Interweave Implementation Guide
0.1.0 - ci-build
Interweave Implementation Guide - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the STU3 profiles here.
Official URL: https://fhir.interweavedigital.nhs.uk/R4/StructureDefinition/Interweave-Observation-ACVPU | Version: 0.0.1 | |||
Draft as of 2024-07-15 | Computable Name: InterweaveObservationACVPU |
Interweave Observation ACVPU resource profile - DRAFT.
Status: DRAFT: For Review
This profile sets out the expectations for the interweave ACVPU observation resource. The base for this profile is the UK Core Observation ACVPU.
We have enforced the use of SNOMED codes where possible and have removed the component field. This is to ensure that the valueCodeableConcept field is used to provide the result.
The following mandatory fields are defined:
status – Fixed value of ‘final’. Only finalised observations should be shared.
category – Fixed value of ‘vital-signs’.
code – Fixed value of SCT: 1104441000000107 (ACVPU (Alert Confusion Voice Pain Unresponsive) scale score).
subject – Reference to the patient who is the subject of this measurement.
effective – An important field to provide details of the time/time period during which the observation was taken.
In addition the following fields are "Must Support" - ie they must be populated if relevant and known.
identifier - A Local Id should be provided, such that could be quoted if manually getting in touch to find out more.
encounter – his will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests). For some observations it may be important to know the link between an observation and a particular encounter.
performer – We limit this field to reference practitioner / practitionerRole/ CareTeam resources only. The organization responsible for the observation can be obtained via the provenance tag.
note – Comments in addition to the result are often recorded for observations, it is therefore important to provide this field when available to give the consumer the full result information.
valueCodeableConcept – The actual result recorded. This is a required binding to the Care Connect ACVPU code system which Include codes from SNOMED_CT where constraint Equal (248234008 (Mentally alert) OR 300202002 (Responds to voice) OR 450847001 (Responds to pain) OR 422768004 (Unresponsive) OR 130987000 (Acute confusion))
dataAbsentReason - The reason why the result is missing, this is valuable if a value has not been obtained for some reason e.g. a patient refused. This field can only be provided when there is no value present.
Other fields are optional and may be populated if known - on the understanding that not all data consumers will necessarily make use of them. Points of note include:
method – Option to provide the mechanism used to perform the observation
device – Opportunity to provide a link to a device resource from which was used to obtain the observation.
basedOn – This field is discouraged as it does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer.
partOf – This field is discouraged as it does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer.
derivedFrom – This field is discouraged as it does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer.
issued – This field has been removed as this information can be taken from the mandatory meta.lastUpdated field, and to also avoid any confusion with the other date fields.
Component – Removed to aid the data consumer, we ask that the result is provided in the valueCodeableConcept field and not in the component field.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from UKCoreObservationACVPU
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | UKCoreObservationACVPU | Measurements and simple assertions | |
id | S | 0..1 | id | Logical id of this artifact |
meta | ||||
id | 0..0 | |||
versionId | S | 0..1 | id | Version specific identifier |
lastUpdated | S | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. |
profile | S | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to. Should list (i) this profile (ii) base profile for this resource. |
security | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers | |
Slices for tag | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system | |
tag:Source | S | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data |
id | 0..0 | |||
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Source | |
version | 0..0 | |||
code | S | 1..1 | code | The Data Provider Id of the system supplying the data |
display | S | 1..1 | string | Name of the system supplying the data |
tag:Provenance | S | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data |
id | 0..0 | |||
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Provenance | |
version | 0..0 | |||
code | S | 1..1 | code | The ODS Code of the organisation responsible for the data |
display | S | 1..1 | string | Name of the organisation supplying the data |
implicitRules | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | |
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) | |
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |
Slices for extension | Content/Rules for all slices | |||
extension:triggeredByR5 | 0..0 | |||
identifier | S | 0..* | Identifier | Business Identifier for observation |
assigner | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | |
basedOn | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | DISCOURAGED - This field does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer. | |
partOf | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | DISCOURAGED - This field does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer. | |
category | ||||
id | 0..0 | |||
coding | ||||
id | 0..0 | |||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
version | 0..0 | |||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: vital-signs | |
display | 1..1 | string | Representation defined by the system Fixed Value: Vital Signs | |
code | ||||
id | 0..0 | |||
coding | ||||
id | 0..0 | |||
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 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Alert Confusion Voice Pain Unresponsive scale score | |
subject | 1..1 | Reference(InterweavePatient) | Who and / or what the observation is about. | |
id | 0..0 | |||
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
focus | 0..0 | |||
encounter | S | 0..1 | Reference(InterweaveEncounter) | Healthcare event during which this observation is made |
effective[x] | 1..1 | This is the time/time period during which the observation was taken. | ||
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
effectiveInstant | instant | |||
issued | 0..0 | |||
performer | 0..* | Reference(Practitioner | PractitionerRole | CareTeam) | Who is responsible for the observation. | |
id | 0..0 | |||
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
value[x] | 0..1 | CodeableConcept | The actual observed result. Binding: UK Core ACVPU (required) | |
coding | ||||
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 | |
display | 1..1 | string | Representation defined by the system | |
dataAbsentReason | S | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (required) |
id | 0..0 | |||
coding | ||||
id | 0..0 | |||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
interpretation | 0..0 | |||
note | S | 0..1 | Annotation | Comments about the observation |
bodySite | 0..0 | |||
method | ||||
id | 0..0 | |||
coding | ||||
id | 0..0 | |||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
specimen | 0..0 | |||
device | 0..1 | Reference(Device) | (Measurement) Device | |
referenceRange | 0..0 | |||
hasMember | 0..0 | |||
derivedFrom | 0..* | Reference(InterweaveObservation | InterweaveQuestionnaireResponse) | Related measurements the observation is made from | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.value[x] | required | UKCoreACVPUhttps://fhir.hl7.org.uk/ValueSet/UKCore-ACVPU from this IG | |
Observation.dataAbsentReason | required | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | UKCoreObservationACVPU | Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present | ||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
versionId | SΣ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. | ||||
profile | SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to. Should list (i) this profile (ii) base profile for this resource. | ||||
security | Σ | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Slices for tag | Σ | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
tag:Source | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Source | ||||
code | SΣ | 1..1 | code | The Data Provider Id of the system supplying the data | ||||
display | SΣ | 1..1 | string | Name of the system supplying the data | ||||
tag:Provenance | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Provenance | ||||
code | SΣ | 1..1 | code | The ODS Code of the organisation responsible for the data | ||||
display | SΣ | 1..1 | string | Name of the organisation supplying the data | ||||
implicitRules | ?!Σ | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | ||||
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |||||
Slices for extension | Content/Rules for all slices | |||||||
bodyStructureR5 | 0..1 | Reference(BodyStructure) | Observed body structure. This is a R5 backport. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.bodyStructure | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | SΣ | 0..* | Identifier | Business Identifier for observation | ||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
assigner | Σ | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | ||||
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | DISCOURAGED - This field does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer. | ||||
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | DISCOURAGED - This field does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer. | ||||
status | ?!SΣ | 1..1 | code | The status of the result value. Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: final | ||||
category | S | 1..1 | CodeableConcept | A code that classifies the general type of observation being made. Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
code | SΣ | 1..1 | CodeableConcept | The type of observation (code / type). Binding: UK Core Observation Type (preferred): A code from the SNOMED Clinical Terminology UK coding system describing a type of observation | ||||
subject | SΣ | 1..1 | Reference(InterweavePatient) | Who and / or what the observation is about. | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
encounter | SΣ | 0..1 | Reference(InterweaveEncounter) | Healthcare event during which this observation is made | ||||
effective[x] | SΣ | 1..1 | This is the time/time period during which the observation was taken. | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
effectiveInstant | instant | |||||||
performer | SΣ | 0..* | Reference(Practitioner | PractitionerRole | CareTeam) | Who is responsible for the observation. | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
value[x] | SΣC | 0..1 | CodeableConcept | The actual observed result. Binding: UK Core ACVPU (required) | ||||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (required) | ||||
note | S | 0..1 | Annotation | Comments about the observation | ||||
device | 0..1 | Reference(Device) | (Measurement) Device | |||||
derivedFrom | Σ | 0..* | Reference(InterweaveObservation | InterweaveQuestionnaireResponse) | Related measurements the observation is made from | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Observation.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
Observation.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
Observation.meta.tag:Source | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
Observation.meta.tag:Provenance | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
Observation.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Observation.extension:triggeredByR5.extension:type.value[x] | required | http://hl7.org/fhir/ValueSet/observation-triggeredbytypehttp://hl7.org/fhir/ValueSet/observation-triggeredbytype | ||||
Observation.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
Observation.status | required | Fixed Value: finalhttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | ||||
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.code | preferred | UKCoreObservationTypehttps://fhir.hl7.org.uk/ValueSet/UKCore-ObservationType from this IG | ||||
Observation.value[x] | required | UKCoreACVPUhttps://fhir.hl7.org.uk/ValueSet/UKCore-ACVPU from this IG | ||||
Observation.dataAbsentReason | required | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.component.code | preferred | UKCoreObservationTypehttps://fhir.hl7.org.uk/ValueSet/UKCore-ObservationType from this IG |
Id | Grade | Path(s) | Details | Requirements |
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() | |
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() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | UKCoreObservationACVPU | Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present | ||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | SΣ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. | ||||
source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
profile | SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to. Should list (i) this profile (ii) base profile for this resource. | ||||
security | Σ | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Slices for tag | Σ | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
tag:Source | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
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: https://fhir.interweavedigital.nhs.uk/Source | ||||
code | SΣ | 1..1 | code | The Data Provider Id of the system supplying the data | ||||
display | SΣ | 1..1 | string | Name of the system supplying the data | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
tag:Provenance | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
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: https://fhir.interweavedigital.nhs.uk/Provenance | ||||
code | SΣ | 1..1 | code | The ODS Code of the organisation responsible for the data | ||||
display | SΣ | 1..1 | string | Name of the organisation supplying the data | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
implicitRules | ?!Σ | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | ||||
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
bodyStructureR5 | 0..1 | Reference(BodyStructure) | Observed body structure. This is a R5 backport. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.bodyStructure | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | SΣ | 0..* | Identifier | Business Identifier for observation | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | ||||
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | DISCOURAGED - This field does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer. | ||||
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | DISCOURAGED - This field does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer. | ||||
status | ?!SΣ | 1..1 | code | The status of the result value. Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: final | ||||
category | S | 1..1 | CodeableConcept | A code that classifies the general type of observation being made. Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
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 | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: vital-signs | ||||
display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Vital Signs | ||||
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 | SΣ | 1..1 | CodeableConcept | The type of observation (code / type). Binding: UK Core Observation Type (preferred): A code from the SNOMED Clinical Terminology UK coding system describing a type of observation | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
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://snomed.info/sct | ||||
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: 1104441000000107 | ||||
display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Alert Confusion Voice Pain Unresponsive scale score | ||||
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(InterweavePatient) | Who and / or what the observation is about. | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
encounter | SΣ | 0..1 | Reference(InterweaveEncounter) | Healthcare event during which this observation is made | ||||
effective[x] | SΣ | 1..1 | This is the time/time period during which the observation was taken. | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
effectiveInstant | instant | |||||||
performer | SΣ | 0..* | Reference(Practitioner | PractitionerRole | CareTeam) | Who is responsible for the observation. | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
value[x] | SΣC | 0..1 | CodeableConcept | The actual observed result. Binding: UK Core ACVPU (required) | ||||
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://snomed.info/sct | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..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 | ||||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (required) | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..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 | ||||
note | S | 0..1 | Annotation | Comments about the observation | ||||
method | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (preferred): Methods for simple observations. | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..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 | ||||
device | 0..1 | Reference(Device) | (Measurement) Device | |||||
derivedFrom | Σ | 0..* | Reference(InterweaveObservation | InterweaveQuestionnaireResponse) | Related measurements the observation is made from | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Observation.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
Observation.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
Observation.meta.tag:Source | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
Observation.meta.tag:Provenance | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
Observation.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Observation.extension:triggeredByR5.extension:type.value[x] | required | http://hl7.org/fhir/ValueSet/observation-triggeredbytypehttp://hl7.org/fhir/ValueSet/observation-triggeredbytype | ||||
Observation.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
Observation.identifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
Observation.status | required | Fixed Value: finalhttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | ||||
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.code | preferred | UKCoreObservationTypehttps://fhir.hl7.org.uk/ValueSet/UKCore-ObservationType from this IG | ||||
Observation.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Observation.performer.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Observation.value[x] | required | UKCoreACVPUhttps://fhir.hl7.org.uk/ValueSet/UKCore-ACVPU from this IG | ||||
Observation.dataAbsentReason | required | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.method | preferred | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methods from the FHIR Standard | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaning from the FHIR Standard | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliesto from the FHIR Standard | ||||
Observation.component.code | preferred | UKCoreObservationTypehttps://fhir.hl7.org.uk/ValueSet/UKCore-ObservationType from this IG | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
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() | |
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 UKCoreObservationACVPU
Summary
Mandatory: 2 elements(23 nested mandatory elements)
Must-Support: 14 elements
Fixed: 8 elements
Prohibited: 28 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from UKCoreObservationACVPU
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | UKCoreObservationACVPU | Measurements and simple assertions | |
id | S | 0..1 | id | Logical id of this artifact |
meta | ||||
id | 0..0 | |||
versionId | S | 0..1 | id | Version specific identifier |
lastUpdated | S | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. |
profile | S | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to. Should list (i) this profile (ii) base profile for this resource. |
security | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers | |
Slices for tag | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system | |
tag:Source | S | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data |
id | 0..0 | |||
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Source | |
version | 0..0 | |||
code | S | 1..1 | code | The Data Provider Id of the system supplying the data |
display | S | 1..1 | string | Name of the system supplying the data |
tag:Provenance | S | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data |
id | 0..0 | |||
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Provenance | |
version | 0..0 | |||
code | S | 1..1 | code | The ODS Code of the organisation responsible for the data |
display | S | 1..1 | string | Name of the organisation supplying the data |
implicitRules | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | |
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) | |
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |
Slices for extension | Content/Rules for all slices | |||
extension:triggeredByR5 | 0..0 | |||
identifier | S | 0..* | Identifier | Business Identifier for observation |
assigner | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | |
basedOn | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | DISCOURAGED - This field does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer. | |
partOf | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | DISCOURAGED - This field does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer. | |
category | ||||
id | 0..0 | |||
coding | ||||
id | 0..0 | |||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
version | 0..0 | |||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: vital-signs | |
display | 1..1 | string | Representation defined by the system Fixed Value: Vital Signs | |
code | ||||
id | 0..0 | |||
coding | ||||
id | 0..0 | |||
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 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Alert Confusion Voice Pain Unresponsive scale score | |
subject | 1..1 | Reference(InterweavePatient) | Who and / or what the observation is about. | |
id | 0..0 | |||
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
focus | 0..0 | |||
encounter | S | 0..1 | Reference(InterweaveEncounter) | Healthcare event during which this observation is made |
effective[x] | 1..1 | This is the time/time period during which the observation was taken. | ||
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
effectiveInstant | instant | |||
issued | 0..0 | |||
performer | 0..* | Reference(Practitioner | PractitionerRole | CareTeam) | Who is responsible for the observation. | |
id | 0..0 | |||
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
value[x] | 0..1 | CodeableConcept | The actual observed result. Binding: UK Core ACVPU (required) | |
coding | ||||
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 | |
display | 1..1 | string | Representation defined by the system | |
dataAbsentReason | S | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (required) |
id | 0..0 | |||
coding | ||||
id | 0..0 | |||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
interpretation | 0..0 | |||
note | S | 0..1 | Annotation | Comments about the observation |
bodySite | 0..0 | |||
method | ||||
id | 0..0 | |||
coding | ||||
id | 0..0 | |||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
specimen | 0..0 | |||
device | 0..1 | Reference(Device) | (Measurement) Device | |
referenceRange | 0..0 | |||
hasMember | 0..0 | |||
derivedFrom | 0..* | Reference(InterweaveObservation | InterweaveQuestionnaireResponse) | Related measurements the observation is made from | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Observation.value[x] | required | UKCoreACVPUhttps://fhir.hl7.org.uk/ValueSet/UKCore-ACVPU from this IG | |
Observation.dataAbsentReason | required | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | UKCoreObservationACVPU | Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present | ||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
versionId | SΣ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. | ||||
profile | SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to. Should list (i) this profile (ii) base profile for this resource. | ||||
security | Σ | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Slices for tag | Σ | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
tag:Source | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Source | ||||
code | SΣ | 1..1 | code | The Data Provider Id of the system supplying the data | ||||
display | SΣ | 1..1 | string | Name of the system supplying the data | ||||
tag:Provenance | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Provenance | ||||
code | SΣ | 1..1 | code | The ODS Code of the organisation responsible for the data | ||||
display | SΣ | 1..1 | string | Name of the organisation supplying the data | ||||
implicitRules | ?!Σ | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | ||||
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |||||
Slices for extension | Content/Rules for all slices | |||||||
bodyStructureR5 | 0..1 | Reference(BodyStructure) | Observed body structure. This is a R5 backport. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.bodyStructure | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | SΣ | 0..* | Identifier | Business Identifier for observation | ||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
assigner | Σ | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | ||||
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | DISCOURAGED - This field does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer. | ||||
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | DISCOURAGED - This field does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer. | ||||
status | ?!SΣ | 1..1 | code | The status of the result value. Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: final | ||||
category | S | 1..1 | CodeableConcept | A code that classifies the general type of observation being made. Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
code | SΣ | 1..1 | CodeableConcept | The type of observation (code / type). Binding: UK Core Observation Type (preferred): A code from the SNOMED Clinical Terminology UK coding system describing a type of observation | ||||
subject | SΣ | 1..1 | Reference(InterweavePatient) | Who and / or what the observation is about. | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
encounter | SΣ | 0..1 | Reference(InterweaveEncounter) | Healthcare event during which this observation is made | ||||
effective[x] | SΣ | 1..1 | This is the time/time period during which the observation was taken. | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
effectiveInstant | instant | |||||||
performer | SΣ | 0..* | Reference(Practitioner | PractitionerRole | CareTeam) | Who is responsible for the observation. | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
value[x] | SΣC | 0..1 | CodeableConcept | The actual observed result. Binding: UK Core ACVPU (required) | ||||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (required) | ||||
note | S | 0..1 | Annotation | Comments about the observation | ||||
device | 0..1 | Reference(Device) | (Measurement) Device | |||||
derivedFrom | Σ | 0..* | Reference(InterweaveObservation | InterweaveQuestionnaireResponse) | Related measurements the observation is made from | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Observation.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
Observation.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
Observation.meta.tag:Source | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
Observation.meta.tag:Provenance | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
Observation.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Observation.extension:triggeredByR5.extension:type.value[x] | required | http://hl7.org/fhir/ValueSet/observation-triggeredbytypehttp://hl7.org/fhir/ValueSet/observation-triggeredbytype | ||||
Observation.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
Observation.status | required | Fixed Value: finalhttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | ||||
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.code | preferred | UKCoreObservationTypehttps://fhir.hl7.org.uk/ValueSet/UKCore-ObservationType from this IG | ||||
Observation.value[x] | required | UKCoreACVPUhttps://fhir.hl7.org.uk/ValueSet/UKCore-ACVPU from this IG | ||||
Observation.dataAbsentReason | required | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.component.code | preferred | UKCoreObservationTypehttps://fhir.hl7.org.uk/ValueSet/UKCore-ObservationType from this IG |
Id | Grade | Path(s) | Details | Requirements |
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() | |
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() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | UKCoreObservationACVPU | Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present | ||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | SΣ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. | ||||
source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
profile | SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to. Should list (i) this profile (ii) base profile for this resource. | ||||
security | Σ | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Slices for tag | Σ | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
tag:Source | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
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: https://fhir.interweavedigital.nhs.uk/Source | ||||
code | SΣ | 1..1 | code | The Data Provider Id of the system supplying the data | ||||
display | SΣ | 1..1 | string | Name of the system supplying the data | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
tag:Provenance | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
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: https://fhir.interweavedigital.nhs.uk/Provenance | ||||
code | SΣ | 1..1 | code | The ODS Code of the organisation responsible for the data | ||||
display | SΣ | 1..1 | string | Name of the organisation supplying the data | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
implicitRules | ?!Σ | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | ||||
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
bodyStructureR5 | 0..1 | Reference(BodyStructure) | Observed body structure. This is a R5 backport. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.bodyStructure | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | SΣ | 0..* | Identifier | Business Identifier for observation | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | ||||
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | DISCOURAGED - This field does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer. | ||||
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | DISCOURAGED - This field does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer. | ||||
status | ?!SΣ | 1..1 | code | The status of the result value. Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: final | ||||
category | S | 1..1 | CodeableConcept | A code that classifies the general type of observation being made. Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
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 | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: vital-signs | ||||
display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Vital Signs | ||||
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 | SΣ | 1..1 | CodeableConcept | The type of observation (code / type). Binding: UK Core Observation Type (preferred): A code from the SNOMED Clinical Terminology UK coding system describing a type of observation | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
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://snomed.info/sct | ||||
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: 1104441000000107 | ||||
display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Alert Confusion Voice Pain Unresponsive scale score | ||||
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(InterweavePatient) | Who and / or what the observation is about. | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
encounter | SΣ | 0..1 | Reference(InterweaveEncounter) | Healthcare event during which this observation is made | ||||
effective[x] | SΣ | 1..1 | This is the time/time period during which the observation was taken. | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
effectiveInstant | instant | |||||||
performer | SΣ | 0..* | Reference(Practitioner | PractitionerRole | CareTeam) | Who is responsible for the observation. | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
value[x] | SΣC | 0..1 | CodeableConcept | The actual observed result. Binding: UK Core ACVPU (required) | ||||
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://snomed.info/sct | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..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 | ||||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (required) | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..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 | ||||
note | S | 0..1 | Annotation | Comments about the observation | ||||
method | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (preferred): Methods for simple observations. | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..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 | ||||
device | 0..1 | Reference(Device) | (Measurement) Device | |||||
derivedFrom | Σ | 0..* | Reference(InterweaveObservation | InterweaveQuestionnaireResponse) | Related measurements the observation is made from | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Observation.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
Observation.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
Observation.meta.tag:Source | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
Observation.meta.tag:Provenance | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
Observation.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Observation.extension:triggeredByR5.extension:type.value[x] | required | http://hl7.org/fhir/ValueSet/observation-triggeredbytypehttp://hl7.org/fhir/ValueSet/observation-triggeredbytype | ||||
Observation.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
Observation.identifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
Observation.status | required | Fixed Value: finalhttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | ||||
Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard | ||||
Observation.code | preferred | UKCoreObservationTypehttps://fhir.hl7.org.uk/ValueSet/UKCore-ObservationType from this IG | ||||
Observation.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Observation.performer.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Observation.value[x] | required | UKCoreACVPUhttps://fhir.hl7.org.uk/ValueSet/UKCore-ACVPU from this IG | ||||
Observation.dataAbsentReason | required | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.method | preferred | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methods from the FHIR Standard | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaning from the FHIR Standard | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliesto from the FHIR Standard | ||||
Observation.component.code | preferred | UKCoreObservationTypehttps://fhir.hl7.org.uk/ValueSet/UKCore-ObservationType from this IG | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
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() | |
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 UKCoreObservationACVPU
Summary
Mandatory: 2 elements(23 nested mandatory elements)
Must-Support: 14 elements
Fixed: 8 elements
Prohibited: 28 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
Element name | Change details |
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extension:bodyStructureR5 |
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category |
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category.coding.system |
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code |
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encounter |
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effective[x] |
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performer |
|
valueCodeableConcept |
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dataAbsentReason |
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interpretation |
|
note |
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referenceRange |
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bodySite |
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derivedFrom |
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