HL7 FHIR Implementation Guide Laboratory Report
0.1.0 - ballot
HL7 FHIR Implementation Guide Laboratory Report
0.1.0 - ballot
This page is part of the HL7 FHIR Implementation Guide Laboratory Report (v0.1.0: Release 1 Ballot 1) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions 
| Official URL: http://hl7.it/fhir/lab-report/StructureDefinition/observation-doc-it-lab | Version: 0.1.0 | |||
| Draft as of 2023-07-11 | Computable Name: ObservationDocRefertoLabIt | |||
Profilo della risorsa Observation che per la descrizione dei vincoli aggiuntivi al profilo Observation-Lab Report per i documenti FHIR.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ObservationRefertoLabIt
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Observation | 0..* | ObservationRefertoLabIt | Observation Referto di Laboratorio | |
  status | 1..1 | code | Descrizione attributo: Stato dell'osservazione. Possibili valori: registered | preliminary | final | amended + Binding: Observation status code (required) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.status | required | ObservationStatusCodeLabReport |
| Name | Flags | Card. | Type | Description & Constraints | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Observation | C | 0..* | ObservationRefertoLabIt | Observation Referto di Laboratorio | ||||||||
  implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||||||
| status | ?!Σ | 1..1 | code | Descrizione attributo: Stato dell'osservazione. Possibili valori: registered | preliminary | final | amended + Binding: Observation status code (required) | ||||||||
  Slices for category | 1..* | CodeableConcept | Codice che classifica il tipo di osservazione. Slice: Unordered, Open by pattern:$this.coding.system Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||||||
   category:esame-laboratorio | 1..1 | CodeableConcept | Classificazione del tipo di osservazione. Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||||||
 category:specialita-esame-laboratorio | 0..* | CodeableConcept | Codice o testo della specialità dell'esame di laboratorio. Binding: Sezioni Composition Lab Report (preferred) | |||||||||
 code | Σ | 1..1 | CodeableConcept | Tipo di osservazione tramite codice. Binding: Tipo Osservazione (preferred) | ||||||||
 subject | Σ | 1..1 | Reference(Patient - Lab Report) | Soggetto della rilevazione clinica. | ||||||||
| performer | Σ | 1..* | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report | Organization - Lab Report | CareTeam | RelatedPerson) | Soggetto responsabile dell'osservazione. | ||||||||
 Slices for value[x] | ΣC | 0..1 | Risultato dell'osservaizone. Slice: Unordered, Open by type:$this | |||||||||
 valueQuantity | Quantity | |||||||||||
| valueCodeableConcept | CodeableConcept | |||||||||||
| valueString | string | |||||||||||
| valueBoolean | boolean | |||||||||||
| valueInteger | integer | |||||||||||
| valueRange | Range | |||||||||||
| valueRatio | Ratio | |||||||||||
| valueSampledData | SampledData | |||||||||||
| valueTime | time | |||||||||||
| valueDateTime | dateTime | |||||||||||
| valuePeriod | Period | |||||||||||
| value[x]:valueQuantity | C | 0..1 | QuantityLab | Risultato misurabile tramite una quantità. | ||||||||
| value[x]:valueCodeableConcept | ΣC | 0..1 | CodeableConcept | Actual result Binding: Risultato osservazione codificato (preferred)
| ||||||||
| Documentation for this format | ||||||||||||
| Path | Conformance | ValueSet | ||||||||||||
| Observation.status | required | ObservationStatusCodeLabReport | ||||||||||||
| Observation.category | preferred | ObservationCategoryCodes | ||||||||||||
| Observation.category:esame-laboratorio | preferred | ObservationCategoryCodes | ||||||||||||
| Observation.category:specialita-esame-laboratorio | preferred | VsSezioniRefertoLaboratorio | ||||||||||||
| Observation.code | preferred | VsResultsLaboratoryObservation | ||||||||||||
| Observation.value[x]:valueCodeableConcept | preferred | VsObservationValueCodeableConcept
|
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ita-lab-1 | error | Observation | se "hasMember" non è presente allora Observation deve avere un" value" : value.exists() or hasMember.exists() | |
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
| qty-3 | error | Observation.value[x]:valueQuantity | If a code for the unit is present, the system SHALL also be present : code.empty() or system.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Observation | C | 0..* | ObservationRefertoLabIt | Observation Referto di Laboratorio | ||||||||
| 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.
| |||||||||
| 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 | ?!Σ | 1..1 | code | Descrizione attributo: Stato dell'osservazione. Possibili valori: registered | preliminary | final | amended + Binding: Observation status code (required) | ||||||||
| Slices for category | 1..* | CodeableConcept | Codice che classifica il tipo di osservazione. Slice: Unordered, Open by pattern:$this.coding.system Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||||||
 category:esame-laboratorio | 1..1 | CodeableConcept | Classificazione del tipo di osservazione. Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||||||
  id | 0..1 | string | Unique id for inter-element referencing | |||||||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||
 coding | Σ | 0..* | Coding | Codice definito da un sistema terminologico. | ||||||||
 id | 0..1 | string | Unique id for inter-element referencing | |||||||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||
| system | Σ | 0..1 | uri | Terminologia utilizzata. Required Pattern: http://terminology.hl7.org/CodeSystem/observation-category | ||||||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||||||
| code | Σ | 0..1 | code | Codice della terminologia per descrivere il dominio di laboratorio. Required Pattern: laboratory | ||||||||
| display | Σ | 0..1 | string | Representation defined by the system | ||||||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||||||
 text | Σ | 0..1 | string | Plain text representation of the concept | ||||||||
 category:specialita-esame-laboratorio | 0..* | CodeableConcept | Codice o testo della specialità dell'esame di laboratorio. Binding: Sezioni Composition Lab Report (preferred) | |||||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||
| coding | Σ | 0..* | Coding | Codice della terminologia per dettagliare la specialità di laboratorio | ||||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||
| system | Σ | 0..1 | uri | Terminologia utilizzata. Required Pattern: http://loinc.org | ||||||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||||||
| code | Σ | 0..1 | code | Symbol in syntax defined by the system | ||||||||
| display | Σ | 0..1 | string | Representation defined by the system | ||||||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||||||
| code | Σ | 1..1 | CodeableConcept | Tipo di osservazione tramite codice. Binding: Tipo Osservazione (preferred) | ||||||||
| subject | Σ | 1..1 | Reference(Patient - Lab Report) | Soggetto della rilevazione clinica. | ||||||||
| focus | ΣTU | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||||||
| encounter | Σ | 0..1 | Reference(Encounter - Lab Report) | Contesto in cui è stata prodotta l'osservazione. | ||||||||
 effective[x] | Σ | 0..1 | Clinically relevant time/time-period for observation | |||||||||
| effectiveDateTime | dateTime | |||||||||||
| effectivePeriod | Period | |||||||||||
| effectiveTiming | Timing | |||||||||||
| effectiveInstant | instant | |||||||||||
| issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||||||
| performer | Σ | 1..* | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report | Organization - Lab Report | CareTeam | RelatedPerson) | Soggetto responsabile dell'osservazione. | ||||||||
| Slices for value[x] | ΣC | 0..1 | Risultato dell'osservaizone. Slice: Unordered, Open by type:$this | |||||||||
| valueQuantity | Quantity | |||||||||||
| valueCodeableConcept | CodeableConcept | |||||||||||
| valueString | string | |||||||||||
| valueBoolean | boolean | |||||||||||
| valueInteger | integer | |||||||||||
| valueRange | Range | |||||||||||
| valueRatio | Ratio | |||||||||||
| valueSampledData | SampledData | |||||||||||
| valueTime | time | |||||||||||
| valueDateTime | dateTime | |||||||||||
| valuePeriod | Period | |||||||||||
| value[x]:valueQuantity | C | 0..1 | QuantityLab | Risultato misurabile tramite una quantità. | ||||||||
| value[x]:valueCodeableConcept | ΣC | 0..1 | CodeableConcept | Actual result Binding: Risultato osservazione codificato (preferred)
| ||||||||
| dataAbsentReason | C | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||||||
| interpretation | 0..* | CodeableConcept | Interpretazione del risultato (Alto, Basso, Normale, ecc.) Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||||||
| note | 0..* | Annotation | Comments about the observation | |||||||||
| bodySite | 0..1 | CodeableConcept | Sito corporeo dell'osservazione. Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||||||
| method | 0..1 | CodeableConcept | Metodo di rilevazione dell'osservazione. Binding: ObservationMethods (example) | |||||||||
| specimen | 0..1 | Reference(Specimen - Lab Report) | Reference al campione su cui si basa l'osservazione. | |||||||||
| device | 0..1 | Reference(Device - Lab Report | DeviceMetric) | Dispositivo utilizzato per ottenere l'osservazione. | |||||||||
| referenceRange | C | 0..* | BackboneElement | Range di riferimento per la caratterizzazione dell'osservazione sulla base di un criterio.
Esempio: Range di normalità per uomo adulto. | ||||||||
| 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 | Limite inferiore del range di riferimento, se rilevante. | ||||||||
| high | C | 0..1 | SimpleQuantity | Limite superiore del range di riferimento, se rilevante. | ||||||||
| type | 0..1 | CodeableConcept | Contesto del range di riferimento. Esempio: Un intervallo atteso in un individuo prima della pubertà. Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range. | |||||||||
| appliesTo | 0..* | CodeableConcept | Categoria della popolazione a cui si applica il range di riferimento. Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to. | |||||||||
| age | 0..1 | Range | Età a cui si applica, se rilevante. | |||||||||
| text | 0..1 | string | Note testuali. | |||||||||
| hasMember | Σ | 0..* | Reference(Observation - Lab Report) | Osservazioni correlate alla risorsa. | ||||||||
| derivedFrom | Σ | 0..* | Reference(Observation - Lab Report | Media - Lab Report) | Reference dell'osservazione da cui deriva questo valore di osservazione. Ad esempio, un gap anionico calcolato o una misurazione fetale basata su un'immagine ecografica. | ||||||||
| component | 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 | Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||||||
| value[x] | 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 | C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||||||
| interpretation | 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 | ||||||||||||
| Path | Conformance | ValueSet | ||||||||||||
| Observation.language | preferred | CommonLanguages
| ||||||||||||
| Observation.status | required | ObservationStatusCodeLabReport | ||||||||||||
| Observation.category | preferred | ObservationCategoryCodes | ||||||||||||
| Observation.category:esame-laboratorio | preferred | ObservationCategoryCodes | ||||||||||||
| Observation.category:specialita-esame-laboratorio | preferred | VsSezioniRefertoLaboratorio | ||||||||||||
| Observation.code | preferred | VsResultsLaboratoryObservation | ||||||||||||
| Observation.value[x]:valueCodeableConcept | preferred | VsObservationValueCodeableConcept
| ||||||||||||
| Observation.dataAbsentReason | extensible | DataAbsentReason | ||||||||||||
| Observation.interpretation | extensible | ObservationInterpretationCodes | ||||||||||||
| Observation.bodySite | example | SNOMEDCTBodyStructures | ||||||||||||
| 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 |
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
| qty-3 | error | Observation.value[x]:valueQuantity | If a code for the unit is present, the system SHALL also be present : code.empty() or system.exists() |
This structure is derived from ObservationRefertoLabIt
Differential View
This structure is derived from ObservationRefertoLabIt
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Observation | 0..* | ObservationRefertoLabIt | Observation Referto di Laboratorio | |
| status | 1..1 | code | Descrizione attributo: Stato dell'osservazione. Possibili valori: registered | preliminary | final | amended + Binding: Observation status code (required) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Observation.status | required | ObservationStatusCodeLabReport |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Observation | C | 0..* | ObservationRefertoLabIt | Observation Referto di Laboratorio | ||||||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||||||
| status | ?!Σ | 1..1 | code | Descrizione attributo: Stato dell'osservazione. Possibili valori: registered | preliminary | final | amended + Binding: Observation status code (required) | ||||||||
| Slices for category | 1..* | CodeableConcept | Codice che classifica il tipo di osservazione. Slice: Unordered, Open by pattern:$this.coding.system Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||||||
| category:esame-laboratorio | 1..1 | CodeableConcept | Classificazione del tipo di osservazione. Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||||||
| category:specialita-esame-laboratorio | 0..* | CodeableConcept | Codice o testo della specialità dell'esame di laboratorio. Binding: Sezioni Composition Lab Report (preferred) | |||||||||
| code | Σ | 1..1 | CodeableConcept | Tipo di osservazione tramite codice. Binding: Tipo Osservazione (preferred) | ||||||||
| subject | Σ | 1..1 | Reference(Patient - Lab Report) | Soggetto della rilevazione clinica. | ||||||||
| performer | Σ | 1..* | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report | Organization - Lab Report | CareTeam | RelatedPerson) | Soggetto responsabile dell'osservazione. | ||||||||
| Slices for value[x] | ΣC | 0..1 | Risultato dell'osservaizone. Slice: Unordered, Open by type:$this | |||||||||
| valueQuantity | Quantity | |||||||||||
| valueCodeableConcept | CodeableConcept | |||||||||||
| valueString | string | |||||||||||
| valueBoolean | boolean | |||||||||||
| valueInteger | integer | |||||||||||
| valueRange | Range | |||||||||||
| valueRatio | Ratio | |||||||||||
| valueSampledData | SampledData | |||||||||||
| valueTime | time | |||||||||||
| valueDateTime | dateTime | |||||||||||
| valuePeriod | Period | |||||||||||
| value[x]:valueQuantity | C | 0..1 | QuantityLab | Risultato misurabile tramite una quantità. | ||||||||
| value[x]:valueCodeableConcept | ΣC | 0..1 | CodeableConcept | Actual result Binding: Risultato osservazione codificato (preferred)
| ||||||||
| Documentation for this format | ||||||||||||
| Path | Conformance | ValueSet | ||||||||||||
| Observation.status | required | ObservationStatusCodeLabReport | ||||||||||||
| Observation.category | preferred | ObservationCategoryCodes | ||||||||||||
| Observation.category:esame-laboratorio | preferred | ObservationCategoryCodes | ||||||||||||
| Observation.category:specialita-esame-laboratorio | preferred | VsSezioniRefertoLaboratorio | ||||||||||||
| Observation.code | preferred | VsResultsLaboratoryObservation | ||||||||||||
| Observation.value[x]:valueCodeableConcept | preferred | VsObservationValueCodeableConcept
|
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ita-lab-1 | error | Observation | se "hasMember" non è presente allora Observation deve avere un" value" : value.exists() or hasMember.exists() | |
| obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
| obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() | |
| qty-3 | error | Observation.value[x]:valueQuantity | If a code for the unit is present, the system SHALL also be present : code.empty() or system.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Observation | C | 0..* | ObservationRefertoLabIt | Observation Referto di Laboratorio | ||||||||
| 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.
| |||||||||
| 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 | ?!Σ | 1..1 | code | Descrizione attributo: Stato dell'osservazione. Possibili valori: registered | preliminary | final | amended + Binding: Observation status code (required) | ||||||||
| Slices for category | 1..* | CodeableConcept | Codice che classifica il tipo di osservazione. Slice: Unordered, Open by pattern:$this.coding.system Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||||||
| category:esame-laboratorio | 1..1 | CodeableConcept | Classificazione del tipo di osservazione. Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||
| coding | Σ | 0..* | Coding | Codice definito da un sistema terminologico. | ||||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||
| system | Σ | 0..1 | uri | Terminologia utilizzata. Required Pattern: http://terminology.hl7.org/CodeSystem/observation-category | ||||||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||||||
| code | Σ | 0..1 | code | Codice della terminologia per descrivere il dominio di laboratorio. Required Pattern: laboratory | ||||||||
| display | Σ | 0..1 | string | Representation defined by the system | ||||||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||||||
| category:specialita-esame-laboratorio | 0..* | CodeableConcept | Codice o testo della specialità dell'esame di laboratorio. Binding: Sezioni Composition Lab Report (preferred) | |||||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||
| coding | Σ | 0..* | Coding | Codice della terminologia per dettagliare la specialità di laboratorio | ||||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||
| system | Σ | 0..1 | uri | Terminologia utilizzata. Required Pattern: http://loinc.org | ||||||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||||||
| code | Σ | 0..1 | code | Symbol in syntax defined by the system | ||||||||
| display | Σ | 0..1 | string | Representation defined by the system | ||||||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||||||
| code | Σ | 1..1 | CodeableConcept | Tipo di osservazione tramite codice. Binding: Tipo Osservazione (preferred) | ||||||||
| subject | Σ | 1..1 | Reference(Patient - Lab Report) | Soggetto della rilevazione clinica. | ||||||||
| focus | ΣTU | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||||||
| encounter | Σ | 0..1 | Reference(Encounter - Lab Report) | Contesto in cui è stata prodotta l'osservazione. | ||||||||
| effective[x] | Σ | 0..1 | Clinically relevant time/time-period for observation | |||||||||
| effectiveDateTime | dateTime | |||||||||||
| effectivePeriod | Period | |||||||||||
| effectiveTiming | Timing | |||||||||||
| effectiveInstant | instant | |||||||||||
| issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||||||
| performer | Σ | 1..* | Reference(Practitioner - Lab Report | PractitionerRole - Lab Report | Organization - Lab Report | CareTeam | RelatedPerson) | Soggetto responsabile dell'osservazione. | ||||||||
| Slices for value[x] | ΣC | 0..1 | Risultato dell'osservaizone. Slice: Unordered, Open by type:$this | |||||||||
| valueQuantity | Quantity | |||||||||||
| valueCodeableConcept | CodeableConcept | |||||||||||
| valueString | string | |||||||||||
| valueBoolean | boolean | |||||||||||
| valueInteger | integer | |||||||||||
| valueRange | Range | |||||||||||
| valueRatio | Ratio | |||||||||||
| valueSampledData | SampledData | |||||||||||
| valueTime | time | |||||||||||
| valueDateTime | dateTime | |||||||||||
| valuePeriod | Period | |||||||||||
| value[x]:valueQuantity | C | 0..1 | QuantityLab | Risultato misurabile tramite una quantità. | ||||||||
| value[x]:valueCodeableConcept | ΣC | 0..1 | CodeableConcept | Actual result Binding: Risultato osservazione codificato (preferred)
| ||||||||
| dataAbsentReason | C | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||||||
| interpretation | 0..* | CodeableConcept | Interpretazione del risultato (Alto, Basso, Normale, ecc.) Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||||||
| note | 0..* | Annotation | Comments about the observation | |||||||||
| bodySite | 0..1 | CodeableConcept | Sito corporeo dell'osservazione. Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||||||
| method | 0..1 | CodeableConcept | Metodo di rilevazione dell'osservazione. Binding: ObservationMethods (example) | |||||||||
| specimen | 0..1 | Reference(Specimen - Lab Report) | Reference al campione su cui si basa l'osservazione. | |||||||||
| device | 0..1 | Reference(Device - Lab Report | DeviceMetric) | Dispositivo utilizzato per ottenere l'osservazione. | |||||||||
| referenceRange | C | 0..* | BackboneElement | Range di riferimento per la caratterizzazione dell'osservazione sulla base di un criterio.
Esempio: Range di normalità per uomo adulto. | ||||||||
| 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 | Limite inferiore del range di riferimento, se rilevante. | ||||||||
| high | C | 0..1 | SimpleQuantity | Limite superiore del range di riferimento, se rilevante. | ||||||||
| type | 0..1 | CodeableConcept | Contesto del range di riferimento. Esempio: Un intervallo atteso in un individuo prima della pubertà. Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range. | |||||||||
| appliesTo | 0..* | CodeableConcept | Categoria della popolazione a cui si applica il range di riferimento. Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to. | |||||||||
| age | 0..1 | Range | Età a cui si applica, se rilevante. | |||||||||
| text | 0..1 | string | Note testuali. | |||||||||
| hasMember | Σ | 0..* | Reference(Observation - Lab Report) | Osservazioni correlate alla risorsa. | ||||||||
| derivedFrom | Σ | 0..* | Reference(Observation - Lab Report | Media - Lab Report) | Reference dell'osservazione da cui deriva questo valore di osservazione. Ad esempio, un gap anionico calcolato o una misurazione fetale basata su un'immagine ecografica. | ||||||||
| component | 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 | Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||||||
| value[x] | 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 | C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||||||
| interpretation | 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 | ||||||||||||
| Path | Conformance | ValueSet | ||||||||||||
| Observation.language | preferred | CommonLanguages
| ||||||||||||
| Observation.status | required | ObservationStatusCodeLabReport | ||||||||||||
| Observation.category | preferred | ObservationCategoryCodes | ||||||||||||
| Observation.category:esame-laboratorio | preferred | ObservationCategoryCodes | ||||||||||||
| Observation.category:specialita-esame-laboratorio | preferred | VsSezioniRefertoLaboratorio | ||||||||||||
| Observation.code | preferred | VsResultsLaboratoryObservation | ||||||||||||
| Observation.value[x]:valueCodeableConcept | preferred | VsObservationValueCodeableConcept
| ||||||||||||
| Observation.dataAbsentReason | extensible | DataAbsentReason | ||||||||||||
| Observation.interpretation | extensible | ObservationInterpretationCodes | ||||||||||||
| Observation.bodySite | example | SNOMEDCTBodyStructures | ||||||||||||
| 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 |
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
| qty-3 | error | Observation.value[x]:valueQuantity | If a code for the unit is present, the system SHALL also be present : code.empty() or system.exists() |
This structure is derived from ObservationRefertoLabIt
Other representations of profile: CSV, Excel, Schematron