AU Core Implementation Guide
0.2.2-preview - Preview Australia flag

This page is part of the Australian Core IG (v0.2.2-preview: AU Core) based on FHIR R4. For a full list of available versions, see the Directory of published versions

Resource Profile: AU Core Head Circumference

Official URL: http://hl7.org.au/fhir/core/StructureDefinition/au-core-headcircum Version: 0.2.2-preview
Standards status: Draft Maturity Level: 0 Computable Name: AUCoreHeadCircumference

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License. HL7 Australia© 2022+; Licensed Under Creative Commons No Rights Reserved.

This resource includes SNOMED Clinical Terms™ (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO). All rights reserved. SNOMED CT®, was originally created by The College of American Pathologists. “SNOMED” and “SNOMED CT” are registered trademarks of the IHTSDO. The rights to use and implement or implementation of SNOMED CT content are limited to the extent it is necessary to allow for the end use of this material. No further rights are granted in respect of the International Release and no further use of any SNOMED CT content by any other party is permitted.

This material contains content from LOINC (http://loinc.org). LOINC is copyright © 1995-2021, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license at http://loinc.org/license. LOINC® is a registered United States trademark of Regenstrief Institute, Inc.

All copies of this resource must include this copyright statement and all information contained in this statement.

This profile sets minimum expectations for an Observation resource to record, search, and fetch head circumference observations with standard coding and units of measure. It is based on the FHIR Head Circumference Profile and identifies the additional mandatory core elements, extensions, vocabularies and value sets that SHALL be present in the Observation resource when conforming to this profile. It provides the floor for standards development for specific uses cases in an Australian context.

Usage scenarios

The following are supported usage scenarios for this profile:

  • Query for observations of head circumference associated with a patient
  • Record or update an observation of head circumference associated with a patient

Comparison with other national and international specifications

A resource conforming to this profile is conformant to:

Conformance in reverse is not guaranteed, i.e. a resource conforming to International Patient Access, International Patient Summary, or US Core MAY NOT conform to AU Core.

Profile specific implementation guidance

  • Observation.category provides an efficient way of supporting system interactions, e.g. restricting searches. Implementers need to understand that data categorisation is somewhat subjective. The categorisation applied by the source may not align with a receiver’s expectations.
  • Observations MAY have additional codes that translate or map to the Observation code or category codes. For example:
    • providing a local code
    • providing a more specific codes such as 8306-3 - Body height - lying in addition to 8302-2 - Body height. Several additional observation codes are provided in the FHIR core specification vital signs table.
  • Observations MAY have [component] observations to qualify the vital sign observation. For example, 8478-0 - Mean blood pressure, 8887-2 - Heart rate device type, 8326-1 - Type of body temperature device. Several of these are provided in the FHIR core specification vital signs table.

Usage:

Formal Views of Profile Content

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

This structure is derived from observation-headcircum

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*observation-headcircumHead circumference
au-core-obs-02: At least value or data absent reason shall be present
... status 1..1coderegistered | preliminary | final | amended +
Fixed Value: final
... code
.... coding 2..*CodingCode defined by a terminology system
.... coding:snomedHeadCircumCode 1..1CodingSNOMED CT Head Circumference
..... system 1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 363812007
... subject 1..1Reference(AU Core Patient)Who and/or what the observation is about
... effective[x] C1..1dateTimeDate, and optionally time, the observation was performed
au-core-obs-01: Date shall be at least to day
... performer S0..*Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization | AU Core Patient | AU Core RelatedPerson)Who is responsible for the observation
... value[x]:valueQuantity C0..1QuantityHead circumference
.... code 1..1codeCoded responses from the common UCUM units for vital signs value set.
Binding: https://healthterminologies.gov.au/fhir/ValueSet/metric-body-length-units-1 (required)
... dataAbsentReason SC0..1CodeableConceptWhy the result is missing
... bodySite C0..1CodeableConceptObserved body part
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
au-core-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.value[x]:valueQuantity.coderequiredhttps://healthterminologies.gov.au/fhir/ValueSet/metric-body-length-units-1
Observation.bodySitepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1

Constraints

IdGradePath(s)DetailsRequirements
au-core-obs-01errorObservation.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10
au-core-obs-02errorObservationAt least value or data absent reason shall be present
: dataAbsentReason.exists() or value.exists()
au-core-obs-04errorObservation.bodySiteIf a coded body site is provided, at least one code shall be from SNOMED CT
: coding.exists() implies coding.where(system='http://snomed.info/sct').exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*observation-headcircumHead circumference
au-core-obs-02: At least value or data absent reason shall be present
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required)
Fixed Value: final
.... category:VSCat S1..1CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


..... coding SΣ1..*CodingCode defined by a terminology system
...... system SΣ1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code SΣ1..1codeSymbol in syntax defined by the system
Fixed Value: vital-signs
... code SΣ1..1CodeableConceptHead Circumference
Binding: VitalSigns (extensible): This identifies the vital sign result type.

.... Slices for coding Σ2..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:code, value:system
..... coding:HeadCircumCode Σ1..1CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
...... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 9843-4
..... coding:snomedHeadCircumCode Σ1..1CodingSNOMED CT Head Circumference
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 363812007
... subject SΣ1..1Reference(AU Core Patient)Who and/or what the observation is about
... encounter SΣ0..1Reference(AU Core Encounter)Healthcare event during which this observation is made
... effective[x] SΣC1..1dateTimeDate, and optionally time, the observation was performed
au-core-obs-01: Date shall be at least to day
... performer SΣ0..*Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization | AU Core Patient | AU Core RelatedPerson)Who is responsible for the observation
... Slices for value[x] SΣC0..1QuantityVital Signs value are recorded using the Quantity data type. For supporting observations such as Cuff size could use other datatypes such as CodeableConcept.
Slice: Unordered, Closed by type:$this
.... value[x]:valueQuantity SΣC0..1QuantityHead circumference
..... value SΣ1..1decimalNumerical value (with implicit precision)
..... comparator ?!Σ0..1code< | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.

..... unit SΣ1..1stringUnit representation
..... system SΣC1..1uriSystem that defines coded unit form
Fixed Value: http://unitsofmeasure.org
..... code SΣ1..1codeCoded responses from the common UCUM units for vital signs value set.
Binding: https://healthterminologies.gov.au/fhir/ValueSet/metric-body-length-units-1 (required)
... dataAbsentReason SC0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... bodySite C0..1CodeableConceptObserved body part
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
au-core-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT
... component SΣC0..*BackboneElementUsed when reporting systolic and diastolic blood pressure.
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code SΣ1..1CodeableConceptType of component observation (code / type)
Binding: VitalSigns (extensible): This identifies the vital sign result type.

.... value[x] SΣC0..1Vital Sign Value recorded with UCUM
Binding: VitalSignsUnits (required): Common UCUM units for recording Vital Signs.

..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason SC0..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 / Code
Observation.statusrequiredFixed Value: final
Observation.categorypreferredObservationCategoryCodes
Observation.category:VSCatpreferredObservationCategoryCodes
Observation.codeextensibleVitalSigns
Observation.value[x]:valueQuantity.comparatorrequiredQuantityComparator
Observation.value[x]:valueQuantity.coderequiredhttps://healthterminologies.gov.au/fhir/ValueSet/metric-body-length-units-1
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.bodySitepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Observation.component.codeextensibleVitalSigns
Observation.component.value[x]requiredVitalSignsUnits
Observation.component.dataAbsentReasonextensibleDataAbsentReason

Constraints

IdGradePath(s)DetailsRequirements
au-core-obs-01errorObservation.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10
au-core-obs-02errorObservationAt least value or data absent reason shall be present
: dataAbsentReason.exists() or value.exists()
au-core-obs-04errorObservation.bodySiteIf a coded body site is provided, at least one code shall be from SNOMED CT
: coding.exists() implies coding.where(system='http://snomed.info/sct').exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*observation-headcircumHead circumference
au-core-obs-02: At least value or data absent reason shall be present
... 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 ?!SΣ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required)
Fixed Value: final
... Slices for category S1..*CodeableConceptClassification of type of observation
Slice: Unordered, Open by value:coding.code, value:coding.system
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:VSCat S1..1CodeableConceptClassification of type of observation
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 SΣ1..*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 SΣ1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version Σ0..1stringVersion of the system - if relevant
...... code SΣ1..1codeSymbol in syntax defined by the system
Fixed Value: vital-signs
...... 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 SΣ1..1CodeableConceptHead Circumference
Binding: VitalSigns (extensible): This identifies the vital sign result type.

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ2..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:code, value:system
..... coding:HeadCircumCode Σ1..1CodingCode 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://loinc.org
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 9843-4
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... coding:snomedHeadCircumCode Σ1..1CodingSNOMED CT Head Circumference
...... 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://snomed.info/sct
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 363812007
...... 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
... subject SΣ1..1Reference(AU Core 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 SΣ0..1Reference(AU Core Encounter)Healthcare event during which this observation is made
... effective[x] SΣC1..1dateTimeDate, and optionally time, the observation was performed
au-core-obs-01: Date shall be at least to day
... issued Σ0..1instantDate/Time this version was made available
... performer SΣ0..*Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization | AU Core Patient | AU Core RelatedPerson)Who is responsible for the observation
... Slices for value[x] SΣC0..1QuantityVital Signs value are recorded using the Quantity data type. For supporting observations such as Cuff size could use other datatypes such as CodeableConcept.
Slice: Unordered, Closed by type:$this
.... value[x]:valueQuantity SΣC0..1QuantityHead circumference
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... value SΣ1..1decimalNumerical value (with implicit precision)
..... comparator ?!Σ0..1code< | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.

..... unit SΣ1..1stringUnit representation
..... system SΣC1..1uriSystem that defines coded unit form
Fixed Value: http://unitsofmeasure.org
..... code SΣ1..1codeCoded responses from the common UCUM units for vital signs value set.
Binding: https://healthterminologies.gov.au/fhir/ValueSet/metric-body-length-units-1 (required)
... dataAbsentReason SC0..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 C0..1CodeableConceptObserved body part
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
au-core-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT
... method 0..1CodeableConceptHow it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1Reference(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 Σ0..*Reference(QuestionnaireResponse | MolecularSequence | Vital Signs Profile)Used when reporting vital signs panel components
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | MolecularSequence | Vital Signs Profile)Related measurements the observation is made from
... component SΣC0..*BackboneElementUsed when reporting systolic and diastolic blood pressure.
.... 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 SΣ1..1CodeableConceptType of component observation (code / type)
Binding: VitalSigns (extensible): This identifies the vital sign result type.

.... value[x] SΣC0..1Vital Sign Value recorded with UCUM
Binding: VitalSignsUnits (required): Common UCUM units for recording Vital Signs.

..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason SC0..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 / Code
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Observation.statusrequiredFixed Value: final
Observation.categorypreferredObservationCategoryCodes
Observation.category:VSCatpreferredObservationCategoryCodes
Observation.codeextensibleVitalSigns
Observation.value[x]:valueQuantity.comparatorrequiredQuantityComparator
Observation.value[x]:valueQuantity.coderequiredhttps://healthterminologies.gov.au/fhir/ValueSet/metric-body-length-units-1
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySitepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codeextensibleVitalSigns
Observation.component.value[x]requiredVitalSignsUnits
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes

Constraints

IdGradePath(s)DetailsRequirements
au-core-obs-01errorObservation.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10
au-core-obs-02errorObservationAt least value or data absent reason shall be present
: dataAbsentReason.exists() or value.exists()
au-core-obs-04errorObservation.bodySiteIf a coded body site is provided, at least one code shall be from SNOMED CT
: coding.exists() implies coding.where(system='http://snomed.info/sct').exists()

Differential View

This structure is derived from observation-headcircum

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*observation-headcircumHead circumference
au-core-obs-02: At least value or data absent reason shall be present
... status 1..1coderegistered | preliminary | final | amended +
Fixed Value: final
... code
.... coding 2..*CodingCode defined by a terminology system
.... coding:snomedHeadCircumCode 1..1CodingSNOMED CT Head Circumference
..... system 1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 363812007
... subject 1..1Reference(AU Core Patient)Who and/or what the observation is about
... effective[x] C1..1dateTimeDate, and optionally time, the observation was performed
au-core-obs-01: Date shall be at least to day
... performer S0..*Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization | AU Core Patient | AU Core RelatedPerson)Who is responsible for the observation
... value[x]:valueQuantity C0..1QuantityHead circumference
.... code 1..1codeCoded responses from the common UCUM units for vital signs value set.
Binding: https://healthterminologies.gov.au/fhir/ValueSet/metric-body-length-units-1 (required)
... dataAbsentReason SC0..1CodeableConceptWhy the result is missing
... bodySite C0..1CodeableConceptObserved body part
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
au-core-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.value[x]:valueQuantity.coderequiredhttps://healthterminologies.gov.au/fhir/ValueSet/metric-body-length-units-1
Observation.bodySitepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1

Constraints

IdGradePath(s)DetailsRequirements
au-core-obs-01errorObservation.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10
au-core-obs-02errorObservationAt least value or data absent reason shall be present
: dataAbsentReason.exists() or value.exists()
au-core-obs-04errorObservation.bodySiteIf a coded body site is provided, at least one code shall be from SNOMED CT
: coding.exists() implies coding.where(system='http://snomed.info/sct').exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*observation-headcircumHead circumference
au-core-obs-02: At least value or data absent reason shall be present
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required)
Fixed Value: final
.... category:VSCat S1..1CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


..... coding SΣ1..*CodingCode defined by a terminology system
...... system SΣ1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code SΣ1..1codeSymbol in syntax defined by the system
Fixed Value: vital-signs
... code SΣ1..1CodeableConceptHead Circumference
Binding: VitalSigns (extensible): This identifies the vital sign result type.

.... Slices for coding Σ2..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:code, value:system
..... coding:HeadCircumCode Σ1..1CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
...... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 9843-4
..... coding:snomedHeadCircumCode Σ1..1CodingSNOMED CT Head Circumference
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 363812007
... subject SΣ1..1Reference(AU Core Patient)Who and/or what the observation is about
... encounter SΣ0..1Reference(AU Core Encounter)Healthcare event during which this observation is made
... effective[x] SΣC1..1dateTimeDate, and optionally time, the observation was performed
au-core-obs-01: Date shall be at least to day
... performer SΣ0..*Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization | AU Core Patient | AU Core RelatedPerson)Who is responsible for the observation
... Slices for value[x] SΣC0..1QuantityVital Signs value are recorded using the Quantity data type. For supporting observations such as Cuff size could use other datatypes such as CodeableConcept.
Slice: Unordered, Closed by type:$this
.... value[x]:valueQuantity SΣC0..1QuantityHead circumference
..... value SΣ1..1decimalNumerical value (with implicit precision)
..... comparator ?!Σ0..1code< | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.

..... unit SΣ1..1stringUnit representation
..... system SΣC1..1uriSystem that defines coded unit form
Fixed Value: http://unitsofmeasure.org
..... code SΣ1..1codeCoded responses from the common UCUM units for vital signs value set.
Binding: https://healthterminologies.gov.au/fhir/ValueSet/metric-body-length-units-1 (required)
... dataAbsentReason SC0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... bodySite C0..1CodeableConceptObserved body part
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
au-core-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT
... component SΣC0..*BackboneElementUsed when reporting systolic and diastolic blood pressure.
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code SΣ1..1CodeableConceptType of component observation (code / type)
Binding: VitalSigns (extensible): This identifies the vital sign result type.

.... value[x] SΣC0..1Vital Sign Value recorded with UCUM
Binding: VitalSignsUnits (required): Common UCUM units for recording Vital Signs.

..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason SC0..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 / Code
Observation.statusrequiredFixed Value: final
Observation.categorypreferredObservationCategoryCodes
Observation.category:VSCatpreferredObservationCategoryCodes
Observation.codeextensibleVitalSigns
Observation.value[x]:valueQuantity.comparatorrequiredQuantityComparator
Observation.value[x]:valueQuantity.coderequiredhttps://healthterminologies.gov.au/fhir/ValueSet/metric-body-length-units-1
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.bodySitepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Observation.component.codeextensibleVitalSigns
Observation.component.value[x]requiredVitalSignsUnits
Observation.component.dataAbsentReasonextensibleDataAbsentReason

Constraints

IdGradePath(s)DetailsRequirements
au-core-obs-01errorObservation.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10
au-core-obs-02errorObservationAt least value or data absent reason shall be present
: dataAbsentReason.exists() or value.exists()
au-core-obs-04errorObservation.bodySiteIf a coded body site is provided, at least one code shall be from SNOMED CT
: coding.exists() implies coding.where(system='http://snomed.info/sct').exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*observation-headcircumHead circumference
au-core-obs-02: At least value or data absent reason shall be present
... 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 ?!SΣ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required)
Fixed Value: final
... Slices for category S1..*CodeableConceptClassification of type of observation
Slice: Unordered, Open by value:coding.code, value:coding.system
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:VSCat S1..1CodeableConceptClassification of type of observation
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 SΣ1..*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 SΣ1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version Σ0..1stringVersion of the system - if relevant
...... code SΣ1..1codeSymbol in syntax defined by the system
Fixed Value: vital-signs
...... 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 SΣ1..1CodeableConceptHead Circumference
Binding: VitalSigns (extensible): This identifies the vital sign result type.

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ2..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:code, value:system
..... coding:HeadCircumCode Σ1..1CodingCode 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://loinc.org
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 9843-4
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... coding:snomedHeadCircumCode Σ1..1CodingSNOMED CT Head Circumference
...... 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://snomed.info/sct
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 363812007
...... 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
... subject SΣ1..1Reference(AU Core 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 SΣ0..1Reference(AU Core Encounter)Healthcare event during which this observation is made
... effective[x] SΣC1..1dateTimeDate, and optionally time, the observation was performed
au-core-obs-01: Date shall be at least to day
... issued Σ0..1instantDate/Time this version was made available
... performer SΣ0..*Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization | AU Core Patient | AU Core RelatedPerson)Who is responsible for the observation
... Slices for value[x] SΣC0..1QuantityVital Signs value are recorded using the Quantity data type. For supporting observations such as Cuff size could use other datatypes such as CodeableConcept.
Slice: Unordered, Closed by type:$this
.... value[x]:valueQuantity SΣC0..1QuantityHead circumference
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... value SΣ1..1decimalNumerical value (with implicit precision)
..... comparator ?!Σ0..1code< | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.

..... unit SΣ1..1stringUnit representation
..... system SΣC1..1uriSystem that defines coded unit form
Fixed Value: http://unitsofmeasure.org
..... code SΣ1..1codeCoded responses from the common UCUM units for vital signs value set.
Binding: https://healthterminologies.gov.au/fhir/ValueSet/metric-body-length-units-1 (required)
... dataAbsentReason SC0..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 C0..1CodeableConceptObserved body part
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
au-core-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT
... method 0..1CodeableConceptHow it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1Reference(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 Σ0..*Reference(QuestionnaireResponse | MolecularSequence | Vital Signs Profile)Used when reporting vital signs panel components
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | MolecularSequence | Vital Signs Profile)Related measurements the observation is made from
... component SΣC0..*BackboneElementUsed when reporting systolic and diastolic blood pressure.
.... 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 SΣ1..1CodeableConceptType of component observation (code / type)
Binding: VitalSigns (extensible): This identifies the vital sign result type.

.... value[x] SΣC0..1Vital Sign Value recorded with UCUM
Binding: VitalSignsUnits (required): Common UCUM units for recording Vital Signs.

..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason SC0..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 / Code
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Observation.statusrequiredFixed Value: final
Observation.categorypreferredObservationCategoryCodes
Observation.category:VSCatpreferredObservationCategoryCodes
Observation.codeextensibleVitalSigns
Observation.value[x]:valueQuantity.comparatorrequiredQuantityComparator
Observation.value[x]:valueQuantity.coderequiredhttps://healthterminologies.gov.au/fhir/ValueSet/metric-body-length-units-1
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySitepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codeextensibleVitalSigns
Observation.component.value[x]requiredVitalSignsUnits
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes

Constraints

IdGradePath(s)DetailsRequirements
au-core-obs-01errorObservation.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10
au-core-obs-02errorObservationAt least value or data absent reason shall be present
: dataAbsentReason.exists() or value.exists()
au-core-obs-04errorObservation.bodySiteIf a coded body site is provided, at least one code shall be from SNOMED CT
: coding.exists() implies coding.where(system='http://snomed.info/sct').exists()

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Below is an overview of the mandatory and optional search parameters and combined search parameters. FHIR search operations and the syntax used to describe the interactions is described here.

Any search parameter defined in FHIR may be ‘allowed’ by the system unless explicitly marked as “SHALL NOT”. A few items are marked as MAY in this implementation guide to highlight their potential relevance.

Parameter(s) Conformance Type(s) Requirements (when used alone or in combination)
patient SHALL reference The client SHALL provide at least an id value and MAY provide both the Type and id values. The server SHALL support both.
patient+category SHALL reference+token
patient+category+date SHALL reference+token+date
patient+code SHALL reference+token
patient+category+status SHOULD reference+token+token
patient+code+date SHOULD reference+token+date
patient.identifier SHOULD reference.token The client SHALL provide both the system and code values. The server SHALL support both. The client SHOULD support search using IHI, Medicare Number, and DVA Number identifiers as defined in the AU Core Patient profile. The server SHOULD support search using the using IHI, Medicare Number, and DVA Number identifiers as defined in the AU Core Patient profile.
category MAY token The client SHALL provide at least a code value and MAY provide both the system and code values. The server SHALL support both. The client SHALL support search using the 'vital-signs' category defined in each profile. The server SHALL support search using the 'vital-signs' category defined in each profile.
code MAY token The client SHALL provide at least a code value and MAY provide both the system and code values. The server SHALL support both. The client SHALL support search using the LOINC codes defined in each profile. The server SHALL support search using the LOINC codes defined in each profile.
date MAY date A client SHALL provide a value precise to the second + time offset. A server SHALL support a value precise to the second + time offset.
status MAY token The client SHALL provide at least a code value and MAY provide both the system and code values. The server SHALL support both.

Mandatory Search Parameters:

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

  1. SHALL support searching using the patient search parameter: - SHALL support these _revinclude parameters: Provenance:target - SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code])

    GET [base]/Observation?patient={Type/}[id] or optionally GET [base]/Observation?patient.identifier=[system|][code]

    Example:

    1. GET [base]/Observation?patient=5678
    2. GET [base]/Observation?patient.identifier=http://ns.electronichealth.net.au/id/medicare-number|32788511952
    3. GET [base]/Observation?patient.identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608833357361

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

  2. SHALL support searching using the combination of the patient and category search parameters:
    • SHALL support these _revinclude parameters: Provenance:target
    • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code])

    GET [base]/Observation?patient={Type/}[id]&category=vital-signs

    Example:

    1. GET [base]/Observation?patient=5678&category=vital-signs

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

  3. SHALL support searching using the combination of the patient and category and date search parameters:
    • SHALL support these _revinclude parameters: Provenance:target
    • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code])
    • SHALL support these date comparators: gt,lt,ge,le
    • SHOULD support multipleAnd search on date (e.g.date=[date]&date=[date]]&...)

    GET [base]/Observation?patient={Type/}[id]&category=vital-signs&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]/Observation?patient=5678&category=vital-signs&date=ge2020-01-01T00:00:00Z

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

  4. SHALL support searching using the combination of the patient and code search parameters:
    • SHALL support these _revinclude parameters: Provenance:target
    • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code])
    • SHOULD support multipleOr search on code (e.g.code={system|}[code],{system|}[code],...)

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

    Example:

    1. GET [base]/Observation?patient=5678&code=http://snomed.info/sct|364075005,http://loinc.org|9843-4,http://loinc.org|85354-9

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

Optional Search Parameters:

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

  1. SHOULD support searching using the combination of the patient and category and status search parameters:
    • SHALL support these _revinclude parameters: Provenance:target
    • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code])
    • SHALL support multipleOr search on status (e.g.status={system|}[code],{system|}[code],...)

    GET [base]/Observation?patient={Type/}[id]&category=vital-signs&status={system|}[code]{,{system|}[code],...}

    Example:

    1. GET [base]/Observation?patient=5678&category=vital-signs&status=final
    2. GET [base]/Observation?patient=5678&category=vital-signs&_revinclude=Provenance:target

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

  2. SHOULD support searching using the combination of the patient and code and date search parameters:
    • SHALL support these _revinclude parameters: Provenance:target
    • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code]
    • SHOULD support multipleOr search on code (e.g.code={system|}[code],{system|}[code],...)
    • SHALL support these date comparators: gt,lt,ge,le
    • SHOULD support multipleAnd search on date (e.g.date=[date]&date=[date]]&...)

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

    Example:

    1. GET [base]/Observation?patient=5678&code=http://snomed.info/sct|364075005,http://loinc.org|9843-4,http://loinc.org|85354-9&date=ge2020-01-01T00:00:00Z
    2. GET [base]/Observation?patient.identifier=http://example.org/fhir/mrn|12345&code=http://snomed.info/sct|364075005,http://loinc.org|9843-4,http://loinc.org|85354-9&date=ge2020-01-01T00:00:00Z

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