My Health Record FHIR IG
1.2.0 - active

My Health Record FHIR IG - Local Development build (v1.2.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

## Resource Profile: ADHA Core Observation

Official URL: http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-observation-core-1 | Version: 1.2.0
Active as of 2024-09-19 | Computable Name: ADHAObservationCore
Copyright/Legal: Copyright © 2022 Australian Digital Health Agency - All rights reserved. This content is licensed under a Creative Commons Attribution 4.0 International License. See https://creativecommons.org/licenses/by/4.0/.

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`.

Usage:

- Refer to this Resource Profile: ADHA Core Encounter, ADHA Core Observation and ADHA Core Procedure
- Examples for this Resource Profile: Observation/air-covid-imm-status-01, Observation/no-current-meds-01 and Observation/no-med-hist-01

### Formal Views of Profile Content

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

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

This structure is derived from Observation

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: Body Site (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

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Observation.bodySite | extensible | BodySite `https://healthterminologies.gov.au/fhir/ValueSet/body-site-1` from https://tx.ontoserver.csiro.au/fhir

#### Constraints

Id | Grade | Path(s) | Details | Requirements
inv-dh-obs-01 | error | Observation.subject | At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists() |
inv-dh-obs-03 | error | Observation.performer | At least reference or display or a valid identifier shall be present : reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists() |
inv-dh-obs-04 | error | Observation.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() |
inv-dh-obs-05 | error | Observation | If there is no component or hasMember element then at least value or data absent reason shall be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
inv-dh-obs-07 | error | Observation.effective[x] | Date shall be at least to day : $this is DateTime implies $this.toString().length() >= 10 |

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | 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 inv-dh-obs-05: If there is no component or hasMember element then at least value or data absent reason shall be present
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!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
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 |
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: Body Site (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.
hasMember | S Σ | 0..* | Reference(ADHA Core Observation) | Related resource that belongs to the Observation group
component | S Σ | 0..* | BackboneElement | Component results
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.
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
Observation.status | required | ObservationStatus `http://hl7.org/fhir/ValueSet/observation-status|4.0.1` from the FHIR Standard
Observation.category | preferred | ObservationCategoryCodes `http://hl7.org/fhir/ValueSet/observation-category` from the FHIR Standard
Observation.code | example | LOINCCodes (a valid code from LOINC) `http://hl7.org/fhir/ValueSet/observation-codes` from the FHIR Standard
Observation.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` from the FHIR Standard
Observation.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` from the FHIR Standard
Observation.bodySite | extensible | BodySite `https://healthterminologies.gov.au/fhir/ValueSet/body-site-1` from https://tx.ontoserver.csiro.au/fhir
Observation.method | example | ObservationMethods `http://hl7.org/fhir/ValueSet/observation-methods` from the FHIR Standard
Observation.component.code | example | LOINCCodes (a valid code from LOINC) `http://hl7.org/fhir/ValueSet/observation-codes` from the FHIR Standard
Observation.component.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` from the FHIR Standard
Observation.component.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` from the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
inv-dh-obs-01 | error | Observation.subject | At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists() |
inv-dh-obs-03 | error | Observation.performer | At least reference or display or a valid identifier shall be present : reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists() |
inv-dh-obs-04 | error | Observation.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() |
inv-dh-obs-05 | error | Observation | If there is no component or hasMember element then at least value or data absent reason shall be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
inv-dh-obs-07 | error | Observation.effective[x] | Date shall be at least to day : $this is DateTime implies $this.toString().length() >= 10 |

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | 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 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: Body Site (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 obs-3: Must have at least a low or a high or text
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

#### Terminology Bindings

Path | Conformance | ValueSet | URI
Observation.language | preferred | CommonLanguages
Additional Bindings | Purpose
AllLanguages | Max Binding
`http://hl7.org/fhir/ValueSet/languages` from the FHIR Standard
Observation.status | required | ObservationStatus `http://hl7.org/fhir/ValueSet/observation-status|4.0.1` from the FHIR Standard
Observation.category | preferred | ObservationCategoryCodes `http://hl7.org/fhir/ValueSet/observation-category` from the FHIR Standard
Observation.code | example | LOINCCodes (a valid code from LOINC) `http://hl7.org/fhir/ValueSet/observation-codes` from the FHIR Standard
Observation.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` from the FHIR Standard
Observation.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` from the FHIR Standard
Observation.bodySite | extensible | BodySite `https://healthterminologies.gov.au/fhir/ValueSet/body-site-1` from https://tx.ontoserver.csiro.au/fhir
Observation.method | example | ObservationMethods `http://hl7.org/fhir/ValueSet/observation-methods` from the FHIR Standard
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes `http://hl7.org/fhir/ValueSet/referencerange-meaning` from the FHIR Standard
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes `http://hl7.org/fhir/ValueSet/referencerange-appliesto` from the FHIR Standard
Observation.component.code | example | LOINCCodes (a valid code from LOINC) `http://hl7.org/fhir/ValueSet/observation-codes` from the FHIR Standard
Observation.component.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` from the FHIR Standard
Observation.component.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` from the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
inv-dh-obs-01 | error | Observation.subject | At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists() |
inv-dh-obs-03 | error | Observation.performer | At least reference or display or a valid identifier shall be present : reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists() |
inv-dh-obs-04 | error | Observation.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() |
inv-dh-obs-05 | error | Observation | If there is no component or hasMember element then at least value or data absent reason shall be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
inv-dh-obs-07 | error | Observation.effective[x] | Date shall be at least to day : $this is DateTime implies $this.toString().length() >= 10 |

This structure is derived from Observation

Summary

Mandatory: 4 elements
Must-Support: 19 elements

Structures

This structure refers to these other structures:

- ADHA Core Patient (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-patient-core-1)
- ADHA Core Encounter (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-encounter-core-1)
- ADHA Authoring PractitionerRole (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-practitionerrole-author-1)
- ADHA Core Organization (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-organization-core-1)
- ADHA Authoring RelatedPerson (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-relatedperson-author-1)
- ADHA Core Observation (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-observation-core-1)

Differential View

This structure is derived from Observation

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: Body Site (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

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Observation.bodySite | extensible | BodySite `https://healthterminologies.gov.au/fhir/ValueSet/body-site-1` from https://tx.ontoserver.csiro.au/fhir

#### Constraints

Id | Grade | Path(s) | Details | Requirements
inv-dh-obs-01 | error | Observation.subject | At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists() |
inv-dh-obs-03 | error | Observation.performer | At least reference or display or a valid identifier shall be present : reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists() |
inv-dh-obs-04 | error | Observation.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() |
inv-dh-obs-05 | error | Observation | If there is no component or hasMember element then at least value or data absent reason shall be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
inv-dh-obs-07 | error | Observation.effective[x] | Date shall be at least to day : $this is DateTime implies $this.toString().length() >= 10 |

Key Elements View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | 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 inv-dh-obs-05: If there is no component or hasMember element then at least value or data absent reason shall be present
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!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
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 |
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: Body Site (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.
hasMember | S Σ | 0..* | Reference(ADHA Core Observation) | Related resource that belongs to the Observation group
component | S Σ | 0..* | BackboneElement | Component results
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.
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
Observation.status | required | ObservationStatus `http://hl7.org/fhir/ValueSet/observation-status|4.0.1` from the FHIR Standard
Observation.category | preferred | ObservationCategoryCodes `http://hl7.org/fhir/ValueSet/observation-category` from the FHIR Standard
Observation.code | example | LOINCCodes (a valid code from LOINC) `http://hl7.org/fhir/ValueSet/observation-codes` from the FHIR Standard
Observation.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` from the FHIR Standard
Observation.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` from the FHIR Standard
Observation.bodySite | extensible | BodySite `https://healthterminologies.gov.au/fhir/ValueSet/body-site-1` from https://tx.ontoserver.csiro.au/fhir
Observation.method | example | ObservationMethods `http://hl7.org/fhir/ValueSet/observation-methods` from the FHIR Standard
Observation.component.code | example | LOINCCodes (a valid code from LOINC) `http://hl7.org/fhir/ValueSet/observation-codes` from the FHIR Standard
Observation.component.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` from the FHIR Standard
Observation.component.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` from the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
inv-dh-obs-01 | error | Observation.subject | At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists() |
inv-dh-obs-03 | error | Observation.performer | At least reference or display or a valid identifier shall be present : reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists() |
inv-dh-obs-04 | error | Observation.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() |
inv-dh-obs-05 | error | Observation | If there is no component or hasMember element then at least value or data absent reason shall be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
inv-dh-obs-07 | error | Observation.effective[x] | Date shall be at least to day : $this is DateTime implies $this.toString().length() >= 10 |

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | 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 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: Body Site (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 obs-3: Must have at least a low or a high or text
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

#### Terminology Bindings

Path | Conformance | ValueSet | URI
Observation.language | preferred | CommonLanguages
Additional Bindings | Purpose
AllLanguages | Max Binding
`http://hl7.org/fhir/ValueSet/languages` from the FHIR Standard
Observation.status | required | ObservationStatus `http://hl7.org/fhir/ValueSet/observation-status|4.0.1` from the FHIR Standard
Observation.category | preferred | ObservationCategoryCodes `http://hl7.org/fhir/ValueSet/observation-category` from the FHIR Standard
Observation.code | example | LOINCCodes (a valid code from LOINC) `http://hl7.org/fhir/ValueSet/observation-codes` from the FHIR Standard
Observation.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` from the FHIR Standard
Observation.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` from the FHIR Standard
Observation.bodySite | extensible | BodySite `https://healthterminologies.gov.au/fhir/ValueSet/body-site-1` from https://tx.ontoserver.csiro.au/fhir
Observation.method | example | ObservationMethods `http://hl7.org/fhir/ValueSet/observation-methods` from the FHIR Standard
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes `http://hl7.org/fhir/ValueSet/referencerange-meaning` from the FHIR Standard
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes `http://hl7.org/fhir/ValueSet/referencerange-appliesto` from the FHIR Standard
Observation.component.code | example | LOINCCodes (a valid code from LOINC) `http://hl7.org/fhir/ValueSet/observation-codes` from the FHIR Standard
Observation.component.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` from the FHIR Standard
Observation.component.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` from the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
inv-dh-obs-01 | error | Observation.subject | At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists() |
inv-dh-obs-03 | error | Observation.performer | At least reference or display or a valid identifier shall be present : reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists() |
inv-dh-obs-04 | error | Observation.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() |
inv-dh-obs-05 | error | Observation | If there is no component or hasMember element then at least value or data absent reason shall be present : (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists()) |
inv-dh-obs-07 | error | Observation.effective[x] | Date shall be at least to day : $this is DateTime implies $this.toString().length() >= 10 |

This structure is derived from Observation

Summary

Mandatory: 4 elements
Must-Support: 19 elements

Structures

This structure refers to these other structures:

- ADHA Core Patient (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-patient-core-1)
- ADHA Core Encounter (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-encounter-core-1)
- ADHA Authoring PractitionerRole (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-practitionerrole-author-1)
- ADHA Core Organization (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-organization-core-1)
- ADHA Authoring RelatedPerson (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-relatedperson-author-1)
- ADHA Core Observation (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-observation-core-1)

Other representations of profile: CSV, Excel, Schematron