AU Core Implementation Guide
2.0.0-ballot - Ballot

AU Core Implementation Guide - Downloaded Version 2.0.0-ballot See the Directory of published versions

## Resource Profile: AU Core Pathology Result Observation

Official URL: http://hl7.org.au/fhir/core/StructureDefinition/au-core-diagnosticresult-path | Version: 2.0.0-ballot
Standards status: Trial-use | Maturity Level: 2 | Computable Name: AUCorePathologyResult
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License. HL7 Australia© 2022+; Licensed Under Creative Commons No Rights Reserved.

This profile sets minimum expectations for an Observation resource to record, search, and fetch pathology results associated with a patient. It is based on the AU Base Pathology Result profile and identifies the additional mandatory core elements, extensions, vocabularies and value sets that SHALL be present in the Observation when conforming to this profile. It provides the floor for standards development for specific uses cases in an Australian context.

See Comparison with other national and international IGs for a comparison between AU Core profiles and profiles in other implementation guides.

### Usage Scenarios

The following are supported usage scenarios for this profile:

- Query for pathology results for a patient
- Query for category of pathology results (e.g. all chemistry)
- Record or update pathology results belonging to a patient

### Profile Specific Implementation Guidance

- `Observation.category` provides an efficient way of supporting system interactions, e.g. restricting searches. Implementers need to understand that data categorisation is somewhat subjective. The categorisation applied by the source may not align with a receiver’s expectations.
- The observations MAY have additional codes that translate or map to the Observation code or category codes. For example:
  - providing a local code
  - providing a more specific code
- The use of coding can vary significantly across systems, requesters need to understand that they may encounter codes they do not recognise and be prepared to handle those resources appropriately. Responders SHOULD populate `Observation.code.text` and/or `Observation.code.coding.display` so that the requester can at least display the observation even if the requester does not recognise the code supplied.
- The Observation resource can represent a result using a single value in `Observation.value`, or can represent a set of results using either `Observation.component.value` or `Observation.hasMember`.
  - Although all are marked as Must Support, responders are not required to support all choices, but they SHALL support at least one of these elements
  - A requester SHALL support all elements (`Observation.value`, `Observation.component.value`, `Observation.hasMember`)
  - for further guidance, see the Observation Grouping section in FHIR Specification.
- `Observation.identifier` may contain the same identifier as in the order or report connecting the resources that are related to a single request fulfilment workflow.
- Source system identifiers that identify the business process (order ids and reporting identifiers) MAY be included as AU Local Order Identifier and AU Local Report Identifier to support workflow and deduplication of Observation resources.
- See guidance on the construction of an identifier on the relevant Identifier profile page and the section on Business Identifiers in AU Base.
- To represent the result of a specialist or other diagnostic (non imaging or pathology) test, see the AU Core Diagnostic Result Observation profile.

Usages:

- Refer to this Profile: AU Core Pathology Result Observation and AU Core Diagnostic Result Observation
- Examples for this Profile: Observation/lipid-hdl-1, Observation/lipid-ldl-1, Observation/lipid-total-chol-1, Observation/lipid-triglyceride-1 and Observation/pathresult-covid-1
- CapabilityStatements using this Profile: AU Core Requester CapabilityStatement and AU Core Responder CapabilityStatement

You can also check for usages in the FHIR IG Statistics

Changes since version 1.0.0:

- New Content

### Formal Views of Profile Content

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

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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation | C | 0..* | AUBasePathologyResult | A pathology test result in an Australian healthcare context Constraints: obs-6, obs-7, inv-obs-0, au-core-obs-01
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!SO Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
Slices for category | SO | 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.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
category:lab | SO | 1..1 | CodeableConcept | Observation generated by laboratories Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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 | SO | 0..* | CodeableConcept | Specific discipline of pathology Binding: Pathology Diagnostic Service Category (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
code | SO Σ | 1..1 | CodeableConcept | Pathology test or test group Binding: RCPA SPIA Pathology Reporting (extensible)
Additional Bindings | Purpose
RCPA - SPIA Chemical Pathology Terminology Reference Set | Component
RCPA - SPIA Haematology Terminology Reference Set | Component
RCPA - SPIA Immunopathology Terminology Reference Set | Component
RCPA - SPIA Microbiology Serology Molecular Pathology Terminology Reference Set | Component
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
subject | SO Σ | 1..1 | Reference(AU Core Patient) | Who and/or what the observation is about
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
effective[x] | SO Σ C | 1..1 |  | Time of specimen collection Constraints: au-core-obs-02
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
effectiveTiming |  |  | Timing |
effectiveInstant |  |  | instant |
performer | SO Σ | 0..* | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization | AU Core Patient | AU Core RelatedPerson) | Who is responsible for the observation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
value[x] | SO Σ C | 0..1 |  | Actual result
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
dataAbsentReason | SO C | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
interpretation | SO | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
specimen | SO | 0..1 | Reference(AU Base Specimen) | Specimen used for this observation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
referenceRange | SO C | 0..* | BackboneElement | Provides guide for interpretation Constraints: obs-3
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
low | SO C | 0..1 | SimpleQuantity | Low Range, if relevant
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
high | SO C | 0..1 | SimpleQuantity | High Range, if relevant
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
type | SO | 0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
text | SO | 0..1 | string | Text based reference range in an observation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
hasMember | SO Σ C | 0..* | Reference(AU Core Pathology Result Observation) | Individual observations in a group, study, or panel
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
component | SO Σ C | 0..* | BackboneElement | Individual tests in a group or panel Constraints: au-core-obs-03
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | SO Σ | 1..1 | CodeableConcept | Individual pathology test Binding: RCPA SPIA Pathology Reporting (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
value[x] | SO Σ C | 0..1 |  | Actual component result
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
dataAbsentReason | SO C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
Observation.status | required | ObservationStatus `http://hl7.org/fhir/ValueSet/observation-status|4.0.1` From the FHIR Standard
Observation.category | preferred | ObservationCategoryCodes `http://hl7.org/fhir/ValueSet/observation-category` From the FHIR Standard
Observation.category:lab | preferred | ObservationCategoryCodes `http://hl7.org/fhir/ValueSet/observation-category` From the FHIR Standard
Observation.category:specificDiscipline | extensible | PathologyDiagnosticServiceCategory `https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1` From https://tx.ontoserver.csiro.au/fhir
Observation.code | extensible | RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` From https://tx.ontoserver.csiro.au/fhir
Observation.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` From the FHIR Standard
Observation.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` From the FHIR Standard
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes `http://hl7.org/fhir/ValueSet/referencerange-meaning` From the FHIR Standard
Observation.component.code | extensible | RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` From https://tx.ontoserver.csiro.au/fhir
Observation.component.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
au-core-obs-01 | error | Observation | If there is no component or hasMember element then at least value or data absent reason shall be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
au-core-obs-02 | error | Observation.effective[x] | Date shall be at least to day or, if not available, the Data Absent Reason extension shall be present : (($this is dateTime implies $this.toString().length() >= 10) and extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').value.exists().not()) xor ($this is dateTime implies ($this.hasValue().not() and extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').value.exists())) |
au-core-obs-03 | error | Observation.component | The component shall at least have a value or a data absent reason : value.exists() or dataAbsentReason.exists() |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
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() |
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() |

This structure is derived from AUBasePathologyResult

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation | C | 0..* | AUBasePathologyResult | A pathology test result in an Australian healthcare context Constraints: au-core-obs-01
status | SO | 1..1 | code | registered | preliminary | final | amended +
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
category | SO | 1..* | CodeableConcept | Classification of the service requested as laboratory + more specific discipline where available
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
Slices for category |  |  |  | Content/Rules for all slices
category:lab | SO | 1..1 | CodeableConcept | Observation generated by laboratories
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
category:specificDiscipline | SO | 0..* | CodeableConcept | Specific discipline of pathology Binding: Pathology Diagnostic Service Category (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
code | SO | 1..1 | CodeableConcept | Pathology test or test group Binding: RCPA SPIA Pathology Reporting (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
subject | SO | 1..1 | Reference(AU Core Patient) | Who and/or what the observation is about
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
effective[x] | SO C | 1..1 | dateTime, Period, Timing, instant | Time of specimen collection Constraints: au-core-obs-02
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
performer | SO | 0..* | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization | AU Core Patient | AU Core RelatedPerson) | Who is responsible for the observation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
value[x] | SO C | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual result
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
dataAbsentReason | SO C | 0..1 | CodeableConcept | Why the result is missing
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
interpretation | SO | 0..* | CodeableConcept | High, low, normal, etc.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
specimen | SO | 0..1 | Reference(AU Base Specimen) | Specimen used for this observation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
referenceRange | SO | 0..* | BackboneElement | Provides guide for interpretation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
low | SO | 0..1 | SimpleQuantity | Low Range, if relevant
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
high | SO | 0..1 | SimpleQuantity | High Range, if relevant
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
type | SO | 0..1 | CodeableConcept | Reference range qualifier
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
text | SO | 0..1 | string | Text based reference range in an observation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
hasMember | SO | 0..* | Reference(AU Core Pathology Result Observation) | Individual observations in a group, study, or panel
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
component | SO C | 0..* | BackboneElement | Individual tests in a group or panel Constraints: au-core-obs-03
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
code | SO | 1..1 | CodeableConcept | Individual pathology test Binding: RCPA SPIA Pathology Reporting (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
value[x] | SO C | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual component result
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
dataAbsentReason | SO C | 0..1 | CodeableConcept | Why the component result is missing
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Observation.category:specificDiscipline | extensible | PathologyDiagnosticServiceCategory `https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1` From https://tx.ontoserver.csiro.au/fhir
Observation.code | extensible | RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` From https://tx.ontoserver.csiro.au/fhir
Observation.component.code | extensible | RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` From https://tx.ontoserver.csiro.au/fhir

#### Constraints

Id | Grade | Path(s) | Details | Requirements
au-core-obs-01 | error | Observation | If there is no component or hasMember element then at least value or data absent reason shall be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
au-core-obs-02 | error | Observation.effective[x] | Date shall be at least to day or, if not available, the Data Absent Reason extension shall be present : (($this is dateTime implies $this.toString().length() >= 10) and extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').value.exists().not()) xor ($this is dateTime implies ($this.hasValue().not() and extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').value.exists())) |
au-core-obs-03 | error | Observation.component | The component shall at least have a value or a data absent reason : value.exists() or dataAbsentReason.exists() |

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation | C | 0..* | AUBasePathologyResult | A pathology test result in an Australian healthcare context Constraints: obs-6, obs-7, inv-obs-0, au-core-obs-01
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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
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 | ?!SO Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
Slices for category | SO | 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.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
category:lab | SO | 1..1 | CodeableConcept | Observation generated by laboratories Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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 | SO | 0..* | CodeableConcept | Specific discipline of pathology Binding: Pathology Diagnostic Service Category (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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 | SO Σ | 1..1 | CodeableConcept | Pathology test or test group Binding: RCPA SPIA Pathology Reporting (extensible)
Additional Bindings | Purpose
RCPA - SPIA Chemical Pathology Terminology Reference Set | Component
RCPA - SPIA Haematology Terminology Reference Set | Component
RCPA - SPIA Immunopathology Terminology Reference Set | Component
RCPA - SPIA Microbiology Serology Molecular Pathology Terminology Reference Set | Component
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
subject | SO Σ | 1..1 | Reference(AU Core Patient) | Who and/or what the observation is about
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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] | SO Σ C | 1..1 |  | Time of specimen collection Constraints: au-core-obs-02
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
effectiveTiming |  |  | Timing |
effectiveInstant |  |  | instant |
issued | Σ | 0..1 | instant | Date/Time this version was made available
performer | SO Σ | 0..* | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization | AU Core Patient | AU Core RelatedPerson) | Who is responsible for the observation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
value[x] | SO Σ C | 0..1 |  | Actual result
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
dataAbsentReason | SO C | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
interpretation | SO | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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 | SO | 0..1 | Reference(AU Base Specimen) | Specimen used for this observation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
device |  | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device
referenceRange | SO C | 0..* | BackboneElement | Provides guide for interpretation Constraints: obs-3
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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 | SO C | 0..1 | SimpleQuantity | Low Range, if relevant
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
high | SO C | 0..1 | SimpleQuantity | High Range, if relevant
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
type | SO | 0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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 | SO | 0..1 | string | Text based reference range in an observation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
hasMember | SO Σ C | 0..* | Reference(AU Core Pathology Result Observation) | Individual observations in a group, study, or panel
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from
component | SO Σ C | 0..* | BackboneElement | Individual tests in a group or panel Constraints: au-core-obs-03
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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 | SO Σ | 1..1 | CodeableConcept | Individual pathology test Binding: RCPA SPIA Pathology Reporting (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
value[x] | SO Σ C | 0..1 |  | Actual component result
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
dataAbsentReason | SO C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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 | URI
Observation.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Observation.status | required | ObservationStatus `http://hl7.org/fhir/ValueSet/observation-status|4.0.1` From the FHIR Standard
Observation.category | preferred | ObservationCategoryCodes `http://hl7.org/fhir/ValueSet/observation-category` From the FHIR Standard
Observation.category:lab | preferred | ObservationCategoryCodes `http://hl7.org/fhir/ValueSet/observation-category` From the FHIR Standard
Observation.category:specificDiscipline | extensible | PathologyDiagnosticServiceCategory `https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1` From https://tx.ontoserver.csiro.au/fhir
Observation.code | extensible | RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` From https://tx.ontoserver.csiro.au/fhir
Observation.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` From the FHIR Standard
Observation.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` From the FHIR Standard
Observation.bodySite | example | SNOMEDCTBodyStructures `http://hl7.org/fhir/ValueSet/body-site` From the FHIR Standard
Observation.method | example | ObservationMethods `http://hl7.org/fhir/ValueSet/observation-methods` From the FHIR Standard
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes `http://hl7.org/fhir/ValueSet/referencerange-meaning` From the FHIR Standard
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes `http://hl7.org/fhir/ValueSet/referencerange-appliesto` From the FHIR Standard
Observation.component.code | extensible | RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` From https://tx.ontoserver.csiro.au/fhir
Observation.component.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` From the FHIR Standard
Observation.component.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
au-core-obs-01 | error | Observation | If there is no component or hasMember element then at least value or data absent reason shall be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
au-core-obs-02 | error | Observation.effective[x] | Date shall be at least to day or, if not available, the Data Absent Reason extension shall be present : (($this is dateTime implies $this.toString().length() >= 10) and extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').value.exists().not()) xor ($this is dateTime implies ($this.hasValue().not() and extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').value.exists())) |
au-core-obs-03 | error | Observation.component | The component shall at least have a value or a data absent reason : value.exists() or dataAbsentReason.exists() |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
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() |
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() |

This structure is derived from AUBasePathologyResult

Summary

Mandatory: 1 element
Must-Support: 22 elements

Structures

This structure refers to these other structures:

- AU Core Patient (http://hl7.org.au/fhir/core/StructureDefinition/au-core-patient)
- AU Core Practitioner (http://hl7.org.au/fhir/core/StructureDefinition/au-core-practitioner)
- AU Core PractitionerRole (http://hl7.org.au/fhir/core/StructureDefinition/au-core-practitionerrole)
- AU Core Organization (http://hl7.org.au/fhir/core/StructureDefinition/au-core-organization)
- AU Core RelatedPerson (http://hl7.org.au/fhir/core/StructureDefinition/au-core-relatedperson)
- AU Core Pathology Result Observation (http://hl7.org.au/fhir/core/StructureDefinition/au-core-diagnosticresult-path)

Maturity: 2

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation | C | 0..* | AUBasePathologyResult | A pathology test result in an Australian healthcare context Constraints: obs-6, obs-7, inv-obs-0, au-core-obs-01
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!SO Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
Slices for category | SO | 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.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
category:lab | SO | 1..1 | CodeableConcept | Observation generated by laboratories Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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 | SO | 0..* | CodeableConcept | Specific discipline of pathology Binding: Pathology Diagnostic Service Category (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
code | SO Σ | 1..1 | CodeableConcept | Pathology test or test group Binding: RCPA SPIA Pathology Reporting (extensible)
Additional Bindings | Purpose
RCPA - SPIA Chemical Pathology Terminology Reference Set | Component
RCPA - SPIA Haematology Terminology Reference Set | Component
RCPA - SPIA Immunopathology Terminology Reference Set | Component
RCPA - SPIA Microbiology Serology Molecular Pathology Terminology Reference Set | Component
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
subject | SO Σ | 1..1 | Reference(AU Core Patient) | Who and/or what the observation is about
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
effective[x] | SO Σ C | 1..1 |  | Time of specimen collection Constraints: au-core-obs-02
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
effectiveTiming |  |  | Timing |
effectiveInstant |  |  | instant |
performer | SO Σ | 0..* | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization | AU Core Patient | AU Core RelatedPerson) | Who is responsible for the observation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
value[x] | SO Σ C | 0..1 |  | Actual result
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
dataAbsentReason | SO C | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
interpretation | SO | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
specimen | SO | 0..1 | Reference(AU Base Specimen) | Specimen used for this observation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
referenceRange | SO C | 0..* | BackboneElement | Provides guide for interpretation Constraints: obs-3
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
low | SO C | 0..1 | SimpleQuantity | Low Range, if relevant
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
high | SO C | 0..1 | SimpleQuantity | High Range, if relevant
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
type | SO | 0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
text | SO | 0..1 | string | Text based reference range in an observation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
hasMember | SO Σ C | 0..* | Reference(AU Core Pathology Result Observation) | Individual observations in a group, study, or panel
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
component | SO Σ C | 0..* | BackboneElement | Individual tests in a group or panel Constraints: au-core-obs-03
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | SO Σ | 1..1 | CodeableConcept | Individual pathology test Binding: RCPA SPIA Pathology Reporting (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
value[x] | SO Σ C | 0..1 |  | Actual component result
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
dataAbsentReason | SO C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
Observation.status | required | ObservationStatus `http://hl7.org/fhir/ValueSet/observation-status|4.0.1` From the FHIR Standard
Observation.category | preferred | ObservationCategoryCodes `http://hl7.org/fhir/ValueSet/observation-category` From the FHIR Standard
Observation.category:lab | preferred | ObservationCategoryCodes `http://hl7.org/fhir/ValueSet/observation-category` From the FHIR Standard
Observation.category:specificDiscipline | extensible | PathologyDiagnosticServiceCategory `https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1` From https://tx.ontoserver.csiro.au/fhir
Observation.code | extensible | RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` From https://tx.ontoserver.csiro.au/fhir
Observation.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` From the FHIR Standard
Observation.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` From the FHIR Standard
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes `http://hl7.org/fhir/ValueSet/referencerange-meaning` From the FHIR Standard
Observation.component.code | extensible | RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` From https://tx.ontoserver.csiro.au/fhir
Observation.component.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
au-core-obs-01 | error | Observation | If there is no component or hasMember element then at least value or data absent reason shall be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
au-core-obs-02 | error | Observation.effective[x] | Date shall be at least to day or, if not available, the Data Absent Reason extension shall be present : (($this is dateTime implies $this.toString().length() >= 10) and extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').value.exists().not()) xor ($this is dateTime implies ($this.hasValue().not() and extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').value.exists())) |
au-core-obs-03 | error | Observation.component | The component shall at least have a value or a data absent reason : value.exists() or dataAbsentReason.exists() |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
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() |
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() |

Differential View

This structure is derived from AUBasePathologyResult

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation | C | 0..* | AUBasePathologyResult | A pathology test result in an Australian healthcare context Constraints: au-core-obs-01
status | SO | 1..1 | code | registered | preliminary | final | amended +
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
category | SO | 1..* | CodeableConcept | Classification of the service requested as laboratory + more specific discipline where available
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
Slices for category |  |  |  | Content/Rules for all slices
category:lab | SO | 1..1 | CodeableConcept | Observation generated by laboratories
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
category:specificDiscipline | SO | 0..* | CodeableConcept | Specific discipline of pathology Binding: Pathology Diagnostic Service Category (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
code | SO | 1..1 | CodeableConcept | Pathology test or test group Binding: RCPA SPIA Pathology Reporting (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
subject | SO | 1..1 | Reference(AU Core Patient) | Who and/or what the observation is about
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
effective[x] | SO C | 1..1 | dateTime, Period, Timing, instant | Time of specimen collection Constraints: au-core-obs-02
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
performer | SO | 0..* | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization | AU Core Patient | AU Core RelatedPerson) | Who is responsible for the observation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
value[x] | SO C | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual result
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
dataAbsentReason | SO C | 0..1 | CodeableConcept | Why the result is missing
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
interpretation | SO | 0..* | CodeableConcept | High, low, normal, etc.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
specimen | SO | 0..1 | Reference(AU Base Specimen) | Specimen used for this observation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
referenceRange | SO | 0..* | BackboneElement | Provides guide for interpretation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
low | SO | 0..1 | SimpleQuantity | Low Range, if relevant
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
high | SO | 0..1 | SimpleQuantity | High Range, if relevant
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
type | SO | 0..1 | CodeableConcept | Reference range qualifier
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
text | SO | 0..1 | string | Text based reference range in an observation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
hasMember | SO | 0..* | Reference(AU Core Pathology Result Observation) | Individual observations in a group, study, or panel
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
component | SO C | 0..* | BackboneElement | Individual tests in a group or panel Constraints: au-core-obs-03
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
code | SO | 1..1 | CodeableConcept | Individual pathology test Binding: RCPA SPIA Pathology Reporting (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
value[x] | SO C | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual component result
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
dataAbsentReason | SO C | 0..1 | CodeableConcept | Why the component result is missing
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Observation.category:specificDiscipline | extensible | PathologyDiagnosticServiceCategory `https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1` From https://tx.ontoserver.csiro.au/fhir
Observation.code | extensible | RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` From https://tx.ontoserver.csiro.au/fhir
Observation.component.code | extensible | RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` From https://tx.ontoserver.csiro.au/fhir

#### Constraints

Id | Grade | Path(s) | Details | Requirements
au-core-obs-01 | error | Observation | If there is no component or hasMember element then at least value or data absent reason shall be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
au-core-obs-02 | error | Observation.effective[x] | Date shall be at least to day or, if not available, the Data Absent Reason extension shall be present : (($this is dateTime implies $this.toString().length() >= 10) and extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').value.exists().not()) xor ($this is dateTime implies ($this.hasValue().not() and extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').value.exists())) |
au-core-obs-03 | error | Observation.component | The component shall at least have a value or a data absent reason : value.exists() or dataAbsentReason.exists() |

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation | C | 0..* | AUBasePathologyResult | A pathology test result in an Australian healthcare context Constraints: obs-6, obs-7, inv-obs-0, au-core-obs-01
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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
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 | ?!SO Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
Slices for category | SO | 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.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
category:lab | SO | 1..1 | CodeableConcept | Observation generated by laboratories Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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 | SO | 0..* | CodeableConcept | Specific discipline of pathology Binding: Pathology Diagnostic Service Category (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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 | SO Σ | 1..1 | CodeableConcept | Pathology test or test group Binding: RCPA SPIA Pathology Reporting (extensible)
Additional Bindings | Purpose
RCPA - SPIA Chemical Pathology Terminology Reference Set | Component
RCPA - SPIA Haematology Terminology Reference Set | Component
RCPA - SPIA Immunopathology Terminology Reference Set | Component
RCPA - SPIA Microbiology Serology Molecular Pathology Terminology Reference Set | Component
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
subject | SO Σ | 1..1 | Reference(AU Core Patient) | Who and/or what the observation is about
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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] | SO Σ C | 1..1 |  | Time of specimen collection Constraints: au-core-obs-02
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
effectiveTiming |  |  | Timing |
effectiveInstant |  |  | instant |
issued | Σ | 0..1 | instant | Date/Time this version was made available
performer | SO Σ | 0..* | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Organization | AU Core Patient | AU Core RelatedPerson) | Who is responsible for the observation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
value[x] | SO Σ C | 0..1 |  | Actual result
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
dataAbsentReason | SO C | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
interpretation | SO | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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 | SO | 0..1 | Reference(AU Base Specimen) | Specimen used for this observation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
device |  | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device
referenceRange | SO C | 0..* | BackboneElement | Provides guide for interpretation Constraints: obs-3
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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 | SO C | 0..1 | SimpleQuantity | Low Range, if relevant
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
high | SO C | 0..1 | SimpleQuantity | High Range, if relevant
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
type | SO | 0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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 | SO | 0..1 | string | Text based reference range in an observation
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
hasMember | SO Σ C | 0..* | Reference(AU Core Pathology Result Observation) | Individual observations in a group, study, or panel
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from
component | SO Σ C | 0..* | BackboneElement | Individual tests in a group or panel Constraints: au-core-obs-03
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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 | SO Σ | 1..1 | CodeableConcept | Individual pathology test Binding: RCPA SPIA Pathology Reporting (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
value[x] | SO Σ C | 0..1 |  | Actual component result
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
dataAbsentReason | SO C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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 | URI
Observation.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Observation.status | required | ObservationStatus `http://hl7.org/fhir/ValueSet/observation-status|4.0.1` From the FHIR Standard
Observation.category | preferred | ObservationCategoryCodes `http://hl7.org/fhir/ValueSet/observation-category` From the FHIR Standard
Observation.category:lab | preferred | ObservationCategoryCodes `http://hl7.org/fhir/ValueSet/observation-category` From the FHIR Standard
Observation.category:specificDiscipline | extensible | PathologyDiagnosticServiceCategory `https://healthterminologies.gov.au/fhir/ValueSet/pathology-diagnostic-service-category-1` From https://tx.ontoserver.csiro.au/fhir
Observation.code | extensible | RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` From https://tx.ontoserver.csiro.au/fhir
Observation.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` From the FHIR Standard
Observation.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` From the FHIR Standard
Observation.bodySite | example | SNOMEDCTBodyStructures `http://hl7.org/fhir/ValueSet/body-site` From the FHIR Standard
Observation.method | example | ObservationMethods `http://hl7.org/fhir/ValueSet/observation-methods` From the FHIR Standard
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes `http://hl7.org/fhir/ValueSet/referencerange-meaning` From the FHIR Standard
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes `http://hl7.org/fhir/ValueSet/referencerange-appliesto` From the FHIR Standard
Observation.component.code | extensible | RCPASPIAPathologyReporting `https://healthterminologies.gov.au/fhir/ValueSet/spia-pathology-reporting-1` From https://tx.ontoserver.csiro.au/fhir
Observation.component.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` From the FHIR Standard
Observation.component.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
au-core-obs-01 | error | Observation | If there is no component or hasMember element then at least value or data absent reason shall be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
au-core-obs-02 | error | Observation.effective[x] | Date shall be at least to day or, if not available, the Data Absent Reason extension shall be present : (($this is dateTime implies $this.toString().length() >= 10) and extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').value.exists().not()) xor ($this is dateTime implies ($this.hasValue().not() and extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').value.exists())) |
au-core-obs-03 | error | Observation.component | The component shall at least have a value or a data absent reason : value.exists() or dataAbsentReason.exists() |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
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() |
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() |

This structure is derived from AUBasePathologyResult

Summary

Mandatory: 1 element
Must-Support: 22 elements

Structures

This structure refers to these other structures:

- AU Core Patient (http://hl7.org.au/fhir/core/StructureDefinition/au-core-patient)
- AU Core Practitioner (http://hl7.org.au/fhir/core/StructureDefinition/au-core-practitioner)
- AU Core PractitionerRole (http://hl7.org.au/fhir/core/StructureDefinition/au-core-practitionerrole)
- AU Core Organization (http://hl7.org.au/fhir/core/StructureDefinition/au-core-organization)
- AU Core RelatedPerson (http://hl7.org.au/fhir/core/StructureDefinition/au-core-relatedperson)
- AU Core Pathology Result Observation (http://hl7.org.au/fhir/core/StructureDefinition/au-core-diagnosticresult-path)

Maturity: 2

Other representations of profile: CSV, Excel, Schematron

### Notes:

Below is an overview of the mandatory and optional search parameters and combined search parameters. See the AU Core CapabilityStatements for a complete list of supported RESTful interactions for this IG.

FHIR search operations are described here and the syntax used to describe AU Core interactions is defined 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+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 | MAY | `reference` | The requester SHALL provide at least an id value and MAY provide both the Type and id values. The responder SHALL support both. The requester SHOULD support chained search patient.identifier using IHI, Medicare Number, and DVA Number identifiers as defined in the AU Core Patient profile. The responder SHOULD support chained search patient.identifier using IHI, Medicare Number, and DVA Number identifiers as defined in the AU Core Patient profile.
category | MAY | `token` | The requester SHALL provide at least a code value and MAY provide both the system and code values. The responder SHALL support both. The requester SHALL support search using the category code defined in this profile. The responder SHALL support search using the category code defined in this profile.
code | MAY | `token` | The requester SHALL provide at least a code value and MAY provide both the system and code values. The responder SHALL support both. The requester SHALL support search using the LOINC codes defined in this profile. The responder SHALL support search using the LOINC codes defined in this profile. The requester SHALL support `multipleOr`. The responder SHALL support `multipleOr`.
date | MAY | `date` | A requester SHALL provide a value precise to the second + time offset. A responder SHALL support a value precise to the second + time offset. The requester SHALL support these search comparators `gt`, `lt`, `ge`, `le`. The responder SHALL support these search comparators `gt`, `lt`, `ge`, `le`. The requester SHOULD support `multipleAnd`, and if `multipleAnd` is supported, SHALL support the search comparators `gt`, `lt`, `ge`, `le`. The responder SHOULD support `multipleAnd`, and if `multipleAnd` is supported, SHALL support the search comparators `gt`, `lt`, `ge`, `le`.
status | MAY | `token` | The requester SHALL provide at least a code value and MAY provide both the system and code values. The responder SHALL support both. The requester SHALL support `multipleOr`.The responder SHALL support `multipleOr`.

#### Mandatory Search Parameters:

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

1. SHALL support searching using the combination of the `patient` and `category` search parameters:
   - SHOULD support chained searching of patient canonical identifier `patient.identifier` (e.g. `patient.identifier=[system|][code]`)

   `GET [base]/Observation?patient={Type/}[id]&category=http://terminology.hl7.org/CodeSystem/observation-category|laboratory`

   Example:

   1. GET [base]/Observation?patient=5678&category=http://terminology.hl7.org/CodeSystem/observation-category|laboratory

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

2. SHALL support searching using the combination of the `patient` and `code` search parameters:
   - SHOULD support chained searching of patient canonical identifier `patient.identifier` (e.g. `patient.identifier=[system|][code]`)
   - SHOULD support multipleOr search on `code` (e.g.`code={system|}[code],{system|}[code],...`)

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

   Example:

   1. GET [base]/Observation?patient=5678&code=http://loinc.org|6690-2,http://loinc.org|789-8

   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)

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

   `GET [base]/Observation?patient={Type/}[id]&category=http://terminology.hl7.org/CodeSystem/observation-category|laboratory&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}`

   Example:

   1. GET [base]/Observation?patient=5678&category=http://terminology.hl7.org/CodeSystem/observation-category|laboratory&date=ge2020-01-01T00:00:00Z 1. GET [base]/Observation?patient=5678&category=http://terminology.hl7.org/CodeSystem/observation-category|laboratory&date=ge2020-01-01T00:00:00Z

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

#### Optional Search Parameters:

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

1. SHOULD support chained searching of patient canonical identifier `patient.identifier` (e.g. `patient.identifier=[system|][code]`)

   `GET [base]/Observation?patient.identifier=[system|][code]`

   Example:

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

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

2. SHOULD support searching using the combination of the `patient` and `category` and `status` search parameters:
   - SHOULD support chained searching of patient canonical identifier `patient.identifier` (e.g. `patient.identifier=[system|][code]`)
   - SHALL support multipleOr search on `status` (e.g.`status={system|}[code],{system|}[code],...`)

   `GET [base]/Observation?patient={Type/}[id]&category=http://terminology.hl7.org/CodeSystem/observation-category|laboratory&status={system|}[code]{,{system|}[code],...}`

   Example:

   1. GET [base]/Observation?patient=5678&category=http://terminology.hl7.org/CodeSystem/observation-category|laboratory&status=final

   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)

3. SHOULD support searching using the combination of the `patient` and `code` and `date` search parameters:
   - SHOULD support chained searching of patient canonical identifier `patient.identifier` (e.g. `patient.identifier=[system|][code]`
   - SHOULD support multipleOr search on `code` (e.g.`code={system|}[code],{system|}[code],...`)
   - SHALL support these `date` comparators: `gt,lt,ge,le`
   - SHOULD support multipleAnd search on `date` (e.g.`date=[date]&date=[date]]&...`), and if multipleAnd is supported, SHALL support the search comparators `gt,lt,ge,le`

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

   Example:

   1. GET [base]/Observation?patient=5678&code=http://loinc.org|6690-2,http://loinc.org|789-8&date=ge2020-01-01T00:00:00Z
   2. GET [base]/Observation?patient.identifier=http://example.org/fhir/mrn|12345&code=http://loinc.org|6690-2,http://loinc.org|789-8&date=ge2020-01-01T00:00:00Z

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