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. In the latter cases, the observation carries the code of the study / panel and the overall comments in the note element, or a global interpretation by the producer of the study in the interpretation element. The observation references the individual test results that make up the study / panel as ‘has-member’ child observations.

Boundaries and relationships

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

When sending observations that group the set of results by a multi-test study or panel:

• a study / panel observation is sent with individual component tests in Observation.hasMember
• an individual component test observation is referenced by that study / panel observation (Observation.hasMember) rather than directly at the diagnostic report level (DiagnosticReport.result)

If the pathology laboratory is a discipline specific laboratory then one of the appropriate discipline specific value sets may be more suitable for use than the entire reporting set available in the profile:

• ValueSet : RCPA - SPIA Chemical Pathology Terminology Reference Set
• ValueSet : RCPA - SPIA Haematology Terminology Reference Set
• ValueSet : RCPA - SPIA Immunopathology Terminology Reference Set
• ValueSet : RCPA - SPIA Microbiology Serology Molecular Pathology Terminology Reference Set

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from Observation

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	A 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..*	CodeableConcept	Classification of the service requested as laboratory + more specific discipline where available Slice: Unordered, Open by value:coding.system, value:coding.code
category:lab		1..1	CodeableConcept	Observation generated by laboratories
coding		1..*	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
code		1..1	code	Symbol in syntax defined by the system Fixed Value: laboratory
category:specificDiscipline		0..*	CodeableConcept	Specific discipline of pathology Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
coding
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
code		1..1	CodeableConcept	Pathology test or test group Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
subject		1..1	Reference(Patient)	Who and/or what the observation is about
effective[x]		1..1		Time of specimen collection
effectiveDateTime			dateTime
effectivePeriod			Period
specimen		0..1	Reference(AU Base Specimen)	Specimen used for this observation
hasMember		0..*	Reference(AU Base Diagnostic Result | AU Base Pathology Result)	Individual tests in a group or panel
component		0..*	BackboneElement	Individual tests in a group or panel
code		1..1	CodeableConcept	Individual pathology test Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Observation.category:specificDiscipline	extensible	https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
Observation.code	preferred	https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
Observation.component.code	preferred	https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-obs-0	error	Observation	A 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()

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	A 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	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation.
Slices for category		1..*	CodeableConcept	Classification 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..1	CodeableConcept	Observation generated by laboratories Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
coding	Σ	1..*	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: laboratory
category:specificDiscipline		0..*	CodeableConcept	Specific discipline of pathology Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
code	Σ	1..1	CodeableConcept	Pathology test or test group Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
subject	Σ	1..1	Reference(Patient)	Who and/or what the observation is about
effective[x]	Σ	1..1		Time of specimen collection
effectiveDateTime			dateTime
effectivePeriod			Period
specimen		0..1	Reference(AU Base Specimen)	Specimen used for this observation
hasMember	Σ	0..*	Reference(AU Base Diagnostic Result | AU Base Pathology Result)	Individual tests in a group or panel
component	Σ	0..*	BackboneElement	Individual tests in a group or panel
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	1..1	CodeableConcept	Individual pathology test Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Observation.status	required	ObservationStatus
Observation.category	preferred	ObservationCategoryCodes
Observation.category:lab	preferred	ObservationCategoryCodes
Observation.category:specificDiscipline	extensible	https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
Observation.code	preferred	https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
Observation.component.code	preferred	https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-obs-0	error	Observation	A 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()

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	A 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	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	Business Identifier for observation
basedOn	Σ	0..*	Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)	Fulfills plan, proposal or order
partOf	Σ	0..*	Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)	Part of referenced event
status	?!Σ	1..1	code	registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation.
Slices for category		1..*	CodeableConcept	Classification 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..1	CodeableConcept	Observation generated by laboratories Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: laboratory
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
category:specificDiscipline		0..*	CodeableConcept	Specific discipline of pathology Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
code	Σ	1..1	CodeableConcept	Pathology test or test group Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
subject	Σ	1..1	Reference(Patient)	Who and/or what the observation is about
focus	Σ	0..*	Reference(Resource)	What the observation is about, when it is not about the subject of record
encounter	Σ	0..1	Reference(Encounter)	Healthcare event during which this observation is made
effective[x]	Σ	1..1		Time of specimen collection
effectiveDateTime			dateTime
effectivePeriod			Period
issued	Σ	0..1	instant	Date/Time this version was made available
performer	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)	Who is responsible for the observation
value[x]	ΣC	0..1		Actual result
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	C	0..1	CodeableConcept	Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note		0..*	Annotation	Comments about the observation
bodySite		0..1	CodeableConcept	Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
method		0..1	CodeableConcept	How it was done Binding: ObservationMethods (example): Methods for simple observations.
specimen		0..1	Reference(AU Base Specimen)	Specimen used for this observation
device		0..1	Reference(Device | DeviceMetric)	(Measurement) Device
referenceRange	C	0..*	BackboneElement	Provides guide for interpretation
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
low	C	0..1	SimpleQuantity	Low Range, if relevant
high	C	0..1	SimpleQuantity	High Range, if relevant
type		0..1	CodeableConcept	Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
appliesTo		0..*	CodeableConcept	Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
age		0..1	Range	Applicable age range, if relevant
text		0..1	string	Text based reference range in an observation
hasMember	Σ	0..*	Reference(AU Base Diagnostic Result | AU Base Pathology Result)	Individual tests in a group or panel
derivedFrom	Σ	0..*	Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)	Related measurements the observation is made from
component	Σ	0..*	BackboneElement	Individual tests in a group or panel
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	1..1	CodeableConcept	Individual pathology test Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
value[x]	Σ	0..1		Actual component result
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	C	0..1	CodeableConcept	Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
referenceRange		0..*	See referenceRange (Observation)	Provides guide for interpretation of component result
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Observation.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Observation.status	required	ObservationStatus
Observation.category	preferred	ObservationCategoryCodes
Observation.category:lab	preferred	ObservationCategoryCodes
Observation.category:specificDiscipline	extensible	https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
Observation.code	preferred	https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
Observation.dataAbsentReason	extensible	DataAbsentReason
Observation.interpretation	extensible	ObservationInterpretationCodes
Observation.bodySite	example	SNOMEDCTBodyStructures
Observation.method	example	ObservationMethods
Observation.referenceRange.type	preferred	ObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesTo	example	ObservationReferenceRangeAppliesToCodes
Observation.component.code	preferred	https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
Observation.component.dataAbsentReason	extensible	DataAbsentReason
Observation.component.interpretation	extensible	ObservationInterpretationCodes

Differential View

This structure is derived from Observation

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	A 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..*	CodeableConcept	Classification of the service requested as laboratory + more specific discipline where available Slice: Unordered, Open by value:coding.system, value:coding.code
category:lab		1..1	CodeableConcept	Observation generated by laboratories
coding		1..*	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
code		1..1	code	Symbol in syntax defined by the system Fixed Value: laboratory
category:specificDiscipline		0..*	CodeableConcept	Specific discipline of pathology Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
coding
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
code		1..1	CodeableConcept	Pathology test or test group Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
subject		1..1	Reference(Patient)	Who and/or what the observation is about
effective[x]		1..1		Time of specimen collection
effectiveDateTime			dateTime
effectivePeriod			Period
specimen		0..1	Reference(AU Base Specimen)	Specimen used for this observation
hasMember		0..*	Reference(AU Base Diagnostic Result | AU Base Pathology Result)	Individual tests in a group or panel
component		0..*	BackboneElement	Individual tests in a group or panel
code		1..1	CodeableConcept	Individual pathology test Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Observation.category:specificDiscipline	extensible	https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
Observation.code	preferred	https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
Observation.component.code	preferred	https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-obs-0	error	Observation	A 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

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	A 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	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation.
Slices for category		1..*	CodeableConcept	Classification 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..1	CodeableConcept	Observation generated by laboratories Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
coding	Σ	1..*	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: laboratory
category:specificDiscipline		0..*	CodeableConcept	Specific discipline of pathology Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
code	Σ	1..1	CodeableConcept	Pathology test or test group Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
subject	Σ	1..1	Reference(Patient)	Who and/or what the observation is about
effective[x]	Σ	1..1		Time of specimen collection
effectiveDateTime			dateTime
effectivePeriod			Period
specimen		0..1	Reference(AU Base Specimen)	Specimen used for this observation
hasMember	Σ	0..*	Reference(AU Base Diagnostic Result | AU Base Pathology Result)	Individual tests in a group or panel
component	Σ	0..*	BackboneElement	Individual tests in a group or panel
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	1..1	CodeableConcept	Individual pathology test Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Observation.status	required	ObservationStatus
Observation.category	preferred	ObservationCategoryCodes
Observation.category:lab	preferred	ObservationCategoryCodes
Observation.category:specificDiscipline	extensible	https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
Observation.code	preferred	https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
Observation.component.code	preferred	https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-obs-0	error	Observation	A 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()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	A 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	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	Business Identifier for observation
basedOn	Σ	0..*	Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)	Fulfills plan, proposal or order
partOf	Σ	0..*	Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)	Part of referenced event
status	?!Σ	1..1	code	registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation.
Slices for category		1..*	CodeableConcept	Classification 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..1	CodeableConcept	Observation generated by laboratories Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: laboratory
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
category:specificDiscipline		0..*	CodeableConcept	Specific discipline of pathology Binding: https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1 (extensible)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
code	Σ	1..1	CodeableConcept	Pathology test or test group Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
subject	Σ	1..1	Reference(Patient)	Who and/or what the observation is about
focus	Σ	0..*	Reference(Resource)	What the observation is about, when it is not about the subject of record
encounter	Σ	0..1	Reference(Encounter)	Healthcare event during which this observation is made
effective[x]	Σ	1..1		Time of specimen collection
effectiveDateTime			dateTime
effectivePeriod			Period
issued	Σ	0..1	instant	Date/Time this version was made available
performer	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)	Who is responsible for the observation
value[x]	ΣC	0..1		Actual result
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	C	0..1	CodeableConcept	Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note		0..*	Annotation	Comments about the observation
bodySite		0..1	CodeableConcept	Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
method		0..1	CodeableConcept	How it was done Binding: ObservationMethods (example): Methods for simple observations.
specimen		0..1	Reference(AU Base Specimen)	Specimen used for this observation
device		0..1	Reference(Device | DeviceMetric)	(Measurement) Device
referenceRange	C	0..*	BackboneElement	Provides guide for interpretation
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
low	C	0..1	SimpleQuantity	Low Range, if relevant
high	C	0..1	SimpleQuantity	High Range, if relevant
type		0..1	CodeableConcept	Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
appliesTo		0..*	CodeableConcept	Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
age		0..1	Range	Applicable age range, if relevant
text		0..1	string	Text based reference range in an observation
hasMember	Σ	0..*	Reference(AU Base Diagnostic Result | AU Base Pathology Result)	Individual tests in a group or panel
derivedFrom	Σ	0..*	Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)	Related measurements the observation is made from
component	Σ	0..*	BackboneElement	Individual tests in a group or panel
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	1..1	CodeableConcept	Individual pathology test Binding: https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1 (preferred)
value[x]	Σ	0..1		Actual component result
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	C	0..1	CodeableConcept	Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
referenceRange		0..*	See referenceRange (Observation)	Provides guide for interpretation of component result
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Observation.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Observation.status	required	ObservationStatus
Observation.category	preferred	ObservationCategoryCodes
Observation.category:lab	preferred	ObservationCategoryCodes
Observation.category:specificDiscipline	extensible	https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1
Observation.code	preferred	https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
Observation.dataAbsentReason	extensible	DataAbsentReason
Observation.interpretation	extensible	ObservationInterpretationCodes
Observation.bodySite	example	SNOMEDCTBodyStructures
Observation.method	example	ObservationMethods
Observation.referenceRange.type	preferred	ObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesTo	example	ObservationReferenceRangeAppliesToCodes
Observation.component.code	preferred	https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1
Observation.component.dataAbsentReason	extensible	DataAbsentReason
Observation.component.interpretation	extensible	ObservationInterpretationCodes

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:

• AU Base Specimen (http://hl7.org.au/fhir/StructureDefinition/au-specimen)
• AU Base Diagnostic Result (http://hl7.org.au/fhir/StructureDefinition/au-diagnosticresult)
• AU Base Pathology Result (http://hl7.org.au/fhir/StructureDefinition/au-pathologyresult)

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

none defined