AU Base Implementation Guide
4.1.2-preview - Preview Australia flag

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

Resource Profile: AU Base Pathology Result

Official URL: http://hl7.org.au/fhir/StructureDefinition/au-pathologyresult Version: 4.1.2-preview
Standards status: Trial-use Maturity Level: 1 Computable Name: AUBasePathologyResult

Copyright/Legal: HL7 Australia© 2018+; Licensed Under Creative Commons No Rights Reserved.

This profile defines an observation structure to represent a pathology test result issued by a diagnostic service provider in an Australian context. This profile is intended to be capable of supporting reporting for all pathology disciplines (e.g. including microbiology, histopathology, cytology, blood transfusion) with the exception of genomics. 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.

This profile does not provide full support for structured pathology reporting. It is expected that this support is best handled by a set of profiles that represent the structured reporting requirements for each specific protocol (see for example RCPA’s structured pathology reporting of cancer); this is not in the scope of this implementation guide at this time.

Usage Notes

Profile specific implementation guidance:

Usage:

Formal Views of Profile Content

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

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationA pathology test result in an Australian healthcare context
inv-obs-0: A pathology 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..*CodeableConceptClassification of the service requested as laboratory + more specific discipline where available
Slice: Unordered, Open by value:coding.system, value:coding.code
.... category:lab 1..1CodeableConceptObservation generated by laboratories
..... coding 1..*CodingCode defined by a terminology system
...... system 1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code 1..1codeSymbol in syntax defined by the system
Fixed Value: laboratory
.... category:specificDiscipline 0..*CodeableConceptSpecific discipline of pathology
Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
..... coding
...... system 1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
... code 1..1CodeableConceptPathology test or test group
Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
... subject 1..1Reference(Patient)Who and/or what the observation is about
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... value[x] C0..1Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, PeriodActual result
... dataAbsentReason C0..1CodeableConceptWhy the result is missing
... specimen 0..1Reference(AU Base Specimen)Specimen used for this observation
... hasMember C0..*Reference(AU Base Diagnostic Result | AU Base Pathology Result)Individual tests in a group or panel
... component 0..*BackboneElementIndividual tests in a group or panel
.... code 1..1CodeableConceptIndividual pathology test
Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
.... value[x] C0..1Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, PeriodActual component result
.... dataAbsentReason C0..1CodeableConceptWhy the component result is missing

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.category:specificDisciplineextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
Observation.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
Observation.component.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1

Constraints

IdGradePath(s)DetailsRequirements
inv-obs-0errorObservationA pathology 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()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationA pathology test result in an Australian healthcare context
inv-obs-0: A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!Σ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

.... category:lab 1..1CodeableConceptObservation generated by laboratories
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


..... coding Σ1..*CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: laboratory
.... category:specificDiscipline 0..*CodeableConceptSpecific discipline of pathology
Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
... code Σ1..1CodeableConceptPathology test or test group
Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
... subject Σ1..1Reference(Patient)Who and/or what the observation is about
... effective[x] Σ1..1Time of specimen collection
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... value[x] ΣC0..1Actual result
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
... dataAbsentReason C0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... specimen 0..1Reference(AU Base Specimen)Specimen used for this observation
... hasMember ΣC0..*Reference(AU Base Diagnostic Result | AU Base Pathology Result)Individual tests in a group or panel
... component Σ0..*BackboneElementIndividual tests in a group or panel
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptIndividual pathology test
Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
.... value[x] ΣC0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason C0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Observation.statusrequiredObservationStatus
Observation.categorypreferredObservationCategoryCodes
Observation.category:labpreferredObservationCategoryCodes
Observation.category:specificDisciplineextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
Observation.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.component.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
Observation.component.dataAbsentReasonextensibleDataAbsentReason

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorObservationIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorObservationIf 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-4errorObservationIf 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-5errorObservationIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceObservationA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
inv-obs-0errorObservationA pathology 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-6errorObservationdataAbsentReason SHALL only be present if Observation.value[x] is not present
: dataAbsentReason.empty() or value.empty()
obs-7errorObservationIf 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()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationA pathology test result in an Australian healthcare context
inv-obs-0: A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!Σ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category 1..*CodeableConceptClassification of the service requested as laboratory + more specific discipline where available
Slice: Unordered, Open by value:coding.system, value:coding.code
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:lab 1..1CodeableConceptObservation generated by laboratories
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ1..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: laboratory
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... text Σ0..1stringPlain text representation of the concept
.... category:specificDiscipline 0..*CodeableConceptSpecific discipline of pathology
Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ0..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ0..1codeSymbol in syntax defined by the system
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... text Σ0..1stringPlain text representation of the concept
... code Σ1..1CodeableConceptPathology test or test group
Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
... subject Σ1..1Reference(Patient)Who and/or what the observation is about
... focus Σ0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter Σ0..1Reference(Encounter)Healthcare event during which this observation is made
... effective[x] Σ1..1Time of specimen collection
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDate/Time this version was made available
... performer Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)Who is responsible for the observation
... value[x] ΣC0..1Actual result
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
... dataAbsentReason C0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

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


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

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

... specimen 0..1Reference(AU Base Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange C0..*BackboneElementProvides guide for interpretation
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low C0..1SimpleQuantityLow Range, if relevant
.... high C0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

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


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember ΣC0..*Reference(AU Base Diagnostic Result | AU Base Pathology Result)Individual tests in a group or panel
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component Σ0..*BackboneElementIndividual tests in a group or panel
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptIndividual pathology test
Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
.... value[x] ΣC0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason C0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

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


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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Observation.statusrequiredObservationStatus
Observation.categorypreferredObservationCategoryCodes
Observation.category:labpreferredObservationCategoryCodes
Observation.category:specificDisciplineextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
Observation.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySiteexampleSNOMEDCTBodyStructures
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorObservationIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorObservationIf 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-4errorObservationIf 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-5errorObservationIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceObservationA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
inv-obs-0errorObservationA pathology 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-3errorObservation.referenceRangeMust have at least a low or a high or text
: low.exists() or high.exists() or text.exists()
obs-6errorObservationdataAbsentReason SHALL only be present if Observation.value[x] is not present
: dataAbsentReason.empty() or value.empty()
obs-7errorObservationIf 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:

Slices

This structure defines the following Slices:

  • The element Observation.category is sliced based on the values of value:coding.system, value:coding.code

Maturity: 1

Differential View

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationA pathology test result in an Australian healthcare context
inv-obs-0: A pathology 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..*CodeableConceptClassification of the service requested as laboratory + more specific discipline where available
Slice: Unordered, Open by value:coding.system, value:coding.code
.... category:lab 1..1CodeableConceptObservation generated by laboratories
..... coding 1..*CodingCode defined by a terminology system
...... system 1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code 1..1codeSymbol in syntax defined by the system
Fixed Value: laboratory
.... category:specificDiscipline 0..*CodeableConceptSpecific discipline of pathology
Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
..... coding
...... system 1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
... code 1..1CodeableConceptPathology test or test group
Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
... subject 1..1Reference(Patient)Who and/or what the observation is about
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... value[x] C0..1Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, PeriodActual result
... dataAbsentReason C0..1CodeableConceptWhy the result is missing
... specimen 0..1Reference(AU Base Specimen)Specimen used for this observation
... hasMember C0..*Reference(AU Base Diagnostic Result | AU Base Pathology Result)Individual tests in a group or panel
... component 0..*BackboneElementIndividual tests in a group or panel
.... code 1..1CodeableConceptIndividual pathology test
Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
.... value[x] C0..1Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, PeriodActual component result
.... dataAbsentReason C0..1CodeableConceptWhy the component result is missing

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.category:specificDisciplineextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
Observation.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
Observation.component.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1

Constraints

IdGradePath(s)DetailsRequirements
inv-obs-0errorObservationA pathology 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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationA pathology test result in an Australian healthcare context
inv-obs-0: A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!Σ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

.... category:lab 1..1CodeableConceptObservation generated by laboratories
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


..... coding Σ1..*CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: laboratory
.... category:specificDiscipline 0..*CodeableConceptSpecific discipline of pathology
Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
... code Σ1..1CodeableConceptPathology test or test group
Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
... subject Σ1..1Reference(Patient)Who and/or what the observation is about
... effective[x] Σ1..1Time of specimen collection
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... value[x] ΣC0..1Actual result
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
... dataAbsentReason C0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... specimen 0..1Reference(AU Base Specimen)Specimen used for this observation
... hasMember ΣC0..*Reference(AU Base Diagnostic Result | AU Base Pathology Result)Individual tests in a group or panel
... component Σ0..*BackboneElementIndividual tests in a group or panel
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptIndividual pathology test
Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
.... value[x] ΣC0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason C0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Observation.statusrequiredObservationStatus
Observation.categorypreferredObservationCategoryCodes
Observation.category:labpreferredObservationCategoryCodes
Observation.category:specificDisciplineextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
Observation.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.component.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
Observation.component.dataAbsentReasonextensibleDataAbsentReason

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorObservationIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorObservationIf 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-4errorObservationIf 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-5errorObservationIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceObservationA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
inv-obs-0errorObservationA pathology 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-6errorObservationdataAbsentReason SHALL only be present if Observation.value[x] is not present
: dataAbsentReason.empty() or value.empty()
obs-7errorObservationIf 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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationA pathology test result in an Australian healthcare context
inv-obs-0: A pathology result shall at least have value or data absent reason or a child observation with a value or data absent reason
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!Σ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category 1..*CodeableConceptClassification of the service requested as laboratory + more specific discipline where available
Slice: Unordered, Open by value:coding.system, value:coding.code
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:lab 1..1CodeableConceptObservation generated by laboratories
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ1..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: laboratory
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... text Σ0..1stringPlain text representation of the concept
.... category:specificDiscipline 0..*CodeableConceptSpecific discipline of pathology
Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ0..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ0..1codeSymbol in syntax defined by the system
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... text Σ0..1stringPlain text representation of the concept
... code Σ1..1CodeableConceptPathology test or test group
Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
... subject Σ1..1Reference(Patient)Who and/or what the observation is about
... focus Σ0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter Σ0..1Reference(Encounter)Healthcare event during which this observation is made
... effective[x] Σ1..1Time of specimen collection
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDate/Time this version was made available
... performer Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)Who is responsible for the observation
... value[x] ΣC0..1Actual result
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
... dataAbsentReason C0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

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


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

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

... specimen 0..1Reference(AU Base Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange C0..*BackboneElementProvides guide for interpretation
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low C0..1SimpleQuantityLow Range, if relevant
.... high C0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

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


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember ΣC0..*Reference(AU Base Diagnostic Result | AU Base Pathology Result)Individual tests in a group or panel
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component Σ0..*BackboneElementIndividual tests in a group or panel
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptIndividual pathology test
Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
.... value[x] ΣC0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason C0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

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


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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Observation.statusrequiredObservationStatus
Observation.categorypreferredObservationCategoryCodes
Observation.category:labpreferredObservationCategoryCodes
Observation.category:specificDisciplineextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
Observation.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySiteexampleSNOMEDCTBodyStructures
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorObservationIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorObservationIf 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-4errorObservationIf 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-5errorObservationIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceObservationA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
inv-obs-0errorObservationA pathology 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-3errorObservation.referenceRangeMust have at least a low or a high or text
: low.exists() or high.exists() or text.exists()
obs-6errorObservationdataAbsentReason SHALL only be present if Observation.value[x] is not present
: dataAbsentReason.empty() or value.empty()
obs-7errorObservationIf 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:

Slices

This structure defines the following Slices:

  • The element Observation.category is sliced based on the values of value:coding.system, value:coding.code

Maturity: 1

 

Other representations of profile: CSV, Excel, Schematron