AU Core Implementation Guide
0.2.2-preview - Preview
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
Official URL: http://hl7.org.au/fhir/core/StructureDefinition/au-core-gestationalage | Version: 0.2.2-preview | |||
Standards status: Draft | Maturity Level: 0 | Computable Name: AUCoreGestationalAge | ||
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This profile sets minimum expectations for an Observation resource to record, search, and fetch observations of gestational age by scan, or gestational age by last menstrual period (LMP) with standard coding and units. It is based on the core FHIR Observation resource 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.
The following are supported usage scenarios for this profile:
A resource conforming to this profile is conformant to:
No equivalent International Patient Summary profile.
Conformance in reverse is not guaranteed, i.e. a resource conforming to International Patient Access or US Core MAY NOT conform to AU Core.
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.Additional codes that translate or map to the Observation code or category codes are allowed. For example providing both a local code and the required code.
Observation.subject
and the fetus as Observation.focus
Specific feedback is sought on appropriate category values for Observations relating to pregnancy.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Observation | Gestational age au-core-obs-02: At least value or data absent reason shall be present |
status | S | 1..1 | code | registered | preliminary | final | amended + Fixed Value: final |
category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this |
code | S | 1..1 | CodeableConcept | Type of observation (code / type) Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57036006 | |
Slices for coding | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:code, value:system | |
coding:loincGestationalAge | 0..1 | Coding | LOINC Gestational Age | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18185-9 | |
coding:loincGestationalAgeByLMP | 0..1 | Coding | LOINC Gestational Age by Last Menstrual Period (LMP) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11885-1 | |
coding:loincGestationalAgeByScan | 0..1 | Coding | LOINC Gestational Age By Scan | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11888-5 | |
subject | S | 1..1 | Reference(Patient) | The pregnant individual |
focus | 0..* | Reference(Resource) | The fetus | |
encounter | S | 0..1 | Reference(AU Core Encounter) | Healthcare event during which this observation is made |
effective[x] | SC | 1..1 | dateTime | Date, and optionally time, the observation was performed au-core-obs-01: Date shall be at least to day |
performer | S | 0..* | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization | AU Core Patient | AU Core RelatedPerson) | Who is responsible for the observation |
value[x] | SC | 0..1 | Quantity | Actual result |
value | 1..1 | decimal | Numerical value (with implicit precision) | |
unit | 1..1 | string | Unit representation | |
system | 0..1 | uri | System that defines coded unit form Fixed Value: http://unitsofmeasure.org | |
code | 0..1 | code | Coded form of the unit Fixed Value: d | |
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing |
Documentation for this format |
Id | Grade | Path(s) | Details | Requirements |
au-core-obs-01 | error | Observation.effective[x] | Date shall be at least to day : $this is DateTime implies $this.toString().length() >= 10 | |
au-core-obs-02 | error | Observation | At least value or data absent reason shall be present : dataAbsentReason.exists() or value.exists() |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Observation | Gestational age au-core-obs-02: At least value or data absent reason shall be present |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: final |
category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57036006 | |
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:code, value:system |
coding:loincGestationalAge | Σ | 0..1 | Coding | LOINC Gestational Age |
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18185-9 |
coding:loincGestationalAgeByLMP | Σ | 0..1 | Coding | LOINC Gestational Age by Last Menstrual Period (LMP) |
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11885-1 |
coding:loincGestationalAgeByScan | Σ | 0..1 | Coding | LOINC Gestational Age By Scan |
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11888-5 |
subject | SΣ | 1..1 | Reference(Patient) | The pregnant individual |
focus | Σ | 0..* | Reference(Resource) | The fetus |
encounter | SΣ | 0..1 | Reference(AU Core Encounter) | Healthcare event during which this observation is made |
effective[x] | SΣC | 1..1 | dateTime | Date, and optionally time, the observation was performed au-core-obs-01: Date shall be at least to day |
performer | SΣ | 0..* | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization | AU Core Patient | AU Core RelatedPerson) | Who is responsible for the observation |
value[x] | SΣC | 0..1 | Quantity | Actual result |
value | Σ | 1..1 | decimal | Numerical value (with implicit precision) |
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. |
unit | Σ | 1..1 | string | Unit representation |
system | ΣC | 0..1 | uri | System that defines coded unit form Fixed Value: http://unitsofmeasure.org |
code | Σ | 0..1 | code | Coded form of the unit Fixed Value: d |
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
Documentation for this format |
Path | Conformance | ValueSet / Code |
Observation.status | required | Fixed Value: final |
Observation.category | preferred | ObservationCategoryCodes |
Observation.code | example | Pattern: SNOMED CT code 57036006 |
Observation.value[x].comparator | required | QuantityComparator |
Observation.dataAbsentReason | extensible | DataAbsentReason |
Id | Grade | Path(s) | Details | Requirements |
au-core-obs-01 | error | Observation.effective[x] | Date shall be at least to day : $this is DateTime implies $this.toString().length() >= 10 | |
au-core-obs-02 | error | Observation | At least value or data absent reason shall be present : dataAbsentReason.exists() or value.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | Gestational age au-core-obs-02: At least value or data absent reason shall be present | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business Identifier for observation | ||||
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | ||||
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: final | ||||
category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57036006 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:code, value:system | ||||
coding:loincGestationalAge | Σ | 0..1 | Coding | LOINC Gestational Age | ||||
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://loinc.org | ||||
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: 18185-9 | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
coding:loincGestationalAgeByLMP | Σ | 0..1 | Coding | LOINC Gestational Age by Last Menstrual Period (LMP) | ||||
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://loinc.org | ||||
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: 11885-1 | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
coding:loincGestationalAgeByScan | Σ | 0..1 | Coding | LOINC Gestational Age By Scan | ||||
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://loinc.org | ||||
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: 11888-5 | ||||
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 | ||||
subject | SΣ | 1..1 | Reference(Patient) | The pregnant individual | ||||
focus | Σ | 0..* | Reference(Resource) | The fetus | ||||
encounter | SΣ | 0..1 | Reference(AU Core Encounter) | Healthcare event during which this observation is made | ||||
effective[x] | SΣC | 1..1 | dateTime | Date, and optionally time, the observation was performed au-core-obs-01: Date shall be at least to day | ||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | SΣ | 0..* | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization | AU Core Patient | AU Core RelatedPerson) | Who is responsible for the observation | ||||
value[x] | SΣC | 0..1 | Quantity | Actual result | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
value | Σ | 1..1 | decimal | Numerical value (with implicit precision) | ||||
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. | ||||
unit | Σ | 1..1 | string | Unit representation | ||||
system | ΣC | 0..1 | uri | System that defines coded unit form Fixed Value: http://unitsofmeasure.org | ||||
code | Σ | 0..1 | code | Coded form of the unit Fixed Value: d | ||||
dataAbsentReason | SC | 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(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(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
component | Σ | 0..* | BackboneElement | Component results | ||||
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 | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
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 |
Path | Conformance | ValueSet / Code | ||||
Observation.language | preferred | CommonLanguages
| ||||
Observation.status | required | Fixed Value: final | ||||
Observation.category | preferred | ObservationCategoryCodes | ||||
Observation.code | example | Pattern: SNOMED CT code 57036006 | ||||
Observation.value[x].comparator | required | QuantityComparator | ||||
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 | example | LOINCCodes (a valid code from LOINC) | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReason | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodes |
Id | Grade | Path(s) | Details | Requirements |
au-core-obs-01 | error | Observation.effective[x] | Date shall be at least to day : $this is DateTime implies $this.toString().length() >= 10 | |
au-core-obs-02 | error | Observation | At least value or data absent reason shall be present : dataAbsentReason.exists() or value.exists() |
This structure is derived from Observation
Summary
Mandatory: 3 elements (8 nested mandatory elements)
Must-Support: 9 elements
Fixed Value: 9 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Maturity: 0
Differential View
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Observation | Gestational age au-core-obs-02: At least value or data absent reason shall be present |
status | S | 1..1 | code | registered | preliminary | final | amended + Fixed Value: final |
category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this |
code | S | 1..1 | CodeableConcept | Type of observation (code / type) Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57036006 | |
Slices for coding | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:code, value:system | |
coding:loincGestationalAge | 0..1 | Coding | LOINC Gestational Age | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18185-9 | |
coding:loincGestationalAgeByLMP | 0..1 | Coding | LOINC Gestational Age by Last Menstrual Period (LMP) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11885-1 | |
coding:loincGestationalAgeByScan | 0..1 | Coding | LOINC Gestational Age By Scan | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11888-5 | |
subject | S | 1..1 | Reference(Patient) | The pregnant individual |
focus | 0..* | Reference(Resource) | The fetus | |
encounter | S | 0..1 | Reference(AU Core Encounter) | Healthcare event during which this observation is made |
effective[x] | SC | 1..1 | dateTime | Date, and optionally time, the observation was performed au-core-obs-01: Date shall be at least to day |
performer | S | 0..* | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization | AU Core Patient | AU Core RelatedPerson) | Who is responsible for the observation |
value[x] | SC | 0..1 | Quantity | Actual result |
value | 1..1 | decimal | Numerical value (with implicit precision) | |
unit | 1..1 | string | Unit representation | |
system | 0..1 | uri | System that defines coded unit form Fixed Value: http://unitsofmeasure.org | |
code | 0..1 | code | Coded form of the unit Fixed Value: d | |
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing |
Documentation for this format |
Id | Grade | Path(s) | Details | Requirements |
au-core-obs-01 | error | Observation.effective[x] | Date shall be at least to day : $this is DateTime implies $this.toString().length() >= 10 | |
au-core-obs-02 | error | Observation | At least value or data absent reason shall be present : dataAbsentReason.exists() or value.exists() |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Observation | Gestational age au-core-obs-02: At least value or data absent reason shall be present |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: final |
category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. |
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57036006 | |
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:code, value:system |
coding:loincGestationalAge | Σ | 0..1 | Coding | LOINC Gestational Age |
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18185-9 |
coding:loincGestationalAgeByLMP | Σ | 0..1 | Coding | LOINC Gestational Age by Last Menstrual Period (LMP) |
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11885-1 |
coding:loincGestationalAgeByScan | Σ | 0..1 | Coding | LOINC Gestational Age By Scan |
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11888-5 |
subject | SΣ | 1..1 | Reference(Patient) | The pregnant individual |
focus | Σ | 0..* | Reference(Resource) | The fetus |
encounter | SΣ | 0..1 | Reference(AU Core Encounter) | Healthcare event during which this observation is made |
effective[x] | SΣC | 1..1 | dateTime | Date, and optionally time, the observation was performed au-core-obs-01: Date shall be at least to day |
performer | SΣ | 0..* | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization | AU Core Patient | AU Core RelatedPerson) | Who is responsible for the observation |
value[x] | SΣC | 0..1 | Quantity | Actual result |
value | Σ | 1..1 | decimal | Numerical value (with implicit precision) |
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. |
unit | Σ | 1..1 | string | Unit representation |
system | ΣC | 0..1 | uri | System that defines coded unit form Fixed Value: http://unitsofmeasure.org |
code | Σ | 0..1 | code | Coded form of the unit Fixed Value: d |
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. |
Documentation for this format |
Path | Conformance | ValueSet / Code |
Observation.status | required | Fixed Value: final |
Observation.category | preferred | ObservationCategoryCodes |
Observation.code | example | Pattern: SNOMED CT code 57036006 |
Observation.value[x].comparator | required | QuantityComparator |
Observation.dataAbsentReason | extensible | DataAbsentReason |
Id | Grade | Path(s) | Details | Requirements |
au-core-obs-01 | error | Observation.effective[x] | Date shall be at least to day : $this is DateTime implies $this.toString().length() >= 10 | |
au-core-obs-02 | error | Observation | At least value or data absent reason shall be present : dataAbsentReason.exists() or value.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | Gestational age au-core-obs-02: At least value or data absent reason shall be present | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business Identifier for observation | ||||
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | ||||
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
status | ?!SΣ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: final | ||||
category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57036006 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:code, value:system | ||||
coding:loincGestationalAge | Σ | 0..1 | Coding | LOINC Gestational Age | ||||
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://loinc.org | ||||
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: 18185-9 | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
coding:loincGestationalAgeByLMP | Σ | 0..1 | Coding | LOINC Gestational Age by Last Menstrual Period (LMP) | ||||
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://loinc.org | ||||
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: 11885-1 | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
coding:loincGestationalAgeByScan | Σ | 0..1 | Coding | LOINC Gestational Age By Scan | ||||
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://loinc.org | ||||
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: 11888-5 | ||||
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 | ||||
subject | SΣ | 1..1 | Reference(Patient) | The pregnant individual | ||||
focus | Σ | 0..* | Reference(Resource) | The fetus | ||||
encounter | SΣ | 0..1 | Reference(AU Core Encounter) | Healthcare event during which this observation is made | ||||
effective[x] | SΣC | 1..1 | dateTime | Date, and optionally time, the observation was performed au-core-obs-01: Date shall be at least to day | ||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | SΣ | 0..* | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization | AU Core Patient | AU Core RelatedPerson) | Who is responsible for the observation | ||||
value[x] | SΣC | 0..1 | Quantity | Actual result | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
value | Σ | 1..1 | decimal | Numerical value (with implicit precision) | ||||
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Binding: QuantityComparator (required): How the Quantity should be understood and represented. | ||||
unit | Σ | 1..1 | string | Unit representation | ||||
system | ΣC | 0..1 | uri | System that defines coded unit form Fixed Value: http://unitsofmeasure.org | ||||
code | Σ | 0..1 | code | Coded form of the unit Fixed Value: d | ||||
dataAbsentReason | SC | 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(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(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
component | Σ | 0..* | BackboneElement | Component results | ||||
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 | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
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 |
Path | Conformance | ValueSet / Code | ||||
Observation.language | preferred | CommonLanguages
| ||||
Observation.status | required | Fixed Value: final | ||||
Observation.category | preferred | ObservationCategoryCodes | ||||
Observation.code | example | Pattern: SNOMED CT code 57036006 | ||||
Observation.value[x].comparator | required | QuantityComparator | ||||
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 | example | LOINCCodes (a valid code from LOINC) | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReason | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodes |
Id | Grade | Path(s) | Details | Requirements |
au-core-obs-01 | error | Observation.effective[x] | Date shall be at least to day : $this is DateTime implies $this.toString().length() >= 10 | |
au-core-obs-02 | error | Observation | At least value or data absent reason shall be present : dataAbsentReason.exists() or value.exists() |
This structure is derived from Observation
Summary
Mandatory: 3 elements (8 nested mandatory elements)
Must-Support: 9 elements
Fixed Value: 9 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Maturity: 0
Other representations of profile: CSV, Excel, Schematron
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. |
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. |
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. |
The following search parameters and search parameter combinations SHALL be supported:
patient
search parameter:
_revinclude
parameters: Provenance:target
patient.identifier
(e.g. patient.identifier=[system|][code]
)GET [base]/Observation?patient={Type/}[id]
or optionally GET [base]/Observation?patient.identifier=[system|][code]
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient (how to search by reference and how to search by token)
patient
and category
search parameters:
_revinclude
parameters: Provenance:target
patient.identifier
(e.g. patient.identifier=[system|][code]
)GET [base]/Observation?patient={Type/}[id]&category={system|}[code]
Example:
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)
patient
and code
search parameters:
_revinclude
parameters: Provenance:target
patient.identifier
(e.g. patient.identifier=[system|][code]
)code
(e.g.code={system|}[code],{system|}[code],...
)GET [base]/Observation?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}
Example:
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)
patient
and category
and date
search parameters:
_revinclude
parameters: Provenance:target
patient.identifier
(e.g. patient.identifier=[system|][code]
)date
comparators: gt,lt,ge,le
date
(e.g.date=[date]&date=[date]]&...
)GET [base]/Observation?patient={Type/}[id]&category={system|}[code]&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}
Example:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and date and a category code = survey
(how to search by reference and how to search by token and how to search by date)
The following search parameters and search parameter combinations SHOULD be supported:
patient
and category
and status
search parameters:
_revinclude
parameters: Provenance:target
patient.identifier
(e.g. patient.identifier=[system|][code]
)status
(e.g.status={system|}[code],{system|}[code],...
)GET [base]/Observation?patient={Type/}[id]&category={system|}[code]&status={system|}[code]{,{system|}[code],...}
Example:
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)
patient
and code
and date
search parameters:
_revinclude
parameters: Provenance:target
patient.identifier
(e.g. patient.identifier=[system|][code]
code
(e.g.code={system|}[code],{system|}[code],...
)date
comparators: gt,lt,ge,le
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:
Implementation Notes: Fetches a bundle of all Observation resources for the specified patient and date and report code(s) (how to search by reference and how to search by token and how to search by date)