pec-observation-1

Observation.identifier

Business Identifier for observation

Identifier

The cardinality or value of this element may be affected by these constraints: ele-1

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())

• rim: n/a
• v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
• rim: II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
• servd: Identifier
• workflow: Event.identifier
• v2: OBX.21 For OBX segments from systems without OBX-21 support a combination of ORC/OBR and OBX must be negotiated between trading partners to uniquely identify the OBX segment. Depending on how V2 has been implemented each of these may be an option: 1) OBR-3 + OBX-3 + OBX-4 or 2) OBR-3 + OBR-4 + OBX-3 + OBX-4 or 2) some other way to uniquely ID the OBR/ORC + OBX-3 + OBX-4.
• rim: id
• w5: id

Observation.basedOn

Fulfills plan, proposal or order

Fulfills

Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ProcedureRequest | ReferralRequest)

The cardinality or value of this element may be affected by these constraints: ele-1

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())
• ref-1: SHALL have a contained resource if a local reference is provided
  reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))

• rim: n/a
• rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
• workflow: Event.basedOn
• v2: ORC
• rim: .outboundRelationship[typeCode=FLFS].target

Observation.category

Classification of type of observation

CodeableConcept

Codes for high level observation categories.

Observation Category Codes (preferred)

The cardinality or value of this element may be affected by these constraints: ele-1

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())

• rim: n/a
• v2: CE/CNE/CWE
• rim: CD
• orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
• rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
• w5: class

Observation.context

Healthcare event during which this observation is made

Encounter

Reference(Encounter | EpisodeOfCare)

The cardinality or value of this element may be affected by these constraints: ele-1

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())
• ref-1: SHALL have a contained resource if a local reference is provided
  reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))

• rim: n/a
• rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
• workflow: Event.context
• v2: PV1
• rim: inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
• w5: context

Observation.performer

Who is responsible for the observation

Reference(Organization | Patient | Practitioner | RelatedPerson)

The cardinality or value of this element may be affected by these constraints: ele-1

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())
• ref-1: SHALL have a contained resource if a local reference is provided
  reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))

• rim: n/a
• rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
• workflow: Event.performer
• v2: OBX.15 / (Practitioner) OBX-16, PRT-5:PRT-4='RO' / (Device) OBX-18 , PRT-10:PRT-4='EQUIP' / (Organization) OBX-23, PRT-8:PRT-4='PO'
• rim: participation[typeCode=PRF]
• w5: who.actor

Observation.value[x]

Actual result

The cardinality or value of this element may be affected by these constraints: ele-1, obs-7

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())
• qty-3: If a code for the unit is present, the system SHALL also be present
  code.empty() or system.exists()

• rim: n/a
• v2: SN (see also Range) or CQ
• rim: PQ, IVL<PQ>, MO, CO, depending on the values
• workflow: Event.notDone, Event.notDoneReason (maps to valeu[x] or dataAbsentReason)
• sct-concept: < 441742003 |Evaluation finding|
• v2: OBX.2, OBX.5, OBX.6
• rim: value
• sct-attr: 363714003 |Interprets|

Observation.dataAbsentReason

Why the result is missing

CodeableConcept

Codes specifying why the result (Observation.value[x]) is missing.

Observation Value Absent Reason (extensible)

The cardinality or value of this element may be affected by these constraints: ele-1, obs-6

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())

• rim: n/a
• v2: CE/CNE/CWE
• rim: CD
• orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
• workflow: Event.notDone, Event.notDoneReason (maps to valeu[x] or dataAbsentReason)
• v2: N/A
• rim: value.nullFlavor

Observation.interpretation

High, low, normal, etc.

Abnormal Flag

CodeableConcept

Codes identifying interpretations of observations.

Observation Interpretation Codes (extensible)

The cardinality or value of this element may be affected by these constraints: ele-1

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())

• rim: n/a
• v2: CE/CNE/CWE
• rim: CD
• orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
• sct-concept: < 260245000 |Findings values|
• v2: OBX-8
• rim: interpretationCode
• sct-attr: 363713009 |Has interpretation|

Observation.bodySite

Observed body part

CodeableConcept

Codes describing anatomical locations. May include laterality.

SNOMED CT Body Structures (example)

The cardinality or value of this element may be affected by these constraints: ele-1

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())

• rim: n/a
• v2: CE/CNE/CWE
• rim: CD
• orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
• sct-concept: < 123037004 |Body structure|
• v2: OBX-20
• rim: targetSiteCode
• sct-attr: 718497002 |Inherent location|

Observation.method

How it was done

CodeableConcept

Methods for simple observations.

Observation Methods (example)

The cardinality or value of this element may be affected by these constraints: ele-1

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())

• rim: n/a
• v2: CE/CNE/CWE
• rim: CD
• orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
• v2: OBX-17
• rim: methodCode

Observation.specimen

Specimen used for this observation

Reference(Specimen)

The cardinality or value of this element may be affected by these constraints: ele-1

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())
• ref-1: SHALL have a contained resource if a local reference is provided
  reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))

• rim: n/a
• rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
• sct-concept: < 123038009 |Specimen|
• v2: SPM segment
• rim: participation[typeCode=SPC].specimen
• sct-attr: 704319004 |Inherent in|

Observation.device

(Measurement) Device

Reference(Device | DeviceMetric)

The cardinality or value of this element may be affected by these constraints: ele-1

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())
• ref-1: SHALL have a contained resource if a local reference is provided
  reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))

• rim: n/a
• rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
• sct-concept: < 49062001 |Device|
• v2: OBX-17 / PRT -10
• rim: participation[typeCode=DEV]
• sct-attr: 424226004 |Using device|

Observation.referenceRange

Provides guide for interpretation

BackboneElement

The cardinality or value of this element may be affected by these constraints: ele-1

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())
• obs-3: Must have at least a low or a high or text
  low.exists() or high.exists() or text.exists()

• rim: n/a
• v2: OBX.7
• rim: outboundRelationship[typeCode=REFV]/target[classCode=OBS, moodCode=EVN]

Observation.related

Resource related to this observation

BackboneElement

The cardinality or value of this element may be affected by these constraints: ele-1

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())

• rim: n/a
• v2: Relationships established by OBX-4 usage
• rim: outBoundRelationship