DSTU2 FHIR Release 3 (STU)

This page is part of the FHIR Specification (v1.0.2: DSTU (v3.0.2: STU 2). 3). 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 R3 R2 R3 R2

Clinical Decision Support Work Group Maturity Level : 1   Trial Use Compartments : Device , Patient , Practitioner

Detailed Descriptions for the elements in the RiskAssessment resource.

Summary CodeableConcept To Do Is this in the 80%?
RiskAssessment
Definition

An assessment of the likely outcome(s) for a patient or other subject as well as the likelihood of each outcome.

Control 1..1
Alternate Names Prognosis
RiskAssessment.subject RiskAssessment.identifier
Definition

The patient or group Business identifier assigned to the risk assessment applies to. assessment.

Note This is a business identifer, not a resource identifier (see discussion )
Control 0..1
Type Identifier
Summary true
RiskAssessment.basedOn
Definition

A reference to the request that is fulfilled by this risk assessment.

Control 0..1
Type Reference ( Patient Any | Group )
RiskAssessment.parent
Definition

A reference to a resource that this risk assessment is part of, such as a Procedure.

Control 0..1
Type Reference ( Any )
RiskAssessment.status
Definition

The status of the RiskAssessment, using the same statuses as an Observation.

Control true 1..1
To Do Terminology Binding Should this cover anything else? Device? Location? ObservationStatus ( Required )
Type code
RiskAssessment.date RiskAssessment.method
Definition

The date (and possibly time) algorithm, process or mechanism used to evaluate the risk assessment was performed. risk.

Control 0..1
Terminology Binding RiskAssessmentMethod :
Type dateTime CodeableConcept
Requirements

The assessment method can influence the results lose validity of the more time elapses from when they are first made. assessment.

Summary true
RiskAssessment.condition RiskAssessment.code
Definition

For assessments or prognosis specific to a particular condition, indicates The type of the condition being assessed. risk assessment performed.

Control 0..1
Type Reference ( Condition CodeableConcept )
Summary true
RiskAssessment.encounter RiskAssessment.subject
Definition

The encounter where patient or group the risk assessment was performed. applies to.

Control 0..1
Type Reference ( Encounter Patient | Group )
Summary true
RiskAssessment.performer RiskAssessment.context
Definition

The provider or software application that performed encounter where the assessment. assessment was performed.

Control 0..1
Type Reference ( Practitioner Encounter | Device EpisodeOfCare )
Summary true
RiskAssessment.identifier RiskAssessment.occurrence[x]
Definition

Business identifier assigned to The date (and possibly time) the risk assessment. assessment was performed.

Control 0..1
Type dateTime | Period
[x] Note This is a business identifer, not a resource identifier (see discussion See Choice of Data Types ) for further information about how to use [x]
Requirements

The assessment results lose validity the more time elapses from when they are first made.

Summary true
RiskAssessment.condition
Definition

For assessments or prognosis specific to a particular condition, indicates the condition being assessed.

Control 0..1
Type Identifier Reference ( Condition )
Summary true
RiskAssessment.method RiskAssessment.performer
Definition

The algorithm, process provider or mechanism used to evaluate software application that performed the risk. assessment.

Control 0..1
Binding Type RiskAssessmentMethod : The mechanism or algorithm used to make the assessment; e.g. TIMI, PRISM, Cardiff Type 2 diabetes, etc. Reference ( Practitioner | Device )
Type Summary true
RiskAssessment.reason[x]
Requirements Definition

The method can influence the results of reason the assessment. risk assessment was performed.

Summary Control true 0..1
To Do Type Is this in the 80%? CodeableConcept | Reference ( Any )
[x] Note See Choice of Data Types for further information about how to use [x]
RiskAssessment.basis
Definition

Indicates the source data considered as part of the assessment (FamilyHistory, Observations, Procedures, Conditions, etc.).

Control 0..*
Type Reference ( Any )
RiskAssessment.prediction
Definition

Describes the expected outcome for the subject.

Control 0..*
Comments

Multiple repetitions can be used to identify the same type of outcome in different timeframes as well as different types of outcomes.

Invariants Defined on this element
ras-2 : Must be <= 100 ( expression : probability is decimal implies probability.as(decimal) <= 100, xpath: not(f:probabilityDecimal) or f:probabilityDecimal/@value <= 100)
RiskAssessment.prediction.outcome
Definition

One of the potential outcomes for the patient (e.g. remission, death, a particular condition).

Control 1..1
Terminology Binding RiskAssessmentOutcome : The condition or other outcome; e.g. death, remission, amputation, infection, etc.
Type CodeableConcept
RiskAssessment.prediction.probability[x]
Definition

How likely is the outcome (in the specified timeframe).

Control 0..1
Binding Risk Probability: The likelihood of the occurrence of a specified outcome ( Example ) Type decimal | Range | CodeableConcept
[x] Note See Choice of Data Types for further information about how to use [x]
Comments

If range is used, it represents the lower and upper bounds of certainty; e.g. 40-60% Decimal values are expressed as percentages as well (max = 100).

Invariants Defined on this element
ras-1 : low and high must be percentages, if present (xpath: ( expression : (low.empty() or ((low.code = '%') and (low.system = %ucum))) and (high.empty() or ((high.code = '%') and (high.system = %ucum))), xpath: (not(f:low) or f:low[f:code/@value='%' and f:system/@value='http://unitsofmeasure.org']) and (not(f:high) or f:high[f:code/@value='%' and f:system/@value='http://unitsofmeasure.org']))
RiskAssessment.prediction.qualitativeRisk
Definition

How likely is the outcome (in the specified timeframe), expressed as a qualitative value (e.g. low, medium, high).

Control 0..1
Terminology Binding Risk Probability ( Example )
Type CodeableConcept ras-2 : Must be <= 100 (xpath: @value <= 100)
RiskAssessment.prediction.relativeRisk
Definition

Indicates the risk for this particular subject (with their specific characteristics) divided by the risk of the population in general. (Numbers greater than 1 = higher risk than the population, numbers less than 1 = lower risk.).

Control 0..1
Type decimal
Requirements

Absolute risk is less meaningful than relative risk.

RiskAssessment.prediction.when[x]
Definition

Indicates the period of time or age range of the subject to which the specified probability applies.

Control 0..1
Type Period | Range
[x] Note See Choice of Data Types for further information about how to use [x]
Comments

If not specified, the risk applies "over the subject's lifespan".

RiskAssessment.prediction.rationale
Definition

Additional information explaining the basis for the prediction.

Control 0..1
Type string
RiskAssessment.mitigation
Definition

A description of the steps that might be taken to reduce the identified risk(s).

Control 0..1
Type string
Requirements

One of the main reasons for assessing risks is to identify whether interventional steps are needed to reduce risk.

RiskAssessment.comment
Definition

Additional comments about the risk assessment.

Control 0..1
Type string