IE (Ireland) Core Implementation Guide
1.0.0-ballot - Ballot Ireland flag

Publication Build: This will be filled in by the publication tooling

Resource Profile: IE Core Observation ADI Documentation Profile

Official URL: http://iehr.ai/fhir/ie/core/StructureDefinition/ie-core-observation-adi-documentation Version: 1.0.0-ballot
Standards status: Trial-use Maturity Level: 3 Computable Name: IECoreObservationADIDocumentationProfile
Other Identifiers: OID:1.3.6.1.4.1.54392.5.2690.42.37

Copyright/Legal: iEHR.ai, all rights reserved Creative Commons License

The IE Core Observation ADI Documentation Profile inherits from the FHIR Observation resource; refer to it for scope and usage definitions. This profile and the IE Core Observation ADI DocumentationReference Profile meet the iEHR IE Core Data for Interoperability (IECDI) Advance Directive Observation Data Element requirements. It is used to communicate the presence and location of advance directive documents for a patient. Examples of advance healthcare directive documents include physician order for life sustaining treatment (POLST), do not resuscitate order (DNR), and medical power of attorney. To communicate the type of advance directive document, the author, the verifier, and other properties, see the IE Core Observation ADI Documentation Profile. This profile sets minimum expectations for the Observation resource to record, search, and fetch findings about the presence of a patient's advance directives. It specifies which core elements, extensions, vocabularies, and value sets SHALL be present in the resource and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption.

Example Usage Scenarios:

The following are example usage scenarios for this profile:

  • Query for the existence and location of any advance directive documents the patient may have.
  • Record or update observations to indicate whether a patient has an advance directive document.

Mandatory and Must Support Data Elements

The following data elements must always be present (Mandatory definition) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Views below provides the formal summary, definitions, and terminology requirements.

Each Observation Must Have:

  1. a status
  2. a fixed code for the presence of advance directives
  3. a patient

Each Observation Must Support:

  1. references to ADI documents if they exist*
  2. a category code of "observation-adi-documentation"
  3. when this verified observation was made available
  4. one or more performers of the observation*
  5. a "yes/no/unknown" value confirming or refuting the code

*See guidance below

Profile Specific Implementation Guidance:

  • * If the system asserts the patient has ADI documents and the references to the (electronic) documents are known, it SHOULD reference them in the Supporting Info Extension using the IE Core ADI DocumentReference Profile to exchange the ADI documents and their properties.
    • If the system asserts the patient has ADI documents, but the location of the documents is unknown, there would be no reference.
  • * An Observation.performer of type Practitioner or Organization typically makes the observation, and an Observation.performer of Patient or RelatedPerson usually supplies the information (for example, a next of kin who answers questions about the patient's advance directives). Systems may use the standard Performer function Extension to distinguish the type of involvement of the performer in the Observation resource.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..* Observation IE Core Observation ADI Presence Profile
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... supporting-info S 0..* (Complex) Relevant ADI documents and information
URL: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo
..... value[x] S 1..1 Reference(IE Core ADI DocumentReference Profile S | Resource) Reference to patient or provider authored ADI documents
... status S 1..1 code registered | preliminary | final | amended +
... Slices for category S 0..* CodeableConcept Classification of type of observation
Slice: Unordered, Open by pattern:$this
.... category:ie-core S 0..1 CodeableConcept Classification of type of observation
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://iehr.ai/fhir/ie/core/CodeSystem/ie-core-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: observation-adi-documentation
... code S 1..1 CodeableConcept Observation ADI Documentation code
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 45473-6
... subject S 1..1 Reference(IE Core Patient Profile) Who and/or what the observation is about
... issued S 0..1 instant Date/Time this observation was made available
... performer S 0..* Reference(IE Core Practitioner Profile S | IE Core Organization Profile | IE Core Patient Profile | PractitionerRole | IE Core CareTeam Profile | IE Core RelatedPerson Profile) Who is responsible for the observation
... value[x] S 0..1 CodeableConcept Actual result
Binding: IE Core Yes, No, and Unknowns (required): Answer Set with Yes No and Unknowns


doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.value[x]requiredIECoreYesNoAndUnknowns
http://iehr.ai/fhir/ie/core/ValueSet/ie-core-yes-no-unknowns
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation IE Core Observation ADI Presence Profile
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... supporting-info S 0..* (Complex) Relevant ADI documents and information
URL: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo
..... extension 0..0
..... url 1..1 uri "http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo"
..... value[x] S 1..1 Reference(IE Core ADI DocumentReference Profile) Reference to patient or provider authored ADI documents
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category S 0..* CodeableConcept Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:ie-core S 0..1 CodeableConcept Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://iehr.ai/fhir/ie/core/CodeSystem/ie-core-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: observation-adi-documentation
... code SΣ 1..1 CodeableConcept Observation ADI Documentation code
Binding: LOINCCodes (example): Codes identifying names of simple observations.


Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 45473-6
... subject SΣ 1..1 Reference(IE Core Patient Profile) Who and/or what the observation is about
... issued SΣ 0..1 instant Date/Time this observation was made available
... performer SΣ 0..* Reference(IE Core Practitioner Profile) Who is responsible for the observation
... value[x] SΣC 0..1 CodeableConcept Actual result
Binding: IE Core Yes, No, and Unknowns (required): Answer Set with Yes No and Unknowns


doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:ie-corepreferredPattern: observation-adi-documentation
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.codeexamplePattern: LOINC Code 45473-6
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.value[x]requiredIECoreYesNoAndUnknowns
http://iehr.ai/fhir/ie/core/ValueSet/ie-core-yes-no-unknowns
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation IE Core Observation ADI Presence Profile
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... supporting-info S 0..* (Complex) Relevant ADI documents and information
URL: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo
..... id 0..1 id Unique id for inter-element referencing
..... extension 0..0
..... url 1..1 uri "http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo"
..... value[x] S 1..1 Reference(IE Core ADI DocumentReference Profile S | Resource) Reference to patient or provider authored ADI documents
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business Identifier for observation
... basedOn Σ 0..* Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Fulfills plan, proposal or order
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Part of referenced event
... status ?!SΣ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category S 0..* CodeableConcept Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:ie-core S 0..1 CodeableConcept Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://iehr.ai/fhir/ie/core/CodeSystem/ie-core-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: observation-adi-documentation
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept Observation ADI Documentation code
Binding: LOINCCodes (example): Codes identifying names of simple observations.


Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 45473-6
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(IE Core Patient Profile) Who and/or what the observation is about
... focus Σ 0..* Reference(Resource) What the observation is about, when it is not about the subject of record
... encounter Σ 0..1 Reference(Encounter) Healthcare event during which this observation is made
... effective[x] Σ 0..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... issued SΣ 0..1 instant Date/Time this observation was made available
... performer SΣ 0..* Reference(IE Core Practitioner Profile S | IE Core Organization Profile | IE Core Patient Profile | PractitionerRole | IE Core CareTeam Profile | IE Core RelatedPerson Profile) Who is responsible for the observation
... value[x] SΣC 0..1 CodeableConcept Actual result
Binding: IE Core Yes, No, and Unknowns (required): Answer Set with Yes No and Unknowns

... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..* Annotation Comments about the observation
... bodySite 0..1 CodeableConcept Observed body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1 CodeableConcept How it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1 Reference(Specimen) Specimen used for this observation
... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... referenceRange C 0..* BackboneElement Provides guide for interpretation
obs-3: Must have at least a low or a high or text
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... low C 0..1 SimpleQuantity Low Range, if relevant
.... high C 0..1 SimpleQuantity High Range, if relevant
.... type 0..1 CodeableConcept Reference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..* CodeableConcept Reference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1 Range Applicable age range, if relevant
.... text 0..1 string Text based reference range in an observation
... hasMember Σ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
... component Σ 0..* BackboneElement Component results
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 CodeableConcept Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ 0..1 Actual component result
..... valueQuantity Quantity
..... valueCodeableConcept CodeableConcept
..... valueString string
..... valueBoolean boolean
..... valueInteger integer
..... valueRange Range
..... valueRatio Ratio
..... valueSampledData SampledData
..... valueTime time
..... valueDateTime dateTime
..... valuePeriod Period
.... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


.... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:ie-corepreferredPattern: observation-adi-documentation
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.codeexamplePattern: LOINC Code 45473-6
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.value[x]requiredIECoreYesNoAndUnknowns
http://iehr.ai/fhir/ie/core/ValueSet/ie-core-yes-no-unknowns
from this IG
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Observation.methodexampleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
http://hl7.org/fhir/ValueSet/referencerange-meaning
from the FHIR Standard
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
http://hl7.org/fhir/ValueSet/referencerange-appliesto
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard

Differential View

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..* Observation IE Core Observation ADI Presence Profile
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... supporting-info S 0..* (Complex) Relevant ADI documents and information
URL: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo
..... value[x] S 1..1 Reference(IE Core ADI DocumentReference Profile S | Resource) Reference to patient or provider authored ADI documents
... status S 1..1 code registered | preliminary | final | amended +
... Slices for category S 0..* CodeableConcept Classification of type of observation
Slice: Unordered, Open by pattern:$this
.... category:ie-core S 0..1 CodeableConcept Classification of type of observation
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://iehr.ai/fhir/ie/core/CodeSystem/ie-core-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: observation-adi-documentation
... code S 1..1 CodeableConcept Observation ADI Documentation code
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 45473-6
... subject S 1..1 Reference(IE Core Patient Profile) Who and/or what the observation is about
... issued S 0..1 instant Date/Time this observation was made available
... performer S 0..* Reference(IE Core Practitioner Profile S | IE Core Organization Profile | IE Core Patient Profile | PractitionerRole | IE Core CareTeam Profile | IE Core RelatedPerson Profile) Who is responsible for the observation
... value[x] S 0..1 CodeableConcept Actual result
Binding: IE Core Yes, No, and Unknowns (required): Answer Set with Yes No and Unknowns


doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.value[x]requiredIECoreYesNoAndUnknowns
http://iehr.ai/fhir/ie/core/ValueSet/ie-core-yes-no-unknowns
from this IG

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation IE Core Observation ADI Presence Profile
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... supporting-info S 0..* (Complex) Relevant ADI documents and information
URL: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo
..... extension 0..0
..... url 1..1 uri "http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo"
..... value[x] S 1..1 Reference(IE Core ADI DocumentReference Profile) Reference to patient or provider authored ADI documents
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category S 0..* CodeableConcept Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:ie-core S 0..1 CodeableConcept Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://iehr.ai/fhir/ie/core/CodeSystem/ie-core-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: observation-adi-documentation
... code SΣ 1..1 CodeableConcept Observation ADI Documentation code
Binding: LOINCCodes (example): Codes identifying names of simple observations.


Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 45473-6
... subject SΣ 1..1 Reference(IE Core Patient Profile) Who and/or what the observation is about
... issued SΣ 0..1 instant Date/Time this observation was made available
... performer SΣ 0..* Reference(IE Core Practitioner Profile) Who is responsible for the observation
... value[x] SΣC 0..1 CodeableConcept Actual result
Binding: IE Core Yes, No, and Unknowns (required): Answer Set with Yes No and Unknowns


doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:ie-corepreferredPattern: observation-adi-documentation
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.codeexamplePattern: LOINC Code 45473-6
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.value[x]requiredIECoreYesNoAndUnknowns
http://iehr.ai/fhir/ie/core/ValueSet/ie-core-yes-no-unknowns
from this IG

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation IE Core Observation ADI Presence Profile
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... supporting-info S 0..* (Complex) Relevant ADI documents and information
URL: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo
..... id 0..1 id Unique id for inter-element referencing
..... extension 0..0
..... url 1..1 uri "http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo"
..... value[x] S 1..1 Reference(IE Core ADI DocumentReference Profile S | Resource) Reference to patient or provider authored ADI documents
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business Identifier for observation
... basedOn Σ 0..* Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Fulfills plan, proposal or order
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Part of referenced event
... status ?!SΣ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category S 0..* CodeableConcept Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:ie-core S 0..1 CodeableConcept Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://iehr.ai/fhir/ie/core/CodeSystem/ie-core-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: observation-adi-documentation
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept Observation ADI Documentation code
Binding: LOINCCodes (example): Codes identifying names of simple observations.


Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 45473-6
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(IE Core Patient Profile) Who and/or what the observation is about
... focus Σ 0..* Reference(Resource) What the observation is about, when it is not about the subject of record
... encounter Σ 0..1 Reference(Encounter) Healthcare event during which this observation is made
... effective[x] Σ 0..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... issued SΣ 0..1 instant Date/Time this observation was made available
... performer SΣ 0..* Reference(IE Core Practitioner Profile S | IE Core Organization Profile | IE Core Patient Profile | PractitionerRole | IE Core CareTeam Profile | IE Core RelatedPerson Profile) Who is responsible for the observation
... value[x] SΣC 0..1 CodeableConcept Actual result
Binding: IE Core Yes, No, and Unknowns (required): Answer Set with Yes No and Unknowns

... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..* Annotation Comments about the observation
... bodySite 0..1 CodeableConcept Observed body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1 CodeableConcept How it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1 Reference(Specimen) Specimen used for this observation
... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... referenceRange C 0..* BackboneElement Provides guide for interpretation
obs-3: Must have at least a low or a high or text
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... low C 0..1 SimpleQuantity Low Range, if relevant
.... high C 0..1 SimpleQuantity High Range, if relevant
.... type 0..1 CodeableConcept Reference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..* CodeableConcept Reference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1 Range Applicable age range, if relevant
.... text 0..1 string Text based reference range in an observation
... hasMember Σ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
... component Σ 0..* BackboneElement Component results
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 CodeableConcept Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ 0..1 Actual component result
..... valueQuantity Quantity
..... valueCodeableConcept CodeableConcept
..... valueString string
..... valueBoolean boolean
..... valueInteger integer
..... valueRange Range
..... valueRatio Ratio
..... valueSampledData SampledData
..... valueTime time
..... valueDateTime dateTime
..... valuePeriod Period
.... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


.... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:ie-corepreferredPattern: observation-adi-documentation
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.codeexamplePattern: LOINC Code 45473-6
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.value[x]requiredIECoreYesNoAndUnknowns
http://iehr.ai/fhir/ie/core/ValueSet/ie-core-yes-no-unknowns
from this IG
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Observation.methodexampleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
http://hl7.org/fhir/ValueSet/referencerange-meaning
from the FHIR Standard
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
http://hl7.org/fhir/ValueSet/referencerange-appliesto
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Quick Start

Below is an overview of the required Server RESTful FHIR interactions for this profile - for example, search and read operations - when supporting the IE Core interactions to access this profile's information (Profile Support + Interaction Support). Note that systems that support only IE Core Profiles (Profile Only Support) are not required to support these interactions. See the IE Core Server CapabilityStatement for a complete list of supported RESTful interactions for this IG.

  • See the Search Syntax section for a description of the IE Core search syntax.
  • See the General Requirements section for additional rules and expectations when a server requires status parameters.
  • See the General Guidance section for additional guidance on searching for multiple patients.

Mandatory Search Parameters:

The following search parameters and search parameter combinations SHALL be supported:

  1. SHALL support searching using the combination of the patient and category search parameters:

    GET [base]/Observation?patient={Type/}[id]&category=http://terminology.hl7.org/CodeSystem/observation-category|laboratory

    Example:

    1. GET [base]/Observation?patient=1134281&category=advance-directive-observation

    Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and a category code = laboratory (how to search by reference and how to search by token)

  2. SHALL support searching using the combination of the patient and code search parameters:
    • including optional support for OR search on code (e.g.code={system|}[code],{system|}[code],...)

    GET [base]/Observation?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}

    Example:

    1. GET [base]/Observation?patient=1134281&code=http://loinc.org|42348-3

    Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and observation code(s). SHOULD support search by multiple report codes. The Observation code parameter searches `Observation.code only. (how to search by reference and how to search by token)

  3. SHALL support searching using the combination of the patient and category and date search parameters:
    • including support for these date comparators: gt,lt,ge,le
    • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)

    GET [base]/Observation?patient={Type/}[id]&category=http://terminology.hl7.org/CodeSystem/observation-category|laboratory&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]Observation?patient=555580&category=advance-directive-observation&date=ge2018-03-14T00:00:00Z

    Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and date and a category code = laboratory (how to search by reference and how to search by token and how to search by date)

Optional Search Parameters:

The following search parameter combinations SHOULD be supported:

  1. SHOULD support searching using the combination of the patient and category and status search parameters:
    • including support for OR search on status (e.g.status={system|}[code],{system|}[code],...)

    GET [base]/Observation?patient={Type/}[id]&category=http://terminology.hl7.org/CodeSystem/observation-category|laboratory&status={system|}[code]{,{system|}[code],...}

    Example:

    1. GET [base]/Observation?patient=1134281&category=advance-directive-observation&status=final

    Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and category = laboratory and status (how to search by reference and how to search by token)

  2. SHOULD support searching using the combination of the patient and category and _lastUpdated search parameters:
    • including support for these _lastUpdated comparators: gt,lt,ge,le
    • including optional support for AND search on _lastUpdated (e.g._lastUpdated=[date]&_lastUpdated=[date]]&...)

    GET [base]/Observation?patient={Type/}[id]&category={system|}[code]&_lastUpdated={gt|lt|ge|le}[date]{&_lastUpdated={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]Observation?patient=555580&advance-directive-observation&_lastUpdated=ge2024-01-01T00:00:00Z

    Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and category and _lastUpdated. See the IE Core General Guidance page for Searching Using lastUpdated. (how to search by reference and how to search by token and how to search by date)

  3. SHOULD support searching using the combination of the patient and code and date search parameters:
    • including optional support for OR search on code (e.g.code={system|}[code],{system|}[code],...)
    • including support for these date comparators: gt,lt,ge,le
    • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)

    GET [base]/Observation?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]Observation?patient=555580&code=http://loinc.org|42348-3&date=ge2019-01-01T00:00:00Z

    Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and date and report code(s). SHOULD support search by multiple report codes. (how to search by reference and how to search by token and how to search by date)