further) constraints on this element Data Type | ||
condition | Σ | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdSpecimen.condition State of the specimen DefinitionA mode or state of being that describes the nature of the specimen. The specimen condition can be used to assess its quality or appropriateness for a specific test. Specimen condition is an observation made about the specimen. It's a point-in-time assessment. It can be used to assess its quality or appropriateness for a specific test. Codes describing the state of the specimen. v2.0493 (extensible)Constraints
|
note | 0..* | Annotation | There are no (further) constraints on this element Element IdSpecimen.note Comments DefinitionTo communicate any details or issues about the specimen or during the specimen collection. (for example: broken vial, sent with patient, frozen). For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
| |
author[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdSpecimen.note.author[x] Individual responsible for the annotation DefinitionThe individual responsible for making the annotation. Organization is used when there's no need for specific attribution as to who made the comment.
| |
authorString | string | There are no (further) constraints on this element Data Type | ||
authorReference | Reference(Practitioner | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Data Type Reference(Practitioner | Patient | RelatedPerson | Organization) | ||
time | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdSpecimen.note.time When the annotation was made DefinitionIndicates when this particular annotation was made.
|
text | Σ | 1..1 | markdown | Element IdSpecimen.note.text Comment Alternate namesToelichting DefinitionComments on the specimen , such as drawing material after a (glucose) stimulus or taking medicine. Systems are not required to have markdown support, so the text should be readable without markdown processing. The markdown syntax is GFM - see https://github.github.com/gfm/
|
Mapping FHIR profile to CBB
Path | map | CBB |
---|---|---|
Specimen | Specimen | HdBe-LaboratoryTestResult |
Specimen.identifier | Specimen.SpecimenId | HdBe-LaboratoryTestResult |
Specimen.type | Specimen.SpecimenMaterial | HdBe-LaboratoryTestResult |
Specimen.type | SpecimenMicroorganism | HdBe-LaboratoryTestResult |
Specimen.receivedTime | Specimen.ReceivedDateTime | HdBe-LaboratoryTestResult |
Specimen.collection.collected[x]:collectedDateTime | Specimen.CollectionDateTime | HdBe-LaboratoryTestResult |
Specimen.collection.collected[x]:collectedPeriod | Specimen.CollectionPeriod | HdBe-LaboratoryTestResult |
Specimen.collection.duration | Specimen.CollectionPeriod | HdBe-LaboratoryTestResult |
Specimen.collection.quantity | Specimen.CollectedVolume | HdBe-LaboratoryTestResult |
Specimen.collection.method | Specimen.CollectionMethod | HdBe-LaboratoryTestResult |
Specimen.collection.bodySite | Specimen.AnatomicalLocation | HdBe-LaboratoryTestResult |
Specimen.collection.bodySite.extension:morphology | Specimen.Morphology | HdBe-LaboratoryTestResult |
Specimen.container.extension:specimenNumberExtension.value[x] | Specimen.SpecimenNumberExtension | HdBe-LaboratoryTestResult |
Specimen.container.type | Specimen.ContainerType | HdBe-LaboratoryTestResult |
Specimen.note.text | Specimen.Comment | HdBe-LaboratoryTestResult |
zib LaboratoryTestResult.Specimen difference
Concept | Category | Description |
---|---|---|
type |
terminology | Replaced SpecimenMaterial valueset values from a SNOMED descendent-of 105590001 (Substance) to a descendent-of 123038009 (Specimen) because this makes it simpler, it is already in use in the DCD's like this and the container element can be used when additional information is required. |
type |
terminology | Replaced Dutch reference set for Microorganism by changing the SNOMED hierarchy 2581000146104 (Dutch microorganism simple reference set) to 410607006 (Organism). |
type |
terminology | Combined ValueSet for SpecimenMaterial and Microorganism in new ValueSet SpecimenMaterial-and-Microorganism. |
receivedTime |
textual | Removed sentence 'This is the issue...' (zib ticket #1551) |
container.type |
terminology | Relaxed binding from required to preferred. (zib ticket #1552) |
HdBe-LaboratoryTestResult.Requester
Instructions |
---|
This is a minimal defined profile on ServiceRequest to capture the requester information of the CBB LaboratoryTestResult. Although the concept Requester is not implemented in the zib profile because it is deemed unimplementable as-is, it has been implemented by this profile using a light profile on ServiceRequest. The profile does not contain enough guidance to implement a requesting service fully. It merely allows capturing the requester information in a native FHIR element. |
ServiceRequest | I | ServiceRequest | Element IdServiceRequest A request for a service to be performed Alternate namesdiagnostic request, referral, referral request, transfer of care request DefinitionA record of a request for service such as diagnostic investigations, treatments, or operations to be performed. This is a minimal defined profile on ServiceRequest to capture the requester information of the CBB LaboratoryTestResult. Although the concept Requester is not implemented in the zib profile because it is deemed unimplementable as-is, it has been implemented by this profile using a light profile on ServiceRequest. The profile does not contain enough guidance to implement a requesting service fully. It merely allows capturing the requester information in a native FHIR element.
| |
identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdServiceRequest.identifier Identifiers assigned to this order DefinitionIdentifiers assigned to this order instance by the orderer and/or the receiver and/or order fulfiller. The identifier.type element is used to distinguish between the identifiers assigned by the orderer (known as the 'Placer' in HL7 v2) and the producer of the observations in response to the order (known as the 'Filler' in HL7 v2). For further discussion and examples see the resource notes section below.
|
instantiatesCanonical | Σ | 0..* | canonical(ActivityDefinition | PlanDefinition) | There are no (further) constraints on this element Element IdServiceRequest.instantiatesCanonical Instantiates FHIR protocol or definition DefinitionThe URL pointing to a FHIR-defined protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. Note: This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. canonical(ActivityDefinition | PlanDefinition) Constraints
|
instantiatesUri | Σ | 0..* | uri | There are no (further) constraints on this element Element IdServiceRequest.instantiatesUri Instantiates external protocol or definition DefinitionThe URL pointing to an externally maintained protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
|
basedOn | Σ I | 0..* | Reference(CarePlan | ServiceRequest | MedicationRequest) | There are no (further) constraints on this element Element IdServiceRequest.basedOn What request fulfills Alternate namesfulfills DefinitionPlan/proposal/order fulfilled by this request. 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(CarePlan | ServiceRequest | MedicationRequest) Constraints
|
replaces | Σ I | 0..* | Reference(ServiceRequest) | There are no (further) constraints on this element Element IdServiceRequest.replaces What request replaces Alternate namessupersedes, prior, renewed order DefinitionThe request takes the place of the referenced completed or terminated request(s). 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.
|
requisition | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element IdServiceRequest.requisition Composite Request ID Alternate namesgrouperId, groupIdentifier DefinitionA shared identifier common to all service requests that were authorized more or less simultaneously by a single author, representing the composite or group identifier. Some business processes need to know if multiple items were ordered as part of the same "requisition" for billing or other purposes. Requests are linked either by a "basedOn" relationship (i.e. one request is fulfilling another) or by having a common requisition. Requests that are part of the same requisition are generally treated independently from the perspective of changing their state or maintaining them after initial creation.
|
status | Σ ?! | 1..1 | codeBinding | Element IdServiceRequest.status draft | active | on-hold | revoked | completed | entered-in-error | unknown DefinitionThe status of the order. Unless a more appropriate status is recorded, it is assumed that only completed ServiceRequest for LaboratoryTestResults will be exchanged. The status of a service order. RequestStatus (required)Constraints
|
intent | Σ ?! | 1..1 | codeBinding | Element IdServiceRequest.intent proposal | plan | directive | order | original-order | reflex-order | filler-order | instance-order | option DefinitionWhether the request is a proposal, plan, an original order or a reflex order. Unless a more appropriate intent is recorded, it is assumed that only ServiceRequest with the intent order for LaboratoryTestResults will be exchanged. The kind of service request. RequestIntent (required)Constraints
|
category | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.category Classification of service DefinitionA code that classifies the service for searching, sorting and display purposes (e.g. "Surgical Procedure"). Used for filtering what service request are retrieved and displayed. There may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set. Classification of the requested service. ServiceRequestCategoryCodes (example)Constraints
|
priority | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element IdServiceRequest.priority routine | urgent | asap | stat DefinitionIndicates how quickly the ServiceRequest should be addressed with respect to other requests. Note that FHIR strings SHALL NOT exceed 1MB in size Identifies the level of importance to be assigned to actioning the request. RequestPriority (required)Constraints
|
doNotPerform | Σ ?! | 0..1 | boolean | There are no (further) constraints on this element Element IdServiceRequest.doNotPerform True if service/procedure should not be performed DefinitionSet this to true if the record is saying that the service/procedure should NOT be performed. Used for do not ambulate, do not elevate head of bed, do not flush NG tube, do not take blood pressure on a certain arm, etc. In general, only the code and timeframe will be present, though occasional additional qualifiers such as body site or even performer could be included to narrow the scope of the prohibition. If the ServiceRequest.code and ServiceRequest.doNotPerform both contain negation, that will reinforce prohibition and should not have a double negative interpretation.
|
code | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.code What is being requested/ordered Alternate namesservice requested DefinitionA code that identifies a particular service (i.e., procedure, diagnostic investigation, or panel of investigations) that have been requested. Many laboratory and radiology procedure codes embed the specimen/organ system in the test order name, for example, serum or serum/plasma glucose, or a chest x-ray. The specimen might not be recorded separately from the test code. Codes for tests or services that can be carried out by a designated individual, organization or healthcare service. For laboratory, LOINC is (preferred)[http://build.fhir.org/terminologies.html#preferred] and a valueset using LOINC Order codes is available [here](valueset-diagnostic-requests.html). ProcedureCodes(SNOMEDCT) (example)Constraints
|
orderDetail | Σ I | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.orderDetail Additional order information Alternate namesdetailed instructions DefinitionAdditional details and instructions about the how the services are to be delivered. For example, and order for a urinary catheter may have an order detail for an external or indwelling catheter, or an order for a bandage may require additional instructions specifying how the bandage should be applied. For information from the medical record intended to support the delivery of the requested services, use the Codified order entry details which are based on order context. ServiceRequestOrderDetailsCodes (example)Constraints
|
quantity[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdServiceRequest.quantity[x] Service amount DefinitionAn amount of service being requested which can be a quantity ( for example $1,500 home modification), a ratio ( for example, 20 half day visits per month), or a range (2.0 to 1.8 Gy per fraction). When ordering a service the number of service items may need to be specified separately from the the service item.
| |
quantityQuantity | Quantity | There are no (further) constraints on this element Data Type | ||
quantityRatio | Ratio | There are no (further) constraints on this element Data Type | ||
quantityRange | Range | There are no (further) constraints on this element Data Type | ||
subject | Σ I | 1..1 | Reference(Patient | Group | Location | Device | HdBe Patient) | Element IdServiceRequest.subject Individual or Entity the service is ordered for DefinitionOn whom or what the service is to be performed. This is usually a human patient, but can also be requested on animals, groups of humans or animals, devices such as dialysis machines, or even locations (typically for environmental scans). 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(Patient | Group | Location | Device | HdBe Patient) Constraints
|
encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdServiceRequest.encounter Encounter in which the request was created Alternate namescontext DefinitionAn encounter that provides additional information about the healthcare context in which this request is made. 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.
|
occurrence[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdServiceRequest.occurrence[x] When service should occur Alternate namesschedule DefinitionThe date/time at which the requested service should occur.
| |
occurrenceDateTime | dateTime | There are no (further) constraints on this element Data Type | ||
occurrencePeriod | Period | There are no (further) constraints on this element Data Type | ||
occurrenceTiming | Timing | There are no (further) constraints on this element Data Type | ||
asNeeded[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdServiceRequest.asNeeded[x] Preconditions for service DefinitionIf a CodeableConcept is present, it indicates the pre-condition for performing the service. For example "pain", "on flare-up", etc. A coded concept identifying the pre-condition that should hold prior to performing a procedure. For example "pain", "on flare-up", etc. SNOMEDCTMedicationAsNeededReasonCodes (example)Constraints
| |
asNeededBoolean | boolean | There are no (further) constraints on this element Data Type | ||
asNeededCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data Type | ||
authoredOn | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdServiceRequest.authoredOn Date request signed Alternate namesorderedOn DefinitionWhen the request transitioned to being actionable.
|
requester | Σ I | 1..1 | pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | HdBe HealthProfessional PractitionerRole) | Element IdServiceRequest.requester A reference from one resource to another Alternate namesauthor, orderer DefinitionThe individual who initiated the request and has responsibility for its activation. Using the PractitionerRole(HdBe-HealthProfessional-PractitionerRole) reference, the affiliated organization can be captured. Each occurrence of the CBB HealthProfessional is normally represented by two FHIR resources: a PractitionerRole resource (instance of HdBe-HealthProfessional-PractitionerRole) and a Practitioner resource (instance of HdBe-HealthProfessional-Practitioner). The Practitioner resource is referenced from the PractitionerRole instance. For this reason, sending systems should fill the reference to the PractitionerRole instance here, and not the Practitioner resource. Receiving systems can then retrieve the reference to the Practitioner resource from that PractitionerRole instance. In rare circumstances, there is only a Practitioner instance, in which case it is that instance which will be referenced here. However, since this should be the exception, the HdBe-HealthProfessional-Practitioner profile is not explicitly mentioned as a target profile. pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | HdBe HealthProfessional PractitionerRole) Constraints
|
performerType | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.performerType Performer role Alternate namesspecialty DefinitionDesired type of performer for doing the requested service. This is a role, not a participation type. In other words, does not describe the task but describes the capacity. For example, “compounding pharmacy”, “psychiatrist” or “internal referral”. Indicates specific responsibility of an individual within the care team, such as "Primary physician", "Team coordinator", "Caregiver", etc. ParticipantRoles (example)Constraints
|
performer | Σ I | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | HealthcareService | Patient | Device | RelatedPerson) | There are no (further) constraints on this element Element IdServiceRequest.performer Requested performer Alternate namesrequest recipient DefinitionThe desired performer for doing the requested service. For example, the surgeon, dermatopathologist, endoscopist, etc. If multiple performers are present, it is interpreted as a list of alternative performers without any preference regardless of order. If order of preference is needed use the request-performerOrder extension. Use CareTeam to represent a group of performers (for example, Practitioner A and Practitioner B). Reference(Practitioner | PractitionerRole | Organization | CareTeam | HealthcareService | Patient | Device | RelatedPerson) Constraints
|
locationCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.locationCode Requested location DefinitionThe preferred location(s) where the procedure should actually happen in coded or free text form. E.g. at home or nursing day care center. 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. A location type where services are delivered. v3.ServiceDeliveryLocationRoleType (example)Constraints
|
locationReference | Σ I | 0..* | Reference(Location) | There are no (further) constraints on this element Element IdServiceRequest.locationReference Requested location DefinitionA reference to the the preferred location(s) where the procedure should actually happen. E.g. at home or nursing day care center. 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.
|
reasonCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.reasonCode Explanation/Justification for procedure or service DefinitionAn explanation or justification for why this service is being requested in coded or textual form. This is often for billing purposes. May relate to the resources referred to in This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. Use Diagnosis or problem codes justifying the reason for requesting the service investigation. ProcedureReasonCodes (example)Constraints
|
reasonReference | Σ I | 0..* | Reference(Condition | Observation | DiagnosticReport | DocumentReference) | There are no (further) constraints on this element Element IdServiceRequest.reasonReference Explanation/Justification for service or service DefinitionIndicates another resource that provides a justification for why this service is being requested. May relate to the resources referred to in This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. To be as specific as possible, a reference to Observation or Condition should be used if available. Otherwise when referencing DiagnosticReport it should contain a finding in Reference(Condition | Observation | DiagnosticReport | DocumentReference) Constraints
|
insurance | I | 0..* | Reference(Coverage | ClaimResponse) | There are no (further) constraints on this element Element IdServiceRequest.insurance Associated insurance coverage DefinitionInsurance plans, coverage extensions, pre-authorizations and/or pre-determinations that may be needed for delivering the requested service. 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(Coverage | ClaimResponse) Constraints
|
supportingInfo | I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdServiceRequest.supportingInfo Additional clinical information Alternate namesAsk at order entry question, AOE DefinitionAdditional clinical information about the patient or specimen that may influence the services or their interpretations. This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as "ask at order entry questions (AOEs)". This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the amount of inspired oxygen for blood gas measurements. To represent information about how the services are to be delivered use the
|
specimen | Σ I | 0..* | Reference(Specimen) | There are no (further) constraints on this element Element IdServiceRequest.specimen Procedure Samples DefinitionOne or more specimens that the laboratory procedure will use. Many diagnostic procedures need a specimen, but the request itself is not actually about the specimen. This element is for when the diagnostic is requested on already existing specimens and the request points to the specimen it applies to. Conversely, if the request is entered first with an unknown specimen, then the Specimen resource points to the ServiceRequest.
|
bodySite | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.bodySite Location on Body Alternate nameslocation DefinitionAnatomic location where the procedure should be performed. This is the target site. Knowing where the procedure is performed is important for tracking if multiple sites are possible. Only used if not implicit in the code found in ServiceRequest.code. If the use case requires BodySite to be handled as a separate resource instead of an inline coded element (e.g. to identify and track separately) then use the standard extension procedure-targetBodyStructure. Codes describing anatomical locations. May include laterality. SNOMEDCTBodyStructures (example)Constraints
|
note | 0..* | Annotation | There are no (further) constraints on this element Element IdServiceRequest.note Comments DefinitionAny other notes and comments made about the service request. For example, internal billing notes. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
| |
patientInstruction | Σ | 0..1 | string | There are no (further) constraints on this element Element IdServiceRequest.patientInstruction Patient or consumer-oriented instructions DefinitionInstructions in terms that are understood by the patient or consumer. Note that FHIR strings SHALL NOT exceed 1MB in size
|
relevantHistory | I | 0..* | Reference(Provenance) | There are no (further) constraints on this element Element IdServiceRequest.relevantHistory Request provenance DefinitionKey events in the history of the request. This might not include provenances for all versions of the request – only those deemed “relevant” or important. This SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude All Provenances should have some historical version of this Request as their subject.
|
ServiceRequest | I | ServiceRequest | Element IdServiceRequest A request for a service to be performed Alternate namesdiagnostic request, referral, referral request, transfer of care request DefinitionA record of a request for service such as diagnostic investigations, treatments, or operations to be performed. This is a minimal defined profile on ServiceRequest to capture the requester information of the CBB LaboratoryTestResult. Although the concept Requester is not implemented in the zib profile because it is deemed unimplementable as-is, it has been implemented by this profile using a light profile on ServiceRequest. The profile does not contain enough guidance to implement a requesting service fully. It merely allows capturing the requester information in a native FHIR element.
| |
identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdServiceRequest.identifier Identifiers assigned to this order DefinitionIdentifiers assigned to this order instance by the orderer and/or the receiver and/or order fulfiller. The identifier.type element is used to distinguish between the identifiers assigned by the orderer (known as the 'Placer' in HL7 v2) and the producer of the observations in response to the order (known as the 'Filler' in HL7 v2). For further discussion and examples see the resource notes section below.
|
instantiatesCanonical | Σ | 0..* | canonical(ActivityDefinition | PlanDefinition) | There are no (further) constraints on this element Element IdServiceRequest.instantiatesCanonical Instantiates FHIR protocol or definition DefinitionThe URL pointing to a FHIR-defined protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. Note: This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. canonical(ActivityDefinition | PlanDefinition) Constraints
|
instantiatesUri | Σ | 0..* | uri | There are no (further) constraints on this element Element IdServiceRequest.instantiatesUri Instantiates external protocol or definition DefinitionThe URL pointing to an externally maintained protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
|
basedOn | Σ I | 0..* | Reference(CarePlan | ServiceRequest | MedicationRequest) | There are no (further) constraints on this element Element IdServiceRequest.basedOn What request fulfills Alternate namesfulfills DefinitionPlan/proposal/order fulfilled by this request. 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(CarePlan | ServiceRequest | MedicationRequest) Constraints
|
replaces | Σ I | 0..* | Reference(ServiceRequest) | There are no (further) constraints on this element Element IdServiceRequest.replaces What request replaces Alternate namessupersedes, prior, renewed order DefinitionThe request takes the place of the referenced completed or terminated request(s). 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.
|
requisition | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element IdServiceRequest.requisition Composite Request ID Alternate namesgrouperId, groupIdentifier DefinitionA shared identifier common to all service requests that were authorized more or less simultaneously by a single author, representing the composite or group identifier. Some business processes need to know if multiple items were ordered as part of the same "requisition" for billing or other purposes. Requests are linked either by a "basedOn" relationship (i.e. one request is fulfilling another) or by having a common requisition. Requests that are part of the same requisition are generally treated independently from the perspective of changing their state or maintaining them after initial creation.
|
status | Σ ?! | 1..1 | codeBinding | Element IdServiceRequest.status draft | active | on-hold | revoked | completed | entered-in-error | unknown DefinitionThe status of the order. Unless a more appropriate status is recorded, it is assumed that only completed ServiceRequest for LaboratoryTestResults will be exchanged. The status of a service order. RequestStatus (required)Constraints
|
intent | Σ ?! | 1..1 | codeBinding | Element IdServiceRequest.intent proposal | plan | directive | order | original-order | reflex-order | filler-order | instance-order | option DefinitionWhether the request is a proposal, plan, an original order or a reflex order. Unless a more appropriate intent is recorded, it is assumed that only ServiceRequest with the intent order for LaboratoryTestResults will be exchanged. The kind of service request. RequestIntent (required)Constraints
|
category | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.category Classification of service DefinitionA code that classifies the service for searching, sorting and display purposes (e.g. "Surgical Procedure"). Used for filtering what service request are retrieved and displayed. There may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set. Classification of the requested service. ServiceRequestCategoryCodes (example)Constraints
|
priority | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element IdServiceRequest.priority routine | urgent | asap | stat DefinitionIndicates how quickly the ServiceRequest should be addressed with respect to other requests. Note that FHIR strings SHALL NOT exceed 1MB in size Identifies the level of importance to be assigned to actioning the request. RequestPriority (required)Constraints
|
doNotPerform | Σ ?! | 0..1 | boolean | There are no (further) constraints on this element Element IdServiceRequest.doNotPerform True if service/procedure should not be performed DefinitionSet this to true if the record is saying that the service/procedure should NOT be performed. Used for do not ambulate, do not elevate head of bed, do not flush NG tube, do not take blood pressure on a certain arm, etc. In general, only the code and timeframe will be present, though occasional additional qualifiers such as body site or even performer could be included to narrow the scope of the prohibition. If the ServiceRequest.code and ServiceRequest.doNotPerform both contain negation, that will reinforce prohibition and should not have a double negative interpretation.
|
code | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.code What is being requested/ordered Alternate namesservice requested DefinitionA code that identifies a particular service (i.e., procedure, diagnostic investigation, or panel of investigations) that have been requested. Many laboratory and radiology procedure codes embed the specimen/organ system in the test order name, for example, serum or serum/plasma glucose, or a chest x-ray. The specimen might not be recorded separately from the test code. Codes for tests or services that can be carried out by a designated individual, organization or healthcare service. For laboratory, LOINC is (preferred)[http://build.fhir.org/terminologies.html#preferred] and a valueset using LOINC Order codes is available [here](valueset-diagnostic-requests.html). ProcedureCodes(SNOMEDCT) (example)Constraints
|
orderDetail | Σ I | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.orderDetail Additional order information Alternate namesdetailed instructions DefinitionAdditional details and instructions about the how the services are to be delivered. For example, and order for a urinary catheter may have an order detail for an external or indwelling catheter, or an order for a bandage may require additional instructions specifying how the bandage should be applied. For information from the medical record intended to support the delivery of the requested services, use the Codified order entry details which are based on order context. ServiceRequestOrderDetailsCodes (example)Constraints
|
quantity[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdServiceRequest.quantity[x] Service amount DefinitionAn amount of service being requested which can be a quantity ( for example $1,500 home modification), a ratio ( for example, 20 half day visits per month), or a range (2.0 to 1.8 Gy per fraction). When ordering a service the number of service items may need to be specified separately from the the service item.
| |
quantityQuantity | Quantity | There are no (further) constraints on this element Data Type | ||
quantityRatio | Ratio | There are no (further) constraints on this element Data Type | ||
quantityRange | Range | There are no (further) constraints on this element Data Type | ||
subject | Σ I | 1..1 | Reference(Patient | Group | Location | Device | HdBe Patient) | Element IdServiceRequest.subject Individual or Entity the service is ordered for DefinitionOn whom or what the service is to be performed. This is usually a human patient, but can also be requested on animals, groups of humans or animals, devices such as dialysis machines, or even locations (typically for environmental scans). 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(Patient | Group | Location | Device | HdBe Patient) Constraints
|
encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdServiceRequest.encounter Encounter in which the request was created Alternate namescontext DefinitionAn encounter that provides additional information about the healthcare context in which this request is made. 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.
|
occurrence[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdServiceRequest.occurrence[x] When service should occur Alternate namesschedule DefinitionThe date/time at which the requested service should occur.
| |
occurrenceDateTime | dateTime | There are no (further) constraints on this element Data Type | ||
occurrencePeriod | Period | There are no (further) constraints on this element Data Type | ||
occurrenceTiming | Timing | There are no (further) constraints on this element Data Type | ||
asNeeded[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdServiceRequest.asNeeded[x] Preconditions for service DefinitionIf a CodeableConcept is present, it indicates the pre-condition for performing the service. For example "pain", "on flare-up", etc. A coded concept identifying the pre-condition that should hold prior to performing a procedure. For example "pain", "on flare-up", etc. SNOMEDCTMedicationAsNeededReasonCodes (example)Constraints
| |
asNeededBoolean | boolean | There are no (further) constraints on this element Data Type | ||
asNeededCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data Type | ||
authoredOn | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdServiceRequest.authoredOn Date request signed Alternate namesorderedOn DefinitionWhen the request transitioned to being actionable.
|
requester | Σ I | 1..1 | pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | HdBe HealthProfessional PractitionerRole) | Element IdServiceRequest.requester A reference from one resource to another Alternate namesauthor, orderer DefinitionThe individual who initiated the request and has responsibility for its activation. Using the PractitionerRole(HdBe-HealthProfessional-PractitionerRole) reference, the affiliated organization can be captured. Each occurrence of the CBB HealthProfessional is normally represented by two FHIR resources: a PractitionerRole resource (instance of HdBe-HealthProfessional-PractitionerRole) and a Practitioner resource (instance of HdBe-HealthProfessional-Practitioner). The Practitioner resource is referenced from the PractitionerRole instance. For this reason, sending systems should fill the reference to the PractitionerRole instance here, and not the Practitioner resource. Receiving systems can then retrieve the reference to the Practitioner resource from that PractitionerRole instance. In rare circumstances, there is only a Practitioner instance, in which case it is that instance which will be referenced here. However, since this should be the exception, the HdBe-HealthProfessional-Practitioner profile is not explicitly mentioned as a target profile. pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | HdBe HealthProfessional PractitionerRole) Constraints
|
performerType | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.performerType Performer role Alternate namesspecialty DefinitionDesired type of performer for doing the requested service. This is a role, not a participation type. In other words, does not describe the task but describes the capacity. For example, “compounding pharmacy”, “psychiatrist” or “internal referral”. Indicates specific responsibility of an individual within the care team, such as "Primary physician", "Team coordinator", "Caregiver", etc. ParticipantRoles (example)Constraints
|
performer | Σ I | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | HealthcareService | Patient | Device | RelatedPerson) | There are no (further) constraints on this element Element IdServiceRequest.performer Requested performer Alternate namesrequest recipient DefinitionThe desired performer for doing the requested service. For example, the surgeon, dermatopathologist, endoscopist, etc. If multiple performers are present, it is interpreted as a list of alternative performers without any preference regardless of order. If order of preference is needed use the request-performerOrder extension. Use CareTeam to represent a group of performers (for example, Practitioner A and Practitioner B). Reference(Practitioner | PractitionerRole | Organization | CareTeam | HealthcareService | Patient | Device | RelatedPerson) Constraints
|
locationCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.locationCode Requested location DefinitionThe preferred location(s) where the procedure should actually happen in coded or free text form. E.g. at home or nursing day care center. 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. A location type where services are delivered. v3.ServiceDeliveryLocationRoleType (example)Constraints
|
locationReference | Σ I | 0..* | Reference(Location) | There are no (further) constraints on this element Element IdServiceRequest.locationReference Requested location DefinitionA reference to the the preferred location(s) where the procedure should actually happen. E.g. at home or nursing day care center. 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.
|
reasonCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.reasonCode Explanation/Justification for procedure or service DefinitionAn explanation or justification for why this service is being requested in coded or textual form. This is often for billing purposes. May relate to the resources referred to in This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. Use Diagnosis or problem codes justifying the reason for requesting the service investigation. ProcedureReasonCodes (example)Constraints
|
reasonReference | Σ I | 0..* | Reference(Condition | Observation | DiagnosticReport | DocumentReference) | There are no (further) constraints on this element Element IdServiceRequest.reasonReference Explanation/Justification for service or service DefinitionIndicates another resource that provides a justification for why this service is being requested. May relate to the resources referred to in This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. To be as specific as possible, a reference to Observation or Condition should be used if available. Otherwise when referencing DiagnosticReport it should contain a finding in Reference(Condition | Observation | DiagnosticReport | DocumentReference) Constraints
|
insurance | I | 0..* | Reference(Coverage | ClaimResponse) | There are no (further) constraints on this element Element IdServiceRequest.insurance Associated insurance coverage DefinitionInsurance plans, coverage extensions, pre-authorizations and/or pre-determinations that may be needed for delivering the requested service. 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(Coverage | ClaimResponse) Constraints
|
supportingInfo | I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdServiceRequest.supportingInfo Additional clinical information Alternate namesAsk at order entry question, AOE DefinitionAdditional clinical information about the patient or specimen that may influence the services or their interpretations. This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as "ask at order entry questions (AOEs)". This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the amount of inspired oxygen for blood gas measurements. To represent information about how the services are to be delivered use the
|
specimen | Σ I | 0..* | Reference(Specimen) | There are no (further) constraints on this element Element IdServiceRequest.specimen Procedure Samples DefinitionOne or more specimens that the laboratory procedure will use. Many diagnostic procedures need a specimen, but the request itself is not actually about the specimen. This element is for when the diagnostic is requested on already existing specimens and the request points to the specimen it applies to. Conversely, if the request is entered first with an unknown specimen, then the Specimen resource points to the ServiceRequest.
|
bodySite | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.bodySite Location on Body Alternate nameslocation DefinitionAnatomic location where the procedure should be performed. This is the target site. Knowing where the procedure is performed is important for tracking if multiple sites are possible. Only used if not implicit in the code found in ServiceRequest.code. If the use case requires BodySite to be handled as a separate resource instead of an inline coded element (e.g. to identify and track separately) then use the standard extension procedure-targetBodyStructure. Codes describing anatomical locations. May include laterality. SNOMEDCTBodyStructures (example)Constraints
|
note | 0..* | Annotation | There are no (further) constraints on this element Element IdServiceRequest.note Comments DefinitionAny other notes and comments made about the service request. For example, internal billing notes. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
| |
patientInstruction | Σ | 0..1 | string | There are no (further) constraints on this element Element IdServiceRequest.patientInstruction Patient or consumer-oriented instructions DefinitionInstructions in terms that are understood by the patient or consumer. Note that FHIR strings SHALL NOT exceed 1MB in size
|
relevantHistory | I | 0..* | Reference(Provenance) | There are no (further) constraints on this element Element IdServiceRequest.relevantHistory Request provenance DefinitionKey events in the history of the request. This might not include provenances for all versions of the request – only those deemed “relevant” or important. This SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude All Provenances should have some historical version of this Request as their subject.
|
ServiceRequest | I | ServiceRequest | Element IdServiceRequest A request for a service to be performed Alternate namesdiagnostic request, referral, referral request, transfer of care request DefinitionA record of a request for service such as diagnostic investigations, treatments, or operations to be performed. This is a minimal defined profile on ServiceRequest to capture the requester information of the CBB LaboratoryTestResult. Although the concept Requester is not implemented in the zib profile because it is deemed unimplementable as-is, it has been implemented by this profile using a light profile on ServiceRequest. The profile does not contain enough guidance to implement a requesting service fully. It merely allows capturing the requester information in a native FHIR element.
| |
identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdServiceRequest.identifier Identifiers assigned to this order DefinitionIdentifiers assigned to this order instance by the orderer and/or the receiver and/or order fulfiller. The identifier.type element is used to distinguish between the identifiers assigned by the orderer (known as the 'Placer' in HL7 v2) and the producer of the observations in response to the order (known as the 'Filler' in HL7 v2). For further discussion and examples see the resource notes section below.
|
instantiatesCanonical | Σ | 0..* | canonical(ActivityDefinition | PlanDefinition) | There are no (further) constraints on this element Element IdServiceRequest.instantiatesCanonical Instantiates FHIR protocol or definition DefinitionThe URL pointing to a FHIR-defined protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. Note: This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. canonical(ActivityDefinition | PlanDefinition) Constraints
|
instantiatesUri | Σ | 0..* | uri | There are no (further) constraints on this element Element IdServiceRequest.instantiatesUri Instantiates external protocol or definition DefinitionThe URL pointing to an externally maintained protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
|
basedOn | Σ I | 0..* | Reference(CarePlan | ServiceRequest | MedicationRequest) | There are no (further) constraints on this element Element IdServiceRequest.basedOn What request fulfills Alternate namesfulfills DefinitionPlan/proposal/order fulfilled by this request. 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(CarePlan | ServiceRequest | MedicationRequest) Constraints
|
replaces | Σ I | 0..* | Reference(ServiceRequest) | There are no (further) constraints on this element Element IdServiceRequest.replaces What request replaces Alternate namessupersedes, prior, renewed order DefinitionThe request takes the place of the referenced completed or terminated request(s). 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.
|
requisition | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element IdServiceRequest.requisition Composite Request ID Alternate namesgrouperId, groupIdentifier DefinitionA shared identifier common to all service requests that were authorized more or less simultaneously by a single author, representing the composite or group identifier. Some business processes need to know if multiple items were ordered as part of the same "requisition" for billing or other purposes. Requests are linked either by a "basedOn" relationship (i.e. one request is fulfilling another) or by having a common requisition. Requests that are part of the same requisition are generally treated independently from the perspective of changing their state or maintaining them after initial creation.
|
status | Σ ?! | 1..1 | codeBinding | Element IdServiceRequest.status draft | active | on-hold | revoked | completed | entered-in-error | unknown DefinitionThe status of the order. Unless a more appropriate status is recorded, it is assumed that only completed ServiceRequest for LaboratoryTestResults will be exchanged. The status of a service order. RequestStatus (required)Constraints
|
intent | Σ ?! | 1..1 | codeBinding | Element IdServiceRequest.intent proposal | plan | directive | order | original-order | reflex-order | filler-order | instance-order | option DefinitionWhether the request is a proposal, plan, an original order or a reflex order. Unless a more appropriate intent is recorded, it is assumed that only ServiceRequest with the intent order for LaboratoryTestResults will be exchanged. The kind of service request. RequestIntent (required)Constraints
|
category | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.category Classification of service DefinitionA code that classifies the service for searching, sorting and display purposes (e.g. "Surgical Procedure"). Used for filtering what service request are retrieved and displayed. There may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set. Classification of the requested service. ServiceRequestCategoryCodes (example)Constraints
|
priority | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element IdServiceRequest.priority routine | urgent | asap | stat DefinitionIndicates how quickly the ServiceRequest should be addressed with respect to other requests. Note that FHIR strings SHALL NOT exceed 1MB in size Identifies the level of importance to be assigned to actioning the request. RequestPriority (required)Constraints
|
doNotPerform | Σ ?! | 0..1 | boolean | There are no (further) constraints on this element Element IdServiceRequest.doNotPerform True if service/procedure should not be performed DefinitionSet this to true if the record is saying that the service/procedure should NOT be performed. Used for do not ambulate, do not elevate head of bed, do not flush NG tube, do not take blood pressure on a certain arm, etc. In general, only the code and timeframe will be present, though occasional additional qualifiers such as body site or even performer could be included to narrow the scope of the prohibition. If the ServiceRequest.code and ServiceRequest.doNotPerform both contain negation, that will reinforce prohibition and should not have a double negative interpretation.
|
code | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.code What is being requested/ordered Alternate namesservice requested DefinitionA code that identifies a particular service (i.e., procedure, diagnostic investigation, or panel of investigations) that have been requested. Many laboratory and radiology procedure codes embed the specimen/organ system in the test order name, for example, serum or serum/plasma glucose, or a chest x-ray. The specimen might not be recorded separately from the test code. Codes for tests or services that can be carried out by a designated individual, organization or healthcare service. For laboratory, LOINC is (preferred)[http://build.fhir.org/terminologies.html#preferred] and a valueset using LOINC Order codes is available [here](valueset-diagnostic-requests.html). ProcedureCodes(SNOMEDCT) (example)Constraints
|
orderDetail | Σ I | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.orderDetail Additional order information Alternate namesdetailed instructions DefinitionAdditional details and instructions about the how the services are to be delivered. For example, and order for a urinary catheter may have an order detail for an external or indwelling catheter, or an order for a bandage may require additional instructions specifying how the bandage should be applied. For information from the medical record intended to support the delivery of the requested services, use the Codified order entry details which are based on order context. ServiceRequestOrderDetailsCodes (example)Constraints
|
quantity[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdServiceRequest.quantity[x] Service amount DefinitionAn amount of service being requested which can be a quantity ( for example $1,500 home modification), a ratio ( for example, 20 half day visits per month), or a range (2.0 to 1.8 Gy per fraction). When ordering a service the number of service items may need to be specified separately from the the service item.
| |
quantityQuantity | Quantity | There are no (further) constraints on this element Data Type | ||
quantityRatio | Ratio | There are no (further) constraints on this element Data Type | ||
quantityRange | Range | There are no (further) constraints on this element Data Type | ||
subject | Σ I | 1..1 | Reference(Patient | Group | Location | Device | HdBe Patient) | Element IdServiceRequest.subject Individual or Entity the service is ordered for DefinitionOn whom or what the service is to be performed. This is usually a human patient, but can also be requested on animals, groups of humans or animals, devices such as dialysis machines, or even locations (typically for environmental scans). 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(Patient | Group | Location | Device | HdBe Patient) Constraints
|
encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdServiceRequest.encounter Encounter in which the request was created Alternate namescontext DefinitionAn encounter that provides additional information about the healthcare context in which this request is made. 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.
|
occurrence[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdServiceRequest.occurrence[x] When service should occur Alternate namesschedule DefinitionThe date/time at which the requested service should occur.
| |
occurrenceDateTime | dateTime | There are no (further) constraints on this element Data Type | ||
occurrencePeriod | Period | There are no (further) constraints on this element Data Type | ||
occurrenceTiming | Timing | There are no (further) constraints on this element Data Type | ||
asNeeded[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdServiceRequest.asNeeded[x] Preconditions for service DefinitionIf a CodeableConcept is present, it indicates the pre-condition for performing the service. For example "pain", "on flare-up", etc. A coded concept identifying the pre-condition that should hold prior to performing a procedure. For example "pain", "on flare-up", etc. SNOMEDCTMedicationAsNeededReasonCodes (example)Constraints
| |
asNeededBoolean | boolean | There are no (further) constraints on this element Data Type | ||
asNeededCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data Type | ||
authoredOn | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdServiceRequest.authoredOn Date request signed Alternate namesorderedOn DefinitionWhen the request transitioned to being actionable.
|
requester | Σ I | 1..1 | pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | HdBe HealthProfessional PractitionerRole) | Element IdServiceRequest.requester A reference from one resource to another Alternate namesauthor, orderer DefinitionThe individual who initiated the request and has responsibility for its activation. Using the PractitionerRole(HdBe-HealthProfessional-PractitionerRole) reference, the affiliated organization can be captured. Each occurrence of the CBB HealthProfessional is normally represented by two FHIR resources: a PractitionerRole resource (instance of HdBe-HealthProfessional-PractitionerRole) and a Practitioner resource (instance of HdBe-HealthProfessional-Practitioner). The Practitioner resource is referenced from the PractitionerRole instance. For this reason, sending systems should fill the reference to the PractitionerRole instance here, and not the Practitioner resource. Receiving systems can then retrieve the reference to the Practitioner resource from that PractitionerRole instance. In rare circumstances, there is only a Practitioner instance, in which case it is that instance which will be referenced here. However, since this should be the exception, the HdBe-HealthProfessional-Practitioner profile is not explicitly mentioned as a target profile. pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | HdBe HealthProfessional PractitionerRole) Constraints
|
performerType | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.performerType Performer role Alternate namesspecialty DefinitionDesired type of performer for doing the requested service. This is a role, not a participation type. In other words, does not describe the task but describes the capacity. For example, “compounding pharmacy”, “psychiatrist” or “internal referral”. Indicates specific responsibility of an individual within the care team, such as "Primary physician", "Team coordinator", "Caregiver", etc. ParticipantRoles (example)Constraints
|
performer | Σ I | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | HealthcareService | Patient | Device | RelatedPerson) | There are no (further) constraints on this element Element IdServiceRequest.performer Requested performer Alternate namesrequest recipient DefinitionThe desired performer for doing the requested service. For example, the surgeon, dermatopathologist, endoscopist, etc. If multiple performers are present, it is interpreted as a list of alternative performers without any preference regardless of order. If order of preference is needed use the request-performerOrder extension. Use CareTeam to represent a group of performers (for example, Practitioner A and Practitioner B). Reference(Practitioner | PractitionerRole | Organization | CareTeam | HealthcareService | Patient | Device | RelatedPerson) Constraints
|
locationCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.locationCode Requested location DefinitionThe preferred location(s) where the procedure should actually happen in coded or free text form. E.g. at home or nursing day care center. 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. A location type where services are delivered. v3.ServiceDeliveryLocationRoleType (example)Constraints
|
locationReference | Σ I | 0..* | Reference(Location) | There are no (further) constraints on this element Element IdServiceRequest.locationReference Requested location DefinitionA reference to the the preferred location(s) where the procedure should actually happen. E.g. at home or nursing day care center. 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.
|
reasonCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.reasonCode Explanation/Justification for procedure or service DefinitionAn explanation or justification for why this service is being requested in coded or textual form. This is often for billing purposes. May relate to the resources referred to in This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. Use Diagnosis or problem codes justifying the reason for requesting the service investigation. ProcedureReasonCodes (example)Constraints
|
reasonReference | Σ I | 0..* | Reference(Condition | Observation | DiagnosticReport | DocumentReference) | There are no (further) constraints on this element Element IdServiceRequest.reasonReference Explanation/Justification for service or service DefinitionIndicates another resource that provides a justification for why this service is being requested. May relate to the resources referred to in This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. To be as specific as possible, a reference to Observation or Condition should be used if available. Otherwise when referencing DiagnosticReport it should contain a finding in Reference(Condition | Observation | DiagnosticReport | DocumentReference) Constraints
|
insurance | I | 0..* | Reference(Coverage | ClaimResponse) | There are no (further) constraints on this element Element IdServiceRequest.insurance Associated insurance coverage DefinitionInsurance plans, coverage extensions, pre-authorizations and/or pre-determinations that may be needed for delivering the requested service. 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(Coverage | ClaimResponse) Constraints
|
supportingInfo | I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdServiceRequest.supportingInfo Additional clinical information Alternate namesAsk at order entry question, AOE DefinitionAdditional clinical information about the patient or specimen that may influence the services or their interpretations. This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as "ask at order entry questions (AOEs)". This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the amount of inspired oxygen for blood gas measurements. To represent information about how the services are to be delivered use the
|
specimen | Σ I | 0..* | Reference(Specimen) | There are no (further) constraints on this element Element IdServiceRequest.specimen Procedure Samples DefinitionOne or more specimens that the laboratory procedure will use. Many diagnostic procedures need a specimen, but the request itself is not actually about the specimen. This element is for when the diagnostic is requested on already existing specimens and the request points to the specimen it applies to. Conversely, if the request is entered first with an unknown specimen, then the Specimen resource points to the ServiceRequest.
|
bodySite | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.bodySite Location on Body Alternate nameslocation DefinitionAnatomic location where the procedure should be performed. This is the target site. Knowing where the procedure is performed is important for tracking if multiple sites are possible. Only used if not implicit in the code found in ServiceRequest.code. If the use case requires BodySite to be handled as a separate resource instead of an inline coded element (e.g. to identify and track separately) then use the standard extension procedure-targetBodyStructure. Codes describing anatomical locations. May include laterality. SNOMEDCTBodyStructures (example)Constraints
|
note | 0..* | Annotation | There are no (further) constraints on this element Element IdServiceRequest.note Comments DefinitionAny other notes and comments made about the service request. For example, internal billing notes. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
| |
patientInstruction | Σ | 0..1 | string | There are no (further) constraints on this element Element IdServiceRequest.patientInstruction Patient or consumer-oriented instructions DefinitionInstructions in terms that are understood by the patient or consumer. Note that FHIR strings SHALL NOT exceed 1MB in size
|
relevantHistory | I | 0..* | Reference(Provenance) | There are no (further) constraints on this element Element IdServiceRequest.relevantHistory Request provenance DefinitionKey events in the history of the request. This might not include provenances for all versions of the request – only those deemed “relevant” or important. This SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude All Provenances should have some historical version of this Request as their subject.
|
Mapping FHIR profile to CBB
Path | map | CBB |
---|---|---|
ServiceRequest.requester | LaboratoryTestResult.Requester | HdBe-LaboratoryTestResult |
zib LaboratoryTestResult.Requester difference
Concept | Category | Description |
---|---|---|
requester |
mapping | Added mapping to a new profile on ServiceRequest to implement the requester element of the CBB/zib. Although this element does not provide enough information to create a profile that describes a full ordering service, it will provide details on capturing a requester in FHIR. |
Terminology Bindings
Path | Name | Strength | URL | ConceptMap |
---|---|---|---|---|
Observation.status | TestResultStatus | required | https://fhir.healthdata.be/ValueSet/TestResultStatus | No bound ConceptMap |
Observation.category | ResultType | required | https://fhir.healthdata.be/ValueSet/ResultType | No bound ConceptMap |
Observation.interpretation | observation-interpretation | extensible | http://hl7.org/fhir/ValueSet/observation-interpretation | https://fhir.healthdata.be/ConceptMap/ResultFlags-to-ObservationInterpretationCodes |
Observation.method | TestMethod | required | https://fhir.healthdata.be/ValueSet/TestMethod | No bound ConceptMap |
Specimen.type | SpecimenMaterial-and-Microorganism | required | https://fhir.healthdata.be/ValueSet/SpecimenMaterial-and-Microorganism | No bound ConceptMap |
Specimen.collection.method | CollectionMethod | required | https://fhir.healthdata.be/ValueSet/CollectionMethod | No bound ConceptMap |
Specimen.collection.bodySite | Location | required | https://fhir.healthdata.be/ValueSet/Location | No bound ConceptMap |
Specimen.container.type | ContainerType | preferred | https://fhir.healthdata.be/ValueSet/ContainerType | No bound ConceptMap |