{ "resourceType": "StructureDefinition", "id": "spark1700", "meta": { "versionId": "spark2488", "lastUpdated": "2016-01-19T22:14:39.647+00:00" }, "url": "http://premierinc.com/fhir/StructureDefinition/tdaf-resultobs", "version": "TWTW10", "name": "Theradoc Data Access Framework (TDAF) Results Profile", "display": "DAF-ResultObs", "status": "draft", "publisher": "Health Level Seven International (Infrastructure and Messaging - Data Access Framework)", "contact": [ { "telecom": [ { "system": "other", "value": "http://www.healthit.gov" } ] } ], "date": "2014-11-17", "description": "Theradoc DAF result observation", "fhirVersion": "1.0.1", "kind": "resource", "constrainedType": "Observation", "abstract": false, "base": "http://hl7.org/fhir/StructureDefinition/Observation", "differential": { "element": [ { "path": "Observation", "name": "DAF-ResultObs", "short": "US Realm DAF result observation", "definition": "US Realm clinical coded results.", "comments": "Used for simple observations such as device measurements, laboratory atomic results, vital signs, height, weight, smoking status, comments, etc. Other resources are used to provide context for observations such as lab reports, etc.", "alias": [ "Obs" ], "min": 0, "max": "*", "type": [ { "code": "Observation" } ], "mapping": [ { "identity": "v2", "map": "OBX" }, { "identity": "rim", "map": "Observation[classCode=OBS, moodCode=EVN]" }, { "identity": "w5", "map": "clinical.diagnostics" } ] }, { "path": "Observation.identifier", "short": "Unique Id for this particular observation", "definition": "A unique identifier for the simple observation instance.", "requirements": "Allows observations to be distinguished and referenced.", "min": 0, "max": "*", "type": [ { "code": "Identifier" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "OBX.21" }, { "identity": "rim", "map": "id" }, { "identity": "w5", "map": "id" } ] }, { "path": "Observation.identifier.use", "short": "usual | official | temp | secondary (If known)", "definition": "The purpose of this identifier.", "comments": "This is labeled as \"Is Modifier\" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.", "requirements": "Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "mustSupport": true, "isModifier": true, "isSummary": true, "binding": { "strength": "required", "description": "Identifies the purpose for this identifier, if known .", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/identifier-use" } }, "mapping": [ { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "Role.code or implied by context" } ] }, { "path": "Observation.identifier.system", "short": "The namespace for the identifier", "definition": "Establishes the namespace in which set of possible id values is unique.", "requirements": "There are many sequences of identifiers. To perform matching, we need to know what sequence we're dealing with. The system identifies a particular sequence or set of unique identifiers.", "min": 1, "max": "1", "type": [ { "code": "uri" } ], "exampleUri": "http://www.acme.com/identifiers/patient or urn:ietf:rfc:3986 if the Identifier.value itself is a full uri", "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "CX.4 / EI-2-4" }, { "identity": "rim", "map": "II.root or Role.id.root" }, { "identity": "servd", "map": "./IdentifierType" } ] }, { "path": "Observation.identifier.value", "short": "The value that is unique", "definition": "The portion of the identifier typically displayed to the user and which is unique within the context of the system.", "comments": "If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986.", "min": 1, "max": "1", "type": [ { "code": "string" } ], "exampleString": "123456", "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "CX.1 / EI.1" }, { "identity": "rim", "map": "II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)" }, { "identity": "servd", "map": "./Value" } ] }, { "path": "Observation.status", "short": "registered | preliminary | final | amended +", "definition": "The status of the result value.", "requirements": "Need to track the status of individual results. Some results are finalized before the whole report is finalized.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "mustSupport": true, "isModifier": true, "isSummary": true, "binding": { "strength": "required", "description": "Codes providing the status of an observation.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/observation-status" } }, "mapping": [ { "identity": "v2", "map": "OBX-11" }, { "identity": "rim", "map": "status Amended & Final are differentiated by whether it is the subject of a ControlAct event with a type of \"revise\"" }, { "identity": "w5", "map": "status" } ] }, { "path": "Observation.code", "short": "US Realm Laboratory Test Name", "definition": "The test that was performed. This is element is bound to LOINC.", "comments": "UsageNote= The typical patterns for codes are: 1) a LOINC code either as a translation from a \"local\" code or as a primary code, or 2) a local code only if no suitable LOINC exists, or 3) both the local and the LOINC translation. Systems SHALL be capable of sending the local code if one exists.", "requirements": "The use of the Logical Observation Identifiers Names and Codes (LOINC) code system is required where a LOINC code is available for the Observation.code, i.e. the being resulted.", "alias": [ "Test Name", "Observation Identifer" ], "min": 1, "max": "1", "type": [ { "code": "CodeableConcept" } ], "mustSupport": true, "isSummary": true, "binding": { "strength": "extensible", "description": "LOINC codes", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/uslab-obs-codes" } }, "mapping": [ { "identity": "v2", "map": "OBX-3" }, { "identity": "rim", "map": "code" }, { "identity": "w5", "map": "what" } ] }, { "path": "Observation.code.coding", "short": "Standard and local codes may be included here by repeating the coding element with a different coding.system.", "definition": "Standard and local codes may be included here by repeating the coding element with a different coding.system.", "comments": "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 labelled as UserSelected = true.", "requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.", "min": 1, "max": "*", "type": [ { "code": "Coding" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" }, { "identity": "orim", "map": "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding" } ] }, { "path": "Observation.code.coding.system", "short": "Identity of the terminology system", "definition": "The identification of the code system that defines the meaning of the symbol in the code.", "comments": "The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.", "requirements": "Need to be unambiguous about the source of the definition of the symbol.", "min": 1, "max": "1", "type": [ { "code": "uri" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.3" }, { "identity": "rim", "map": "./codeSystem" }, { "identity": "orim", "map": "fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem" } ] }, { "path": "Observation.code.coding.code", "short": "Symbol in syntax defined by the system", "definition": "A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).", "comments": "Logical Observation Identifiers Names and Codes (LOINC) is a database and universal standard for identifying medical laboratory observations.", "requirements": "Need to refer to a particular code in the system.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.1" }, { "identity": "rim", "map": "./code" }, { "identity": "orim", "map": "fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code" } ] }, { "path": "Observation.code.coding.display", "short": "Representation defined by the system", "definition": "A representation of the meaning of the code in the system, following the rules of the system.", "comments": "When using LOINC 'long common name' is preferred although the LOINC 'short name' or the LOINC 'fully-specified name can also be used. ( http://lionc.org.terms-of-use).", "requirements": "Need to be able to carry a human-readable meaning of the code for readers that do not know the system.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.2 - but note this is not well followed" }, { "identity": "rim", "map": "CV.displayName" }, { "identity": "orim", "map": "fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName" } ] }, { "path": "Observation.code.text", "short": "Display text", "definition": "This is the laboratory defined display text for the lab test if different from the code display text(s).", "comments": "If this exists, this is the text to be used for display.", "requirements": "Used when the laboratory define how the dsplay text if different from the code display text.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.9. But note many systems use C*E.2 for this" }, { "identity": "rim", "map": "./originalText[mediaType/code=\"text/plain\"]/data" }, { "identity": "orim", "map": "fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText" } ] }, { "path": "Observation.subject", "short": "Who and/or what this is about", "definition": "The patient, or group of patients, location, or device whose characteristics (direct or indirect) are described by the observation and into whose record the observation is placed. Comments: Indirect characteristics may be those of a specimen, fetus, donor, other observer (for example a relative or EMT), or any observation made about the subject.", "comments": "One would expect this element to be a cardinality of 1..1. The only circumstance in which the subject can be missing is when the observation is made by a device that does not know the patient. In this case, the observation SHALL be matched to a patient through some context/channel matching technique, and at this point, the observation should be updated. If the target of the observation is different than the subject, the general extension [observation-focal-subject](extension-observation-focal-subject.html). may be used. However, the distinction between the patient's own value for an observation versus that of the fetus, or the donor or blood product unit, etc., are often specified in the observation code.", "requirements": "Observations have no value if you don't know who or what they're about.", "min": 1, "max": "1", "type": [ { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/daf-patient" ] } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "PID-3" }, { "identity": "rim", "map": "participation[typeCode=SBJ]" }, { "identity": "w5", "map": "who.focus" } ] }, { "path": "Observation.encounter", "short": "Healthcare event during which this observation is made", "definition": "The healthcare event (e.g. a patient and healthcare provider interaction) during which this observation is made.", "requirements": "For some observations it may be important to know the link between an observation and a particular encounter.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/daf-encounter" ] } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "PV1" }, { "identity": "rim", "map": "inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]" }, { "identity": "w5", "map": "context" } ] }, { "path": "Observation.effective[x]", "short": "Clinically relevant time/time-period for observation", "definition": "For lab tests this is the specimen collection date. For Ask at Order Entry Questions (AOE)'s this is the date the question was asked.", "comments": "At least a date should be present unless this observation is a historical report.", "requirements": "Minimum Precision to Day.", "min": 0, "max": "1", "type": [ { "code": "dateTime" }, { "code": "Period" } ], "condition": [ "inv-1" ], "constraint": [ { "key": "inv-1", "severity": "error", "human": "Datetime must be at least to day.", "xpath": "f:matches(effectiveDateTime,/\\d{4}-[01]\\d-[0-3]\\dT[0-2]\\d:[0-5]\\d([+-][0-2]\\d:[0-5]\\d|Z)/)" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "OBX-14, and/or OBX-19 after v2.4 (depends on who observation made)" }, { "identity": "rim", "map": "effectiveTime" }, { "identity": "w5", "map": "when.done" } ] }, { "path": "Observation.issued", "short": "Date/Time this was made available", "definition": "The date and time this observation was made available to providers, typically after the results have been reviewed and verified.", "comments": "Updated when the result is updated.", "requirements": "Minimum Precision to Day.", "min": 0, "max": "1", "type": [ { "code": "instant" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "OBR.22 (or MSH.7), or perhaps OBX-19 (depends on who observation made)" }, { "identity": "rim", "map": "participation[typeCode=AUT].time" }, { "identity": "w5", "map": "when.recorded" } ] }, { "path": "Observation.performer", "short": "Who is responsible for the observation", "definition": "Who was responsible for asserting the observed value as \"true\".", "requirements": "May give a degree of confidence in the observation and also indicates where follow-up questions should be directed.", "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/daf-pract" ] }, { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/daf-organization" ] }, { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/daf-patient" ] }, { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/daf-relatedperson" ] } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "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'" }, { "identity": "rim", "map": "participation[typeCode=PRF]" }, { "identity": "w5", "map": "who.actor" } ] }, { "path": "Observation.value[x]", "short": "Actual result", "definition": "If codeableConcept, valueCodeableConcept must be selected from [SNOMED CT](http://hl7.org/fhir/ValueSet/uslab-obs-codedresults).", "comments": "Normally, an observation will have either a value or a set of related observations. A few observations (e.g. Apgar score) may have both a value and related observations (for an Apgar score, the observations from which the measure is derived). If a value is present, the datatype for this element should be determined by Observation.code. This element has a variable name depending on the type as follows: valueQuantity, valueCodeableConcept, valueString, valueRange, valueRatio, valueSampledData, valueAttachment, valueTime, valueDateTime, or valuePeriod. (The name format is \"'value' + the type name\" with a capital on the first letter of the type). If the data element is usually coded or if the type associated with the Observation.value defines a coded value, use CodeableConcept instead of string datatype even if the value is uncoded text. A value set is bound to the ValueCodeableConcept element. For boolean values use valueCodeableConcept and select codes from [HL7 Version 2 Table 0136](v2/0136/index.html). These \"yes/no\" concepts can be mapped to the display name \"true/false\" or other mutually exclusive terms that may be needed. For further discussion and examples see the [notes section](observation.html#4.20.4) below.", "requirements": "An observation exists to have a value, though it may not if it is in error, or it represents a group of observations.", "min": 0, "max": "1", "type": [ { "code": "Quantity" }, { "code": "CodeableConcept" }, { "code": "string" }, { "code": "Range" }, { "code": "Ratio" }, { "code": "SampledData" }, { "code": "Attachment" }, { "code": "time" }, { "code": "dateTime" }, { "code": "Period" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "OBX.2, OBX.5, OBX.6" }, { "identity": "rim", "map": "value" } ] }, { "path": "Observation.dataAbsentReason", "short": "Why the result is missing", "definition": "Provides a reason why the expected value in the element Observation.value[x] is missing.", "comments": "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. Because of these options, use-case agreements are required to interpret general observations for exceptional values.", "requirements": "For many results it is necessary to handle exceptional values in measurements.", "min": 0, "max": "0", "type": [ { "code": "CodeableConcept" } ], "condition": [ "obs-6" ], "mapping": [ { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "value.nullFlavor" } ] }, { "path": "Observation.interpretation", "short": "High, low, normal, etc.", "definition": "The assessment made based on the result of the observation. Intended as a simple compact code often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result. Otherwise known as abnormal flag.", "requirements": "For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result.", "alias": [ "Abnormal Flag" ], "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "mustSupport": true, "binding": { "strength": "required", "description": "Codes identifying interpretations of observations", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/observation-interpretation" } }, "mapping": [ { "identity": "v2", "map": "OBX-8" }, { "identity": "rim", "map": "interpretationCode" } ] }, { "path": "Observation.interpretation.coding", "short": "Code defined by a terminology system", "definition": "A reference to a code defined by a terminology system.", "comments": "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 labelled as UserSelected = true.", "requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.", "min": 1, "max": "*", "type": [ { "code": "Coding" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" }, { "identity": "orim", "map": "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding" } ] }, { "path": "Observation.interpretation.coding.system", "short": "Identity of the terminology system", "definition": "The identification of the code system that defines the meaning of the symbol in the code.", "comments": "The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.", "requirements": "Need to be unambiguous about the source of the definition of the symbol.", "min": 1, "max": "1", "type": [ { "code": "uri" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.3" }, { "identity": "rim", "map": "./codeSystem" }, { "identity": "orim", "map": "fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem" } ] }, { "path": "Observation.interpretation.coding.code", "short": "Symbol in syntax defined by the system", "definition": "A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).", "requirements": "Need to refer to a particular code in the system.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.1" }, { "identity": "rim", "map": "./code" }, { "identity": "orim", "map": "fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code" } ] }, { "path": "Observation.bodySite", "short": "Observed body part", "definition": "Indicates the site on the subject's body where the observation was made (i.e. the target site).", "comments": "Only used if not implicit in code found in Observation.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[ body-site-instance](extension-body-site-instance.html).", "requirements": "Knowing where the observation is made is important for tracking if multiple sites are possible.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "mustSupport": false, "binding": { "strength": "example", "description": "Codes describing anatomical locations. May include laterality.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/body-site" } }, "mapping": [ { "identity": "v2", "map": "OBX-20" }, { "identity": "rim", "map": "targetSiteCode" } ] }, { "path": "Observation.specimen", "short": "Specimen used for this observation", "definition": "The specimen that was used when this observation was made.", "comments": "Observations are not made on specimens themselves; they are made on a subject, but usually by the means of a specimen. Note that although specimens are often involved, they are not always tracked and reported explicitly. Also note that observation resources may be used in contexts that track the specimen explicitly (e.g. Diagnostic Report).", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/daf-spec" ] } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "SPM segment" }, { "identity": "rim", "map": "participation[typeCode=SPC].specimen" } ] }, { "path": "Observation.referenceRange", "name": "referenceRange", "short": "Provides guide for interpretation", "definition": "Guidance on how to interpret the value by comparison to a normal or recommended range.", "comments": "Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g. specific to the patient's age, gender, weight and other factors), but this may not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.", "requirements": "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.", "min": 0, "max": "1", "type": [ { "code": "BackboneElement" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "OBX.7" }, { "identity": "rim", "map": "outboundRelationship[typeCode=REFV]/target[classCode=OBS, moodCode=EVN]" } ] }, { "path": "Observation.related", "short": "Components of Panel/Battery", "definition": "A set of related observations that together form the panel or battery of this observation.", "comments": "For a discussion on the ways Observations can assembled in groups together see [Notes below](observation.html#4.20.4).", "requirements": "Normally, an observation will have either a value or a set of related observations. A few observations (e.g. Apgar score) may have both a value and a set of related observations or sometimes QuestionnaireResponse from which the measure is derived.", "min": 0, "max": "*", "type": [ { "code": "BackboneElement" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "Relationships established by OBX-4 usage" }, { "identity": "rim", "map": "outBoundRelationship" } ] }, { "path": "Observation.related.type", "short": "has-member | derived-from | sequel-to | replaces | qualified-by | interfered-by", "definition": "A code specifying the kind of relationship that exists with the target resource.", "comments": "\"derived-from\" is only logical choice when referencing QuestionnaireAnswer resource.", "requirements": "A relationship type SHOULD be provided.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "fixedCode": "has-member", "mustSupport": true, "binding": { "strength": "required", "description": "Codes specifying how two observations are related.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/observation-relationshiptypes" } }, "mapping": [ { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": ".typeCode" } ] }, { "path": "Observation.related.target", "short": "US DAF Component observations", "definition": "US DAF Component observations.", "min": 1, "max": "1", "type": [ { "code": "Reference", "profile": [ "http://premierinc.com/fhir/StructureDefinition/tdaf-resultobs" ] } ], "mustSupport": true, "mapping": [ { "identity": "rim", "map": ".targetObservation" } ] }, { "path": "Observation.component", "short": "Component results", "definition": "Some 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.", "comments": "For a discussion on the ways Observations can assembled in groups together see [Notes below](observation.html#4.20.4).", "requirements": "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.", "min": 0, "max": "*", "type": [ { "code": "BackboneElement" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "containment by OBX-4?" }, { "identity": "rim", "map": "outBoundRelationship[typeCode=COMP]" } ] }, { "path": "Observation.component.code", "short": "US Realm Laboratory Test Name", "definition": "The laboratory test that was performed. This is element is bound to LOINC.", "comments": "UsageNote= The typical patterns for codes are: 1) a LOINC code either as a translation from a \"local\" code or as a primary code, or 2) a local code only if no suitable LOINC exists, or 3) both the local and the LOINC translation. Systems SHALL be capable of sending the local code if one exists.", "requirements": "Knowing what kind of observation is being made is essential to understanding the observation.", "min": 1, "max": "1", "type": [ { "code": "CodeableConcept" } ], "condition": [ "obs-7" ], "mustSupport": true, "isSummary": true, "binding": { "strength": "extensible", "description": "LOINC codes", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/uslab-obs-codes" } }, "mapping": [ { "identity": "v2", "map": "OBX-3" }, { "identity": "rim", "map": "code" }, { "identity": "w5", "map": "what" } ] }, { "path": "Observation.component.code.coding", "short": "Code defined by a terminology system", "definition": "A reference to a code defined by a terminology system.", "comments": "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 labelled as UserSelected = true.", "requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.", "min": 1, "max": "*", "type": [ { "code": "Coding" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" }, { "identity": "orim", "map": "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding" } ] }, { "path": "Observation.component.code.coding.system", "short": "Identity of the terminology system", "definition": "The identification of the code system that defines the meaning of the symbol in the code.", "comments": "The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.", "requirements": "Need to be unambiguous about the source of the definition of the symbol.", "min": 1, "max": "1", "type": [ { "code": "uri" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.3" }, { "identity": "rim", "map": "./codeSystem" }, { "identity": "orim", "map": "fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem" } ] }, { "path": "Observation.component.code.coding.code", "short": "Symbol in syntax defined by the system", "definition": "A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).", "comments": "Logical Observation Identifiers Names and Codes (LOINC) is a database and universal standard for identifying medical laboratory observations.", "requirements": "Need to refer to a particular code in the system.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.1" }, { "identity": "rim", "map": "./code" }, { "identity": "orim", "map": "fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code" } ] }, { "path": "Observation.component.code.coding.display", "short": "Representation defined by the system", "definition": "A representation of the meaning of the code in the system, following the rules of the system.", "comments": "When using LOINC 'long common name' is preferred although the LOINC 'short name' or the LOINC 'fully-specified name can also be used. ( http://lionc.org.terms-of-use).", "requirements": "Need to be able to carry a human-readable meaning of the code for readers that do not know the system.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.2 - but note this is not well followed" }, { "identity": "rim", "map": "CV.displayName" }, { "identity": "orim", "map": "fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName" } ] }, { "path": "Observation.component.code.text", "short": "Display text", "definition": "This is the laboratory defined display text for the lab test if different from the code display text(s).", "comments": "If this exists, this is the text to be used for display.", "requirements": "Used when the laboratory define how the dsplay text if different from the code display text.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "C*E.9. But note many systems use C*E.2 for this" }, { "identity": "rim", "map": "./originalText[mediaType/code=\"text/plain\"]/data" }, { "identity": "orim", "map": "fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText" } ] }, { "path": "Observation.component.value[x]", "short": "Actual component result", "definition": "The information determined as a result of making the observation, if the information has a simple value.", "comments": "Normally, an observation will have either a value or a set of related observations. A few observations (e.g. Apgar score) may have both a value and related observations (for an Apgar score, the observations from which the measure is derived). If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For boolean values use valueCodeableConcept and select codes from (These \"yes/no\" concepts can be mapped to the display name \"true/false\" or other mutually exclusive terms that may be needed\"). The element, Observation.value[x], has a variable name depending on the type as follows: valueQuantity, valueCodeableConcept, valueRatio, valueChoice, valuePeriod, valueSampleData, or valueString (The name format is \"'value' + the type name\" with a capital on the first letter of the type).", "requirements": "An observation exists to have a value, though it may not if it is in error, or it represents a group of observations.", "min": 0, "max": "1", "type": [ { "code": "Quantity" }, { "code": "CodeableConcept" }, { "code": "string" }, { "code": "Range" }, { "code": "Ratio" }, { "code": "SampledData" }, { "code": "Attachment" }, { "code": "time" }, { "code": "dateTime" }, { "code": "Period" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "OBX.2, OBX.5, OBX.6" }, { "identity": "rim", "map": "value" } ] }, { "path": "Observation.component.dataAbsentReason", "short": "Why the component result is missing", "definition": "Provides a reason why the expected value in the element Observation.value[x] is missing.", "comments": "\"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.", "requirements": "For many results it is necessary to handle exceptional values in measurements.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "condition": [ "obs-6" ], "mustSupport": true, "binding": { "strength": "extensible", "description": "Codes specifying why the result (Observation.value[x]) is missing.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/observation-valueabsentreason" } }, "mapping": [ { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "value.nullFlavor" } ] }, { "path": "Observation.component.referenceRange", "short": "Provides guide for interpretation of component result", "definition": "Guidance on how to interpret the value by comparison to a normal or recommended range.", "comments": "Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g. specific to the patient's age, gender, weight and other factors), but this may not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.", "requirements": "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.", "min": 0, "max": "1", "nameReference": "referenceRange", "mustSupport": true, "mapping": [ { "identity": "v2", "map": "OBX.7" }, { "identity": "rim", "map": "outboundRelationship[typeCode=REFV]/target[classCode=OBS, moodCode=EVN]" } ] } ] } }