| Australian Digital Health Agency FHIR Implementation Guide 1.0.0

Australian Digital Health Agency FHIR Implementation Guide. This is the current published version. It is based on FHIR® version 4.0.1. See the Directory of published versions for a list of available versions.

### StructureDefinition: ADHA Core Observation [Active]

The purpose of this profile is to provide a core representation of a generic observation for the electronic exchange of health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia.

This profile identifies the additional constraints, extensions, and value sets that build on and extend Observation that are supported.

Where a more specific Observation profile is applicable, e.g. diagnostic result or vital signs, an implementation SHALL ensure the resource conforms to that specific profile.

This profile is designed to set a core Observation standard for:

- Query for a generic observation for a patient
- Record or update a generic observation belonging to a patient

#### Profile specific 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.
- Antenatal observations will represent the pregnant individual as `Observation.subject` and the fetus as `Observation.focus`.

#### Boundaries and relationships

This profile is referenced by ADHA Core Encounter, ADHA Core Observation, and ADHA Core Procedure.

#### Formal Views of Profile Content

The official URL for this profile is:

    http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-observation-core-1

The purpose of this profile is to provide a core representation of a generic observation for the electronic exchange of health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia.

This profile builds on Observation.

This profile was published on 2023-04-14 04:02:01+0000 as a active by Australian Digital Health Agency.

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

- Differential Table
- Snapshot Table
- All

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions inv-dh-obs-05: If there is no component or hasMember element then at least value or data absent reason shall be present
status | S | 1..1 | code | registered | preliminary | final | amended +
category | S | 1..* | CodeableConcept | Classification of type of observation
code | S | 1..1 | CodeableConcept | Type of observation (code / type)
subject | S C | 1..1 | Reference(ADHA Core Patient) | Who and/or what the observation is about inv-dh-obs-01: At least reference or a valid identifier shall be present
encounter | S | 0..1 | Reference(ADHA Core Encounter) | Healthcare event during which this observation is made
effective[x] | S C | 1..1 | dateTime, Period, Timing, instant | Clinically relevant time/time-period for observation inv-dh-obs-07: Date shall be at least to day
performer | S C | 1..* | Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA Core Patient | ADHA Authoring RelatedPerson) | Who is responsible for the observation inv-dh-obs-03: At least reference or display or a valid identifier shall be present
value[x] | S C | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual result
dataAbsentReason | S C | 0..1 | CodeableConcept | Why the result is missing
interpretation | S | 0..* | CodeableConcept | High, low, normal, etc.
note | S | 0..* | Annotation | Comments about the observation
bodySite | S C | 0..1 | CodeableConcept | Observed body part Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible) inv-dh-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT
method | S | 0..1 | CodeableConcept | How it was done
hasMember | S | 0..* | Reference(ADHA Core Observation) | Related resource that belongs to the Observation group
component | S | 0..* | BackboneElement | Component results
code | S | 1..1 | CodeableConcept | Type of component observation (code / type)
value[x] | S | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual component result
dataAbsentReason | S | 0..1 | CodeableConcept | Why the component result is missing
interpretation | S | 0..* | CodeableConcept | High, low, normal, etc.
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions inv-dh-obs-05: If there is no component or hasMember element then at least value or data absent reason shall be present
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business Identifier for observation
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event
status | ?!S Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation.
category | S | 1..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
code | S Σ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
subject | S Σ C | 1..1 | Reference(ADHA Core Patient) | Who and/or what the observation is about inv-dh-obs-01: At least reference or a valid identifier shall be present
focus | Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record
encounter | S Σ | 0..1 | Reference(ADHA Core Encounter) | Healthcare event during which this observation is made
effective[x] | S Σ C | 1..1 |  | Clinically relevant time/time-period for observation inv-dh-obs-07: Date shall be at least to day
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
effectiveTiming |  |  | Timing |
effectiveInstant |  |  | instant |
issued | Σ | 0..1 | instant | Date/Time this version was made available
performer | S Σ C | 1..* | Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA Core Patient | ADHA Authoring RelatedPerson) | Who is responsible for the observation inv-dh-obs-03: At least reference or display or a valid identifier shall be present
value[x] | S Σ C | 0..1 |  | Actual result
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
dataAbsentReason | S C | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation | S | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note | S | 0..* | Annotation | Comments about the observation
bodySite | S C | 0..1 | CodeableConcept | Observed body part Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible) inv-dh-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT
method | S | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations.
specimen |  | 0..1 | Reference(Specimen) | Specimen used for this observation
device |  | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device
referenceRange | C | 0..* | BackboneElement | Provides guide for interpretation
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
low | C | 0..1 | SimpleQuantity | Low Range, if relevant
high | C | 0..1 | SimpleQuantity | High Range, if relevant
type |  | 0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
appliesTo |  | 0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
age |  | 0..1 | Range | Applicable age range, if relevant
text |  | 0..1 | string | Text based reference range in an observation
hasMember | S Σ | 0..* | Reference(ADHA Core Observation) | Related resource that belongs to the Observation group
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from
component | S Σ | 0..* | BackboneElement | Component results
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | S Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
value[x] | S Σ | 0..1 |  | Actual component result
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
dataAbsentReason | S C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation | S | 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

Differential View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions inv-dh-obs-05: If there is no component or hasMember element then at least value or data absent reason shall be present
status | S | 1..1 | code | registered | preliminary | final | amended +
category | S | 1..* | CodeableConcept | Classification of type of observation
code | S | 1..1 | CodeableConcept | Type of observation (code / type)
subject | S C | 1..1 | Reference(ADHA Core Patient) | Who and/or what the observation is about inv-dh-obs-01: At least reference or a valid identifier shall be present
encounter | S | 0..1 | Reference(ADHA Core Encounter) | Healthcare event during which this observation is made
effective[x] | S C | 1..1 | dateTime, Period, Timing, instant | Clinically relevant time/time-period for observation inv-dh-obs-07: Date shall be at least to day
performer | S C | 1..* | Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA Core Patient | ADHA Authoring RelatedPerson) | Who is responsible for the observation inv-dh-obs-03: At least reference or display or a valid identifier shall be present
value[x] | S C | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual result
dataAbsentReason | S C | 0..1 | CodeableConcept | Why the result is missing
interpretation | S | 0..* | CodeableConcept | High, low, normal, etc.
note | S | 0..* | Annotation | Comments about the observation
bodySite | S C | 0..1 | CodeableConcept | Observed body part Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible) inv-dh-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT
method | S | 0..1 | CodeableConcept | How it was done
hasMember | S | 0..* | Reference(ADHA Core Observation) | Related resource that belongs to the Observation group
component | S | 0..* | BackboneElement | Component results
code | S | 1..1 | CodeableConcept | Type of component observation (code / type)
value[x] | S | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Actual component result
dataAbsentReason | S | 0..1 | CodeableConcept | Why the component result is missing
interpretation | S | 0..* | CodeableConcept | High, low, normal, etc.
Documentation for this format

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions inv-dh-obs-05: If there is no component or hasMember element then at least value or data absent reason shall be present
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business Identifier for observation
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event
status | ?!S Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation.
category | S | 1..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
code | S Σ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
subject | S Σ C | 1..1 | Reference(ADHA Core Patient) | Who and/or what the observation is about inv-dh-obs-01: At least reference or a valid identifier shall be present
focus | Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record
encounter | S Σ | 0..1 | Reference(ADHA Core Encounter) | Healthcare event during which this observation is made
effective[x] | S Σ C | 1..1 |  | Clinically relevant time/time-period for observation inv-dh-obs-07: Date shall be at least to day
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
effectiveTiming |  |  | Timing |
effectiveInstant |  |  | instant |
issued | Σ | 0..1 | instant | Date/Time this version was made available
performer | S Σ C | 1..* | Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA Core Patient | ADHA Authoring RelatedPerson) | Who is responsible for the observation inv-dh-obs-03: At least reference or display or a valid identifier shall be present
value[x] | S Σ C | 0..1 |  | Actual result
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
dataAbsentReason | S C | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation | S | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note | S | 0..* | Annotation | Comments about the observation
bodySite | S C | 0..1 | CodeableConcept | Observed body part Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible) inv-dh-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT
method | S | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations.
specimen |  | 0..1 | Reference(Specimen) | Specimen used for this observation
device |  | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device
referenceRange | C | 0..* | BackboneElement | Provides guide for interpretation
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
low | C | 0..1 | SimpleQuantity | Low Range, if relevant
high | C | 0..1 | SimpleQuantity | High Range, if relevant
type |  | 0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
appliesTo |  | 0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
age |  | 0..1 | Range | Applicable age range, if relevant
text |  | 0..1 | string | Text based reference range in an observation
hasMember | S Σ | 0..* | Reference(ADHA Core Observation) | Related resource that belongs to the Observation group
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from
component | S Σ | 0..* | BackboneElement | Component results
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | S Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
value[x] | S Σ | 0..1 |  | Actual component result
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
dataAbsentReason | S C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation | S | 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

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

#### Terminology Bindings

Path | Conformance | ValueSet
Observation.language | preferred | CommonLanguages
Additional Bindings | Purpose
AllLanguages | Max Binding
Observation.status | required | ObservationStatus
Observation.category | preferred | ObservationCategoryCodes
Observation.code | example | LOINCCodes (a valid code from LOINC)
Observation.dataAbsentReason | extensible | DataAbsentReason
Observation.interpretation | extensible | ObservationInterpretationCodes
Observation.bodySite | extensible | https://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Observation.method | example | ObservationMethods
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes
Observation.component.code | example | LOINCCodes (a valid code from LOINC)
Observation.component.dataAbsentReason | extensible | DataAbsentReason
Observation.component.interpretation | extensible | ObservationInterpretationCodes

#### Search Parameters

None defined.