German Oncological Data Standard (GOLD)
0.1.0 - CI Build
German Oncological Data Standard (GOLD) - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
Official URL: https://www.vision-zero-oncology.de/fhir/StructureDefinition/body-weight | Version: 0.1.0 | |||
Draft as of 2023-12-13 | Computable Name: Body_Weight | |||
Copyright/Legal: CC-BY-SA-4.0 |
Profile for body weight of a patient
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Vital_Signs_Base
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | Vital_Signs_Base | Measurements and simple assertions | |
code | 1..1 | CodeableConcept | Body Weight | |
Slices for coding | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this | |
coding:loinc | 1..* | Coding | Code defined by a terminology system Required Pattern: At least the following | |
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: 29463-7 | |
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
coding:snomed | 0..* | Coding | Code defined by a terminology system Required Pattern: At least the following | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 27113001 | |
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
value[x] | S | 0..1 | Quantity | Vital Signs value are recorded using the Quantity data type. For supporting observations such as Cuff size could use other datatypes such as CodeableConcept. |
value | S | 1..1 | decimal | Numerical value (with implicit precision) |
unit | S | 1..1 | string | Unit representation |
system | S | 1..1 | uri | System that defines coded unit form Required Pattern: http://unitsofmeasure.org |
code | S | 1..1 | code | Coded form of the unit Binding: BodyWeightUnits (required) |
dataAbsentReason | S | 0..1 | CodeableConcept | Why the result is missing |
Documentation for this format |
Path | Conformance | ValueSet |
Observation.value[x].code | required | BodyWeightUnits |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Vital_Signs_Base | Measurements and simple assertions |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
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 | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
category:vs-cat | 1..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://terminology.hl7.org/CodeSystem/observation-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: vital-signs | |
code | SΣ | 1..1 | CodeableConcept | Body Weight Binding: LOINCCodes (example): Codes identifying names of simple observations. |
Slices for coding | Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this |
coding:loinc | Σ | 1..* | Coding | Code defined by a terminology system Required Pattern: At least the following |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29463-7 | |
system | Σ | 1..1 | uri | Identity of the terminology system |
code | Σ | 1..1 | code | Symbol in syntax defined by the system |
coding:snomed | Σ | 0..* | Coding | Code defined by a terminology system Required Pattern: At least the following |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 27113001 | |
system | Σ | 1..1 | uri | Identity of the terminology system |
code | Σ | 1..1 | code | Symbol in syntax defined by the system |
subject | SΣ | 1..1 | Reference(Patient) | Who and/or what the observation is about |
effective[x] | SΣC | 1..1 | Often just a dateTime for vital signs Slice: Unordered, Open by type:$this | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
value[x] | SΣC | 0..1 | Quantity | Vital Signs value are recorded using the Quantity data type. For supporting observations such as Cuff size could use other datatypes such as CodeableConcept. |
value | SΣ | 1..1 | decimal | Numerical value (with implicit precision) |
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. |
unit | SΣ | 1..1 | string | Unit representation |
system | SΣC | 1..1 | uri | System that defines coded unit form Required Pattern: http://unitsofmeasure.org |
code | SΣ | 1..1 | code | Coded form of the unit Binding: BodyWeightUnits (required) |
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
Documentation for this format |
Path | Conformance | ValueSet / Code |
Observation.status | required | ObservationStatus |
Observation.category | preferred | ObservationCategoryCodes |
Observation.category:vs-cat | preferred | Pattern: vital-signs |
Observation.code | example | LOINCCodes (a valid code from LOINC) |
Observation.value[x].comparator | required | QuantityComparator |
Observation.value[x].code | required | BodyWeightUnits |
Observation.dataAbsentReason | extensible | DataAbsentReason |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
vs-1 | error | Observation.effective[x] | Datetime must be at least to day : ($this as dateTime).hasValue() implies ($this as dateTime).toString().length() >= 8 | |
vs-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present. : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Vital_Signs_Base | Measurements and simple assertions | ||||
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.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
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 | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
category:vs-cat | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: vital-signs | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
code | SΣ | 1..1 | CodeableConcept | Body Weight Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this | ||||
coding:loinc | Σ | 1..* | Coding | Code defined by a terminology system Required Pattern: At least the following | ||||
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: 29463-7 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
coding:snomed | Σ | 0..* | Coding | Code defined by a terminology system Required Pattern: At least the following | ||||
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://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 27113001 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
subject | SΣ | 1..1 | Reference(Patient) | 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] | SΣC | 1..1 | Often just a dateTime for vital signs Slice: Unordered, Open by type:$this | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation | ||||
value[x] | SΣC | 0..1 | Quantity | Vital Signs value are recorded using the Quantity data type. For supporting observations such as Cuff size could use other datatypes such as CodeableConcept. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
value | SΣ | 1..1 | decimal | Numerical value (with implicit precision) | ||||
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. | ||||
unit | SΣ | 1..1 | string | Unit representation | ||||
system | SΣC | 1..1 | uri | System that defines coded unit form Required Pattern: http://unitsofmeasure.org | ||||
code | SΣ | 1..1 | code | Coded form of the unit Binding: BodyWeightUnits (required) | ||||
dataAbsentReason | SC | 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 | ||||
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) | Used when reporting vital signs panel components | ||||
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 | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | ||||
Observation.language | preferred | CommonLanguages
| ||||
Observation.status | required | ObservationStatus | ||||
Observation.category | preferred | ObservationCategoryCodes | ||||
Observation.category:vs-cat | preferred | Pattern: vital-signs | ||||
Observation.code | example | LOINCCodes (a valid code from LOINC) | ||||
Observation.value[x].comparator | required | QuantityComparator | ||||
Observation.value[x].code | required | BodyWeightUnits | ||||
Observation.dataAbsentReason | extensible | DataAbsentReason | ||||
Observation.interpretation | extensible | ObservationInterpretationCodes | ||||
Observation.bodySite | example | SNOMEDCTBodyStructures | ||||
Observation.method | example | ObservationMethods | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes | ||||
Observation.component.code | example | LOINCCodes (a valid code from LOINC) | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReason | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodes |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
vs-1 | error | Observation.effective[x] | Datetime must be at least to day : ($this as dateTime).hasValue() implies ($this as dateTime).toString().length() >= 8 | |
vs-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present. : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
This structure is derived from Vital_Signs_Base
Summary
Mandatory: 4 elements (6 nested mandatory elements)
Must-Support: 6 elements
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Vital_Signs_Base
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | Vital_Signs_Base | Measurements and simple assertions | |
code | 1..1 | CodeableConcept | Body Weight | |
Slices for coding | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this | |
coding:loinc | 1..* | Coding | Code defined by a terminology system Required Pattern: At least the following | |
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: 29463-7 | |
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
coding:snomed | 0..* | Coding | Code defined by a terminology system Required Pattern: At least the following | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 27113001 | |
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
value[x] | S | 0..1 | Quantity | Vital Signs value are recorded using the Quantity data type. For supporting observations such as Cuff size could use other datatypes such as CodeableConcept. |
value | S | 1..1 | decimal | Numerical value (with implicit precision) |
unit | S | 1..1 | string | Unit representation |
system | S | 1..1 | uri | System that defines coded unit form Required Pattern: http://unitsofmeasure.org |
code | S | 1..1 | code | Coded form of the unit Binding: BodyWeightUnits (required) |
dataAbsentReason | S | 0..1 | CodeableConcept | Why the result is missing |
Documentation for this format |
Path | Conformance | ValueSet |
Observation.value[x].code | required | BodyWeightUnits |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Vital_Signs_Base | Measurements and simple assertions |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
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 | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
category:vs-cat | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: vital-signs | |
code | SΣ | 1..1 | CodeableConcept | Body Weight Binding: LOINCCodes (example): Codes identifying names of simple observations. |
Slices for coding | Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this |
coding:loinc | Σ | 1..* | Coding | Code defined by a terminology system Required Pattern: At least the following |
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: 29463-7 | |
system | Σ | 1..1 | uri | Identity of the terminology system |
code | Σ | 1..1 | code | Symbol in syntax defined by the system |
coding:snomed | Σ | 0..* | Coding | Code defined by a terminology system Required Pattern: At least the following |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 27113001 | |
system | Σ | 1..1 | uri | Identity of the terminology system |
code | Σ | 1..1 | code | Symbol in syntax defined by the system |
subject | SΣ | 1..1 | Reference(Patient) | Who and/or what the observation is about |
effective[x] | SΣC | 1..1 | Often just a dateTime for vital signs Slice: Unordered, Open by type:$this | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
value[x] | SΣC | 0..1 | Quantity | Vital Signs value are recorded using the Quantity data type. For supporting observations such as Cuff size could use other datatypes such as CodeableConcept. |
value | SΣ | 1..1 | decimal | Numerical value (with implicit precision) |
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. |
unit | SΣ | 1..1 | string | Unit representation |
system | SΣC | 1..1 | uri | System that defines coded unit form Required Pattern: http://unitsofmeasure.org |
code | SΣ | 1..1 | code | Coded form of the unit Binding: BodyWeightUnits (required) |
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
Documentation for this format |
Path | Conformance | ValueSet / Code |
Observation.status | required | ObservationStatus |
Observation.category | preferred | ObservationCategoryCodes |
Observation.category:vs-cat | preferred | Pattern: vital-signs |
Observation.code | example | LOINCCodes (a valid code from LOINC) |
Observation.value[x].comparator | required | QuantityComparator |
Observation.value[x].code | required | BodyWeightUnits |
Observation.dataAbsentReason | extensible | DataAbsentReason |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
vs-1 | error | Observation.effective[x] | Datetime must be at least to day : ($this as dateTime).hasValue() implies ($this as dateTime).toString().length() >= 8 | |
vs-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present. : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Vital_Signs_Base | Measurements and simple assertions | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business Identifier for observation | ||||
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | ||||
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
category:vs-cat | 1..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://terminology.hl7.org/CodeSystem/observation-category | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: vital-signs | |||||
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 | Body Weight Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this | ||||
coding:loinc | Σ | 1..* | Coding | Code defined by a terminology system Required Pattern: At least the following | ||||
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: 29463-7 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
coding:snomed | Σ | 0..* | Coding | Code defined by a terminology system Required Pattern: At least the following | ||||
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://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 27113001 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
subject | SΣ | 1..1 | Reference(Patient) | 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] | SΣC | 1..1 | Often just a dateTime for vital signs Slice: Unordered, Open by type:$this | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation | ||||
value[x] | SΣC | 0..1 | Quantity | Vital Signs value are recorded using the Quantity data type. For supporting observations such as Cuff size could use other datatypes such as CodeableConcept. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
value | SΣ | 1..1 | decimal | Numerical value (with implicit precision) | ||||
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. | ||||
unit | SΣ | 1..1 | string | Unit representation | ||||
system | SΣC | 1..1 | uri | System that defines coded unit form Required Pattern: http://unitsofmeasure.org | ||||
code | SΣ | 1..1 | code | Coded form of the unit Binding: BodyWeightUnits (required) | ||||
dataAbsentReason | SC | 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 | ||||
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) | Used when reporting vital signs panel components | ||||
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 | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | ||||
Observation.language | preferred | CommonLanguages
| ||||
Observation.status | required | ObservationStatus | ||||
Observation.category | preferred | ObservationCategoryCodes | ||||
Observation.category:vs-cat | preferred | Pattern: vital-signs | ||||
Observation.code | example | LOINCCodes (a valid code from LOINC) | ||||
Observation.value[x].comparator | required | QuantityComparator | ||||
Observation.value[x].code | required | BodyWeightUnits | ||||
Observation.dataAbsentReason | extensible | DataAbsentReason | ||||
Observation.interpretation | extensible | ObservationInterpretationCodes | ||||
Observation.bodySite | example | SNOMEDCTBodyStructures | ||||
Observation.method | example | ObservationMethods | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes | ||||
Observation.component.code | example | LOINCCodes (a valid code from LOINC) | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReason | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodes |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
vs-1 | error | Observation.effective[x] | Datetime must be at least to day : ($this as dateTime).hasValue() implies ($this as dateTime).toString().length() >= 8 | |
vs-2 | error | Observation | If there is no component or hasMember element then either a value[x] or a data absent reason must be present. : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
This structure is derived from Vital_Signs_Base
Summary
Mandatory: 4 elements (6 nested mandatory elements)
Must-Support: 6 elements
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron