AU Base Implementation Guide
4.1.2-preview - Preview
This page is part of the Australian Base IG (v4.1.2-preview: AU Base) based on FHIR R4. For a full list of available versions, see the Directory of published versions
Official URL: http://hl7.org.au/fhir/StructureDefinition/au-imagingresult | Version: 4.1.2-preview | |||
Standards status: Trial-use | Maturity Level: 1 | Computable Name: AUBaseDiagnosticImagingResult | ||
Copyright/Legal: HL7 Australia© 2018+; Licensed Under Creative Commons No Rights Reserved. |
This profile defines an observation structure to represent a imaging examination result issued by a diagnostic service provider in an Australian context. The observation may represent the result of a simple test such as haemoglobin or it may group the set of results produced by a multi-test study or panel such as a full blood count, or urine specimen study.
Profile specific implementation guidance:
Observation.code
andObservation.bodySite
.Observation.code
Observation.note
Observation.interpretation
Observation.component
or by referencing individual observation results in Observation.hasMember
Observation.hasMember
.Observation.hasMember
) rather than directly at the diagnostic report level (DiagnosticReport.result
).Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Observation | A imaging examination result in an Australian healthcare context inv-obs-0: An imaging result shall at least have value or data absent reason or a child observation with a value or data absent reason |
Slices for category | 1..* | CodeableConcept | Relevant diagnostic imaging category: service, modality and anatomic region Slice: Unordered, Open by value:coding.system, value:coding.code | |
category:diagImg | 1..1 | CodeableConcept | Observation generated by imaging | |
coding | 1..* | Coding | Code defined by a terminology system | |
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: imaging | |
category:anatomicRegionOfInterest | 0..* | CodeableConcept | Anatomic Region Of Interest Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (extensible) | |
coding | ||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | CodeableConcept | Diagnostic imaging examination or study Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred) | |
subject | 1..1 | Reference(Patient) | Who and/or what the observation is about | |
effective[x] | 1..1 | Time of diagnostic imaging examination | ||
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
value[x] | C | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual result |
dataAbsentReason | C | 0..1 | CodeableConcept | Why the result is missing |
bodySite | 0..1 | CodeableConcept | Observed body part Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred) | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
bodySite | 0..1 | Reference(BodyStructure) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite | |
hasMember | C | 0..* | Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result) | Individual examinations in a group or study series |
component | 0..* | BackboneElement | Individual examinations in a group or study series | |
code | 1..1 | CodeableConcept | Diagnostic imaging examination or study Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred) | |
value[x] | C | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual component result |
dataAbsentReason | C | 0..1 | CodeableConcept | Why the component result is missing |
Documentation for this format |
Path | Conformance | ValueSet |
Observation.category:anatomicRegionOfInterest | extensible | https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 |
Observation.code | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 |
Observation.bodySite | preferred | https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 |
Observation.component.code | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 |
Id | Grade | Path(s) | Details | Requirements |
inv-obs-0 | error | Observation | An imaging result shall at least have value or data absent reason or a child observation with a value or data absent reason : value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.exists() |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Observation | A imaging examination result in an Australian healthcare context inv-obs-0: An imaging result shall at least have value or data absent reason or a child observation with a value or data absent reason |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
Slices for category | 1..* | CodeableConcept | Relevant diagnostic imaging category: service, modality and anatomic region Slice: Unordered, Open by value:coding.system, value:coding.code Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |
category:diagImg | 1..1 | CodeableConcept | Observation generated by imaging Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |
coding | Σ | 1..* | Coding | Code defined by a terminology system |
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category |
code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging |
category:anatomicRegionOfInterest | 0..* | CodeableConcept | Anatomic Region Of Interest Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (extensible) | |
code | Σ | 1..1 | CodeableConcept | Diagnostic imaging examination or study Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred) |
subject | Σ | 1..1 | Reference(Patient) | Who and/or what the observation is about |
effective[x] | Σ | 1..1 | Time of diagnostic imaging examination | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
value[x] | ΣC | 0..1 | Actual 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 result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
bodySite | 0..1 | CodeableConcept | Observed body part Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred) | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
bodySite | 0..1 | Reference(BodyStructure) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite | |
hasMember | ΣC | 0..* | Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result) | Individual examinations in a group or study series |
component | Σ | 0..* | BackboneElement | Individual examinations in a group or study series |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | Σ | 1..1 | CodeableConcept | Diagnostic imaging examination or study Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred) |
value[x] | ΣC | 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. |
Documentation for this format |
Path | Conformance | ValueSet |
Observation.status | required | ObservationStatus |
Observation.category | preferred | ObservationCategoryCodes |
Observation.category:diagImg | preferred | ObservationCategoryCodes |
Observation.category:anatomicRegionOfInterest | extensible | https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 |
Observation.code | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 |
Observation.dataAbsentReason | extensible | DataAbsentReason |
Observation.bodySite | preferred | https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 |
Observation.component.code | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 |
Observation.component.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() | |
inv-obs-0 | error | Observation | An imaging result shall at least have value or data absent reason or a child observation with a value or data absent reason : value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.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() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | A imaging examination result in an Australian healthcare context inv-obs-0: An imaging result shall at least have value or data absent reason or a child observation with a value or data absent reason | ||||
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 | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
Slices for category | 1..* | CodeableConcept | Relevant diagnostic imaging category: service, modality and anatomic region Slice: Unordered, Open by value:coding.system, value:coding.code Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||
category:diagImg | 1..1 | CodeableConcept | Observation generated by imaging Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 1..* | Coding | Code defined by a terminology system | ||||
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 Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging | ||||
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 | ||||
category:anatomicRegionOfInterest | 0..* | CodeableConcept | Anatomic Region Of Interest Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (extensible) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
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 Fixed Value: http://snomed.info/sct | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 0..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 | ||||
code | Σ | 1..1 | CodeableConcept | Diagnostic imaging examination or study Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred) | ||||
subject | Σ | 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] | Σ | 1..1 | Time of diagnostic imaging examination | |||||
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] | ΣC | 0..1 | Actual 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 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: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
bodySite | 0..1 | Reference(BodyStructure) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
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 | ΣC | 0..* | Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result) | Individual examinations in a group or study series | ||||
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
component | Σ | 0..* | BackboneElement | Individual examinations in a group or study series | ||||
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 | Diagnostic imaging examination or study Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred) | ||||
value[x] | ΣC | 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 |
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() | |
inv-obs-0 | error | Observation | An imaging result shall at least have value or data absent reason or a child observation with a value or data absent reason : value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.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() |
This structure is derived from Observation
Summary
Mandatory: 7 elements (1 nested mandatory element)
Fixed Value: 3 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 1
Differential View
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Observation | A imaging examination result in an Australian healthcare context inv-obs-0: An imaging result shall at least have value or data absent reason or a child observation with a value or data absent reason |
Slices for category | 1..* | CodeableConcept | Relevant diagnostic imaging category: service, modality and anatomic region Slice: Unordered, Open by value:coding.system, value:coding.code | |
category:diagImg | 1..1 | CodeableConcept | Observation generated by imaging | |
coding | 1..* | Coding | Code defined by a terminology system | |
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: imaging | |
category:anatomicRegionOfInterest | 0..* | CodeableConcept | Anatomic Region Of Interest Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (extensible) | |
coding | ||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | CodeableConcept | Diagnostic imaging examination or study Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred) | |
subject | 1..1 | Reference(Patient) | Who and/or what the observation is about | |
effective[x] | 1..1 | Time of diagnostic imaging examination | ||
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
value[x] | C | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual result |
dataAbsentReason | C | 0..1 | CodeableConcept | Why the result is missing |
bodySite | 0..1 | CodeableConcept | Observed body part Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred) | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
bodySite | 0..1 | Reference(BodyStructure) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite | |
hasMember | C | 0..* | Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result) | Individual examinations in a group or study series |
component | 0..* | BackboneElement | Individual examinations in a group or study series | |
code | 1..1 | CodeableConcept | Diagnostic imaging examination or study Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred) | |
value[x] | C | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual component result |
dataAbsentReason | C | 0..1 | CodeableConcept | Why the component result is missing |
Documentation for this format |
Path | Conformance | ValueSet |
Observation.category:anatomicRegionOfInterest | extensible | https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 |
Observation.code | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 |
Observation.bodySite | preferred | https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 |
Observation.component.code | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 |
Id | Grade | Path(s) | Details | Requirements |
inv-obs-0 | error | Observation | An imaging result shall at least have value or data absent reason or a child observation with a value or data absent reason : value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.exists() |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Observation | A imaging examination result in an Australian healthcare context inv-obs-0: An imaging result shall at least have value or data absent reason or a child observation with a value or data absent reason |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. |
Slices for category | 1..* | CodeableConcept | Relevant diagnostic imaging category: service, modality and anatomic region Slice: Unordered, Open by value:coding.system, value:coding.code Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |
category:diagImg | 1..1 | CodeableConcept | Observation generated by imaging Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |
coding | Σ | 1..* | Coding | Code defined by a terminology system |
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category |
code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging |
category:anatomicRegionOfInterest | 0..* | CodeableConcept | Anatomic Region Of Interest Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (extensible) | |
code | Σ | 1..1 | CodeableConcept | Diagnostic imaging examination or study Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred) |
subject | Σ | 1..1 | Reference(Patient) | Who and/or what the observation is about |
effective[x] | Σ | 1..1 | Time of diagnostic imaging examination | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
value[x] | ΣC | 0..1 | Actual 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 result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
bodySite | 0..1 | CodeableConcept | Observed body part Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred) | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
bodySite | 0..1 | Reference(BodyStructure) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite | |
hasMember | ΣC | 0..* | Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result) | Individual examinations in a group or study series |
component | Σ | 0..* | BackboneElement | Individual examinations in a group or study series |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | Σ | 1..1 | CodeableConcept | Diagnostic imaging examination or study Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred) |
value[x] | ΣC | 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. |
Documentation for this format |
Path | Conformance | ValueSet |
Observation.status | required | ObservationStatus |
Observation.category | preferred | ObservationCategoryCodes |
Observation.category:diagImg | preferred | ObservationCategoryCodes |
Observation.category:anatomicRegionOfInterest | extensible | https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 |
Observation.code | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 |
Observation.dataAbsentReason | extensible | DataAbsentReason |
Observation.bodySite | preferred | https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 |
Observation.component.code | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 |
Observation.component.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() | |
inv-obs-0 | error | Observation | An imaging result shall at least have value or data absent reason or a child observation with a value or data absent reason : value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.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() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | A imaging examination result in an Australian healthcare context inv-obs-0: An imaging result shall at least have value or data absent reason or a child observation with a value or data absent reason | ||||
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 | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
Slices for category | 1..* | CodeableConcept | Relevant diagnostic imaging category: service, modality and anatomic region Slice: Unordered, Open by value:coding.system, value:coding.code Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||
category:diagImg | 1..1 | CodeableConcept | Observation generated by imaging Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 1..* | Coding | Code defined by a terminology system | ||||
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 Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging | ||||
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 | ||||
category:anatomicRegionOfInterest | 0..* | CodeableConcept | Anatomic Region Of Interest Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 (extensible) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
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 Fixed Value: http://snomed.info/sct | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 0..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 | ||||
code | Σ | 1..1 | CodeableConcept | Diagnostic imaging examination or study Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred) | ||||
subject | Σ | 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] | Σ | 1..1 | Time of diagnostic imaging examination | |||||
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] | ΣC | 0..1 | Actual 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 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: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
bodySite | 0..1 | Reference(BodyStructure) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
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 | ΣC | 0..* | Reference(AU Base Diagnostic Result | AU Base Diagnostic Imaging Result) | Individual examinations in a group or study series | ||||
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
component | Σ | 0..* | BackboneElement | Individual examinations in a group or study series | ||||
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 | Diagnostic imaging examination or study Binding: https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 (preferred) | ||||
value[x] | ΣC | 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 | ||||
Observation.language | preferred | CommonLanguages
| ||||
Observation.status | required | ObservationStatus | ||||
Observation.category | preferred | ObservationCategoryCodes | ||||
Observation.category:diagImg | preferred | ObservationCategoryCodes | ||||
Observation.category:anatomicRegionOfInterest | extensible | https://healthterminologies.gov.au/fhir/ValueSet/imaging-anatomic-region-of-interest-1 | ||||
Observation.code | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 | ||||
Observation.dataAbsentReason | extensible | DataAbsentReason | ||||
Observation.interpretation | extensible | ObservationInterpretationCodes | ||||
Observation.bodySite | preferred | https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 | ||||
Observation.method | example | ObservationMethods | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes | ||||
Observation.component.code | preferred | https://healthterminologies.gov.au/fhir/ValueSet/imaging-procedure-1 | ||||
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() | |
inv-obs-0 | error | Observation | An imaging result shall at least have value or data absent reason or a child observation with a value or data absent reason : value.exists() or dataAbsentReason.exists() or hasMember.exists() or component.value.exists() or component.dataAbsentReason.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() |
This structure is derived from Observation
Summary
Mandatory: 7 elements (1 nested mandatory element)
Fixed Value: 3 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 1
Other representations of profile: CSV, Excel, Schematron