Release 4 5 Snapshot #1

This page is part of the FHIR Specification (v4.0.1: R4 - Mixed Normative and STU ) in it's permanent home (it will always be available at this URL). (v5.0.0-snapshot1: R5 Snapshot #1). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4

Orders and Observations Work Group Maturity Level : 0 1   Trial Use Security Category : Business Compartments : Not linked to any defined compartments

Detailed Descriptions for the elements in the ObservationDefinition resource.

ObservationDefinition
Element Id ObservationDefinition
Definition

Set of definitional characteristics for a kind of observation or measurement produced or consumed by an orderable health care service.

Cardinality 0..*
Type DomainResource
Requirements

In a catalog of health-related services that use or produce observations and measurements, this resource describes the expected characteristics of these observation / measurements.

Summary false
Comments

An instance of this resource informs the consumer of a health-related service (such as a lab diagnostic test or panel) about how the observations used or produced by this service will look like.

Invariants
Defined on this element
cnl-0 Warning Name should be usable as an identifier for the module by machine processing applications such as code generation name.matches('[A-Z]([A-Za-z0-9_]){0,254}')
ObservationDefinition.category ObservationDefinition.url
Element Id ObservationDefinition.category ObservationDefinition.url
Definition

An absolute URL that is used to identify this ObservationDefinition when it is referenced in a specification, model, design or an instance. This SHALL be a URL, SHOULD be globally unique, and SHOULD be an address at which this ObservationDefinition is (or will be) published. The URL SHOULD include the major version of the ObservationDefinition. For more information see Technical and Business Versions.

Cardinality 0..1
Type uri
Requirements

Allows the ObservationDefinition to be referenced by a single globally unique identifier.

Summary true
Comments

Can be a urn:uuid: or a urn:oid:, but real http: addresses are preferred. This is the URI that will be used when making canonical references to this resource.

ObservationDefinition.identifier
Element Id ObservationDefinition.identifier
Definition

Business identifiers assigned to this ObservationDefinition. by the performer and/or other systems. These identifiers remain constant as the resource is updated and propagates from server to server.

Note This is a business identifier, not a resource identifier (see discussion )
Cardinality 0..1
Type Identifier
Requirements

Allows identification of the ObservationDefinition as it is known by various participating systems and in a way that remains consistent across servers.

Summary true
Comments

This is a business identifier, not a resource identifier. It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types.

ObservationDefinition.version
Element Id ObservationDefinition.version
Definition

The identifier that is used to identify this version of the ObservationDefinition when it is referenced in a specification, model, design or instance. This is an arbitrary value managed by the ObservationDefinition author and is not expected to be globally unique. For example, it might be a timestamp (e.g. yyyymmdd) if a managed version is not available. There is also no expectation that versions are orderable.

Note This is a business versionId, not a resource version id (see discussion )
Cardinality 0..1
Type string
Summary true
Comments

There may be multiple different instances of a ObservationDefinition that have the same identifier but different versions.

ObservationDefinition.name
Element Id ObservationDefinition.name
Definition

A natural language name identifying the ObservationDefinition. This name should be usable as an identifier for the module by machine processing applications such as code generation.

Cardinality 0..1
Type string
Requirements

Support human navigation and code generation.

Summary true
Comments

The name is not expected to be globally unique. The name should be a simple alphanumeric type name to ensure that classifies it is machine-processing friendly.

Invariants
Affect this element
cnl-0 Warning Name should be usable as an identifier for the general type module by machine processing applications such as code generation name.matches('[A-Z]([A-Za-z0-9_]){0,254}')
ObservationDefinition.title
Element Id ObservationDefinition.title
Definition

A short, descriptive, user-friendly title for the ObservationDefinition.

Cardinality 0..1
Type string
Summary true
ObservationDefinition.status
Element Id ObservationDefinition.status
Definition

The current state of observation. the ObservationDefinition.

Cardinality 0..* 1..1
Terminology Binding Observation Category Codes PublicationStatus ( Example Required )
Type CodeableConcept code
Requirements Is Modifier true (Reason: Not known why this is labelled a modifier)
Summary true
Comments

Used A nominal state-transition diagram can be found in the [[definition.html#statemachine | Definition pattern]] documentation Unknown does not represent "other" - one of the defined statuses must apply. Unknown is used when the authoring system is not sure what the current status is.

ObservationDefinition.experimental
Element Id ObservationDefinition.experimental
Definition

A flag to indicate that this ObservationDefinition is authored for testing purposes (or education/evaluation/marketing), and is not intended to be used for genuine usage.

Cardinality 0..1
Type boolean
Is Modifier true (Reason: Not known why this is labelled a modifier)
Summary true
Comments

Allows filtering what kinds of observations ObservationDefinition that are retrieved appropriate for use vs. not.

ObservationDefinition.date
Element Id ObservationDefinition.date
Definition

The date (and optionally time) when the ObservationDefinition was published. The date must change when the business version changes and displayed. it must change if the status code changes. In addition, it should change when the substantive content of the ObservationDefinition changes.

Cardinality 0..1
Type dateTime
Alternate Names Class of observation revision date
Summary true
Comments

This element allows various categorization schemes based on Note that this is not the owner’s definition same as the resource last-modified-date, since the resource may be a secondary representation of the category and effectively multiple categories can ObservationDefinition. Additional specific dates may be used added as extensions or be found by consulting Provenances associated with past versions of the resource.

ObservationDefinition.publisher
Element Id ObservationDefinition.publisher
Definition

Helps establish the "authority/credibility" of the ObservationDefinition. May also allow for one instance contact.

Cardinality 0..1
Type Reference ( Practitioner | PractitionerRole | Organization )
Patterns Reference(Practitioner,PractitionerRole,Organization): Common patterns = Participant
Requirements

Usually an organization, but may be an individual. The publisher (or steward) of the ObservationDefinition is the organization or individual primarily responsible for the maintenance and upkeep of the ObservationDefinition. This is not necessarily the same individual or organization that developed and initially authored the content. The level publisher is the primary point of granularity contact for questions or issues with the ObservationDefinition. This item SHOULD be populated unless the information is defined by available from context.

Summary true
ObservationDefinition.contact
Element Id ObservationDefinition.contact
Definition

Contact details to assist a user in finding and communicating with the category concepts publisher.

Cardinality 0..*
Type ContactDetail
Summary true
Comments

May be a web site, an email address, a telephone number, etc.

ObservationDefinition.description
Element Id ObservationDefinition.description
Definition

A free text natural language description of the ObservationDefinition from the consumer's perspective.

Cardinality 0..1
Type markdown
Summary false
Comments

This description can be used to capture details such as why the ObservationDefinition was built, comments about misuse, instructions for clinical use and interpretation, literature references, examples from the paper world, etc. It is not a rendering of the module as conveyed in the value set. text field of the resource itself. This item SHOULD be populated unless the information is available from context.

ObservationDefinition.code ObservationDefinition.useContext
Element Id ObservationDefinition.code ObservationDefinition.useContext
Definition

Describes what will The content was developed with a focus and intent of supporting the contexts that are listed. These contexts may be observed. Sometimes this general categories (gender, age, ...) or may be references to specific programs (insurance plans, studies, ...) and may be used to assist with indexing and searching for appropriate ObservationDefinition instances.

Cardinality 0..*
Type UsageContext
Requirements

Assist in searching for appropriate content.

Summary true
Comments

When multiple usageContexts are specified, there is called no expectation for whether all or any of the observation "name". contexts apply.

ObservationDefinition.jurisdiction
Element Id ObservationDefinition.jurisdiction
Definition

A jurisdiction in which the ObservationDefinition is intended to be used.

Cardinality 1..1 0..*
Terminology Binding LOINC Codes Jurisdiction ( Example Extensible )
Type CodeableConcept
Requirements Summary true
Comments

Knowing what kind It may be possible for the ObservationDefinition to be used in jurisdictions other than those for which it was originally designed or intended.

ObservationDefinition.purpose
Element Id ObservationDefinition.purpose
Definition

Explains why this ObservationDefinition is needed and why it has been designed as it has.

Cardinality 0..1
Type markdown
Summary false
Comments

This element does not describe the usage of observation the ObservationDefinition. Rather it is being made for traceability of ''why'' the resource is essential either needed or ''why'' it is defined as it is. This may be used to understanding point to source materials or specifications that drove the observation. structure of this ObservationDefinition.

ObservationDefinition.copyright
Element Id ObservationDefinition.copyright
Definition

Copyright statement relating to the ObservationDefinition and/or its contents. Copyright statements are generally legal restrictions on the use and publishing of the ObservationDefinition.

Cardinality 0..1
Type markdown
Requirements

Consumers of the ObservationDefinition must be able to determine any legal restrictions on the use of the artifact and/or its content.

Alternate Names Name License; Restrictions
Summary false
ObservationDefinition.approvalDate
Element Id ObservationDefinition.approvalDate
Definition

The date on which the asset content was approved by the publisher. Approval happens once when the content is officially approved for usage.

Cardinality 0..1
Type date
Summary false
Comments

The date may be more recent than the approval date because of minor changes / editorial corrections.

ObservationDefinition.lastReviewDate
Element Id ObservationDefinition.lastReviewDate
Definition

The date on which the asset content was last reviewed. Review happens periodically after that, but doesn't change the original approval date.

Cardinality 0..1
Type date
Summary false
Comments

If specified, this is usually after the approval date.

ObservationDefinition.effectivePeriod
Element Id ObservationDefinition.effectivePeriod
Definition

The period during which the ObservationDefinition content was or is planned to be effective.

Cardinality 0..1
Type Period
Summary true
Comments

The effective period for an ObservationDefinition determines when the content is applicable for usage and is independent of publication and review dates. For example, an observation intended to be used for the year 2021 might be published in 2020.

ObservationDefinition.identifier ObservationDefinition.derivedFromCanonical
Element Id ObservationDefinition.identifier ObservationDefinition.derivedFromCanonical
Definition

A unique identifier assigned The canonical URL pointing to another FHIR-defined ObservationDefinition that is adhered to in whole or in part by this definition.

Cardinality 0..*
Type canonical ( ObservationDefinition artifact. )
Summary true
ObservationDefinition.derivedFromUri
Element Id ObservationDefinition.derivedFromUri
Definition

The URL pointing to an externally-defined observation definition, guideline or other definition that is adhered to in whole or in part by this definition.

Note Cardinality This 0..*
Type uri
Requirements

Observation definitions may be refinements of other definitions.

Summary true
ObservationDefinition.subject
Element Id ObservationDefinition.subject
Definition

A code that describes the intended kind of subject of Observation instances conforming to this ObservationDefinition.

Cardinality 0..*
Type CodeableConcept
Summary true
Comments

Examples: person, animal, device, air, surface ….

ObservationDefinition.performerType
Element Id ObservationDefinition.performerType
Definition

The type of individual/organization/device that is a business identifier, not a resource identifier (see discussion expected to act upon instances of this definition.

Cardinality ) 0..1
Type CodeableConcept
Summary true
ObservationDefinition.category
Element Id ObservationDefinition.category
Definition

A code that classifies the general type of observation.

Cardinality 0..*
Terminology Binding Observation Category Codes ( Example )
Type Identifier CodeableConcept
Requirements

Used for filtering what kinds of observations are retrieved and displayed.

Alternate Names Class of observation
Summary true
Comments

This element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used for one instance of ObservationDefinition. The level of granularity is defined by the category concepts in the value set.

ObservationDefinition.code
Element Id ObservationDefinition.code
Definition

Describes what will be observed. Sometimes this is called the observation "name".

Cardinality 1..1
Terminology Binding LOINC Codes ( Example )
Type CodeableConcept
Summary true
ObservationDefinition.permittedDataType
Element Id ObservationDefinition.permittedDataType
Definition

The data types allowed for the value element of the instance observations conforming to this ObservationDefinition.

Cardinality 0..*
Terminology Binding ObservationDataType ( Required )
Type code
Summary false
ObservationDefinition.multipleResultsAllowed
Element Id ObservationDefinition.multipleResultsAllowed
Definition

Multiple results allowed for observations conforming to this ObservationDefinition.

Cardinality 0..1
Type boolean
Summary false
Comments

An example of observation allowing multiple results is "bacteria identified by culture". Conversely, the measurement of a potassium level allows a single result.

ObservationDefinition.bodySite
Element Id ObservationDefinition.bodySite
Definition

The site on the subject's body where the observation is to be made.

Cardinality 0..1
Terminology Binding SNOMED CT Body Structures ( Example )
Type CodeableConcept
Summary false
Comments

Only used if the defined observation is to be made directly on a body part and if this body part is not implied by code found in ObservationDefinition.code. Not used for in vitro diagnostic observations. Example: 14975008 |Forearm structure|.

ObservationDefinition.method
Element Id ObservationDefinition.method
Definition

The method or technique used to perform the observation.

Cardinality 0..1
Terminology Binding Observation Methods ( Example )
Type CodeableConcept
Requirements

In some cases, method can impact results.

Summary false
Comments

Only used if not implicit in observation code. code Example: 702659008 |Automated count technique|.

ObservationDefinition.specimen
Element Id ObservationDefinition.specimen
Definition

The kind of specimen that this type of observation is produced on.

Cardinality 0..*
Type Reference ( SpecimenDefinition )
Summary false
Comments

Only used for in vitro observations. When multiple occurrences of specimen are present, they are to be combined with a logical AND: all specified specimens are needed for the observation.

ObservationDefinition.device
Element Id ObservationDefinition.device
Definition

The measurement model of device or actual device used to produce observations of this type.

Cardinality 0..*
Type Reference ( DeviceDefinition | Device )
Patterns Reference(DeviceDefinition,Device): No common pattern
Summary false
Comments

When multiple occurrences of device are present, they are to be combined with a logical OR: at least one of the specified devices is used to produce the observation.

ObservationDefinition.preferredReportName
Element Id ObservationDefinition.preferredReportName
Definition

The preferred name to be used when reporting the results of observations conforming to this ObservationDefinition.

Cardinality 0..1
Type string
Summary false
ObservationDefinition.quantitativeDetails
Element Id ObservationDefinition.quantitativeDetails
Definition

Characteristics for quantitative results of observations conforming to this observation. ObservationDefinition.

Cardinality 0..1
Summary false
ObservationDefinition.quantitativeDetails.customaryUnit ObservationDefinition.quantitativeDetails.unit
Element Id ObservationDefinition.quantitativeDetails.customaryUnit ObservationDefinition.quantitativeDetails.unit
Definition

Customary Primary unit used to report quantitative results of observations conforming to this ObservationDefinition.

Cardinality 0..1
Terminology Binding UCUM Codes ( Extensible )
Type CodeableConcept
Summary false
ObservationDefinition.quantitativeDetails.unit ObservationDefinition.quantitativeDetails.customaryUnit
Element Id ObservationDefinition.quantitativeDetails.unit ObservationDefinition.quantitativeDetails.customaryUnit
Definition

SI Secondary unit used to report quantitative results of observations conforming to this ObservationDefinition.

Cardinality 0..1
Terminology Binding UCUM Codes ( Extensible )
Type CodeableConcept
Summary false
ObservationDefinition.quantitativeDetails.conversionFactor
Element Id ObservationDefinition.quantitativeDetails.conversionFactor
Definition

Factor for converting value expressed with SI primary unit to value expressed with customary secondary unit.

Cardinality 0..1
Type decimal
Summary false
ObservationDefinition.quantitativeDetails.decimalPrecision
Element Id ObservationDefinition.quantitativeDetails.decimalPrecision
Definition

Number of digits after decimal separator when the results of such observations are of type Quantity.

Cardinality 0..1
Type integer
Summary false
ObservationDefinition.qualifiedInterval ObservationDefinition.qualifiedValue
Element Id ObservationDefinition.qualifiedInterval ObservationDefinition.qualifiedValue
Definition

Multiple ranges A set of results qualified by different contexts values associated with a context and a set of conditions - provides a range for quantitative and ordinal or continuous observations conforming to this ObservationDefinition. and a collection of value sets for qualitative observations.

Cardinality 0..*
Summary false
ObservationDefinition.qualifiedInterval.category ObservationDefinition.qualifiedValue.context
Element Id ObservationDefinition.qualifiedInterval.category ObservationDefinition.qualifiedValue.context
Definition

The category of interval of values A concept defining the context for continuous or ordinal observations conforming to this ObservationDefinition. set of qualified values.

Cardinality 0..1
Terminology Binding ObservationRangeCategory Observation Reference Range Meaning Codes ( Required Extensible )
Type code CodeableConcept
Summary false
ObservationDefinition.qualifiedInterval.range ObservationDefinition.qualifiedValue.appliesTo
Element Id ObservationDefinition.qualifiedInterval.range ObservationDefinition.qualifiedValue.appliesTo
Definition

The low and high values determining the interval. There may be only one target population this set of the two. qualified values applies to.

Cardinality 0..1 0..*
Terminology Binding Observation Reference Range Applies To Codes ( Example )
Type Range CodeableConcept
Requirements Summary false
Comments

The unit may be not relevant for ordinal values. In case it is there, it If this element is not present then the same as quantitativeDetails.unit. global population is assumed.

ObservationDefinition.qualifiedInterval.context ObservationDefinition.qualifiedValue.gender
Element Id ObservationDefinition.qualifiedInterval.context ObservationDefinition.qualifiedValue.gender
Definition

Codes to indicate the health context the range The gender this set of qualified values applies to. For example, the normal or therapeutic range.

Cardinality 0..1
Terminology Binding Observation Reference Range Meaning Codes AdministrativeGender ( Extensible Required )
Type CodeableConcept code
Summary false
ObservationDefinition.qualifiedInterval.appliesTo ObservationDefinition.qualifiedValue.age
Element Id ObservationDefinition.qualifiedInterval.appliesTo ObservationDefinition.qualifiedValue.age
Definition

Codes to indicate the target population this reference The age range this set of qualified values applies to.

Cardinality 0..* 0..1
Terminology Binding Type Observation Reference Range Applies To Codes ( Example
Summary ) false
Comments

Some analytes vary greatly over age.

ObservationDefinition.qualifiedValue.gestationalAge
Element Id ObservationDefinition.qualifiedValue.gestationalAge
Definition

The gestational age this set of qualified values applies to.

Cardinality 0..1
Type CodeableConcept Range
Comments Summary false
ObservationDefinition.qualifiedValue.condition
Element Id ObservationDefinition.qualifiedValue.condition
Definition

If this element is not present then Text based condition for which the global population the set of qualified values is assumed. valid.

Cardinality 0..1
Type string
Summary false
ObservationDefinition.qualifiedInterval.gender ObservationDefinition.qualifiedValue.rangeCategory
Element Id ObservationDefinition.qualifiedInterval.gender ObservationDefinition.qualifiedValue.rangeCategory
Definition

Sex The category of the population the range applies to. of values for continuous or ordinal observations that match the criteria of this set of qualified values.

Cardinality 0..1
Terminology Binding AdministrativeGender ObservationRangeCategory ( Required )
Type code
Summary false
ObservationDefinition.qualifiedInterval.age ObservationDefinition.qualifiedValue.range
Element Id ObservationDefinition.qualifiedInterval.age ObservationDefinition.qualifiedValue.range
Definition

The age at which this reference range is applicable. This is a neonatal age (e.g. number of weeks at term) if values defined for continuous or ordinal observations that match the meaning says so. criteria of this set of qualified values.

Cardinality 0..1
Type Range
Comments Requirements

Some analytes vary greatly over age. The unit may be not relevant for ordinal values. In case it is there, it is the same as quantitativeDetails.unit.

Summary false
ObservationDefinition.qualifiedInterval.gestationalAge ObservationDefinition.qualifiedValue.validCodedValueSet
Element Id ObservationDefinition.qualifiedInterval.gestationalAge ObservationDefinition.qualifiedValue.validCodedValueSet
Definition

The gestational age to which this reference range is applicable, in set of valid coded results for qualitative observations that match the context criteria of pregnancy. this set of qualified values.

Cardinality 0..1
Type Range canonical ( ValueSet )
Summary false
ObservationDefinition.qualifiedInterval.condition ObservationDefinition.qualifiedValue.normalCodedValueSet
Element Id ObservationDefinition.qualifiedInterval.condition ObservationDefinition.qualifiedValue.normalCodedValueSet
Definition

Text based condition The set of normal coded results for which qualitative observations that match the reference range is valid. criteria of this set of qualified values.

Cardinality 0..1
Type string canonical ( ValueSet )
Summary false
ObservationDefinition.validCodedValueSet ObservationDefinition.qualifiedValue.abnormalCodedValueSet
Element Id ObservationDefinition.validCodedValueSet ObservationDefinition.qualifiedValue.abnormalCodedValueSet
Definition

The set of valid abnormal coded results for the qualitative observations conforming to that match the criteria of this ObservationDefinition. set of qualified values.

Cardinality 0..1
Type Reference canonical ( ValueSet )
Summary false
ObservationDefinition.normalCodedValueSet ObservationDefinition.qualifiedValue.criticalCodedValueSet
Element Id ObservationDefinition.normalCodedValueSet ObservationDefinition.qualifiedValue.criticalCodedValueSet
Definition

The set of normal critical coded results for the qualitative observations conforming to that match the criteria of this ObservationDefinition. set of qualified values.

Cardinality 0..1
Type Reference canonical ( ValueSet )
Summary false
ObservationDefinition.abnormalCodedValueSet ObservationDefinition.hasMember
Element Id ObservationDefinition.abnormalCodedValueSet ObservationDefinition.hasMember
Definition

The This ObservationDefinition defines a group observation (e.g. a battery, a panel of tests, a set of abnormal coded results for vital sign measurements) that includes the observation conforming to this ObservationDefinition. target as a member of the group.

Cardinality 0..1 0..*
Type Reference ( ValueSet ObservationDefinition | Questionnaire )
Patterns Reference(ObservationDefinition,Questionnaire): No common pattern
Summary false
ObservationDefinition.criticalCodedValueSet ObservationDefinition.component
Element Id ObservationDefinition.criticalCodedValueSet ObservationDefinition.component
Definition

The set Some observations have multiple component observations, expressed as separate code value pairs.

Cardinality 0..*
Requirements

Component observations share the same attributes as the primary observation and are always treated as a part of critical coded results it (they are not separable).

Summary false
ObservationDefinition.component.code
Element Id ObservationDefinition.component.code
Definition

Describes what will be observed.

Cardinality 1..1
Terminology Binding LOINC Codes ( Example )
Type CodeableConcept
Summary false
ObservationDefinition.component.permittedDataType
Element Id ObservationDefinition.component.permittedDataType
Definition

The data types allowed for the observation conforming to value element of the instance of this ObservationDefinition. component observations.

Cardinality 0..*
Terminology Binding ObservationDataType ( Required )
Type code
Summary false
ObservationDefinition.component.quantitativeDetails
Element Id ObservationDefinition.component.quantitativeDetails
Definition

Characteristics for quantitative results of this observation.

Cardinality 0..1
Type Reference See ObservationDefinition.quantitativeDetails ( ValueSet
Summary ) false
ObservationDefinition.component.qualifiedValue
Element Id ObservationDefinition.component.qualifiedValue
Definition

A set of qualified values associated with a context and a set of conditions - provides a range for quantitative and ordinal observations and a collection of value sets for qualitative observations.

Cardinality 0..*
Type See ObservationDefinition.qualifiedValue
Summary false