Australian Base Implementation Guide (AU Base 1.1.1)

This page is part of the Australian Base IG (v1.1.1: AU Base 1.1 on STU3 Draft) based on FHIR R3. The current version which supercedes this version is 1.0.2. For a full list of available versions, see the Directory of published versions

1.0 StructureDefinition-au-norelevantfinding

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

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

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

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

Examples

No history of procedure

No history of immunisation

No known history of conditions

Patient not taking any medications

1.0.1 Formal Views of Profile Content

The official URL for this profile is: 

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

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

This profile builds on Observation.

This profile was published on Wed Jan 22 10:17:54 AEDT 2020 as a draft by Health Level Seven Australia (Orders and Observations WG).

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*ObservationStatement of clinical judgement that there are no items of specific interest
... code 1..1CodeableConceptFixed Value: As shown (Assertion)
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/v3/ActCode
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: ASSERTION
... subject 1..1Reference(Patient | Group)
... performer 0..*Reference(Practitioner | Organization | Patient | RelatedPerson)Asserter of the statement
... valueCodeableConcept:valueCodeableConcept 1..1CodeableConceptCoded value of the observation
Binding: https://healthterminologies.gov.au/fhir/ValueSet/assertion-of-absence-1 (extensible)
... dataAbsentReason 0..0

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I0..*ObservationStatement of clinical judgement that there are no items of specific interest
... id Σ0..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: Common Languages (extensible)
Max Binding: All Languages
... text I0..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 | ProcedureRequest | ReferralRequest)Fulfills plan, proposal or order
... status ?!Σ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required)
... category 0..*CodeableConceptClassification of type of observation
Binding: Observation Category Codes (preferred)
... code Σ1..1CodeableConceptType of observation (code / type)
Binding: LOINC Codes (example)
Fixed Value: As shown (Assertion)
.... id0..0stringxml:id (or equivalent in JSON)
.... extension0..0ExtensionAdditional Content defined by implementations
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..0stringxml:id (or equivalent in JSON)
..... extension0..0ExtensionAdditional Content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/v3/ActCode
..... version0..0stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: ASSERTION
..... display0..0stringRepresentation defined by the system
..... userSelected0..0booleanIf this coding was chosen directly by the user
.... text0..0stringPlain text representation of the concept
... subject Σ1..1Reference(Patient | Group)Who and/or what this is about
... context 0..1Reference(Encounter | EpisodeOfCare)Healthcare event during which this observation is made
... effective[x] Σ0..1Clinically relevant time/time-period for observation
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDate/Time this was made available
... performer Σ0..*Reference(Practitioner | Organization | Patient | RelatedPerson)Asserter of the statement
... value[x] ΣI1..1(Slice Definition)Actual result
Slice: Unordered, Closed by type:$this
.... value[x]:valueCodeableConcept ΣI1..1CodeableConceptCoded value of the observation
Binding: https://healthterminologies.gov.au/fhir/ValueSet/assertion-of-absence-1 (extensible)
... interpretation 0..1CodeableConceptHigh, low, normal, etc.
Binding: Observation Interpretation Codes (extensible)
... comment 0..1stringComments about result
... bodySite 0..1CodeableConceptObserved body part
Binding: SNOMED CT Body Structures (example)
... method 0..1CodeableConceptHow it was done
Binding: Observation Methods (example)
... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange I0..*BackboneElementProvides guide for interpretation
obs-3: Must have at least a low or a high or text
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... low I0..1SimpleQuantityLow Range, if relevant
.... high I0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: Observation Reference Range Meaning Codes (extensible)
.... appliesTo 0..*CodeableConceptReference range population
Binding: Observation Reference Range Applies To Codes (example)
.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... related ΣI0..*BackboneElementResource related to this observation
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... type 0..1codehas-member | derived-from | sequel-to | replaces | qualified-by | interfered-by
Binding: ObservationRelationshipType (required)
.... target 1..1Reference(Observation | QuestionnaireResponse | Sequence)Resource that is related to this one
... component ΣI0..*BackboneElementComponent results
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: LOINC Codes (example)
.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueAttachmentAttachment
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: Observation Value Absent Reason (extensible)
.... interpretation 0..1CodeableConceptHigh, low, normal, etc.
Binding: Observation Interpretation Codes (extensible)
.... referenceRange 0..*Unknown reference to #Observation.referenceRange
Provides guide for interpretation of component result

doco Documentation for this format

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*ObservationStatement of clinical judgement that there are no items of specific interest
... code 1..1CodeableConceptFixed Value: As shown (Assertion)
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/v3/ActCode
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: ASSERTION
... subject 1..1Reference(Patient | Group)
... performer 0..*Reference(Practitioner | Organization | Patient | RelatedPerson)Asserter of the statement
... valueCodeableConcept:valueCodeableConcept 1..1CodeableConceptCoded value of the observation
Binding: https://healthterminologies.gov.au/fhir/ValueSet/assertion-of-absence-1 (extensible)
... dataAbsentReason 0..0

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I0..*ObservationStatement of clinical judgement that there are no items of specific interest
... id Σ0..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: Common Languages (extensible)
Max Binding: All Languages
... text I0..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 | ProcedureRequest | ReferralRequest)Fulfills plan, proposal or order
... status ?!Σ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required)
... category 0..*CodeableConceptClassification of type of observation
Binding: Observation Category Codes (preferred)
... code Σ1..1CodeableConceptType of observation (code / type)
Binding: LOINC Codes (example)
Fixed Value: As shown (Assertion)
.... id0..0stringxml:id (or equivalent in JSON)
.... extension0..0ExtensionAdditional Content defined by implementations
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..0stringxml:id (or equivalent in JSON)
..... extension0..0ExtensionAdditional Content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/v3/ActCode
..... version0..0stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: ASSERTION
..... display0..0stringRepresentation defined by the system
..... userSelected0..0booleanIf this coding was chosen directly by the user
.... text0..0stringPlain text representation of the concept
... subject Σ1..1Reference(Patient | Group)Who and/or what this is about
... context 0..1Reference(Encounter | EpisodeOfCare)Healthcare event during which this observation is made
... effective[x] Σ0..1Clinically relevant time/time-period for observation
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDate/Time this was made available
... performer Σ0..*Reference(Practitioner | Organization | Patient | RelatedPerson)Asserter of the statement
... value[x] ΣI1..1(Slice Definition)Actual result
Slice: Unordered, Closed by type:$this
.... value[x]:valueCodeableConcept ΣI1..1CodeableConceptCoded value of the observation
Binding: https://healthterminologies.gov.au/fhir/ValueSet/assertion-of-absence-1 (extensible)
... interpretation 0..1CodeableConceptHigh, low, normal, etc.
Binding: Observation Interpretation Codes (extensible)
... comment 0..1stringComments about result
... bodySite 0..1CodeableConceptObserved body part
Binding: SNOMED CT Body Structures (example)
... method 0..1CodeableConceptHow it was done
Binding: Observation Methods (example)
... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange I0..*BackboneElementProvides guide for interpretation
obs-3: Must have at least a low or a high or text
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... low I0..1SimpleQuantityLow Range, if relevant
.... high I0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: Observation Reference Range Meaning Codes (extensible)
.... appliesTo 0..*CodeableConceptReference range population
Binding: Observation Reference Range Applies To Codes (example)
.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... related ΣI0..*BackboneElementResource related to this observation
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... type 0..1codehas-member | derived-from | sequel-to | replaces | qualified-by | interfered-by
Binding: ObservationRelationshipType (required)
.... target 1..1Reference(Observation | QuestionnaireResponse | Sequence)Resource that is related to this one
... component ΣI0..*BackboneElementComponent results
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: LOINC Codes (example)
.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueAttachmentAttachment
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: Observation Value Absent Reason (extensible)
.... interpretation 0..1CodeableConceptHigh, low, normal, etc.
Binding: Observation Interpretation Codes (extensible)
.... referenceRange 0..*Unknown reference to #Observation.referenceRange
Provides guide for interpretation of component result

doco Documentation for this format

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

 

1.0.2 Quick Start

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

Summary of Search Criteria for StructureDefinition-au-norelevantfinding

none defined