Australian Base Implementation Guide (AU Base 2)

This page is part of the Australian Base IG (v2.1.0: AU Base 2 on R4) based on FHIR R4. For a full list of available versions, see the Directory of published versions

1.0 StructureDefinition-au-norelevantfinding

AU Assertion of No Relevant Finding Profile [FMM Level 1]

This profile provides an observation information structure for asserting a clinical judgement that there are no items of specific interest, e.g. allergies, no medications, for a patient.

This observation may be time bound, e.g. the patient is not currently taking medications on this date. In such a scenario it is expected that status will be ‘final’.

An assertion of no relevant finding may be used in continuity of care or transfer or care related lists and composition sections. One possible use scenario is in a summary document to positively state that there is no known history of conditions for a patient. In such a scenario it is expected that status will be ‘final’.

Examples

No history of procedure

No history of immunisation

No known history of conditions

Patient not taking any medications

1.0.1 Formal Views of Profile Content

The official URL for this profile is: 

http://hl7.org.au/fhir/StructureDefinition/au-norelevantfinding

This profile provides an observation information structure for asserting a clinical judgement that there are no items of specific interest, e.g. allergies, no medications, for a patient.

This profile builds on Observation.

This profile was published on Mon Jul 29 00:00:00 AEST 2019 as a draft by Health Level Seven Australia (Orders and Observations WG).

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*ObservationStatement of clinical judgement that there are no items of specific interest
... code 1..1CodeableConceptType of observation (code / type)
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: ASSERTION
... subject 1..1Reference(Patient | Group)Who and/or what the observation is about
... performer 0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)Asserter of the statement
... value[x] 1..1(Slice Definition)Actual result
Slice: Unordered, Unspecified by type:$this
.... value[x]:valueCodeableConcept 1..1CodeableConceptCoded value of the observation
Binding: https://healthterminologies.gov.au/fhir/ValueSet/assertion-of-absence-1 (extensible)
... dataAbsentReason 0..0

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I0..*ObservationStatement of clinical judgement that there are no items of specific interest
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... language I0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier ΣI0..*IdentifierBusiness Identifier for observation
... basedOn ΣI0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf ΣI0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!ΣI1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required)
... category I0..*CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred)
... code ΣI1..1CodeableConceptType of observation (code / type)
Binding: LOINCCodes (example)
Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: ASSERTION
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... subject ΣI1..1Reference(Patient | Group)Who and/or what the observation is about
... focus ΣI0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter ΣI0..1Reference(Encounter)Healthcare event during which this observation is made
... effective[x] ΣI0..1Clinically relevant time/time-period for observation
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
.... effectiveTimingTiming
.... effectiveInstantinstant
... issued ΣI0..1instantDate/Time this version was made available
... performer ΣI0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)Asserter of the statement
... value[x] ΣI1..1(Slice Definition)Actual result
Slice: Unordered, Closed by type:$this
.... value[x]:valueCodeableConcept ΣI1..1CodeableConceptCoded value of the observation
Binding: https://healthterminologies.gov.au/fhir/ValueSet/assertion-of-absence-1 (extensible)
... interpretation I0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
... note I0..*AnnotationComments about the observation
... bodySite I0..1CodeableConceptObserved body part
Binding: SNOMEDCTBodyStructures (example)
... method I0..1CodeableConceptHow it was done
Binding: ObservationMethods (example)
... specimen I0..1Reference(Specimen)Specimen used for this observation
... device I0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange I0..*BackboneElementProvides guide for interpretation
obs-3: Must have at least a low or a high or text
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low I0..1SimpleQuantityLow Range, if relevant
.... high I0..1SimpleQuantityHigh Range, if relevant
.... type I0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred)
.... appliesTo I0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example)
.... age I0..1RangeApplicable age range, if relevant
.... text I0..1stringText based reference range in an observation
... hasMember ΣI0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)Related resource that belongs to the Observation group
... derivedFrom ΣI0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component ΣI0..*BackboneElementComponent results
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣI1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example)
.... value[x] ΣI0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible)
.... interpretation I0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
.... referenceRange I0..*See referenceRangeProvides guide for interpretation of component result

doco Documentation for this format

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*ObservationStatement of clinical judgement that there are no items of specific interest
... code 1..1CodeableConceptType of observation (code / type)
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: ASSERTION
... subject 1..1Reference(Patient | Group)Who and/or what the observation is about
... performer 0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)Asserter of the statement
... value[x] 1..1(Slice Definition)Actual result
Slice: Unordered, Unspecified by type:$this
.... value[x]:valueCodeableConcept 1..1CodeableConceptCoded value of the observation
Binding: https://healthterminologies.gov.au/fhir/ValueSet/assertion-of-absence-1 (extensible)
... dataAbsentReason 0..0

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I0..*ObservationStatement of clinical judgement that there are no items of specific interest
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... language I0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier ΣI0..*IdentifierBusiness Identifier for observation
... basedOn ΣI0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf ΣI0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!ΣI1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required)
... category I0..*CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred)
... code ΣI1..1CodeableConceptType of observation (code / type)
Binding: LOINCCodes (example)
Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: ASSERTION
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... subject ΣI1..1Reference(Patient | Group)Who and/or what the observation is about
... focus ΣI0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter ΣI0..1Reference(Encounter)Healthcare event during which this observation is made
... effective[x] ΣI0..1Clinically relevant time/time-period for observation
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
.... effectiveTimingTiming
.... effectiveInstantinstant
... issued ΣI0..1instantDate/Time this version was made available
... performer ΣI0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)Asserter of the statement
... value[x] ΣI1..1(Slice Definition)Actual result
Slice: Unordered, Closed by type:$this
.... value[x]:valueCodeableConcept ΣI1..1CodeableConceptCoded value of the observation
Binding: https://healthterminologies.gov.au/fhir/ValueSet/assertion-of-absence-1 (extensible)
... interpretation I0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
... note I0..*AnnotationComments about the observation
... bodySite I0..1CodeableConceptObserved body part
Binding: SNOMEDCTBodyStructures (example)
... method I0..1CodeableConceptHow it was done
Binding: ObservationMethods (example)
... specimen I0..1Reference(Specimen)Specimen used for this observation
... device I0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange I0..*BackboneElementProvides guide for interpretation
obs-3: Must have at least a low or a high or text
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low I0..1SimpleQuantityLow Range, if relevant
.... high I0..1SimpleQuantityHigh Range, if relevant
.... type I0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred)
.... appliesTo I0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example)
.... age I0..1RangeApplicable age range, if relevant
.... text I0..1stringText based reference range in an observation
... hasMember ΣI0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)Related resource that belongs to the Observation group
... derivedFrom ΣI0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component ΣI0..*BackboneElementComponent results
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣI1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example)
.... value[x] ΣI0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible)
.... interpretation I0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
.... referenceRange I0..*See referenceRangeProvides guide for interpretation of component result

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron

 

1.0.2 Quick Start

Below is an overview of the required search and read operations.

Summary of Search Criteria for StructureDefinition-au-norelevantfinding

none defined