Observation - Lab Report - HL7 FHIR Implementation Guide Laboratory Report v0.2.0

This page is part of the HL7 FHIR Implementation Guide Laboratory Report (v0.2.0: Release 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Resource Profile: Observation - Lab Report

Official URL: http://hl7.it/fhir/lab-report/StructureDefinition/observation-it-lab				Version: 0.2.0
Standards status: Trial-use			Maturity Level: 1	Computable Name: ObservationRefertoLabIt

Descrizione delle rilevazioni cliniche tramite il profilo della risorsa Observation per il referto di laboratorio.

Usage:

Derived from this Resource Profile: Observation Document - Lab Report and Observation battery - Lab Report
Refer to this Resource Profile: Composition - Lab Report, DiagnosticReport - Lab Report and Observation - Lab Report
Examples for this Resource Profile: Observation/5ea6e05a-e271-4ef9-bcc1-0bd10e55c90c, Observation/9474efca-8c8a-436d-a1a4-5706a1dd057a, Observation/a7d1b3b0-9aee-4bc7-b0f2-46d441ba6244, Observation/a7d1b3b0-9aee-4bc7-b0f2-46d441ba6245... Show 2 more

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
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This structure is derived from ObservationResultsLaboratoryEu

Name	Card.	Type	Description & Constraints
Observation	0..*	ObservationResultsLaboratoryEu	Observation Referto di Laboratorio
status	1..1	code	Descrizione attributo: Stato dell'osservazione. Possibili valori: registered \| preliminary \| final \| amended + Binding: ObservationStatus (required)
category	1..*	CodeableConceptIPS	Codice che classifica il tipo di osservazione.
category:laboratory	1..1	CodeableConcept	Indica genericamente che si riferisce ad un esame di Laboratorio
category:studyType	0..*	CodeableConcept	Classificazione per tipo di studio
category:specialty	0..*	CodeableConcept	Classificazione per specialità
code	1..1	CodeableConceptIPS	Tipo di osservazione tramite codice. Binding: Tipo Osservazione (preferred)
subject	1..1	Reference(Patient - Lab Report)	Soggetto della rilevazione clinica.
encounter	0..1	Reference(Encounter - Lab Report)	Contesto in cui è stata prodotta l'osservazione.
performer	1..*	Reference(Practitioner - Lab Report \| PractitionerRole - Lab Report \| Organization - Lab Report \| CareTeam \| RelatedPerson)	Soggetto responsabile dell'osservazione.
value[x]	0..1	Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period	Risultato dell'osservazione.
value[x]:valueQuantity	0..1	QuantityLab	Risultato misurabile tramite una quantità.
value[x]:valueCodeableConcept	0..1	CodeableConceptIPS	Concept - reference to a terminology or just text Binding: Risultato osservazione codificato (preferred)
interpretation	0..*	CodeableConceptIPS	Interpretazione del risultato (Alto, Basso, Normale, ecc.)
bodySite	0..1	CodeableConcept	Sito corporeo dell'osservazione.
method	0..1	CodeableConceptIPS	Metodo di rilevazione dell'osservazione. Binding: ObservationMethods (preferred)
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	0..*	BackboneElement	Range di riferimento per la caratterizzazione dell'osservazione sulla base di un criterio. Esempio: Range di normalità per uomo adulto.
low	0..1	SimpleQuantity	Limite inferiore del range di riferimento, se rilevante.
high	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.
appliesTo	0..*	CodeableConcept	Categoria della popolazione a cui si applica il range di riferimento.
age	0..1	Range	Età a cui si applica, se rilevante.
text	0..1	string	Note testuali.
hasMember	0..*	Reference(Observation - Lab Report)	Osservazioni correlate alla risorsa.
derivedFrom	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.
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Observation.status	required	ObservationStatus `http://hl7.org/fhir/ValueSet/observation-status` from the FHIR Standard
Observation.code	preferred	VsResultsLaboratoryObservation `http://hl7.it/fhir/lab-report/ValueSet/risultato-osservazione` from this IG
Observation.value[x]:valueCodeableConcept	preferred	VsObservationValueCodeableConcept `http://hl7.it/fhir/lab-report/ValueSet/valueset-valuecodeableconcept-obs-it` from this IG
Observation.method	preferred	ObservationMethods `http://hl7.org/fhir/ValueSet/observation-methods` from the FHIR Standard

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	ObservationResultsLaboratoryEu	Observation Referto di Laboratorio 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 eu-lab-1: If observation status is other then "registered" or "cancelled", at least one of these Observation elements shall be provided: "value", "dataAbsentReason", "hasMember" or "component" eu-lab-2: If observation has components and observation status is other then "registered" or "cancelled", at least one of these Observation.component elements shall be provided: "value" or "dataAbsentReason"
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
supportingInfo		0..*	Reference(Resource)	Other information that may be relevant to this event. URL: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo
triggeredBy-r5		0..*	(Complex)	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.triggeredBy
extension:observation		0..*	Extension	Triggering observation.
extension		0..0
url		1..1	uri	"observation"
value[x]		1..1	Reference(Observation)	Value of extension
extension:type		0..*	Extension	The type of trigger
extension		0..0
url		1..1	uri	"type"
value[x]		1..1	code	Value of extension
extension:reason		0..*	Extension	Extension
extension		0..0
url		1..1	uri	"reason"
value[x]		1..1	string	Value of extension
url		1..1	uri	"http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.triggeredBy"
certifiedRefMaterialCodeable		0..*	CodeableConcept	Certified Reference Material: CodeableConcept URL: http://hl7.eu/fhir/laboratory/StructureDefinition/observation-certifiedRefMaterialCodeable Binding: Laboratory Certified Reference Material (example)
certifiedRefMaterialIdentifer		0..*	Identifier	Certified Reference Material: Identifier URL: http://hl7.eu/fhir/laboratory/StructureDefinition/observation-certifiedRefMaterialIdentifer
labTestKit		0..*	Reference(Device)	Device Laboratory Test Kit URL: http://hl7.eu/fhir/laboratory/StructureDefinition/observation-deviceLabTestKit
value-r5		0..1	Attachment, Reference(MolecularSequence)	only for result of type Attachment URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.value[x]
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.value[x]"
value[x]		1..1	Attachment	Value of extension
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: ObservationStatus (required)
Slices for category		1..*	CodeableConceptIPS	Codice che classifica il tipo di osservazione. Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
category:laboratory		1..1	CodeableConcept	Indica genericamente che si riferisce ad un esame di Laboratorio Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
code		1..1	code	Symbol in syntax defined by the system Fixed Value: laboratory
category:studyType		0..*	CodeableConcept	Classificazione per tipo di studio Binding: Laboratory Study Types (required)
category:specialty		0..*	CodeableConcept	Classificazione per specialità Binding: Laboratory Specialty (required)
code		1..1	CodeableConceptIPS	Tipo di osservazione tramite codice. Binding: Tipo Osservazione (preferred)
subject	Σ	1..1	Reference(Patient - Lab Report)	Soggetto della rilevazione clinica.
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
encounter	Σ	0..1	Reference(Encounter - Lab Report)	Contesto in cui è stata prodotta l'osservazione.
effective[x]	Σ	1..1		Clinically relevant time/time-period for observation
effective[x]:All Types				Content/Rules for all Types
data-absent-reason		0..1	code	effective[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required): Used to specify why the normally expected content of the data element is missing.
effectiveDateTime			dateTime
effectivePeriod			Period
performer	Σ	1..*	Reference(Practitioner - Lab Report \| PractitionerRole - Lab Report \| Organization - Lab Report \| CareTeam \| RelatedPerson)	Soggetto responsabile dell'osservazione.
performerFunction		0..*	CodeableConcept	Type of performance URL: http://hl7.org/fhir/StructureDefinition/event-performerFunction Binding: Performer Function Codes (extensible)
Slices for value[x]	ΣC	0..1		Risultato dell'osservazione. Slice: Unordered, Closed 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. qty-3: If a code for the unit is present, the system SHALL also be present
value[x]:valueCodeableConcept		0..1	CodeableConceptIPS	Concept - reference to a terminology or just text Binding: Risultato osservazione codificato (preferred)
value[x]:valueString	ΣC	0..1	string	Actual result
value[x]:valueRange	C	0..1	RangeIPS	Set of values bounded by low and high rng-2: If present, low SHALL have a lower value than high
value[x]:valueRatio	C	0..1	RatioEuLab	A measured ratio using UCUM rat-1: Numerator and denominator SHALL both be present, or both are absent. If both are absent, there SHALL be some extension present
value[x]:valueTime	ΣC	0..1	time	Actual result
value[x]:valueDateTime	ΣC	0..1	dateTime	Actual result
value[x]:valuePeriod	ΣC	0..1	Period	Actual result
interpretation		0..*	CodeableConceptIPS	Interpretazione del risultato (Alto, Basso, Normale, ecc.) Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
bodySite		0..1	CodeableConcept	Sito corporeo dell'osservazione. Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
method		0..1	CodeableConceptIPS	Metodo di rilevazione dell'osservazione. Binding: ObservationMethods (preferred)
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. obs-3: Must have at least a low or a high or text
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.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Observation.status	required	ObservationStatus `http://hl7.org/fhir/ValueSet/observation-status` from the FHIR Standard
Observation.category	preferred	ObservationCategoryCodes `http://hl7.org/fhir/ValueSet/observation-category` from the FHIR Standard
Observation.category:laboratory	preferred	Pattern: laboratory `http://hl7.org/fhir/ValueSet/observation-category` from the FHIR Standard
Observation.category:studyType	required	LabStudyTypesEuVs `http://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab`
Observation.category:specialty	required	LabSpecialtyEuVs `http://hl7.eu/fhir/laboratory/ValueSet/lab-specialty-eu-lab`
Observation.code	preferred	VsResultsLaboratoryObservation `http://hl7.it/fhir/lab-report/ValueSet/risultato-osservazione` from this IG
Observation.value[x]:valueCodeableConcept	preferred	VsObservationValueCodeableConcept `http://hl7.it/fhir/lab-report/ValueSet/valueset-valuecodeableconcept-obs-it` from this IG
Observation.interpretation	extensible	ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` from the FHIR Standard
Observation.bodySite	example	SNOMEDCTBodyStructures `http://hl7.org/fhir/ValueSet/body-site` from the FHIR Standard
Observation.method	preferred	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

Constraints

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())
eu-lab-1	error	Observation	If observation status is other then "registered" or "cancelled", at least one of these Observation elements shall be provided: "value", "dataAbsentReason", "hasMember" or "component" : (status in ('registered'\|'cancelled')) or value.exists() or hasMember.exists() or component.exists() or dataAbsentReason.exists()
eu-lab-2	error	Observation	If observation has components and observation status is other then "registered" or "cancelled", at least one of these Observation.component elements shall be provided: "value" or "dataAbsentReason" : component.exists() implies (status in ('registered'\|'cancelled')) or component.value.exists() or component.dataAbsentReason.exists()
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()
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()
rat-1	error	Observation.value[x]:valueRatio	Numerator and denominator SHALL both be present, or both are absent. If both are absent, there SHALL be some extension present : (numerator.empty() xor denominator.exists()) and (numerator.exists() or extension.exists())
rng-2	error	Observation.value[x]:valueRange	If present, low SHALL have a lower value than high : low.empty() or high.empty() or (low <= high)

Description & Constraints

Observation

0..*

ObservationResultsLaboratoryEu

Observation Referto di Laboratorio
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
eu-lab-1: If observation status is other then "registered" or "cancelled", at least one of these Observation elements shall be provided: "value", "dataAbsentReason", "hasMember" or "component"
eu-lab-2: If observation has components and observation status is other then "registered" or "cancelled", at least one of these Observation.component elements shall be provided: "value" or "dataAbsentReason"

0..1

Logical id of this artifact

Terminology Bindings

Path Conformance ValueSet / Code URI

Observation.language