| Table of Contents - FHIR Resources & Profiles | FHIR R4 Version 4.0.1 | US Core Profile Version 3.1.1* | Cross-measure Requirements |
| Condition - US Core | 3.1.1 | MS | |
| Coverage | 4.0.1** | MS | |
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4.0.1 | MS | |
| Diagnostic Report (Lab) - US Core | 3.1.1 | MS | |
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3.1.1 | MS | |
| Encounter-US Core | 3.1.1 | R | |
| Implantable Device - US Core | 3.1.1 | MS | |
| Laboratory Result Observation - US Core | 3.1.1 | MS | |
| Location-US Core | 3.1.1 | R | |
| Medication-US Core | 3.1.1 | R | |
| MedicationAdministration | 4.0.1** | MS | |
| MedicationRequest-US Core | 3.1.1 | R | |
| Observation | 4.0.1 | R | |
| Patient - US Core | 3.1.1 | R | |
| Procedure - US Core | 3.1.1 | MS | |
| Service Request | 4.0.1** | MS | |
| Specimen | 4.0.1** | MS | |
| Comment: | |||
| * 3.1.0 Version cited in 21 st Centuries Cures Act https://www.federalregister.gov/documents/2020/05/01/2020-07419/21st-century-cures-act-interoperability-information-blocking-and-the-onc-health-it-certification | 3.1.1 is the bug fix release-use this one. | ||
| FHIR R4: | |||
| http://hl7.org/fhir/R4/downloads.html | |||
| Abbreviation | Name | Details | Comments |
| MS | Must Support | If available in FHIR API/EHR, must send as required for measure calculation or risk adjustment | Must be designated as MS or R if wanted in the Silver table. |
| R | Required | Required to send for NHSN Application to determine initial population | Must be designated as MS or R if wanted in the Silver table. |
| NR | Not Required | Not required for calculating the metrics, No current use for technical eval on data side, will not appear in the Bronze table | Elements designated as NR will go into the bronze table but will not progress to Silver. |
| NRT | Not Required by Technical Team | After review, the technical team determined these data elements were not needed. | NRT elements will not be copied to Bronze and will only exist in the bundle itself, which we archive so in the future we could switch them back as needed. |
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| FHIR Path | Min | Max | Must Support? | Data Type(s) | Description & Constraints | FHIR Definition | Binding Strength | Binding Description | FHIR Binding Value Set | Cross Measure Requirements |
| Condition | 0 | * | Condition | Detailed information about conditions, problems or diagnoses us-core-1: A code in Condition.category SHOULD be from US Core Condition Category Codes value set. |
MS [0..*] | |||||
| Condition.id | 0 | 1 | string |
Logical id of this artifact | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | R [1..1] | ||||
| Condition.meta | 0 | 1 | Meta |
Metadata about the resource | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | NRT | ||||
| Condition.implicitRules | 0 | 1 | uri |
A set of rules under which this content was created | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | NRT | ||||
| Condition.language | 0 | 1 | code |
Language of the resource content | The base language in which the resource is written. | preferred | Common Languages. | http://hl7.org/fhir/R4/valueset-languages.html | NRT | |
| Condition.text | 0 | 1 | Narrative |
Text summary of the resource, for human interpretation | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | NRT | ||||
| Condition.contained | 0 | * | Resource |
Contained, inline Resources | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | NRT | ||||
| Condition.extension | 0 | * | Extension |
Additional content defined by implementations | An Extension | NRT | ||||
| Condition.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Condition.identifier | 0 | * | Identifier |
External Ids for this condition | Business identifiers assigned to this condition by the performer or other systems which remain constant as the resource is updated and propagates from server to server. | NRT | ||||
| Condition.clinicalStatus | 0 | 1 | Y | CodeableConcept |
active | recurrence | relapse | inactive | remission | resolved | The clinical status of the condition. NOTE (7/31/2023): This is an invariant. Whe clinicalStatus is not present (empty), then a verificationStatus of "entered in error " is required. This will not be captured in FHIR validation. | required | ConditionClinicalStatusCodes | http://hl7.org/fhir/R4/ValueSet/condition-clinical | MS [0..1] |
| Condition.verificationStatus | 0 | 1 | Y | CodeableConcept |
unconfirmed | provisional | differential | confirmed | refuted | entered-in-error | The verification status to support the clinical status of the condition. NOTE (7/31/2023): This is an invariant. Whe clinicalStatus is not present (empty), then a verificationStatus of "entered in error " is required. This will not be captured in FHIR validation. |
required | ConditionVerificationStatus | http://hl7.org/fhir/R4/ValueSet/condition-ver-status | MS [0..1] |
| Condition.category | 1 | * | Y | CodeableConcept |
problem-list-item | encounter-diagnosis | health-concern | A category assigned to the condition. | extensible | US Core Condition Category Codes | http://hl7.org/fhir/us/core/STU3.1.1/ValueSet-us-core-condition-category.html | R [1..*] |
| Condition.severity | 0 | 1 | CodeableConcept |
Subjective severity of condition | A subjective assessment of the severity of the condition as evaluated by the clinician. | preferred | Condition/DagnosisSeverity | http://hl7.org/fhir/R4/ValueSet/condition-severity | NR | |
| Condition.code | 1 | 1 | Y | CodeableConcept |
Identification of the condition, problem or diagnosis | Identification of the condition, problem or diagnosis. | extensible | US Core Condition Code | http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code | R [1..1] |
| Condition.bodySite | 0 | * | CodeableConcept |
Anatomical location, if relevant | The anatomical location where this condition manifests itself. | example | SNOMEDCTBodyStructures | https://hl7.org/fhir/valueset-body-site.html | NR | |
| Condition.subject | 1 | 1 | Y | Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient) |
Who has the condition? | Indicates the patient or group who the condition record is associated with. | R [1..1] | |||
| Condition.encounter | 0 | 1 | Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter) |
Encounter created as part of | The Encounter during which this Condition was created or to which the creation of this record is tightly associated. | MS [0..1] | ||||
| Condition.onset[x] | 0 | 1 | dateTime Age Period Range String |
Estimated or actual date, date-time, or age | Estimated or actual date or date-time the condition began, in the opinion of the clinician. | MS [0..1] | ||||
| Condition.abatement[x] | 0 | 1 | dateTime Age Period Range String |
When in resolution/remission | The date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate. | MS [0..1] | ||||
| Condition.recordedDate | 0 | 1 | dateTime |
Date record was first recorded | The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date. | MS [0..1] | ||||
| Condition.recorder | 0 | 1 | Reference(Practitioner|PractitionerRole|Patient|RelatedPerson) |
Who recorded the condition | Individual who recorded the record and takes responsibility for its content. | NRT | ||||
| Condition.asserter | 0 | 1 | Reference(Practitioner|PractitionerRole|Patient|RelatedPerson) |
Person who asserts this condition | Individual who is making the condition statement. | NRT | ||||
| Condition.stage | 0 | * | BackboneElement |
Stage/grade, usually assessed formally | Clinical stage or grade of a condition. May include formal severity assessments. | NR | ||||
| Condition.stage.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| Condition.stage.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Condition.stage.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Condition.stage.summary | 0 | 1 | CodeableConcept |
Simple summary (disease specific) | A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific. | example | ConditionStage | https://hl7.org/fhir/valueset-condition-stage.html | NR | |
| Condition.stage.assessment | 0 | * | Reference(ClinicalImpression|DiagnosticReport|Observation) |
Formal record of assessment | Reference to a formal record of the evidence on which the staging assessment is based. | NR | ||||
| Condition.stage.type | 0 | 1 | CodeableConcept |
Kind of staging | The kind of staging, such as pathological or clinical staging. | example | ConditionStageType | https://hl7.org/fhir/valueset-condition-stage-type.html | NR | |
| Condition.evidence | 0 | * | BackboneElement |
Supporting evidence | Supporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition. | NR | ||||
| Condition.evidence.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| Condition.evidence.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Condition.evidence.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Condition.evidence.code | 0 | * | CodeableConcept |
Manifestation/symptom | A manifestation or symptom that led to the recording of this condition. | example | ManifestationAndSymptomCodes | https://hl7.org/fhir/valueset-manifestation-or-symptom.html | NR | |
| Condition.evidence.detail | 0 | * | Reference(Resource) |
Supporting information found elsewhere | Links to other relevant information, including pathology reports. | NR | ||||
| Condition.note | 0 | * | Annotation |
Additional information about the Condition | Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis. | NR |
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| FHIR Path | Min | Max | Type(s) | FHIR Short Description | FHIR Definition | Binding Strength | Binding Description | Binding Value Set | Cross Measure Requirements | |
| Coverage | DomainResource | Insurance or medical plan or a payment agreement Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension |
Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment. | MS [0..*] | ||||||
| Coverage.id | 0 | 1 | id |
Logical id of this artifact | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | R [1..1] | ||||
| Coverage.meta | 0 | 1 | Meta |
Metadata about the resource | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | NRT | ||||
| Coverage.implicitRules | 0 | 1 | uri |
A set of rules under which this content was created | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | NRT | ||||
| Coverage.language | 0 | 1 | code |
Language of the resource content | The base language in which the resource is written. | preferred | IETF language tag | https://hl7.org/fhir/valueset-languages.html | NRT | |
| Coverage.text | 0 | 1 | Narrative |
Text summary of the resource, for human interpretation | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | NRT | ||||
| Coverage.contained | 0 | * | Resource |
Contained, inline Resources | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | NRT | ||||
| Coverage.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Coverage.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Coverage.identifier | 0 | * | Identifier |
Business Identifier for the coverage | A unique identifier assigned to this coverage. | NRT | ||||
| Coverage.status | 1 | 1 | code |
active | cancelled | draft | entered-in-error | The status of the resource instance. | Required | FinancialResourceStatusCodes | http://hl7.org/fhir/ValueSet/fm-status | R [1..1] | |
| Coverage.type | 0 | 1 | CodeableConcept |
Coverage category such as medical or accident | The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization. | Preferred | CoverageTypeAndSelf-PayCodes | http://hl7.org/fhir/R4/ValueSet/coverage-type | MS [0..1] | |
| Coverage.policyHolder | 0 | 1 | Reference(Patient|RelatedPerson|Organization) |
Owner of the policy | The party who 'owns' the insurance policy. | MS [0..1] | ||||
| Coverage.subscriber | 0 | 1 | Reference(Patient|RelatedPerson) |
Subscriber to the policy | The party who has signed-up for or 'owns' the contractual relationship to the policy or to whom the benefit of the policy for services rendered to them or their family is due. | MS [0..1] | ||||
| Coverage.subscriberId | 0 | 1 | string |
ID assigned to the subscriber | The insurer assigned ID for the Subscriber. | MS [0..1] | ||||
| Coverage.beneficiary | 1 | 1 | Reference(Patient) |
Plan beneficiary | The party who benefits from the insurance coverage; the patient when products and/or services are provided. | R[1..1] | ||||
| Coverage.dependent | 0 | 1 | string |
Dependent number | A unique identifier for a dependent under the coverage. | MS [0..1] | ||||
| Coverage.relationship | 0 | 1 | CodeableConcept |
Beneficiary relationship to the subscriber | The relationship of beneficiary (patient) to the subscriber. | Extensible | SubscriberRelationshipCodes | http://hl7.org/fhir/ValueSet/subscriber-relationship | MS [0..1] | |
| Coverage.period | 0 | 1 | Period |
Coverage start and end dates | Time period during which the coverage is in force. A missing start date indicates the start date isn't known, a missing end date means the coverage is continuing to be in force. | MS [0..1] | ||||
| Coverage.payor | 1 | * | Reference(Organization|Patient|RelatedPerson) |
Issuer of the policy | The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements. | R [1..*] | ||||
| Coverage.class | 0 | * | BackboneElement |
Additional coverage classifications | A suite of underwriter specific classifiers. | NR | ||||
| Coverage.class.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| Coverage.class.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Coverage.class.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Coverage.class.type | 1 | 1 | CodeableConcept |
Type of class such as 'group' or 'plan' | The type of classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan. | Extensible | CoverageClassCodes | http://hl7.org/fhir/ValueSet/coverage-class | NRT | |
| Coverage.class.value | 1 | 1 | string |
Value associated with the type | The alphanumeric string value associated with the insurer issued label. | NR | ||||
| Coverage.class.name | 0 | 1 | string |
Human readable description of the type and value | A short description for the class. | NR | ||||
| Coverage.order | 0 | 1 | positiveInt |
Relative order of the coverage | The order of applicability of this coverage relative to other coverages which are currently in force. Note, there may be gaps in the numbering and this does not imply primary, secondary etc. as the specific positioning of coverages depends upon the episode of care. | NR | ||||
| Coverage.network | 0 | 1 | string |
Insurer network | The insurer-specific identifier for the insurer-defined network of providers to which the beneficiary may seek treatment which will be covered at the 'in-network' rate, otherwise 'out of network' terms and conditions apply. | NR | ||||
| Coverage.costToBeneficiary | 0 | * | BackboneElement |
Patient payments for services/products | A suite of codes indicating the cost category and associated amount which have been detailed in the policy and may have been included on the health card. | NRT | ||||
| Coverage.costToBeneficiary.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| Coverage.costToBeneficiary.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Coverage.costToBeneficiary.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Coverage.costToBeneficiary.type | 0 | 1 | CodeableConcept |
Cost category | The category of patient centric costs associated with treatment. | Extensible | CoverageCopayTypeCodes | http://hl7.org/fhir/ValueSet/coverage-copay-type | NRT | |
| Coverage.costToBeneficiary.value[x] valueQuantity valueMoney |
1 | 1 | SimpleQuantity Money |
The amount or percentage due from the beneficiary | The amount due from the patient for the cost category. | NRT | ||||
| Coverage.costToBeneficiary.exception | 0 | * | BackboneElement |
Exceptions for patient payments | A suite of codes indicating exceptions or reductions to patient costs and their effective periods. | NRT | ||||
| Coverage.costToBeneficiary.exception.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| Coverage.costToBeneficiary.exception.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Coverage.costToBeneficiary.exception.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Coverage.costToBeneficiary.exception.type | 1 | 1 | CodeableConcept |
Exception category | The code for the specific exception. | Example | ExampleCoverageFinancialExceptionCodes | http://hl7.org/fhir/ValueSet/coverage-financial-exception | NRT | |
| Coverage.costToBeneficiary.exception.period | 0 | 1 | Period |
The effective period of the exception | The timeframe during when the exception is in force. | NRT | ||||
| Coverage.subrogation | 0 | 1 | boolean |
Reimbursement to insurer | When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs. | NR | ||||
| Coverage.contract | 0 | * | Reference(Contract) |
Contract details | The policy(s) which constitute this insurance coverage. | NR |
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| Path | Min | Max | Must Support? | Data Type(s) | FHIR Short Description | FHIR Definition | Comments | Binding Strength | Binding Description | FHIR Binding Value Set | Cross Measure Requirements |
| Device | 0 | * | Item used in healthcare | A type of a manufactured item that is used in the provision of healthcare without being substantially changed through that activity. The device may be a medical or non-medical device. | MS[0..*] | ||||||
| Device.text | 0 | 1 | Narrative | Text summary of the resource, for human interpretation | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | Contained resources do not have a narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. | NRT | ||||
| Device.contained | 0 | * | Resource | Contained, inline Resources | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning. | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags in their meta elements, but SHALL NOT have security labels. | NRT | ||||
| Device.id | 0 | 1 | id | Logical id of this artifact | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case. | R[1..1] | ||||
| Device.meta | 0 | 1 | Meta | Metadata about the resource | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | NRT | |||||
| Device.implicitRules | 0 | 1 | uri | A set of rules under which this content was created | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of its narrative along with other profiles, value sets, etc. | NRT | ||||
| Device.language | 0 | 1 | code | Language of the resource content | The base language in which the resource is written. | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). | required | IETF language tag for a human language | http://hl7.org/fhir/ValueSet/all-languages|5.0.0 | NRT | |
| Device.extension | 0 | * | Extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| Device.modifierExtension | 0 | * | Extension | Extensions that cannot be ignored | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| Device.identifier | 0 | * | Identifier | Instance identifier | Unique instance identifiers assigned to a device by manufacturers other organizations or owners. | Certain attributes, like serial number and UDI Carrier (the HRF or AIDC barcode string) are not device instance identifiers as they are not consistently able to uniquely identify the instance of a device, thus are not appropriate to be used to value Device.identifier. The barcode string from a barcode present on a device label or package may identify the instance, include names given to the device in local usage, or may identify the type of device. If the identifier identifies the type of device, Device.type element should be used. The identifier is typically valued if the serialNumber or lotNumber is not valued and represents a different type of identifier. However, it is permissible to still include those identifiers in DeviceDefinition.identifier with the appropriate identifier.type. | NRT | ||||
| Device.definition | 0 | 1 | CodeableReference(DeviceDefinition) | The reference to the definition for the device | The reference to the definition for the device. | NR | |||||
| Device.udiCarrier | 0 | * | BackboneElement | Unique Device Identifier (UDI) Barcode string | Unique device identifier (UDI) assigned to device label or package. Note that the Device may include multiple udiCarriers as it either may include just the udiCarrier for the jurisdiction it is sold, or for multiple jurisdictions it could have been sold. | UDI may identify an unique instance of a device, or it may only identify the type of the device. See [UDI mappings](device-mappings.html#udi) for a complete mapping of UDI parts to Device. | MS[0..*] | ||||
| Device.udiCarrier.id | 0 | 1 | string | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | |||||
| Device.udiCarrier.extension | 0 | * | Extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| Device.udiCarrier.modifierExtension | 0 | * | Extension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| Device.udiCarrier.deviceIdentifier | 0 | 1 | string | Mandatory fixed portion of UDI | The device identifier (DI) is a mandatory, fixed portion of a UDI that identifies the labeler and the specific version or model of a device. | MS[0..1] | |||||
| Device.udiCarrier.issuer | 0 | 1 | uri | UDI Issuing Organization | Organization that is charged with issuing UDIs for devices. For example, the US FDA issuers include: 1) GS1: http://hl7.org/fhir/NamingSystem/gs1-di, 2) HIBCC: http://hl7.org/fhir/NamingSystem/hibcc-diI, 3) ICCBBA for blood containers: http://hl7.org/fhir/NamingSystem/iccbba-blood-di, 4) ICCBA for other devices: http://hl7.org/fhir/NamingSystem/iccbba-other-di # Informationsstelle für Arzneispezialitäten (IFA GmbH) (EU only): http://hl7.org/fhir/NamingSystem/ifa-gmbh-di. |
NR | |||||
| Device.udiCarrier.jurisdiction | 0 | 1 | uri | Regional UDI authority | The identity of the authoritative source for UDI generation within a jurisdiction. All UDIs are globally unique within a single namespace with the appropriate repository uri as the system. For example, UDIs of devices managed in the U.S. by the FDA, the value is http://hl7.org/fhir/NamingSystem/us-fda-udi or in the European Union by the European Commission http://hl7.org/fhir/NamingSystem/eu-ec-udi. | NR | |||||
| Device.udiCarrier.carrierAIDC | 0 | 1 | base64Binary | UDI Machine Readable Barcode String | The full UDI carrier of the Automatic Identification and Data Capture (AIDC) technology representation of the barcode string as printed on the packaging of the device - e.g., a barcode or RFID. Because of limitations on character sets in XML and the need to round-trip JSON data through XML, AIDC Formats *SHALL* be base64 encoded. | The AIDC form of UDIs should be scanned or otherwise used for the identification of the device whenever possible to minimize errors in records resulting from manual transcriptions. If separate barcodes for DI and PI are present, concatenate the string with DI first and in order of human readable expression on label. | MS[0..1] | ||||
| Device.udiCarrier.carrierHRF | 0 | 1 | string | UDI Human Readable Barcode String | The full UDI carrier as the human readable form (HRF) representation of the barcode string as printed on the packaging of the device. | If separate barcodes for DI and PI are present, concatenate the string with DI first and in order of human readable expression on label. | MS[0..1] | ||||
| Device.udiCarrier.entryType | 0 | 1 | code | barcode | rfid | manual | card | self-reported | electronic-transmission | unknown | A coded entry to indicate how the data was entered. | required | Codes to identify how UDI data was entered. | http://hl7.org/fhir/ValueSet/udi-entry-type|5.0.0 | MS[0..1] | ||
| Device.status | 0 | 1 | code | Status of the Device availability. | required | The record status of the device. | http://hl7.org/fhir/ValueSet/device-status|5.0.0 | MS[0..1] | |||
| Device.statusReason | 0 | * | Extensible/Codeable Concept | Reason for the status of the Device availability. | NR | ||||||
| Device.distinctIdentifier | 0 | 1 | string | The distinct identification string as required by regulation for a human cell, tissue, or cellular and tissue-based product. | For example, this applies to devices in the United States regulated under Code of Federal Regulation 21CFR§1271.290(c). | MS[0..1] | |||||
| Device.manufacturer | 0 | 1 | string | Name of device manufacturer | A name of the manufacturer or entity legally responsible for the device. | NR | |||||
| Device.manufactureDate | 0 | 1 | dateTime | Date when the device was made | The date and time when the device was manufactured. | NR | |||||
| Device.expirationDate | 0 | 1 | dateTime | Date and time of expiry of this device (if applicable) | The date and time beyond which this device is no longer valid or should not be used (if applicable). | NR | |||||
| Device.lotNumber | 0 | 1 | string | Lot number of manufacture | Lot number assigned by the manufacturer. | NR | |||||
| Device.serialNumber | 0 | 1 | string | Serial number assigned by the manufacturer | The serial number assigned by the organization when the device was manufactured. | Alphanumeric Maximum 20. While a serial number is a type of identifier, in the context of devices for which a UDI is required, thus a serial number may be part of the production identifier, it is more informative to have the serial number as a dedicated attribute together with the other UDI production identifier. When the device is not subject to including the UDI (e.g., its presence and exchange is not mandated by local regulatory requirements or specific use case at hand), thus the concept of production identifiers is not relevant as a set, it remains helpful for consistency to still use Device.serialNumber rather than using Device.identifier with an appropriate type. Systems that do not realize an identifier is a serial number may place it in Device.identifier or if the identifier.system is known for the serial number, it may also be populated in the Device.identifier as a globally unique id_. | NR | ||||
| Device.deviceName | 0 | * | BackboneElement | The name or names of the device as known to the manufacturer and/or patient | This represents the manufacturer's name of the device as provided by the device, from a UDI label, or by a person describing the Device. This typically would be used when a person provides the name(s) or when the device represents one of the names available from DeviceDefinition. | MS [0..*] | |||||
| Device.deviceName.id | 0 | 1 | string | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | |||||
| Device.deviceName.extension | 0 | * | Extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| Device.deviceName.modifierExtension | 0 | * | Extension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| Device.deviceName.name | 1 | 1 | string | The name of the device. | R[1..1] | ||||||
| Device.deviceName.type | 1 | 1 | code | udi-label-name | user-friendly-name | patient-reported-name | manufacturer-name | model-name | other | required | Device Name Type | https://hl7.org/fhir/R4/valueset-device-nametype.html | R[1..1] | |||
| Device.modelNumber | 0 | 1 | string | The manufacturer's model number for the device | The manufacturer's model number for the device. | NR | |||||
| Device.partNumber | 0 | 1 | string | The part number or catalog number of the device | The part number or catalog number of the device. | Alphanumeric Maximum 20. | NR | ||||
| Device.type | 0 | 1 | CodeableConcept | The kind or type of device | The kind or type of device. A device instance may have more than one type - in which case those are the types that apply to the specific instance of the device. | Multiple device types are use when a device is categorized in more than one context – for example, hybrid devices in which the device is both of type gateway and sensor. | example | Codes to identify medical devices. | https://hl7.org/fhir/R4/valueset-device-type | R[1..1] | |
| Device.specialization | 0 | * | Backbone Element | The capabilities supported on a device, the standards to which the device conforms for a particular purpose, and used for the communication. | NR | ||||||
| Device.specialization.systemType | 1 | 1 | Codeable Concept | The standard that is used to operate and communicate. | NR | ||||||
| Device.specialization.version | 0 | 1 | string | The version of the standard that is used to operate and communicate | This is a business versionId, not a resource version id | NR | |||||
| Device.version | 0 | * | BackboneElement | The actual design of the device or software version running on the device | The actual design of the device or software version running on the device. | NR | |||||
| Device.version.type | 0 | 1 | CodeableConcept | The type of the device version, e.g. manufacturer, approved, internal | The type of the device version, e.g. manufacturer, approved, internal. | example | The type of version indicated for the device. | http://hl7.org/fhir/ValueSet/device-versiontype | NR | ||
| Device.version.component | 0 | 1 | Identifier | A single component of the device version | NR | ||||||
| Device.version.value | 1 | 1 | string | The version text | The version text. | NR | |||||
| Device.property | 0 | * | BackboneElement | The actual configuration settings of a device as it actually operates, e.g., regulation status, time properties. | NR | ||||||
| Device.property.id | 0 | 1 | string | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NR | |||||
| Device.property.extension | 0 | * | Extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| Device.property.modifierExtension | 0 | * | Extension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| Device.property.type | 1 | 1 | CodeableConcept | Updated definition-Code that specifies the property DeviceDefinitionPropetyCode (Extensible) | example | Device property type. | http://hl7.org/fhir/ValueSet/device-property-type | NR | |||
| Device.property.valueQuantity | 0 | * | Quantity | Value of the property | Property value as a quantity. | NR | |||||
| Device.property.valueCode | 0 | * | Codeable Concept | Property value as a code, e.g., NTP4 (synced to NTP). | NR | ||||||
| Device.patient | 0 | 1 | Reference (Patient) | Patient information, If the device is affixed to a person. | If the device is implanted in a patient, then need to associate the device to the patient. | R[1..1] | |||||
| Device.owner | 0 | 1 | Reference(Organization) | Organization responsible for device | An organization that is responsible for the provision and ongoing maintenance of the device. | NR | |||||
| Device.contact | 0 | * | ContactPoint | Details for human/organization for support | Contact details for an organization or a particular human that is responsible for the device. | used for troubleshooting etc. | NR | ||||
| Device.location | 0 | 1 | Reference(Location) | Where the device is found | The place where the device can be found. | NR | |||||
| Device.url | 0 | 1 | uri | Network address to contact device | A network address on which the device may be contacted directly. | If the device is running a FHIR server, the network address should be the Base URL from which a conformance statement may be retrieved. | NR | ||||
| Device.note | 0 | * | Annotation | Device notes and comments | Descriptive information, usage information or implantation information that is not captured in an existing element. | NR | |||||
| Device.safety | 0 | * | CodeableConcept | Safety Characteristics of Device | Provides additional safety characteristics about a medical device. For example devices containing latex. | example | http://hl7.org/fhir/ValueSet/device-safety | NR | |||
| Device.parent | 0 | 1 | Reference(Device) | The parent device. | For example a vital signs monitor (parent) where three separate modules can be plugged into such as interchangeable blood pressure, oximeter, temperature modules. These modules are represented as devices with the .parent valued to the vital signs monitor when plugged in. | NR | |||||
| http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-lab | |||||||||||
| Back to TOC | |||||||||||
| FHIR Path | Min | Max | Must Support? | Data Type(s) | FHIR Short Description | FHIR Definition | Comments | Binding Strength | Binding Description | FHIR Binding Value Set | Cross Measure Requirements |
| DiagnosticReport | 0 | * | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | The US Core Diagnostic Report Profile is based upon the core FHIR DiagnosticReport Resource and created to meet the 2015 Edition Common Clinical Data Set 'Laboratory test(s) and Laboratory value(s)/result(s)' requirements. | This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing. | MS [0..*] | |||||
| DiagnosticReport.id | 0 | 1 | string |
Logical id of this artifact | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | R[1..1] | ||||
| DiagnosticReport.meta | 0 | 1 | Meta |
Metadata about the resource | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | NRT | |||||
| DiagnosticReport.implicitRules | 0 | 1 | uri |
A set of rules under which this content was created | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. | NRT | ||||
| DiagnosticReport.language | 0 | 1 | code |
Language of the resource content | The base language in which the resource is written. | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). | preferred | CommonLanguages Max Binding: All Languages |
http://hl7.org/fhir/ValueSet/languages | NRT | |
| DiagnosticReport.text | 0 | 1 | Narrative |
Text summary of the resource, for human interpretation | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. | NR | ||||
| DiagnosticReport.contained | 0 | * | Resource |
Contained, inline Resources | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. | NRT | ||||
| DiagnosticReport.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| DiagnosticReport.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| DiagnosticReport.identifier | 0 | * | Identifier |
Business identifier for report | Identifiers assigned to this report by the performer or other systems. | Usually assigned by the Information System of the diagnostic service provider (filler id). | NRT | ||||
| DiagnosticReport.basedOn | 0 | * | Reference(CarePlan|ImmunizationRecommendation|MedicationRequest|NutritionOrder|ServiceRequest) |
What was requested | Details concerning a service requested. | Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports. | NR | ||||
| DiagnosticReport.status | 1 | 1 | Y | code |
registered | partial | preliminary | final + | The status of the diagnostic report. | required | http://hl7.org/fhir/R4/ValueSet/diagnostic-report-status | R [1..1] | ||
| DiagnosticReport.category | 1 | * | Y | CodeableConcept |
Service category | A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes. | Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code. | example | Codes for diagnostic service sections. | http://hl7.org/fhir/R4/ValueSet/diagnostic-service-sections | R [1..*] |
| DiagnosticReport.category:LaboratorySlice | 1 | 1 | Y | CodeableConcept |
Service category | A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes. | Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code. | example | Required Pattern: At least the following | R [1..1] | |
| DiagnosticReport.category:LaboratorySlice.id | 0 | 1 | string |
Unique id for inter-element referencing | NRT | ||||||
| DiagnosticReport.category:LaboratorySlice.id.extension | 0 | * | Extension |
Additional content defined by implementations | NRT | ||||||
| DiagnosticReport.category:LaboratorySlice.coding | 1 | * | Coding | Code defined by a terminology system | Complex | Fixed Value: (complex) | NR | ||||
| DiagnosticReport.category:LaboratorySlice.coding.id | 0 | 1 | string |
Unique id for inter-element referencing | NRT | ||||||
| DiagnosticReport.category:LaboratorySlice.coding.system | 1 | 1 | url |
identity of the terminology system | Fixed Value | diagnostiServiceSectionID | https://terminology.hl7.org/5.2.0/CodeSystem-v2-0074.html | NR | |||
| DiagnosticReport.category:LaboratorySlice.coding.version | 0 | 1 | string |
Version of the system - if relevant | NR | ||||||
| DiagnosticReport.category:LaboratorySlice.coding.code | 0 | 2 | code | Symbol in syntax defined by the system | Fixed Value | NR | |||||
| DiagnosticReport.category:LaboratorySlice.coding.display | 0 | 1 | string |
Representation defined by the system | NR | ||||||
| DiagnosticReport.category:LaboratorySlice.coding.userSelected | 0 | 1 | boolean |
If this coding was chosen directly by the user | NR | ||||||
| DiagnosticReport.code | 1 | 1 | Y | CodeableConcept |
US Core Laboratory Report Order Code | The test, panel or battery that was ordered. | UsageNote= The typical patterns for codes are: 1) a LOINC code either as a translation from a "local" code or as a primary code, or 2) a local code only if no suitable LOINC exists, or 3) both the local and the LOINC translation. Systems SHALL be capable of sending the local code if one exists. | extensible | US Core Diagnostic Report Laboratory Codes (LOINC codes) | https://www.hl7.org/fhir/valueset-report-codes.html | R [1..1] |
| DiagnosticReport.subject | 1 | 1 | Y | Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient) |
The subject of the report - usually, but not always, the patient | The subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources. | R [1..1] | ||||
| DiagnosticReport.encounter | 0 | 1 | Reference(Encounter) |
Health care event when test ordered | The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. | This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests). | NR | ||||
| DiagnosticReport.effective[x] | 1 | 1 | Y | dateTime Period |
Specimen Collection Datetime or Period | The time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself. | If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic. | R [1..1] | |||
| DiagnosticReport.issued | 1 | 1 | Y | instant |
DateTime this version was made | The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. | May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report. | R [1..1] | |||
| DiagnosticReport.performer | 0 | * | Y | Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization|http://hl7.org/fhir/us/core/StructureDefinition/us-core-careteam|http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitionerrole) |
Responsible Diagnostic Service | The diagnostic service that is responsible for issuing the report. | This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report. | NR | |||
| DiagnosticReport.resultsInterpreter | 0 | * | Reference(Practitioner|PractitionerRole|Organization|CareTeam) |
Primary result interpreter | The practitioner or organization that is responsible for the report's conclusions and interpretations. | Might not be the same entity that takes responsibility for the clinical report. | NR | ||||
| DiagnosticReport.specimen | 0 | * | Reference(Specimen) |
Specimens this report is based on | Details about the specimens on which this diagnostic report is based. | If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group. | MS [0..*] | ||||
| DiagnosticReport.result | 0 | * | Y | Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab) |
Observations | [Observations](http://hl7.org/fhir/R4/observation.html) that are part of this diagnostic report. | Observations can contain observations. | MS [0..*] | |||
| DiagnosticReport.imagingStudy | 0 | * | Reference(ImagingStudy) |
Reference to full details of imaging associated with the diagnostic report | One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images. | ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided. | NR | ||||
| DiagnosticReport.media | 0 | * | BackboneElement |
Key images associated with this report | A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest). | NR | |||||
| DiagnosticReport.media.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | MS [0..*] | |||||
| DiagnosticReport.media.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| DiagnosticReport.media.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| DiagnosticReport.media.comment | 0 | 1 | string |
Comment about the image (e.g. explanation) | A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features. | The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion. | NR | ||||
| DiagnosticReport.media.link | 1 | 1 | Reference(Media) |
Reference to the image source | Reference to the image source. | NR | |||||
| DiagnosticReport.conclusion | 0 | 1 | string |
Clinical conclusion (interpretation) of test results | Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. | NR | |||||
| DiagnosticReport.conclusionCode | 0 | * | CodeableConcept |
Codes for the clinical conclusion of test results | One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report. | example | SNOMEDCTCLinicalFindings | http://hl7.org/fhir/ValueSet/clinical-findings | NR | ||
| DiagnosticReport.presentedForm | 0 | * | Attachment |
Entire report as issued | Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent. | "application/pdf" is recommended as the most reliable and interoperable in this context. | NR |
| Back to TOC | |||||||||||
| Path | Min | Max | Must Support? | Data Type(s) | FHIR Short Description | FHIR Definition | Comments | Binding Strength | Binding Description | FHIR Binding Value Set | Cross Measure Requirements |
| DiagnosticReport | 0 | * | US Core Diagnostic Report Profile for Report and Note exchange | Clinical Testing and Imaging tests performed on a patient that results in structured or unstructured (narrative) findings specific to the patient. | This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing. | MS [0..*] | |||||
| DiagnosticReport.id | 0 | 1 | string |
Logical id of this artifact | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | R[1..1] | ||||
| DiagnosticReport.meta | 0 | 1 | Meta |
Metadata about the resource | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | NRT | |||||
| DiagnosticReport.implicitRules | 0 | 1 | uri |
A set of rules under which this content was created | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. | NRT | ||||
| DiagnosticReport.language | 0 | 1 | code |
Language of the resource content | The base language in which the resource is written. | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). | preferred | A human language. | http://hl7.org/fhir/ValueSet/languages | NRT | |
| DiagnosticReport.text | 0 | 1 | Narrative |
Text summary of the resource, for human interpretation | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. | NR | ||||
| DiagnosticReport.contained | 0 | * | Resource |
Contained, inline Resources | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. | NRT | ||||
| DiagnosticReport.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| DiagnosticReport.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| DiagnosticReport.identifier | 0 | * | Identifier |
Business identifier for report | Identifiers assigned to this report by the performer or other systems. | Usually assigned by the Information System of the diagnostic service provider (filler id). | NRT | ||||
| DiagnosticReport.basedOn | 0 | * | Reference(CarePlan|ImmunizationRecommendation|MedicationRequest|NutritionOrder|ServiceRequest) |
What was requested | Details concerning a service requested. | Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports. | MS [0..*] | ||||
| DiagnosticReport.status | 1 | 1 | Y | code |
registered | partial | preliminary | final + | The status of the diagnostic report. | required | http://hl7.org/fhir/ValueSet/diagnostic-report-status | R[1..1] | ||
| DiagnosticReport.category | 0 | * | Y | CodeableConcept |
Service category | A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes. | Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code. | required | http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category | R[1..*] | |
| DiagnosticReport.code | 1 | 1 | Y | CodeableConcept |
US Core Report Code | The test, panel, report, or note that was ordered. | The typical patterns for codes are: 1) a LOINC code either as a translation from a "local" code or as a primary code, or 2) a local code only if no suitable LOINC exists, or 3) both the local and the LOINC translation. Systems SHALL be capable of sending the local code if one exists. | extensible | LOINC codes | http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes | R[1..1] |
| DiagnosticReport.subject | 1 | 1 | Y | Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient) |
The subject of the report - usually, but not always, the patient | The subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources. | R[1..1] | ||||
| DiagnosticReport.encounter | 0 | 1 | Y | Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter) |
Health care event when test ordered | The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. | This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests). | MS [0..1] | |||
| DiagnosticReport.effective[x] | 1 | 1 | Y | dateTime Period |
Clinically relevant time/time-period for report | The time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself. | If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic. | R[1..1] | |||
| DiagnosticReport.issued | 0 | 1 | Y | instant |
DateTime this version was made | The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. | May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report. | MS[0..1] | |||
| DiagnosticReport.performer | 0 | * | Y | Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization|http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitionerrole|http://hl7.org/fhir/us/core/StructureDefinition/us-core-careteam) |
Responsible Diagnostic Service | The diagnostic service that is responsible for issuing the report. | This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report. | NR | |||
| DiagnosticReport.resultsInterpreter | 0 | * | Reference(Practitioner|PractitionerRole|Organization|CareTeam) |
Primary result interpreter | The practitioner or organization that is responsible for the report's conclusions and interpretations. | Might not be the same entity that takes responsibility for the clinical report. | NR | ||||
| DiagnosticReport.specimen | 0 | * | Reference(Specimen) |
Specimens this report is based on | Details about the specimens on which this diagnostic report is based. | If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group. | NR | ||||
| DiagnosticReport.result | 0 | * | Y | Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab|http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-clinical-test|http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-imaging) |
Observations | [Observations](http://hl7.org/fhir/R4/observation.html) that are part of this diagnostic report. | Observations can contain observations. | NR | |||
| DiagnosticReport.imagingStudy | 0 | * | Y | Reference(ImagingStudy) |
Reference to full details of imaging associated with the diagnostic report | One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images. | ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided. | NR | |||
| DiagnosticReport.media | 0 | * | Y | BackboneElement |
Key images associated with this report | A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest). | NR | ||||
| DiagnosticReport.media.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | |||||
| DiagnosticReport.media.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| DiagnosticReport.media.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| DiagnosticReport.media.comment | 0 | 1 | string |
Comment about the image (e.g. explanation) | A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features. | The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion. | NR | ||||
| DiagnosticReport.media.link | 1 | 1 | Y | Reference(Media) |
Reference to the image source | Reference to the image source. | NR | ||||
| DiagnosticReport.conclusion | 0 | 1 | string |
Clinical conclusion (interpretation) of test results | Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. | NR | |||||
| DiagnosticReport.conclusionCode | 0 | * | CodeableConcept |
Codes for the clinical conclusion of test results | One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report. | example | Diagnosis codes provided as adjuncts to the report. | http://hl7.org/fhir/ValueSet/clinical-findings | MS[0..*] | ||
| DiagnosticReport.presentedForm | 0 | * | Y | Attachment |
Entire report as issued | Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent. | "application/pdf" is recommended as the most reliable and interoperable in this context. | NR |
| Back to TOC | ||||||||||
| FHIR Path |
Min | Max | Must Support? | Data Type(s) | Short Description | FHIR Definition | Binding Strength | Binding Description | FHIR Binding Value Set | Cross Measure Requirements |
| Encounter | 0 | * | Encounter |
An interaction during which services are provided to the patient | This is basic constraint on Encounter for use in US Core resources. | R [1..1] | ||||
| Encounter.id | 0 | 1 | string |
Logical id of this artifact | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | R [1..1] | ||||
| Encounter.meta | 0 | 1 | Meta |
Metadata about the resource | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | NRT | ||||
| Encounter.implicitRules | 0 | 1 | uri |
A set of rules under which this content was created | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | NRT | ||||
| Encounter.language | 0 | 1 | code |
Language of the resource content | The base language in which the resource is written. | Preferred Max Binding |
CommonLanguages AllLanguages |
http://hl7.org/fhir/ValueSet/languages http://hl7.org/fhir/ValueSet/all-languages | NRT | |
| Encounter.text | 0 | 1 | Narrative |
Text summary of the resource, for human interpretation |
|
NRT | ||||
| Encounter.contained | 0 | * | Resource |
Contained, inline Resources | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | NRT | ||||
| Encounter.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Encounter.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Encounter.identifier | 0 | * | Y | Identifier |
Identifier(s) by which this encounter is known | Identifier(s) by which this encounter is known. | R [1..*] | |||
| Encounter.identifier.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| Encounter.identifier.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Encounter.identifier.use | 0 | 1 | code |
usual | official | temp | secondary | old (If known) | The purpose of this identifier. | required | IdentifierUse | http://hl7.org/fhir/ValueSet/identifier-use | MS [0..1] | |
| Encounter.identifier.type | 0 | 1 | CodeableConcept |
Description of identifier | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose. | extensible | IdentifierType | http://hl7.org/fhir/ValueSet/identifier-type | MS[0..1] | |
| Encounter.identifier.system | 1 | 1 | Y | uri |
The namespace for the identifier value | Establishes the namespace for the value - that is, a URL that describes a set values that are unique. | R[1..1] | |||
| Encounter.identifier.value | 1 | 1 | Y | string |
The value that is unique | The portion of the identifier typically relevant to the user and which is unique within the context of the system. | R [1..1] | |||
| Encounter.identifier.period | 0 | 1 | Period |
Time period when id is/was valid for use | Time period during which identifier is/was valid for use. | MS [0..1] | ||||
| Encounter.identifier.assigner | 0 | 1 | Reference(Organization) |
Organization that issued id (may be just text) | Organization that issued/manages the identifier. | NRT | ||||
| Encounter.status | 1 | 1 | Y | code |
planned | arrived | triaged | in-progress | onleave | finished | cancelled + | planned | arrived | triaged | in-progress | onleave | finished | cancelled +. | required | EncounterStatus | http://hl7.org/fhir/ValueSet/encounter-status | R [1..1] |
| Encounter.statusHistory | 0 | * | BackboneElement |
List of past encounter statuses | The status history permits the encounter resource to contain the status history without needing to read through the historical versions of the resource, or even have the server store them. | NR | ||||
| Encounter.statusHistory.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| Encounter.statusHistory.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Encounter.statusHistory.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Encounter.statusHistory.status | 1 | 1 | code |
planned | arrived | triaged | in-progress | onleave | finished | cancelled + | planned | arrived | triaged | in-progress | onleave | finished | cancelled +. | required | EncounterStatus | http://hl7.org/fhir/ValueSet/encounter-status | NR | |
| Encounter.statusHistory.period | 1 | 1 | Period |
The time that the episode was in the specified status | The time that the episode was in the specified status. | NR | ||||
| Encounter.class | 1 | 1 | Y | Coding |
Classification of patient encounter | Concepts representing classification of patient encounter such as ambulatory (outpatient), inpatient, emergency, home health or others due to local variations. | extensible | ActEncounterCode | http://hl7.org/fhir/R4/v3/ActEncounterCode/vs.html | R [1..1] |
| Encounter.classHistory | 0 | * | BackboneElement |
List of past encounter classes | The class history permits the tracking of the encounters transitions without needing to go through the resource history. This would be used for a case where an admission starts of as an emergency encounter, then transitions into an inpatient scenario. Doing this and not restarting a new encounter ensures that any lab/diagnostic results can more easily follow the patient and not require re-processing and not get lost or cancelled during a kind of discharge from emergency to inpatient. | MS [0..*] | ||||
| Encounter.classHistory.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| Encounter.classHistory.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Encounter.classHistory.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Encounter.classHistory.class | 1 | 1 | Coding |
inpatient | outpatient | ambulatory | emergency + | inpatient | outpatient | ambulatory | emergency +. | extensible | ActEncounterCode | http://terminology.hl7.org/ValueSet/v3-ActEncounterCode | R [1..1] | |
| Encounter.classHistory.period | 1 | 1 | Period |
The time that the episode was in the specified class | The time that the episode was in the specified class. | R [1..1] | ||||
| Encounter.type | 1 | * | Y | CodeableConcept |
Specific type of encounter | Specific type of encounter (e.g. e-mail consultation, surgical day-care, skilled nursing, rehabilitation). | extensible | USCoreEncounterType | http://hl7.org/fhir/us/core/ValueSet/us-core-encounter-type | R [1..*] |
| Encounter.serviceType | 0 | 1 | CodeableConcept |
Specific type of service | Broad categorization of the service that is to be provided (e.g. cardiology). | example | ServiceType | http://hl7.org/fhir/ValueSet/service-type | NR | |
| Encounter.priority | 0 | 1 | CodeableConcept |
Indicates the urgency of the encounter | Indicates the urgency of the encounter. | example | ActPriority | http://terminology.hl7.org/ValueSet/v3-ActPriority | NR | |
| Encounter.subject | 1 | 1 | Y | Reference(US Core Patient Profile) |
The patient or group present at the encounter | The patient or group present at the encounter. | R [1..1] | |||
| Encounter.episodeOfCare | 0 | * | Reference(EpisodeOfCare) |
Episode(s) of care that this encounter should be recorded against | Where a specific encounter should be classified as a part of a specific episode(s) of care this field should be used. This association can facilitate grouping of related encounters together for a specific purpose, such as government reporting, issue tracking, association via a common problem. The association is recorded on the encounter as these are typically created after the episode of care and grouped on entry rather than editing the episode of care to append another encounter to it (the episode of care could span years). | NRT | ||||
| Encounter.basedOn | 0 | * | Reference(ServiceRequest) |
The ServiceRequest that initiated this encounter | The request this encounter satisfies (e.g. incoming referral or procedure request). | NRT | ||||
| Encounter.participant | 0 | * | Y | BackboneElement |
List of participants involved in the encounter | The list of people responsible for providing the service. | NR | |||
| Encounter.participant.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| Encounter.participant.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Encounter.participant.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Encounter.participant.type | 0 | * | Y | CodeableConcept |
Role of participant in encounter | Role of participant in encounter. | extensible | ParticipantType | http://hl7.org/fhir/ValueSet/encounter-participant-type | NR |
| Encounter.participant.period | 0 | 1 | Y | Period |
Period of time during the encounter that the participant participated | The period of time that the specified participant participated in the encounter. These can overlap or be sub-sets of the overall encounter's period. | NR | |||
| Encounter.participant.individual | 0 | 1 | Y | Reference(US Core Practitioner Profile) | Persons involved in the encounter other than the patient | Persons involved in the encounter other than the patient. | NR | |||
| Encounter.appointment | 0 | * | Reference(Appointment) |
The appointment that scheduled this encounter | The appointment that scheduled this encounter. | NRT | ||||
| Encounter.period | 0 | 1 | Y | Period |
The start and end time of the encounter | The start and end time of the encounter. | R[1..1] | |||
| Encounter.length | 0 | 1 | Duration |
Quantity of time the encounter lasted (less time absent) | Quantity of time the encounter lasted. This excludes the time during leaves of absence. | NR | ||||
| Encounter.reasonCode | 0 | * | Y | CodeableConcept |
Coded reason the encounter takes place | Reason the encounter takes place, expressed as a code. For admissions, this can be used for a coded admission diagnosis. | preferred | EncounterReasonCodes | http://hl7.org/fhir/ValueSet/encounter-reason | MS [0..*] |
| Encounter.reasonReference | 0 | * | Y | Reference(Condition | Procedure | Observation | ImmunizationRecommendation) | Reason the encounter takes place (reference) | Reason the encounter takes place, expressed as a code. For admissions, this can be used for a coded admission diagnosis. | NR | |||
| Encounter.diagnosis | 0 | * | BackboneElement |
The list of diagnosis relevant to this encounter | The list of diagnosis relevant to this encounter. | MS [0..*] | ||||
| Encounter.diagnosis.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| Encounter.diagnosis.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Encounter.diagnosis.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Encounter.diagnosis.condition | 1 | 1 | Reference(Condition|Procedure) |
The diagnosis or procedure relevant to the encounter | Reason the encounter takes place, as specified using information from another resource. For admissions, this is the admission diagnosis. The indication will typically be a Condition (with other resources referenced in the evidence.detail), or a Procedure. | R [1..1] | ||||
| Encounter.diagnosis.use | 0 | 1 | CodeableConcept |
Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …) | Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …). | preferred | DiagnosisRole | http://hl7.org/fhir/ValueSet/diagnosis-role | MS [0..1] |
|
| Encounter.diagnosis.rank | 0 | 1 | positiveInt |
Ranking of the diagnosis (for each role type) | Ranking of the diagnosis (for each role type). | MS [0..1] | ||||
| Encounter.account | 0 | * | Reference(Account) |
The set of accounts that may be used for billing for this Encounter | The set of accounts that may be used for billing for this Encounter. | NR | ||||
| Encounter.hospitalization | 0 | 1 | Y | BackboneElement |
Details about the admission to a healthcare service | Details about the admission to a healthcare service. | R [1..1] | |||
| Encounter.hospitalization.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| Encounter.hospitalization.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Encounter.hospitalization.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Encounter.hospitalization.preAdmissionIdentifier | 0 | 1 | Identifier |
Pre-admission identifier | Pre-admission identifier. | NR | ||||
| Encounter.hospitalization.origin | 0 | 1 | Reference(Location|Organization) |
The location/organization from which the patient came before admission | The location/organization from which the patient came before admission. | NR | ||||
| Encounter.hospitalization.admitSource | 0 | 1 | CodeableConcept |
From where patient was admitted (physician referral, transfer) | From where patient was admitted (physician referral, transfer). | preferred | AdmitSource | http://hl7.org/fhir/ValueSet/encounter-admit-source | MS [0..1] | |
| Encounter.hospitalization.reAdmission | 0 | 1 | CodeableConcept |
The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission | Whether this hospitalization is a readmission and why if known. | example | Hl7VSReAdmissionIndicator | http://terminology.hl7.org/ValueSet/v2-0092 | MS [0..1] | |
| Encounter.hospitalization.dietPreference | 0 | * | CodeableConcept |
Diet preferences reported by the patient | Diet preferences reported by the patient. | example | Diet | http://hl7.org/fhir/ValueSet/encounter-diet | MS [0..1] | |
| Encounter.hospitalization.specialCourtesy | 0 | * | CodeableConcept |
Special courtesies (VIP, board member) | Special courtesies (VIP, board member). | preferred | SpecialCourtesy | http://hl7.org/fhir/ValueSet/encounter-special-courtesy | NR | |
| Encounter.hospitalization.specialArrangement | 0 | * | CodeableConcept |
Wheelchair, translator, stretcher, etc. | Any special requests that have been made for this hospitalization encounter, such as the provision of specific equipment or other things. | preferred | SpecialArrangements | http://hl7.org/fhir/ValueSet/encounter-special-arrangements | NR | |
| Encounter.hospitalization.destination | 0 | 1 | Reference(Location|Organization) |
Location/organization to which the patient is discharged | Location/organization to which the patient is discharged. | NR | ||||
| Encounter.hospitalization.dischargeDisposition | 0 | 1 | Y | CodeableConcept |
Category or kind of location after discharge | Category or kind of location after discharge. | example | DischargeDisposition | http://hl7.org/fhir/R4/ValueSet/encounter-discharge-disposition | MS [0..1] |
| Encounter.location | 0 | * | Y | BackboneElement |
List of locations where the patient has been | List of locations where the patient has been during this encounter. | R [1..*] | |||
| Encounter.location.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| Encounter.location.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Encounter.location.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Encounter.location.location | 1 | 1 | Y | Reference(Location) |
Location the encounter takes place | The location where the encounter takes place. | R [1..1] | |||
| Encounter.location.status | 0 | 1 | code |
planned | active | reserved | completed | The status of the participants' presence at the specified location during the period specified. If the participant is no longer at the location, then the period will have an end date/time. | required | EncounterLocationStatus | http://hl7.org/fhir/ValueSet/encounter-location-status | MS [0..1] | |
| Encounter.location.physicalType | 0 | 1 | CodeableConcept |
The physical type of the location (usually the level in the location hierachy - bed room ward etc.) | This will be used to specify the required levels (bed/ward/room/etc.) desired to be recorded to simplify either messaging or query. | example | LocationType | http://hl7.org/fhir/R4/valueset-location-physical-type.html | MS [0..1] | |
| Encounter.location.period | 0 | 1 | Period |
Time period during which the patient was present at the location | Time period during which the patient was present at the location. | R [1..1] | ||||
| Encounter.serviceProvider | 0 | 1 | Y | Reference(Organization) |
The organization (facility) responsible for this encounter | The organization that is primarily responsible for this Encounter's services. This MAY be the same as the organization on the Patient record, however it could be different, such as if the actor performing the services was from an external organization (which may be billed seperately) for an external consultation. Refer to the example bundle showing an abbreviated set of Encounters for a colonoscopy. | NRT | |||
| Encounter.partOf | 0 | 1 | Reference(Encounter) |
Another Encounter this encounter is part of | Another Encounter of which this encounter is a part of (administratively or in time). | NR |
| Back to TOC | |||||||||||
| Path | Min | Max | Must Support? | Type(s) | Short | Definition | Comments | Binding Strength | Binding Description | Binding Value Set Note: if the binding strength is an example, the binding value set in this column is not required to be used. |
Cross Measure Requirements |
| Device.id | 0 | 1 | string |
Logical id of this artifact | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | R [1..1] | ||||
| Device.udiCarrier.deviceIdentifier | 1 | 1 | Y | string |
Mandatory fixed portion of UDI | The device identifier (DI) is a mandatory, fixed portion of a UDI that identifies the labeler and the specific version or model of a device. | R [1..1] | ||||
| Device.deviceName.name | 1 | 1 | string |
The name of the device | The name of the device. | R [1..1] | |||||
| Device.deviceName.type | 1 | 1 | code |
udi-label-name | user-friendly-name | patient-reported-name | manufacturer-name | model-name | other | The type of deviceName. UDILabelName | UserFriendlyName | PatientReportedName | ManufactureDeviceName | ModelName. |
required | The type of name the device is referred by. | http://hl7.org/fhir/ValueSet/device-nametype|4.0.1 | R [1..1] | ||
| Device.type | 1 | 1 | Y | CodeableConcept |
The kind or type of device | The kind or type of device. | extensible | Codes to identify medical devices | http://hl7.org/fhir/ValueSet/device-kind | R [1..1] | |
| Device.patient | 1 | 1 | Y | Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient) |
Patient to whom Device is affixed | Patient information, If the device is affixed to a person. | R [1..1] | ||||
| Device.meta | 0 | 1 | Meta |
Metadata about the resource | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | NRT | |||||
| Device.implicitRules | 0 | 1 | uri |
A set of rules under which this content was created | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. | NRT | ||||
| Device.language | 0 | 1 | code |
Language of the resource content | The base language in which the resource is written. | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). | preferred | A human language. | http://hl7.org/fhir/ValueSet/languages | NRT | |
| Device.text | 0 | 1 | Narrative |
Text summary of the resource, for human interpretation | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. | NRT | ||||
| Device.contained | 0 | * | Resource |
Contained, inline Resources | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. | NRT | ||||
| Device.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| Device.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| Device.identifier | 0 | * | Identifier |
Instance identifier | Unique instance identifiers assigned to a device by manufacturers other organizations or owners. | The barcode string from a barcode present on a device label or package may identify the instance, include names given to the device in local usage, or may identify the type of device. If the identifier identifies the type of device, Device.type element should be used. | NRT | ||||
| Device.deviceName.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | |||||
| Device.deviceName.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| Device.deviceName.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| Device.specialization.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | |||||
| Device.specialization.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| Device.specialization.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| Device.version.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | |||||
| Device.version.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| Device.version.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| Device.property.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | |||||
| Device.property.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| Device.property.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | ||||
| Device.definition | 0 | 1 | Reference(DeviceDefinition) |
The reference to the definition for the device | The reference to the definition for the device. | NR | |||||
| Device.udiCarrier.issuer | 0 | 1 | uri |
UDI Issuing Organization | Organization that is charged with issuing UDIs for devices. For example, the US FDA issuers include : 1) GS1: http://hl7.org/fhir/NamingSystem/gs1-di, 2) HIBCC: http://hl7.org/fhir/NamingSystem/hibcc-dI, 3) ICCBBA for blood containers: http://hl7.org/fhir/NamingSystem/iccbba-blood-di, 4) ICCBA for other devices: http://hl7.org/fhir/NamingSystem/iccbba-other-di. |
NR | |||||
| Device.udiCarrier.jurisdiction | 0 | 1 | uri |
Regional UDI authority | The identity of the authoritative source for UDI generation within a jurisdiction. All UDIs are globally unique within a single namespace with the appropriate repository uri as the system. For example, UDIs of devices managed in the U.S. by the FDA, the value is http://hl7.org/fhir/NamingSystem/fda-udi. | NR | |||||
| Device.udiCarrier.entryType | 0 | 1 | code |
barcode | rfid | manual + | A coded entry to indicate how the data was entered. | required | Codes to identify how UDI data was entered. | http://hl7.org/fhir/ValueSet/udi-entry-type|4.0.1 | NR | ||
| Device.statusReason | 0 | * | CodeableConcept |
online | paused | standby | offline | not-ready | transduc-discon | hw-discon | off | Reason for the status of the Device availability. | extensible | The availability status reason of the device. | http://hl7.org/fhir/ValueSet/device-status-reason | NR | ||
| Device.manufacturer | 0 | 1 | string |
Name of device manufacturer | A name of the manufacturer. | NR | |||||
| Device.modelNumber | 0 | 1 | string |
The model number for the device | The model number for the device. | NR | |||||
| Device.partNumber | 0 | 1 | string |
The part number of the device | The part number of the device. | Alphanumeric Maximum 20. | NR | ||||
| Device.specialization | 0 | * | BackboneElement |
The capabilities supported on a device, the standards to which the device conforms for a particular purpose, and used for the communication | The capabilities supported on a device, the standards to which the device conforms for a particular purpose, and used for the communication. | NR | |||||
| Device.specialization.systemType | 1 | 1 | CodeableConcept |
The standard that is used to operate and communicate | The standard that is used to operate and communicate. | NR | |||||
| Device.specialization.version | 0 | 1 | string |
The version of the standard that is used to operate and communicate | The version of the standard that is used to operate and communicate. | NR | |||||
| Device.version | 0 | * | BackboneElement |
The actual design of the device or software version running on the device | The actual design of the device or software version running on the device. | NR | |||||
| Device.version.type | 0 | 1 | CodeableConcept |
The type of the device version | The type of the device version. | NR | |||||
| Device.version.component | 0 | 1 | Identifier |
A single component of the device version | A single component of the device version. | NR | |||||
| Device.version.value | 1 | 1 | string |
The version text | The version text. | NR | |||||
| Device.property | 0 | * | BackboneElement |
The actual configuration settings of a device as it actually operates, e.g., regulation status, time properties | The actual configuration settings of a device as it actually operates, e.g., regulation status, time properties. | NR | |||||
| Device.property.type | 1 | 1 | CodeableConcept |
Code that specifies the property DeviceDefinitionPropetyCode (Extensible) | Code that specifies the property DeviceDefinitionPropetyCode (Extensible). | NR | |||||
| Device.property.valueQuantity | 0 | * | Quantity |
Property value as a quantity | Property value as a quantity. | NR | |||||
| Device.property.valueCode | 0 | * | CodeableConcept |
Property value as a code, e.g., NTP4 (synced to NTP) | Property value as a code, e.g., NTP4 (synced to NTP). | NR | |||||
| Device.udiCarrier | 0 | 1 | Y | BackboneElement |
Unique Device Identifier (UDI) Barcode string | Unique device identifier (UDI) assigned to device label or package. Note that the Device may include multiple udiCarriers as it either may include just the udiCarrier for the jurisdiction it is sold, or for multiple jurisdictions it could have been sold. | Some devices may not have UDI information (for example. historical data or patient reported data). | MS [0..1] | |||
| Device.udiCarrier.carrierAIDC | 0 | 1 | Y | base64Binary |
UDI Machine Readable Barcode String | The full UDI carrier of the Automatic Identification and Data Capture (AIDC) technology representation of the barcode string as printed on the packaging of the device - e.g., a barcode or RFID. Because of limitations on character sets in XML and the need to round-trip JSON data through XML, AIDC Formats *SHALL* be base64 encoded. | The AIDC form of UDIs should be scanned or otherwise used for the identification of the device whenever possible to minimize errors in records resulting from manual transcriptions. If separate barcodes for DI and PI are present, concatenate the string with DI first and in order of human readable expression on label. | MS [0..1] | |||
| Device.udiCarrier.carrierHRF | 0 | 1 | Y | string |
UDI Human Readable Barcode String | The full UDI carrier as the human readable form (HRF) representation of the barcode string as printed on the packaging of the device. | If separate barcodes for DI and PI are present, concatenate the string with DI first and in order of human readable expression on label. | MS [0..1] | |||
| Device.status | 0 | 1 | code |
active | inactive | entered-in-error | unknown | Status of the Device availability. | This element is labeled as a modifier because the status contains the codes inactive and entered-in-error that mark the device (record)as not currently valid. | required | The availability status of the device. | http://hl7.org/fhir/ValueSet/device-status|4.0.1 | MS [0..1] | |
| Device.distinctIdentifier | 0 | 1 | Y | string |
The distinct identification string | The distinct identification string as required by regulation for a human cell, tissue, or cellular and tissue-based product. | For example, this applies to devices in the United States regulated under *Code of Federal Regulation 21CFR§1271.290(c)*. | MS [0..1] | |||
| Device.manufactureDate | 0 | 1 | Y | dateTime |
Date when the device was made | The date and time when the device was manufactured. | MS [0..1] | ||||
| Device.expirationDate | 0 | 1 | Y | dateTime |
Date and time of expiry of this device (if applicable) | The date and time beyond which this device is no longer valid or should not be used (if applicable). | MS [0..1] | ||||
| Device.lotNumber | 0 | 1 | Y | string |
Lot number of manufacture | Lot number assigned by the manufacturer. | MS [0..1] | ||||
| Device.serialNumber | 0 | 1 | Y | string |
Serial number assigned by the manufacturer | The serial number assigned by the organization when the device was manufactured. | Alphanumeric Maximum 20. | MS [0..1] | |||
| Device.deviceName | 0 | * | BackboneElement |
The name of the device as given by the manufacturer | This represents the manufacturer's name of the device as provided by the device, from a UDI label, or by a person describing the Device. This typically would be used when a person provides the name(s) or when the device represents one of the names available from DeviceDefinition. | MS [0..1*] | |||||
| Device | 0 | * | Item used in healthcare | The US Core Implantable Device Profile is based upon the core FHIR Device Resource and created to meet the 2015 Edition Common Clinical Data Set 'Unique device identifier(s) for a patient’s implantable device(s)' requirements. | MS [0..*] |
| Back to TOC | link to change log | ||||||||||
| FHIR Path | Min | Max | Must Support? | Type(s) | Short | Definition | Binding Strength | Binding Description (Value Set Name) | Binding Value Set | Cross Measure = Requirements | |
| Observation | 0 | * | Observation | Measurements and simple assertions | This profile is created to meet the 2015 Edition Common Clinical Data Set 'Laboratory test(s) and Laboratory value(s)/result(s)' requirements. | MS [0..*] | |||||
| Observation.id | 0 | 1 | string |
Logical id of this artifact | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | R [1..1] | |||||
| Observation.meta | 0 | 1 | Meta |
Metadata about the resource | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | NRT | |||||
| Observation.implicitRules | 0 | 1 | uri |
A set of rules under which this content was created | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | NRT | |||||
| Observation.language | 0 | 1 | code |
Language of the resource content | The base language in which the resource is written. | preferred | CommonLanguages | http://hl7.org/fhir/ValueSet/languages | NRT | ||
| Observation.text | 0 | 1 | Narrative |
Text summary of the resource, for human interpretation | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | NRT | |||||
| Observation.contained | 0 | * | Resource |
Contained, inline Resources | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | NRT | |||||
| Observation.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | |||||
| Observation.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | |||||
| Observation.identifier | 0 | * | Identifier |
Business Identifier for observation | A unique identifier assigned to this observation. | NRT | |||||
| Observation.basedOn | 0 | * | Reference(CarePlan|DeviceRequest|ImmunizationRecommendation|MedicationRequest|NutritionOrder|ServiceRequest) |
Fulfills plan, proposal or order | A plan, proposal or order that is fulfilled in whole or in part by this event. For example, a MedicationRequest may require a patient to have laboratory test performed before it is dispensed. | NR | |||||
| Observation.partOf | 0 | * | Reference(MedicationAdministration|MedicationDispense|MedicationStatement|Procedure|Immunization|ImagingStudy) |
Part of referenced event | A larger event of which this particular Observation is a component or step. For example, an observation as part of a procedure. | NR | |||||
| Observation.status | 1 | 1 | Y | code |
registered | preliminary | final | amended + | The status of the result value. | required | ObservationStatus | http://hl7.org/fhir/R4/ValueSet/observation-status | R [1..1] | |
| Observation.category | 1 | * | Y | Slice Definition |
Classification of type of observation Slice: Unordered, Open by pattern:$this |
A code that classifies the general type of observation being made. | preferred | ObservationCategoryCodes | http://hl7.org/fhir/ValueSet/observation-category | R [1..*] | RPS question for FHIR SME: what does this mean? 5/10/23 Per Dave: Observation.category notes the classification of the type of the observation. It is a flag that can be use (ie implemented) to represent one or many concepts referring to the type or classification of the observation. Some common examples of classifications we might see (some of the time) are here. I could see a hospital including a local code ‘transmission-based-precaution’ or ‘tbp’ code here; I could also see a hospital using one of these codes or their own other codes to represent the concept of ‘tbp’. But also, expect some hospitals may not use Observations to convey the concept of a TBP. In a nutshell, to me, Observation.category is a key element that Link should transmit to NHSN. beyond that, I think we need to wait and see multiple hospitals’ data before we can begin to inform an understanding/expectation regarding what coded concepts we may expect here. And our understanding will need to keep evolving as we onboard more and more hospitals. Note- while many .category repetitions are allowed for a single Observation, at least 1 is required, so any Observation that does not have at least one Observation.category will be an invalid Observation. |
| Observation.category:Laboratory | 1 | 1 | Y | CodeableConcept |
Classification of type of observation | A code that classifies the general type of observation being made. | preferred | ObservationCategoryCodes | http://hl7.org/fhir/ValueSet/observation-category | R [1..1] | |
| Observation.category.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | |||||
| Observation.category.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | |||||
| Observation.category.coding | 1 | * | Y | Coding | Code defined by a terminology system | A reference to a code defined by a terminology system. | NR | ||||
| Observation.category.coding.id | 0 | 1 | string | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NR | |||||
| Observation.category.coding.extension | 0 | * | Extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NR | |||||
| Observation.category.coding.system | 1 | 1 | Y | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category |
The identification of the code system that defines the meaning of the symbol in the code. | NR | ||||
| Observation.category.coding.version | 0 | 1 | string | Version of the system - if relevant | The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. | NR | |||||
| Observation.category.coding.code | 1 | 1 | Y | code | Symbol in syntax defined by the system Fixed Value: laboratory |
A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). | NR | ||||
| Observation.category.coding.display | 0 | 1 | string | Representation defined by the system | A representation of the meaning of the code in the system, following the rules of the system. | NR | |||||
| Observation.category.coding.userSelected | 0 | 1 | boolean | If this coding was chosen directly by the user | Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). | NR | |||||
| Observation.category.text | 0 | 1 | string | Plain text representation of the concept | A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. | NR | |||||
| Observation.code | 1 | 1 | Y | CodeableConcept |
Laboratory Test Name | The test that was performed. A LOINC **SHALL** be used if the concept is present in LOINC. | extensible | LOINCCodes | http://hl7.org/fhir/ValueSet/observation-codes | R [1..1] The following constraint is written into the CQL: "Blood Glucose Laboratory and Point of Care Tests" http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1190.38 |
|
| Observation.subject | 1 | 1 | Y | Reference(US Core Patient Profile) |
Who and/or what the observation is about | The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the `focus` element or the `code` itself specifies the actual focus of the observation. | R [1..1] | ||||
| Observation.focus | 0 | * | Reference(Resource) |
What the observation is about, when it is not about the subject of record | The actual focus of an observation when it is not the patient of record representing something or someone associated with the patient such as a spouse, parent, fetus, or donor. For example, fetus observations in a mother's record. The focus of an observation could also be an existing condition, an intervention, the subject's diet, another observation of the subject, or a body structure such as tumor or implanted device. An example use case would be using the Observation resource to capture whether the mother is trained to change her child's tracheostomy tube. In this example, the child is the patient of record and the mother is the focus. | NR | |||||
| Observation.encounter | 0 | 1 | Reference(Encounter) |
Healthcare event during which this observation is made | The healthcare event (e.g. a patient and healthcare provider interaction) during which this observation is made. | MS [0..1] | |||||
| Observation.effective[x] | 0 | 1 | Y | dateTime Period |
Clinically relevant time/time-period for observation us-core-1: Datetime must be at least to day. |
For lab tests this is the specimen collection date. For Ask at Order Entry Questions (AOE)'s this is the date the question was asked. | R [1..1] | ||||
| Observation.issued | 0 | 1 | instant |
Date/Time this version was made available | The date and time this version of the observation was made available to providers, typically after the results have been reviewed and verified. | MS [0..1] | |||||
| Observation.performer | 0 | * | Reference(Practitioner|PractitionerRole|Organization|CareTeam|Patient|RelatedPerson) |
Who is responsible for the observation | Who was responsible for asserting the observed value as "true". | NR | |||||
| Observation.value[x] | 0 | 1 | Y | Quantity CodeableConcept string boolean integer Range Ratio SampledData time dateTime Period |
Result Value | The Laboratory result value. If a coded value, the valueCodeableConcept.code **SHOULD** be selected from [SNOMED CT](http://hl7.org/fhir/ValueSet/uslab-obs-codedresults) if the concept exists. If a numeric value, valueQuantity.code **SHALL** be selected from [UCUM](http://unitsofmeasure.org). A FHIR [UCUM Codes value set](http://hl7.org/fhir/STU3/valueset-ucum-units.html) that defines all UCUM codes is in the FHIR specification. | MS [0..1] | ||||
| Observation.dataAbsentReason | 0 | 1 | Y | CodeableConcept |
Why the result is missing | Provides a reason why the expected value in the element Observation.value[x] is missing. | extensible | DataAbsentReason | http://hl7.org/fhir/R4/ValueSet/data-absent-reason | MS [0..1] | |
| Observation.interpretation | 0 | * | CodeableConcept |
High, low, normal, etc. | A categorical assessment of an observation value. For example, high, low, normal. | extensible | ObservationInterpretationCodes | http://hl7.org/fhir/ValueSet/observation-interpretation | MS [0..*] | ||
| Observation.note | 0 | * | Annotation |
Comments about the observation | Comments about the observation or the results. | NR | |||||
| Observation.bodySite | 0 | 1 | CodeableConcept |
Observed body part | Indicates the site on the subject's body where the observation was made (i.e. the target site). | example | SNOMEDCTBodyStructures | http://hl7.org/fhir/ValueSet/body-site | MS [0..1} | ||
| Observation.method | 0 | 1 | CodeableConcept |
How it was done | Indicates the mechanism used to perform the observation. | example | ObservationMethods | http://hl7.org/fhir/ValueSet/observation-methods | MS [0..1} | ||
| Observation.specimen | 0 | 1 | Reference(Specimen) |
Specimen used for this observation | The specimen that was used when this observation was made. | MS [0..1] | |||||
| Observation.device | 0 | 1 | Reference(Device|DeviceMetric) |
(Measurement) Device | The device used to generate the observation data. | NR | |||||
| Observation.referenceRange | 0 | * | BackboneElement |
Provides guide for interpretation | Guidance on how to interpret the value by comparison to a normal or recommended range. Multiple reference ranges are interpreted as an "OR". In other words, to represent two distinct target populations, two `referenceRange` elements would be used. | NR | |||||
| Observation.referenceRange.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | |||||
| Observation.referenceRange.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | |||||
| Observation.referenceRange.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | |||||
| Observation.referenceRange.low | 0 | 1 | SimpleQuantity |
Low Range, if relevant | The value of the low bound of the reference range. The low bound of the reference range endpoint is inclusive of the value (e.g. reference range is >=5 - <=9). If the low bound is omitted, it is assumed to be meaningless (e.g. reference range is <=2.3). | NR | |||||
| Observation.referenceRange.high | 0 | 1 | SimpleQuantity |
High Range, if relevant | The value of the high bound of the reference range. The high bound of the reference range endpoint is inclusive of the value (e.g. reference range is >=5 - <=9). If the high bound is omitted, it is assumed to be meaningless (e.g. reference range is >= 2.3). | NR | |||||
| Observation.referenceRange.type | 0 | 1 | CodeableConcept |
Reference range qualifier | Codes to indicate the what part of the targeted reference population it applies to. For example, the normal or therapeutic range. | preferred | ObservationReferenceRangeMeaningCodes | http://hl7.org/fhir/ValueSet/referencerange-meaning | NR | ||
| Observation.referenceRange.appliesTo | 0 | * | CodeableConcept |
Reference range population | Codes to indicate the target population this reference range applies to. For example, a reference range may be based on the normal population or a particular sex or race. Multiple `appliesTo` are interpreted as an "AND" of the target populations. For example, to represent a target population of African American females, both a code of female and a code for African American would be used. | example | ObservationReferenceRangeAppliesToCodes | http://hl7.org/fhir/ValueSet/referencerange-appliesto | NR | ||
| Observation.referenceRange.age | 0 | 1 | Range |
Applicable age range, if relevant | The age at which this reference range is applicable. This is a neonatal age (e.g. number of weeks at term) if the meaning says so. | NR | |||||
| Observation.referenceRange.text | 0 | 1 | string |
Text based reference range in an observation | Text based reference range in an observation which may be used when a quantitative range is not appropriate for an observation. An example would be a reference value of "Negative" or a list or table of "normals". | NR | |||||
| Observation.hasMember | 0 | * | Reference(Observation|QuestionnaireResponse|MolecularSequence) |
Related resource that belongs to the Observation group | This observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group. | NR | |||||
| Observation.derivedFrom | 0 | * | Reference(DocumentReference|ImagingStudy|Media|QuestionnaireResponse|Observation|MolecularSequence) |
Related measurements the observation is made from | The target resource that represents a measurement from which this observation value is derived. For example, a calculated anion gap or a fetal measurement based on an ultrasound image. | NR | |||||
| Observation.component | 0 | * | BackboneElement |
Component results | Some observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes. Examples include systolic and diastolic component observations for blood pressure measurement and multiple component observations for genetics observations. | MS [0..*] | |||||
| Observation.component.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | |||||
| Observation.component.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | |||||
| Observation.component.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | |||||
| Observation.component.code | 1 | 1 | CodeableConcept |
Type of component observation (code / type) | Describes what was observed. Sometimes this is called the observation "code". | example | LOINCCodes | http://hl7.org/fhir/R4/valueset-observation-codes.html | R [1..1] | ||
| Observation.component.value[x] | 0 | 1 | Quantity CodeableConcept string boolean integer Range Ratio SampledData time dateTime Period |
Actual component result | The information determined as a result of making the observation, if the information has a simple value. | MS [0..1] | |||||
| Observation.component.dataAbsentReason | 0 | 1 | CodeableConcept |
Why the component result is missing | Provides a reason why the expected value in the element Observation.component.value[x] is missing. | extensible | DataAbsentReason | http://hl7.org/fhir/R4/ValueSet/data-absent-reason | NR | ||
| Observation.component.interpretation | 0 | * | CodeableConcept |
High, low, normal, etc. | A categorical assessment of an observation value. For example, high, low, normal. | extensible | ObservationInterpretationCodes | http://hl7.org/fhir/ValueSet/observation-interpretation | MS [0..*] | ||
| Observation.component.referenceRange | 0 | * | Provides guide for interpretation of component result | Guidance on how to interpret the value by comparison to a normal or recommended range. | NR |
| Back to TOC | ||||||||||
| FHIR Path - http://hl7.org/fhir/us/core/StructureDefinition/us-core-location |
Min | Max | Must Support | Type(s) | Short | Definition | Binding Strength | Binding Description | Binding Value Set | Cross Measure Requirements |
| Location | 0 | * | Details and position information for a physical place | Details and position information for a physical place where services are provided and resources and participants may be stored, found, contained, or accommodated. | R [1..*] | |||||
| Location.id | 0 | 1 | Y | string |
Logical id of this artifact | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | R [1..1] | |||
| Location.meta | 0 | 1 | Meta |
Metadata about the resource | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | NRT | ||||
| Location.implicitRules | 0 | 1 | uri |
A set of rules under which this content was created | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | NRT | ||||
| Location.language | 0 | 1 | code |
Language of the resource content | The base language in which the resource is written. | preferred | CommonLanguages | http://hl7.org/fhir/ValueSet/languages | NRT | |
| Location.text | 0 | 1 | Narrative |
Text summary of the resource, for human interpretation | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | NRT | ||||
| Location.contained | 0 | * | Resource |
Contained, inline Resources | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | NRT | ||||
| Location.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Location.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Location.identifier | 0 | * | Identifier |
Unique code or number identifying the location to its users | Unique code or number identifying the location to its users. | NR | ||||
| Location.status | 0 | 1 | Y | code |
active | suspended | inactive | The status property covers the general availability of the resource, not the current value which may be covered by the operationStatus, or by a schedule/slots if they are configured for the location. | required | LocationStatus | http://hl7.org/fhir/ValueSet/location-status|4.0.1 | MS [0..1] |
| Location.operationalStatus | 0 | 1 | Coding |
The operational status of the location (typically only for a bed/room) | The operational status covers operation values most relevant to beds (but can also apply to rooms/units/chairs/etc. such as an isolation unit/dialysis chair). This typically covers concepts such as contamination, housekeeping, and other activities like maintenance. | preferred | hl7VS-bedStatus | http://terminology.hl7.org/ValueSet/v2-0116 | NR | |
| Location.name | 1 | 1 | Y | string |
Name of the location as used by humans | Name of the location as used by humans. Does not need to be unique. | R [1..1] | |||
| Location.alias | 0 | * | string |
A list of alternate names that the location is known as, or was known as, in the past | A list of alternate names that the location is known as, or was known as, in the past. | MS [0..*] | ||||
| Location.description | 0 | 1 | string |
Additional details about the location that could be displayed as further information to identify the location beyond its name | Description of the Location, which helps in finding or referencing the place. | NR | ||||
| Location.mode | 0 | 1 | code |
instance | kind | Indicates whether a resource instance represents a specific location or a class of locations. | required | LocationMode | http://hl7.org/fhir/ValueSet/location-mode|4.0.1 | NR | |
| Location.type | 0 | * | CodeableConcept |
Type of function performed | Indicates the type of function performed at the location. | extensible | ServiceDeliveryLocationRoleType | http://terminology.hl7.org/ValueSet/v3-ServiceDeliveryLocationRoleType | R [1..*] The following constraint is written into the CQL: valueset "Inpatient, Emergency, and Observation Locations": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1046.265' |
|
| Location.telecom | 0 | * | Y | ContactPoint |
Contact details of the location | The contact details of communication devices available at the location. This can include phone numbers, fax numbers, mobile numbers, email addresses and web sites. | MS [0..*] | |||
| Location.address | 0 | 1 | Y | Address |
Physical location | Physical location. | MS [0..1] | |||
| Location.address.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| Location.address.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Location.address.use | 0 | 1 | code |
home | work | temp | old | billing - purpose of this address | The purpose of this address. | required | AddressUse | http://hl7.org/fhir/ValueSet/address-use|4.0.1 | MS [0..1] | |
| Location.address.type | 0 | 1 | code |
postal | physical | both | Distinguishes between physical addresses (those you can visit) and mailing addresses (e.g. PO Boxes and care-of addresses). Most addresses are both. | required | AddressType | http://hl7.org/fhir/ValueSet/address-type|4.0.1 | NR | |
| Location.address.text | 0 | 1 | string |
Text representation of the address | Specifies the entire address as it should be displayed e.g. on a postal label. This may be provided instead of or as well as the specific parts. | NR | ||||
| Location.address.line | 0 | * | Y | string |
Street name, number, direction & P.O. Box etc. | This component contains the house number, apartment number, street name, street direction, P.O. Box number, delivery hints, and similar address information. | NR | |||
| Location.address.city | 0 | 1 | Y | string |
Name of city, town etc. | The name of the city, town, suburb, village or other community or delivery center. | NR | |||
| Location.address.district | 0 | 1 | string |
District name (aka county) | The name of the administrative area (county). | NR | ||||
| Location.address.state | 0 | 1 | Y | string |
Sub-unit of country (abbreviations ok) | Sub-unit of a country with limited sovereignty in a federally organized country. A code may be used if codes are in common use (e.g. US 2 letter state codes). | extensible | USPS Two Letter Alphabetic Codes | http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state | NR |
| Location.address.postalCode | 0 | 1 | Y | string |
US Zip Codes | A postal code designating a region defined by the postal service. | NR | |||
| Location.address.country | 0 | 1 | string |
Country (e.g. can be ISO 3166 2 or 3 letter code) | Country - a nation as commonly understood or generally accepted. | NR | ||||
| Location.address.period | 0 | 1 | Period |
Time period when address was/is in use | Time period when address was/is in use. | NR | ||||
| Location.physicalType | 0 | 1 | CodeableConcept |
Physical form of the location | Physical form of the location, e.g. building, room, vehicle, road. | example | Physical form of the location. | http://hl7.org/fhir/ValueSet/location-physical-type | MS [0..1] | |
| Location.position | 0 | 1 | BackboneElement |
The absolute geographic location | The absolute geographic location of the Location, expressed using the WGS84 datum (This is the same co-ordinate system used in KML). | NR | ||||
| Location.position.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| Location.position.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Location.position.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Location.position.longitude | 1 | 1 | decimal |
Longitude with WGS84 datum | Longitude. The value domain and the interpretation are the same as for the text of the longitude element in KML (see notes below). | NR | ||||
| Location.position.latitude | 1 | 1 | decimal |
Latitude with WGS84 datum | Latitude. The value domain and the interpretation are the same as for the text of the latitude element in KML (see notes below). | NR | ||||
| Location.position.altitude | 0 | 1 | decimal |
Altitude with WGS84 datum | Altitude. The value domain and the interpretation are the same as for the text of the altitude element in KML (see notes below). | NR | ||||
| Location.managingOrganization | 0 | 1 | Y | Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization) |
Organization responsible for provisioning and upkeep | The organization responsible for the provisioning and upkeep of the location. | MS [0..1] | |||
| Location.partOf | 0 | 1 | Reference(Location) |
Another Location this one is physically a part of | Another Location of which this Location is physically a part of. | MS [0..1] | ||||
| Location.hoursOfOperation | 0 | * | BackboneElement |
What days/times during a week is this location usually open | What days/times during a week is this location usually open. | NR | ||||
| Location.hoursOfOperation.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| Location.hoursOfOperation.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Location.hoursOfOperation.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Location.hoursOfOperation.daysOfWeek | 0 | * | code |
mon | tue | wed | thu | fri | sat | sun | Indicates which days of the week are available between the start and end Times. | required | The days of the week. | http://hl7.org/fhir/ValueSet/days-of-week|4.0.1 | NR | |
| Location.hoursOfOperation.allDay | 0 | 1 | boolean |
The Location is open all day | The Location is open all day. | NR | ||||
| Location.hoursOfOperation.openingTime | 0 | 1 | time |
Time that the Location opens | Time that the Location opens. | NR | ||||
| Location.hoursOfOperation.closingTime | 0 | 1 | time |
Time that the Location closes | Time that the Location closes. | NR | ||||
| Location.availabilityExceptions | 0 | 1 | string |
Description of availability exceptions | A description of when the locations opening ours are different to normal, e.g. public holiday availability. Succinctly describing all possible exceptions to normal site availability as detailed in the opening hours Times. | NR | ||||
| Location.endpoint | 0 | * | Reference(Endpoint) |
Technical endpoints providing access to services operated for the location | Technical endpoints providing access to services operated for the location. | NR |
| Back to TOC | Link to Change Log | |||||||||
| FHIR Path |
Min | Max | Must Support? | Type(s) | Short | Definition | Binding Strength | Binding Description | Binding Value Set | Cross Measure Requirements |
| Medication | 0 | * | Medication |
Definition of a Medication | The US Core Medication Profile is based upon the core FHIR Medication Resource and created to meet the 2015 Edition Common Clinical Data Set 'Medications' requirements. | MS [0..*] | ||||
| Medication.id | 0 | 1 | string |
Logical id of this artifact | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | R [1..1] | ||||
| Medication.meta | 0 | 1 | Meta |
Metadata about the resource | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | NRT | ||||
| Medication.implicitRules | 0 | 1 | uri |
A set of rules under which this content was created | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | NRT | ||||
| Medication.language | 0 | 1 | code |
Language of the resource content | The base language in which the resource is written. (ex English) | preferred | CommonLanguages | http://hl7.org/fhir/ValueSet/languages | NRT | |
| Medication.text | 0 | 1 | Narrative |
Text summary of the resource, for human interpretation | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | NRT | ||||
| Medication.contained | 0 | * | Resource |
Contained, inline Resources | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | NRT | ||||
| Medication.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Medication.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Medication.identifier | 0 | * | Identifier |
Business identifier for this medication | Business identifier for this medication. | NRT | ||||
| Medication.code | 1 | 1 | Y | CodeableConcept |
Codes that identify this medication | A code (or set of codes) that specify this medication, or a textual description if no code is available. Usage note: This could be a standard medication code such as a code from RxNorm, SNOMED CT, IDMP etc. It could also be a national or local formulary code, optionally with translations to other code systems. | extensible | USCoreMedicationCodes | http://hl7.org/fhir/us/core/STU3.1.1/ValueSet-us-core-medication-codes.html | R [1..1] |
| Medication.status | 0 | 1 | code |
active | inactive | entered-in-error | A code to indicate if the medication is in active use. | required | Medication Status Codes | http://hl7.org/fhir/ValueSet/medication-status|4.0.1 | NR | |
| Medication.manufacturer | 0 | 1 | Reference(Organization) |
Manufacturer of the item | Describes the details of the manufacturer of the medication product. This is not intended to represent the distributor of a medication product. | NR | ||||
| Medication.form | 0 | 1 | CodeableConcept |
powder | tablets | capsule + | Describes the form of the item. Powder; tablets; capsule. | example | 4.0.1 SNOMEDCTFormCodes |
http://hl7.org/fhir/ValueSet/medication-form-codes | MS [0..1] | |
| Medication.amount | 0 | 1 | Ratio |
Amount of drug in package | Specific amount of the drug in the packaged product. For example, when specifying a product that has the same strength (For example, Insulin glargine 100 unit per mL solution for injection), this attribute provides additional clarification of the package amount (For example, 3 mL, 10mL, etc.). | MS [0..1] | ||||
| Medication.ingredient | 0 | * | BackboneElement |
Active or inactive ingredient | Identifies a particular constituent of interest in the product. | MS [0..*] | ||||
| Medication.ingredient.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| Medication.ingredient.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Medication.ingredient.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Medication.ingredient.item[x] | 1 | 1 | CodeableConcept Reference(Substance|Medication) |
The actual ingredient or content | The actual ingredient - either a substance (simple ingredient) or another medication of a medication. | R [1..1] | ||||
| Medication.ingredient.isActive | 0 | 1 | boolean |
Active ingredient indicator | Indication of whether this ingredient affects the therapeutic action of the drug. | NRT | ||||
| Medication.ingredient.strength | 0 | 1 | Ratio |
Quantity of ingredient present | Specifies how many (or how much) of the items there are in this Medication. For example, 250 mg per tablet. This is expressed as a ratio where the numerator is 250mg and the denominator is 1 tablet. | NR | ||||
| Medication.batch | 0 | 1 | BackboneElement |
Details about packaged medications | Information that only applies to packages (not products). | NR | ||||
| Medication.batch.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| Medication.batch.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Medication.batch.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Medication.batch.lotNumber | 0 | 1 | string |
Identifier assigned to batch | The assigned lot number of a batch of the specified product. | NR | ||||
| Medication.batch.expirationDate | 0 | 1 | dateTime |
When batch will expire | When this specific batch of product will expire. | NR |
| Back to TOC | |||||||||
| FHIRPath | Min | Max | Type(s) | Short | Definition | Binding Strength | Binding Description (Value Set Name) | Binding Value Set | Cross Measure Requirements |
| MedicationAdministration | 0 | * | Administration of medication to a patient | Describes the event of a patient consuming or otherwise being administered a medication. This may be as simple as swallowing a tablet or it may be a long running infusion. Related resources tie this event to the authorizing prescription, and the specific encounter between patient and health care practitioner. | MS [0..*] | ||||
| MedicationAdministration.id | 0 | 1 | id |
Logical id of this artifact | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | R [1..1] | |||
| MedicationAdministration.meta | 0 | 1 | Meta |
Metadata about the resource | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | NRT | |||
| MedicationAdministration.implicitRules | 0 | 1 | uri |
A set of rules under which this content was created | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | NRT | |||
| MedicationAdministration.language | 0 | 1 | code |
Language of the resource content | The base language in which the resource is written. | preferred but limited to AllLanguages | CommonLanguages | http://hl7.org/fhir/ValueSet/languages | NRT |
| MedicationAdministration.text | 0 | 1 | Narrative |
Text summary of the resource, for human interpretation | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | NRT | |||
| MedicationAdministration.contained | 0 | * | Resource |
Contained, inline Resources | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | NRT | |||
| MedicationAdministration.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | |||
| MedicationAdministration.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | |||
| MedicationAdministration.identifier | 0 | * | Identifier |
External identifier | Identifiers associated with this Medication Administration that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate. They are business identifiers assigned to this resource by the performer or other systems and remain constant as the resource is updated and propagates from server to server. | NRT | |||
| MedicationAdministration.instantiates | 0 | * | uri |
Instantiates protocol or definition | A protocol, guideline, orderset, or other definition that was adhered to in whole or in part by this event. | NR | |||
| MedicationAdministration.partOf | 0 | * | Reference(MedicationAdministration|Procedure) |
Part of referenced event | A larger event of which this particular event is a component or step. | NR | |||
| MedicationAdministration.status | 1 | 1 | code |
in-progress | not-done | on-hold | completed | entered-in-error | stopped | unknown | Will generally be set to show that the administration has been completed. For some long running administrations such as infusions, it is possible for an administration to be started but not completed or it may be paused while some other process is under way. | required | MedicationAdministration Status Codes | http://hl7.org/fhir/ValueSet/medication-admin-status | R [1..1] |
| MedicationAdministration.statusReason | 0 | * | CodeableConcept |
Reason administration not performed | A code indicating why the administration was not performed. | example | SNOMEDCTReasonMedicationNotGivenCodes | http://hl7.org/fhir/ValueSet/reason-medication-not-given-codes | MS [0..*] |
| MedicationAdministration.category | 0 | 1 | CodeableConcept |
Type of medication usage | Indicates where the medication is expected to be consumed or administered. | preferred | MedicationAdministration Category Codes | http://hl7.org/fhir/R4/valueset-medication-admin-category.html | MS [0..*] |
| MedicationAdministration.medication[x] | 1 | 1 | CodeableConcept Reference(Medication) |
What was administered | Identifies the medication that was administered. This is either a link to a resource representing the details of the medication or a simple attribute carrying a code that identifies the medication from a known list of medications. | example | SNOMEDCTMedicationCodes | http://hl7.org/fhir/ValueSet/medication-codes | R [1..1] |
| MedicationAdministration.subject | 1 | 1 | Reference(Patient|Group) |
Who received medication | The person or animal or group receiving the medication. | R [1..1] | |||
| MedicationAdministration.context | 0 | 1 | Reference(Encounter|EpisodeOfCare) |
Encounter or Episode of Care administered as part of | The visit, admission, or other contact between patient and health care provider during which the medication administration was performed. | MS [0..1] | |||
| MedicationAdministration.supportingInformation | 0 | * | Reference(Any) |
Additional information to support administration | Additional information (for example, patient height and weight) that supports the administration of the medication. | NR | |||
| MedicationAdministration.effective[x] | 1 | 1 | dateTime Period |
Start and end time of administration | A specific date/time or interval of time during which the administration took place (or did not take place, when the 'notGiven' attribute is true). For many administrations, such as swallowing a tablet the use of dateTime is more appropriate. | R [1..1] | |||
| MedicationAdministration.performer | 0 | * | BackboneElement |
Who performed the medication administration and what they did | Indicates who or what performed the medication administration and how they were involved. | NR | |||
| MedicationAdministration.performer.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | |||
| MedicationAdministration.performer.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | |||
| MedicationAdministration.performer.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | |||
| MedicationAdministration.performer.function | 0 | 1 | CodeableConcept |
Type of performance | Distinguishes the type of involvement of the performer in the medication administration. | example | MedicationAdministration Performer Function Codes | http://hl7.org/fhir/ValueSet/med-admin-perform-function | NR |
| MedicationAdministration.performer.actor | 1 | 1 | Reference(Practitioner|PractitionerRole|Patient|RelatedPerson|Device) |
Who performed the medication administration | Indicates who or what performed the medication administration. | NR | |||
| MedicationAdministration.reasonCode | 0 | * | CodeableConcept |
Reason administration performed | A code indicating why the medication was given. | example | ReasonMedicationGivenCodes | http://hl7.org/fhir/ValueSet/reason-medication-given-codes | MS [0..*] |
| MedicationAdministration.reasonReference | 0 | * | Reference(Condition|Observation|DiagnosticReport) |
Condition or observation that supports why the medication was administered | Condition or observation that supports why the medication was administered. | MS [0..*] | |||
| MedicationAdministration.request | 0 | 1 | Reference(MedicationRequest) |
Request administration performed against | The original request, instruction or authority to perform the administration. | MS [0..1] | |||
| MedicationAdministration.device | 0 | * | Reference(Device) |
Device used to administer | The device used in administering the medication to the patient. For example, a particular infusion pump. | NR | |||
| MedicationAdministration.note | 0 | * | Annotation |
Information about the administration | Extra information about the medication administration that is not conveyed by the other attributes. | NR | |||
| MedicationAdministration.dosage | 0 | 1 | BackboneElement |
Details of how medication was taken + Rule: SHALL have at least one of dosage.dose or dosage.rate[x] |
Describes the medication dosage information details e.g. dose, rate, site, route, etc. | R [1..1] | |||
| MedicationAdministration.dosage.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | |||
| MedicationAdministration.dosage.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | |||
| MedicationAdministration.dosage.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | |||
| MedicationAdministration.dosage.text | 0 | 1 | string |
Free text dosage instructions e.g. SIG | Free text dosage can be used for cases where the dosage administered is too complex to code. When coded dosage is present, the free text dosage may still be present for display to humans._x000D__x000D_The dosage instructions should reflect the dosage of the medication that was administered. | NR | |||
| MedicationAdministration.dosage.site | 0 | 1 | CodeableConcept |
Body site administered to | A coded specification of the anatomic site where the medication first entered the body. For example, "left arm". | example | SNOMEDCTAnatomicalStructureForAdministrationSiteCodes | http://hl7.org/fhir/ValueSet/approach-site-codes | NR |
| MedicationAdministration.dosage.route | 0 | 1 | CodeableConcept |
Path of substance into body | A code specifying the route or physiological path of administration of a therapeutic agent into or onto the patient. For example, topical, intravenous, etc. | example | SNOMEDCTRouteCodes | http://hl7.org/fhir/ValueSet/route-codes | R [1..1] |
| MedicationAdministration.dosage.method | 0 | 1 | CodeableConcept |
How drug was administered | A coded value indicating the method by which the medication is intended to be or was introduced into or on the body. This attribute will most often NOT be populated. It is most commonly used for injections. For example, Slow Push, Deep IV. | example | SNOMEDCTAdministrationMethodCodes | http://hl7.org/fhir/ValueSet/administration-method-codes | MS [0..1] |
| MedicationAdministration.dosage.dose | 0 | 1 | SimpleQuantity |
Amount of medication per dose | The amount of the medication given at one administration event. Use this value when the administration is essentially an instantaneous event such as a swallowing a tablet or giving an injection. | R [1..1] | |||
| MedicationAdministration.dosage.rate[x] | 0 | 1 | Ratio SimpleQuantity |
Dose quantity per unit of time | Identifies the speed with which the medication was or will be introduced into the patient. Typically, the rate for an infusion e.g. 100 ml per 1 hour or 100 ml/hr. May also be expressed as a rate per unit of time, e.g. 500 ml per 2 hours. Other examples: 200 mcg/min or 200 mcg/1 minute; 1 liter/8 hours. | NR | |||
| MedicationAdministration.eventHistory | 0 | * | Reference(Provenance) |
A list of events of interest in the lifecycle | A summary of the events of interest that have occurred, such as when the administration was verified. | NR |
| Back to TOC | ||||||||||
| FHIR Path | Min | Max | Must Support? | Type(s) | Short | Definition | Binding Strength | Binding Description | Binding Value Set | Cross Measure Requirements |
| MedicationRequest | 0 | * | Ordering of medication for patient or group | The US Core Medication Request (Order) Profile is based upon the core FHIR MedicationRequest Resource and created to meet the 2015 Edition Common Clinical Data Set 'Medications' requirements. | MS [0..*] | |||||
| MedicationRequest.id | 0 | 1 | string |
Logical id of this artifact | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | R [1..1] | ||||
| MedicationRequest.meta | 0 | 1 | Meta |
Metadata about the resource | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | NRT | ||||
| MedicationRequest.implicitRules | 0 | 1 | uri |
A set of rules under which this content was created | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | NRT | ||||
| MedicationRequest.language | 0 | 1 | code |
Language of the resource content | The base language in which the resource is written. | preferred | CommonLanguages | http://hl7.org/fhir/ValueSet/languages | NRT | |
| MedicationRequest.text | 0 | 1 | Narrative |
Text summary of the resource, for human interpretation | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | NRT | ||||
| MedicationRequest.contained | 0 | * | Resource |
Contained, inline Resources | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | NRT | ||||
| MedicationRequest.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| MedicationRequest.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| MedicationRequest.identifier | 0 | * | Identifier |
External ids for this request | Identifiers associated with this medication request that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate. They are business identifiers assigned to this resource by the performer or other systems and remain constant as the resource is updated and propagates from server to server. | NRT | ||||
| MedicationRequest.status | 1 | 1 | Y | code |
active | on-hold | cancelled | completed | entered-in-error | stopped | draft | unknown | A code specifying the current state of the order. Generally, this will be active or completed state. | required | medicationrequest Status | http://hl7.org/fhir/ValueSet/medicationrequest-status | R [1..1] |
| MedicationRequest.statusReason | 0 | 1 | CodeableConcept |
Reason for current status | Captures the reason for the current state of the MedicationRequest. | example | medicationRequest Status Reason Codes | http://hl7.org/fhir/ValueSet/medicationrequest-status-reason | MS[0..1] | |
| MedicationRequest.intent | 1 | 1 | Y | code |
proposal | plan | order | original-order | reflex-order | filler-order | instance-order | option | Whether the request is a proposal, plan, or an original order. | required | medicationRequest Intent | http://hl7.org/fhir/ValueSet/medicationrequest-intent | R [1..1] |
| MedicationRequest.category | 0 | * | CodeableConcept |
Type of medication usage | Indicates the type of medication request (for example, where the medication is expected to be consumed or administered (i.e. inpatient or outpatient)). | example | medicationRequest Category Codes | http://hl7.org/fhir/ValueSet/medicationrequest-category | MS [0..*] | |
| MedicationRequest.priority | 0 | 1 | code |
routine | urgent | asap | stat | Indicates how quickly the Medication Request should be addressed with respect to other requests. | required | RequestPriority | http://hl7.org/fhir/ValueSet/request-priority|4.0.1 | MS [0..1] | |
| MedicationRequest.doNotPerform | 0 | 1 | boolean |
True if request is prohibiting action | If true indicates that the provider is asking for the medication request not to occur. | MS [0..1] | ||||
| MedicationRequest.reported[x] | 0 | 1 | Y | boolean Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization|http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitionerrole|http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson) |
Reported rather than primary record | Indicates if this record was captured as a secondary 'reported' record rather than as an original primary source-of-truth record. It may also indicate the source of the report. | MS [0..1] | |||
| MedicationRequest.medication[x] | 1 | 1 | Y | CodeableConcept Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication) |
Medication to be taken | Identifies the medication being requested. This is a link to a resource that represents the medication which may be the details of the medication or simply an attribute carrying a code that identifies the medication from a known list of medications. | extensible | US Core Medication Codes (RxNorm) | http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1010.4 | R [1..1] |
| MedicationRequest.subject | 1 | 1 | Y | Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient) |
Who or group medication request is for | A link to a resource representing the person or set of individuals to whom the medication will be given. | R [1..1] | |||
| MedicationRequest.encounter | 0 | 1 | Y | Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter) |
Encounter created as part of encounter/admission/stay | The Encounter during which this [x] was created or to which the creation of this record is tightly associated. | MS [0..1] | |||
| MedicationRequest.supportingInformation | 0 | * | Reference(Resource) |
Information to support ordering of the medication | Include additional information (for example, patient height and weight) that supports the ordering of the medication. | NRT | ||||
| MedicationRequest.authoredOn | 1 | 1 | Y | dateTime |
When request was initially authored | The date (and perhaps time) when the prescription was initially written or authored on. | R [1..1] | |||
| MedicationRequest.requester | 1 | 1 | Y | Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile) | Who/What requested the Request | The individual, organization, or device that initiated the request and has responsibility for its activation. | R [1..1] | |||
| MedicationRequest.performer | 0 | 1 | Reference(Practitioner|PractitionerRole|Organization|Patient|Device|RelatedPerson|CareTeam) |
Intended performer of administration | The specified desired performer of the medication treatment (e.g. the performer of the medication administration). | NRT | ||||
| MedicationRequest.performerType | 0 | 1 | CodeableConcept |
Desired kind of performer of the medication administration | Indicates the type of performer of the administration of the medication. | example | Procedure Performer Role Codes | http://hl7.org/fhir/ValueSet/performer-role | NRT | |
| MedicationRequest.recorder | 0 | 1 | Reference(Practitioner|PractitionerRole) |
Person who entered the request | The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order. | NR | ||||
| MedicationRequest.reasonCode | 0 | * | CodeableConcept |
Reason or indication for ordering or not ordering the medication | The reason or the indication for ordering or not ordering the medication. | example | Condition/Problem/Diagnosis Codes | http://hl7.org/fhir/ValueSet/condition-code | MS [0..*] | |
| MedicationRequest.reasonReference | 0 | * | Reference(Condition|Observation) |
Condition or observation that supports why the prescription is being written | Condition or observation that supports why the medication was ordered. | MS [0..*] | ||||
| MedicationRequest.instantiatesCanonical | 0 | * | canonical |
Instantiates FHIR protocol or definition | The URL pointing to a protocol, guideline, orderset, or other definition that is adhered to in whole or in part by this MedicationRequest. | MS [0..*] | ||||
| MedicationRequest.instantiatesUri | 0 | * | uri |
Instantiates external protocol or definition | The URL pointing to an externally maintained protocol, guideline, orderset or other definition that is adhered to in whole or in part by this MedicationRequest. | MS [0..*] | ||||
| MedicationRequest.basedOn | 0 | * | Reference(CarePlan|MedicationRequest|ServiceRequest|ImmunizationRecommendation) |
What request fulfills | A plan or request that is fulfilled in whole or in part by this medication request. | NRT | ||||
| MedicationRequest.groupIdentifier | 0 | 1 | Identifier |
Composite request this is part of | A shared identifier common to all requests that were authorized more or less simultaneously by a single author, representing the identifier of the requisition or prescription. | NRT | ||||
| MedicationRequest.courseOfTherapyType | 0 | 1 | CodeableConcept |
Overall pattern of medication administration | The description of the overall pattern of the administration of the medication to the patient. | example | Medication request course of therapy codes | http://hl7.org/fhir/R4/ValueSet/medicationrequest-course-of-therapy | MS [0..1] | |
| MedicationRequest.insurance | 0 | * | Reference(Coverage|ClaimResponse) |
Associated insurance coverage | Insurance plans, coverage extensions, pre-authorizations and/or pre-determinations that may be required for delivering the requested service. | NRT | ||||
| MedicationRequest.note | 0 | * | Annotation |
Information about the prescription | Extra information about the prescription that could not be conveyed by the other attributes. | NRT | ||||
| MedicationRequest.dosageInstruction | 0 | * | Y | Dosage |
How the medication should be taken | Indicates how the medication is to be used by the patient. | MS [0..*] | |||
| MedicationRequest.dosageInstruction.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| MedicationRequest.dosageInstruction.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| MedicationRequest.dosageInstruction.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| MedicationRequest.dosageInstruction.sequence | 0 | 1 | integer |
The order of the dosage instructions | Indicates the order in which the dosage instructions should be applied or interpreted. | NRT | ||||
| MedicationRequest.dosageInstruction.text | 0 | 1 | Y | string |
Free text dosage instructions e.g. SIG | Free text dosage instructions e.g. SIG. | MS [0..1] | |||
| MedicationRequest.dosageInstruction.additionalInstruction | 0 | * | CodeableConcept |
Supplemental instruction or warnings to the patient - e.g. "with meals", "may cause drowsiness" | Supplemental instructions to the patient on how to take the medication (e.g. "with meals" or"take half to one hour before food") or warnings for the patient about the medication (e.g. "may cause drowsiness" or "avoid exposure of skin to direct sunlight or sunlamps"). | example | A coded concept identifying additional instructions such as "take with water" or "avoid operating heavy machinery". | http://hl7.org/fhir/R4/ValueSet/additional-instruction-codes | NRT | |
| MedicationRequest.dosageInstruction.patientInstruction | 0 | 1 | string |
Patient or consumer oriented instructions | Instructions in terms that are understood by the patient or consumer. | NR | ||||
| MedicationRequest.dosageInstruction.timing | 0 | 1 | Timing |
When medication should be administered | When medication should be administered. | MS [0..1] | ||||
| MedicationRequest.dosageInstruction.asNeeded[x] | 0 | 1 | boolean CodeableConcept |
Take "as needed" (for x) | Indicates whether the Medication is only taken when needed within a specific dosing schedule (Boolean option), or it indicates the precondition for taking the Medication (CodeableConcept). | example | A coded concept identifying the precondition that should be met or evaluated prior to consuming or administering a medication dose. For example "pain", "30 minutes prior to sexual intercourse", "on flare-up" etc. | http://hl7.org/fhir/ValueSet/medication-as-needed-reason | MS [0..1] | |
| MedicationRequest.dosageInstruction.site | 0 | 1 | CodeableConcept |
Body site to administer to | Body site to administer to. | example | A coded concept describing the site location the medicine enters into or onto the body. | http://hl7.org/fhir/ValueSet/approach-site-codes | MS [0..1] | |
| MedicationRequest.dosageInstruction.route | 0 | 1 | CodeableConcept |
How drug should enter body | How drug should enter body. | example | A coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject. | http://hl7.org/fhir/R4/ValueSet/route-codes | R [1..1] | |
| MedicationRequest.dosageInstruction.method | 0 | 1 | CodeableConcept |
Technique for administering medication | Technique for administering medication. | example | A coded concept describing the technique by which the medicine is administered. | http://hl7.org/fhir/R4/ValueSet/administration-method-codes | MS [0..1] | |
| MedicationRequest.dosageInstruction.doseAndRate | 0 | * | Element |
Amount of medication administered | The amount of medication administered. | MS [0..*] | ||||
| MedicationRequest.dosageInstruction.doseAndRate.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| MedicationRequest.dosageInstruction.doseAndRate.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| MedicationRequest.dosageInstruction.doseAndRate.type | 0 | 1 | CodeableConcept |
The kind of dose or rate specified | The kind of dose or rate specified, for example, ordered or calculated. | example | The kind of dose or rate specified. | http://hl7.org/fhir/R4/ValueSet/dose-rate-type | MS [0..1] | |
| MedicationRequest.dosageInstruction.doseAndRate.dose[x] | 0 | 1 | Range Quantity {SimpleQuantity} |
Amount of medication per dose | Amount of medication per dose. | MS [0..1] | ||||
| MedicationRequest.dosageInstruction.doseAndRate.rate[x] | 0 | 1 | Ratio RangeQuantity {SimpleQuantity} |
Amount of medication per unit of time | Amount of medication per unit of time. | MS [0..1] | ||||
| MedicationRequest.dosageInstruction.maxDosePerPeriod | 0 | 1 | Ratio |
Upper limit on medication per unit of time | Upper limit on medication per unit of time. | NRT | ||||
| MedicationRequest.dosageInstruction.maxDosePerAdministration | 0 | 1 | Quantity {SimpleQuantity} |
Upper limit on medication per administration | Upper limit on medication per administration. | NRT | ||||
| MedicationRequest.dosageInstruction.maxDosePerLifetime | 0 | 1 | Quantity {SimpleQuantity} |
Upper limit on medication per lifetime of the patient | Upper limit on medication per lifetime of the patient. | NRT | ||||
| MedicationRequest.dispenseRequest | 0 | 1 | BackboneElement |
Medication supply authorization | Indicates the specific details for the dispense or medication supply part of a medication request (also known as a Medication Prescription or Medication Order). Note that this information is not always sent with the order. There may be in some settings (e.g. hospitals) institutional or system support for completing the dispense details in the pharmacy department. | NRT | ||||
| MedicationRequest.dispenseRequest.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| MedicationRequest.dispenseRequest.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| MedicationRequest.dispenseRequest.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| MedicationRequest.dispenseRequest.initialFill | 0 | 1 | BackboneElement |
First fill details | Indicates the quantity or duration for the first dispense of the medication. | NRT | ||||
| MedicationRequest.dispenseRequest.initialFill.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| MedicationRequest.dispenseRequest.initialFill.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| MedicationRequest.dispenseRequest.initialFill.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| MedicationRequest.dispenseRequest.initialFill.quantity | 0 | 1 | Quantity {SimpleQuantity} |
First fill quantity | The amount or quantity to provide as part of the first dispense. | NRT | ||||
| MedicationRequest.dispenseRequest.initialFill.duration | 0 | 1 | Duration |
First fill duration | The length of time that the first dispense is expected to last. | NRT | ||||
| MedicationRequest.dispenseRequest.dispenseInterval | 0 | 1 | Duration |
Minimum period of time between dispenses | The minimum period of time that must occur between dispenses of the medication. | NRT | ||||
| MedicationRequest.dispenseRequest.validityPeriod | 0 | 1 | Period |
Time period supply is authorized for | This indicates the validity period of a prescription (stale dating the Prescription). | NRT | ||||
| MedicationRequest.dispenseRequest.numberOfRepeatsAllowed | 0 | 1 | unsignedInt |
Number of refills authorized | An integer indicating the number of times, in addition to the original dispense, (aka refills or repeats) that the patient can receive the prescribed medication. Usage Notes: This integer does not include the original order dispense. This means that if an order indicates dispense 30 tablets plus "3 repeats", then the order can be dispensed a total of 4 times and the patient can receive a total of 120 tablets. A prescriber may explicitly say that zero refills are permitted after the initial dispense. | NRT | ||||
| MedicationRequest.dispenseRequest.quantity | 0 | 1 | Quantity {SimpleQuantity} |
Amount of medication to supply per dispense | The amount that is to be dispensed for one fill. | NRT | ||||
| MedicationRequest.dispenseRequest.expectedSupplyDuration | 0 | 1 | Duration |
Number of days supply per dispense | Identifies the period time over which the supplied product is expected to be used, or the length of time the dispense is expected to last. | NRT | ||||
| MedicationRequest.dispenseRequest.performer | 0 | 1 | Reference(Organization) |
Intended dispenser | Indicates the intended dispensing Organization specified by the prescriber. | NRT | ||||
| MedicationRequest.substitution | 0 | 1 | BackboneElement |
Any restrictions on medication substitution | Indicates whether or not substitution can or should be part of the dispense. In some cases, substitution must happen, in other cases substitution must not happen. This block explains the prescriber's intent. If nothing is specified substitution may be done. | NRT | ||||
| MedicationRequest.substitution.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| MedicationRequest.substitution.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| MedicationRequest.substitution.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| MedicationRequest.substitution.allowed[x] | 1 | 1 | boolean CodeableConcept |
Whether substitution is allowed or not | True if the prescriber allows a different drug to be dispensed from what was prescribed. | example | ActSubstanceAdminSubstitutionCode | http://terminology.hl7.org/ValueSet/v3-ActSubstanceAdminSubstitutionCode | NR | |
| MedicationRequest.substitution.reason | 0 | 1 | CodeableConcept |
Why should (not) substitution be made | Indicates the reason for the substitution, or why substitution must or must not be performed. | example | SubstanceAdminSubstitutionReason | http://terminology.hl7.org/ValueSet/v3-SubstanceAdminSubstitutionReason | NR | |
| MedicationRequest.priorPrescription | 0 | 1 | Reference(MedicationRequest) |
An order/prescription that is being replaced | A link to a resource representing an earlier order related order or prescription. | Y | NRT | |||
| MedicationRequest.detectedIssue | 0 | * | Reference(DetectedIssue) |
Clinical Issue with action | Indicates an actual or potential clinical issue with or between one or more active or proposed clinical actions for a patient; e.g. Drug-drug interaction, duplicate therapy, dosage alert etc. | Y | NRT | |||
| MedicationRequest.eventHistory | 0 | * | Reference(Provenance) |
A list of events of interest in the lifecycle | Links to Provenance records for past versions of this resource or fulfilling request or event resources that identify key state transitions or updates that are likely to be relevant to a user looking at the current version of the resource. | Y | NRT |
| Back to TOC | |||||||||
| Path | Min | Max | Type(s) | Short | Definition | Binding Strength | Binding Description (Value Set Name) | Binding Value Set | Cross Measure Requirements |
| Observation | 0 | * | DomainResource | Measurements and simple assertions | Measurements and simple assertions made about a patient, device or other subject. | R [1..*] | |||
| Observation.id | 0 | 1 | id |
Logical id of this artifact | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | R[1..1] | |||
| Observation.meta | 0 | 1 | Meta |
Metadata about the resource | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | NRT | |||
| Observation.implicitRules | 0 | 1 | uri |
A set of rules under which this content was created | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | NRT | |||
| Observation.language | 0 | 1 | code |
Language of the resource content | The base language in which the resource is written. | preferred but limited to AllLanguages | CommonLanguages | http://hl7.org/fhir/ValueSet/languages | NRT |
| Observation.text | 0 | 1 | Narrative |
Text summary of the resource, for human interpretation | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | NRT | |||
| Observation.contained | 0 | * | Resource |
Contained, inline Resources | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | NRT | |||
| Observation.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | |||
| Observation.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | |||
| Observation.identifier | 0 | * | Identifier |
Business Identifier for observation | A unique identifier assigned to this observation. | NRT | |||
| Observation.basedOn | 0 | * | Reference(CarePlan|DeviceRequest|ImmunizationRecommendation|MedicationRequest|NutritionOrder|ServiceRequest) |
Fulfills plan, proposal or order | A plan, proposal or order that is fulfilled in whole or in part by this event. For example, a MedicationRequest may require a patient to have laboratory test performed before it is dispensed. | NRT | |||
| Observation.partOf | 0 | * | Reference(MedicationAdministration|MedicationDispense|MedicationStatement|Procedure|Immunization|ImagingStudy) |
Part of referenced event | A larger event of which this particular Observation is a component or step. For example, an observation as part of a procedure. | NR | |||
| Observation.status | 1 | 1 | code |
registered | preliminary | final | amended + | The status of the result value. | required | ObservationStatus | http://hl7.org/fhir/ValueSet/observation-status | R [1..1] |
| Observation.category | 0 | * | CodeableConcept |
Classification of type of observation | A code that classifies the general type of observation being made. | preferred | ObservationCategoryCodes | http://hl7.org/fhir/ValueSet/observation-category | R [1..*] CQL will be constrained to these Categories: Vital-signs, laboratory, procedure |
| Observation.code | 1 | 1 | CodeableConcept |
Type of observation (code / type) | Describes what was observed. Sometimes this is called the observation "name". | example | LOINCCodes | http://hl7.org/fhir/ValueSet/observation-codes | R [1..1] |
| Observation.subject | 0 | 1 | Reference(Patient | Group | Device | Location) | Who and/or what the observation is about | The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the `focus` element or the `code` itself specifies the actual focus of the observation. | R [1..1] | |||
| Observation.focus | 0 | * | Reference(Any) |
What the observation is about, when it is not about the subject of record | The actual focus of an observation when it is not the patient of record representing something or someone associated with the patient such as a spouse, parent, fetus, or donor. For example, fetus observations in a mother's record. The focus of an observation could also be an existing condition, an intervention, the subject's diet, another observation of the subject, or a body structure such as tumor or implanted device. An example use case would be using the Observation resource to capture whether the mother is trained to change her child's tracheostomy tube. In this example, the child is the patient of record and the mother is the focus. | NR | |||
| Observation.encounter | 0 | 1 | Reference(Encounter) |
Healthcare event during which this observation is made | The healthcare event (e.g. a patient and healthcare provider interaction) during which this observation is made. | MS [0..1] | |||
| Observation.effective[x] | 0 | 1 | dateTime Period Timing Instant |
Clinically relevant time/time-period for observation | The time or time-period the observed value is asserted as being true. For biological subjects - e.g. human patients - this is usually called the "physiologically relevant time". This is usually either the time of the procedure or of specimen collection, but very often the source of the date/time is not known, only the date/time itself. | R [1..1] | |||
| Observation.issued | 0 | 1 | instant |
Date/Time this version was made available | The date and time this version of the observation was made available to providers, typically after the results have been reviewed and verified. | MS [0..1] | |||
| Observation.performer | 0 | * | Reference(Practitioner|PractitionerRole|Organization|CareTeam|Patient|RelatedPerson) |
Who is responsible for the observation | Who was responsible for asserting the observed value as "true". | NR | |||
| Observation.value[x] | 0 | 1 | Quantity CodeableConcept string boolean integer Range Ratio SampledData time dateTime Period |
Actual result | The information determined as a result of making the observation, if the information has a simple value. | MS [0..1] | |||
| Observation.dataAbsentReason | 0 | 1 | CodeableConcept |
Why the result is missing | Provides a reason why the expected value in the element Observation.value[x] is missing. | extensible | DataAbsentReason | http://hl7.org/fhir/ValueSet/data-absent-reason | NR |
| Observation.interpretation | 0 | * | CodeableConcept |
High, low, normal, etc. | A categorical assessment of an observation value. For example, high, low, normal. | extensible | ObservationInterpretationCodes | http://hl7.org/fhir/ValueSet/observation-interpretation | MS [0..*] |
| Observation.note | 0 | * | Annotation |
Comments about the observation | Comments about the observation or the results. | NR | |||
| Observation.bodySite | 0 | 1 | CodeableConcept |
Observed body part | Indicates the site on the subject's body where the observation was made (i.e. the target site). | example | SNOMEDCTBodyStructures | http://hl7.org/fhir/ValueSet/body-site | MS [0..1] |
| Observation.method | 0 | 1 | CodeableConcept |
How it was done | Indicates the mechanism used to perform the observation. | example | ObservationMethods | http://hl7.org/fhir/ValueSet/observation-methods | MS [0..1] |
| Observation.specimen | 0 | 1 | Reference(Specimen) |
Specimen used for this observation | The specimen that was used when this observation was made. | NR | |||
| Observation.device | 0 | 1 | Reference(Device|DeviceMetric) |
(Measurement) Device | The device used to generate the observation data. | NR | |||
| Observation.referenceRange | 0 | * | BackboneElement |
Provides guide for interpretation + Rule: Must have at least a low or a high or text |
Guidance on how to interpret the value by comparison to a normal or recommended range. Multiple reference ranges are interpreted as an "OR". In other words, to represent two distinct target populations, two `referenceRange` elements would be used. | NR | |||
| Observation.referenceRange.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | |||
| Observation.referenceRange.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | |||
| Observation.referenceRange.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | |||
| Observation.referenceRange.low | 0 | 1 | SimpleQuantity | Low Range, if relevant | The value of the low bound of the reference range. The low bound of the reference range endpoint is inclusive of the value (e.g. reference range is >=5 - <=9). If the low bound is omitted, it is assumed to be meaningless (e.g. reference range is <=2.3). | NR | |||
| Observation.referenceRange.high | 0 | 1 | SimpleQuantity | High Range, if relevant | The value of the high bound of the reference range. The high bound of the reference range endpoint is inclusive of the value (e.g. reference range is >=5 - <=9). If the high bound is omitted, it is assumed to be meaningless (e.g. reference range is >= 2.3). | NR | |||
| Observation.referenceRange.type | 0 | 1 | CodeableConcept |
Reference range qualifier | Codes to indicate the what part of the targeted reference population it applies to. For example, the normal or therapeutic range. | preferred | ObservationReferenceRangeMeaningCodes | http://hl7.org/fhir/ValueSet/referencerange-meaning | NR |
| Observation.referenceRange.appliesTo | 0 | * | CodeableConcept |
Reference range population | Codes to indicate the target population this reference range applies to. For example, a reference range may be based on the normal population or a particular sex or race. Multiple `appliesTo` are interpreted as an "AND" of the target populations. For example, to represent a target population of African American females, both a code of female and a code for African American would be used. | example | ObservationReferenceRangeAppliesToCodes | http://hl7.org/fhir/ValueSet/referencerange-appliesto | NR |
| Observation.referenceRange.age | 0 | 1 | Range |
Applicable age range, if relevant | The age at which this reference range is applicable. This is a neonatal age (e.g. number of weeks at term) if the meaning says so. | NR | |||
| Observation.referenceRange.text | 0 | 1 | string |
Text based reference range in an observation | Text based reference range in an observation which may be used when a quantitative range is not appropriate for an observation. An example would be a reference value of "Negative" or a list or table of "normals". | NR | |||
| Observation.hasMember | 0 | * | Reference(Observation|QuestionnaireResponse|MolecularSequence) |
Related resource that belongs to the Observation group | This observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group. | MS [0..*] | |||
| Observation.derivedFrom | 0 | * | Reference(DocumentReference|ImagingStudy|Media|QuestionnaireResponse|Observation|MolecularSequence) |
Related measurements the observation is made from | The target resource that represents a measurement from which this observation value is derived. For example, a calculated anion gap or a fetal measurement based on an ultrasound image. | NR | |||
| Observation.component | 0 | * | BackboneElement |
Component results | Some observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes. Examples include systolic and diastolic component observations for blood pressure measurement and multiple component observations for genetics observations. | MS [0..*] | |||
| Observation.component.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | |||
| Observation.component.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | |||
| Observation.component.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | |||
| Observation.component.code | 1 | 1 | CodeableConcept |
Type of component observation (code / type) | Describes what was observed. Sometimes this is called the observation "code". | example | LOINCCodes | http://hl7.org/fhir/ValueSet/observation-codes | MS [1..1] |
| Observation.component.value[x] | 0 | 1 | Quantity CodeableConcept string boolean integer Range Ratio SampledData time dateTime Period |
Actual component result | The information determined as a result of making the observation, if the information has a simple value. | MS [0..1] | |||
| Observation.component.dataAbsentReason | 0 | 1 | CodeableConcept |
Why the component result is missing | Provides a reason why the expected value in the element Observation.component.value[x] is missing. | extensible | DataAbsentReason | http://hl7.org/fhir/ValueSet/data-absent-reason | NR |
| Observation.component.interpretation | 0 | * | CodeableConcept |
High, low, normal, etc. | A categorical assessment of an observation value. For example, high, low, normal. | extensible | ObservationInterpretationCodes | http://hl7.org/fhir/ValueSet/observation-interpretation | MS [0..*] |
| Observation.component.referenceRange | 0 | * | Provides guide for interpretation of component result | Guidance on how to interpret the value by comparison to a normal or recommended range. | MS [0..*] |
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| FHIR Path | Min | Max | Must Support? | Type(s) | Short | Definition | Binding Strength | Binding Description | Binding Value Set | Cross Measure Requirements |
| Patient | 0 | * | Information about an individual or animal receiving health care services | The US Core Patient Profile is based upon the core FHIR Patient Resource and designed to meet the applicable patient demographic data elements from the 2015 Edition Common Clinical Data Set. | R [1..1] | |||||
| Patient.id | 0 | 1 | string |
Logical id of this artifact | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | R [1..1] | ||||
| Patient.meta | 0 | 1 | Meta |
Metadata about the resource | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | NRT | ||||
| Patient.implicitRules | 0 | 1 | uri |
A set of rules under which this content was created | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | NRT | ||||
| Patient.language | 0 | 1 | code |
Language of the resource content | The base language in which the resource is written. | preferred | A human language. | http://hl7.org/fhir/ValueSet/languages | NRT | |
| Patient.text | 0 | 1 | Narrative |
Text summary of the resource, for human interpretation | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | NRT | ||||
| Patient.contained | 0 | * | Resource |
Contained, inline Resources | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | NRT | ||||
| Patient.extension | 0 | * | Extension |
Extension | An Extension | NR | ||||
| Patient.extension (race) | 0 | 1 | Y | (Complex) optional ‘ombCategory’, optional ‘detailed’ and a required ‘text’. -‘ombCategory’ component is optional, but allows for up to 5 races from ombCategory-race ValueSet (note this is denoted by the 0..5 cardinality on the 3.1.1 definition of us-core-race oWhen present, the structure will always following a ‘coding’ datatype, as denoted by ‘valueCoding’ -‘detailed’ component is also optional, but may be present an infinite number of times, each ‘detailed’ containing one of the 917 race codes oWhen present, the structure will always following a ‘coding’ datatype, as denoted by ‘valueCoding’ -‘text’ as required is required to be present, but there are no rules around this data beyond it’ll be a string (ie it likely will be some combination of ombCategory and/or ‘detailed’, if present, but that’s about the as far as I’d go with a safe assumption). http://hl7.org/fhir/us/core/STU3.1.1/StructureDefinition-us-core-race.html |
US Core Race Extension | Concepts classifying the person into a named category of humans sharing common history, traits, geographical origin or nationality. The race codes used to represent these concepts are based upon the [CDC Race and Ethnicity Code Set Version 1.0](http://www.cdc.gov/phin/resources/vocabulary/index.html) which includes over 900 concepts for representing race and ethnicity of which 921 reference race. The race concepts are grouped by and pre-mapped to the 5 OMB race categories: - American Indian or Alaska Native - Asian - Black or African American - Native Hawaiian or Other Pacific Islander - White. |
US Core Race Extension | http://hl7.org/fhir/us/core/StructureDefinition/us-core-race | MS[0...*] | |
| Patient.extension (ethnicity) | 0 | 1 | Y | (Complex) |
US Core ethnicity Extension | Concepts classifying the person into a named category of humans sharing common history, traits, geographical origin or nationality. The ethnicity codes used to represent these concepts are based upon the [CDC ethnicity and Ethnicity Code Set Version 1.0](http://www.cdc.gov/phin/resources/vocabulary/index.html) which includes over 900 concepts for representing race and ethnicity of which 43 reference ethnicity. The ethnicity concepts are grouped by and pre-mapped to the 2 OMB ethnicity categories: - Hispanic or Latino - Not Hispanic or Latino. | US Core ethnicity Extension | http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity | MS[0..*] | |
| Patient.extension (sex at birth) | 0 | 1 | Y | code |
Extension | A code classifying the person's sex assigned at birth as specified by the [Office of the National Coordinator for Health IT (ONC)](https://www.healthit.gov/newsroom/about-onc). | required | Birth Sex | http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex | MS [0..1] |
| Patient.extension (gender identity) | 0 | 1 | Extension {http://hl7.org/fhir/us/core/StructureDefinition/us-core-genderIdentity} |
Extension | An Extension | MS [0..1] | ||||
| Patient.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Patient.identifier | 1 | * | Y | Identifier |
An identifier for this patient | An identifier for this patient. | R [1..*] | |||
| Patient.identifier.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NR | ||||
| Patient.identifier.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NR | ||||
| Patient.identifier.use | 0 | 1 | code |
usual | official | temp | secondary | old (If known) | The purpose of this identifier. | required | Identifier Use | http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 | MS[0..1] | |
| Patient.identifier.type | 0 | 1 | CodeableConcept |
Description of identifier | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose. | extensible | Identifier Type Codes | http://hl7.org/fhir/ValueSet/identifier-type | MS[0..1] | |
| Patient.identifier.system | 1 | 1 | Y | uri |
The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
Establishes the namespace for the value - that is, a URL that describes a set values that are unique. | NR | |||
| Patient.identifier.value | 1 | 1 | Y | string |
The value that is unique within the system. | The portion of the identifier typically relevant to the user and which is unique within the context of the system. | R [1..1] | |||
| Patient.identifier.period | 0 | 1 | Period |
Time period when id is/was valid for use | Time period during which identifier is/was valid for use. | MS [0..1] | ||||
| Patient.identifier.assigner | 0 | 1 | Reference(Organization) |
Organization that issued id (may be just text) | Organization that issued/manages the identifier. | NR | ||||
| Patient.active | 0 | 1 | boolean |
Whether this patient's record is in active use | Whether this patient record is in active use. Many systems use this property to mark as non-current patients, such as those that have not been seen for a period of time based on an organization's business rules. It is often used to filter patient lists to exclude inactive patients Deceased patients may also be marked as inactive for the same reasons, but may be active for some time after death. |
NR | ||||
| Patient.name | 1 | * | Y | HumanName |
A name associated with the patient us-core-8: Either Patient.name.given and/or Patient.name.family SHALL be present or a Data Absent Reason Extension SHALL be present. |
A name associated with the individual. | R [1..*] | |||
| Patient.name.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NR | ||||
| Patient.name.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NR | ||||
| Patient.name.use | 0 | 1 | code |
usual | official | temp | nickname | anonymous | old | maiden | Identifies the purpose for this name. | required | NameUse | http://hl7.org/fhir/ValueSet/name-use|4.0.1 | MS[0..1] | |
| Patient.name.text | 0 | 1 | string |
Text representation of the full name | Specifies the entire name as it should be displayed e.g. on an application UI. This may be provided instead of or as well as the specific parts. | MS[0..1] | ||||
| Patient.name.family | 0 | 1 | Y | string |
Family name (often called 'Surname') | The part of a name that links to the genealogy. In some cultures (e.g. Eritrea) the family name of a son is the first name of his father. | MS[0..1] | |||
| Patient.name.given | 0 | * | Y | string |
Given names (not always 'first'). Includes middle names This repeating element order: Given Names appear in the correct order for presenting the name |
Given name. | MS[0..*] | |||
| Patient.name.prefix | 0 | * | string |
Parts that come before the name This repeating element order: Prefixes appear in the correct order for presenting the name |
Part of the name that is acquired as a title due to academic, legal, employment or nobility status, etc. and that appears at the start of the name. | MS[0..*] | ||||
| Patient.name.suffix | 0 | * | string |
Parts that come after the name This repeating element order: Suffixes appear in the correct order for presenting the name |
Part of the name that is acquired as a title due to academic, legal, employment or nobility status, etc. and that appears at the end of the name. | MS[0..*] | ||||
| Patient.name.period | 0 | 1 | Period |
Time period when name was/is in use | Indicates the period of time when this name was valid for the named person. | MS[0..1] | ||||
| Patient.telecom | 0 | * | Y | ContactPoint |
A contact detail for the individual | A contact detail (e.g. a telephone number or an email address) by which the individual may be contacted. | MS[0..*] | |||
| Patient.telecom.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||
| Patient.telecom.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | ||||
| Patient.telecom.system | 1 | 1 | Y | code |
phone | fax | email | pager | url | sms | other | Telecommunications form for contact point - what communications system is required to make use of the contact. | required | ContactPointSystem | http://hl7.org/fhir/ValueSet/contact-point-system | R [1..1] |
| Patient.telecom.value | 1 | 1 | Y | string |
The actual contact point details | The actual contact point details, in a form that is meaningful to the designated communication system (i.e. phone number or email address). | R [1..1] | |||
| Patient.telecom.use | 0 | 1 | Y | code |
home | work | temp | old | mobile - purpose of this contact point | Identifies the purpose for the contact point. | required | ContactPointUse | http://hl7.org/fhir/ValueSet/contact-point-use | MS[0..1] |
| Patient.telecom.rank | 0 | 1 | positiveInt |
Specify preferred order of use (1 = highest) | Specifies a preferred order in which to use a set of contacts. ContactPoints with lower rank values are more preferred than those with higher rank values. | MS[0..1] | ||||
| Patient.telecom.period | 0 | 1 | Period |
Time period when the contact point was/is in use | Time period when the contact point was/is in use. | MS[0..1] | ||||
| Patient.gender | 1 | 1 | Y | code |
male | female | other | unknown | Administrative Gender - the gender that the patient is considered to have for administration and record keeping purposes. | required | AdminstrativeGender | http://hl7.org/fhir/ValueSet/administrative-gender | R [1..1] |
| Patient.birthDate | 0 | 1 | Y | date |
The date of birth for the individual | The date of birth for the individual. | R [1..1] | |||
| Patient.deceased[x] | 0 | 1 | boolean dateTime |
Indicates if the individual is deceased or not | Indicates if the individual is deceased or not. | MS[0..1] | ||||
| Patient.address | 0 | * | Y | Address |
An address for the individual | An address for the individual. | MS[0..*] | |||
| Patient.address.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NR | ||||
| Patient.address.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NR | ||||
| Patient.address.use | 0 | 1 | code |
home | work | temp | old | billing - purpose of this address | The purpose of this address. | required | AddressUse | http://hl7.org/fhir/ValueSet/address-use|4.0.1 | MS[0..1] | |
| Patient.address.type | 0 | 1 | code |
home|postal | physical | both | Distinguishes between physical addresses (those you can visit) and mailing addresses (e.g. PO Boxes and care-of addresses). Most addresses are both. | required | AddressType | http://hl7.org/fhir/ValueSet/address-type|4.0.1 | MS[0..1] | |
| Patient.address.text | 0 | 1 | string |
Text representation of the address | Specifies the entire address as it should be displayed e.g. on a postal label. This may be provided instead of or as well as the specific parts. | MS[0..1] | ||||
| Patient.address.line | 0 | * | Y | string |
Street name, number, direction & P.O. Box etc. This repeating element order: The order in which lines should appear in an address label |
This component contains the house number, apartment number, street name, street direction, P.O. Box number, delivery hints, and similar address information. | MS[0..*] | |||
| Patient.address.city | 0 | 1 | Y | string |
Name of city, town etc. | The name of the city, town, suburb, village or other community or delivery center. | MS[0..1] | |||
| Patient.address.district | 0 | 1 | string |
District name (aka county) | The name of the administrative area (county). | MS[0..1] | ||||
| Patient.address.state | 0 | 1 | Y | string |
Sub-unit of country (abbreviations ok) | Sub-unit of a country with limited sovereignty in a federally organized country. A code may be used if codes are in common use (e.g. US 2 letter state codes). | extensible | USPS Two Letter Alphabetic Codes | http://hl7.org/fhir/us/core/ValueSet/us-core-usps-state | MS[0..1] |
| Patient.address.postalCode | 0 | 1 | Y | string |
US Zip Codes | A postal code designating a region defined by the postal service. | MS[0..1] | |||
| Patient.address.country | 0 | 1 | string |
Country (e.g. can be ISO 3166 2 or 3 letter code) | Country - a nation as commonly understood or generally accepted. | MS[0..1] | ||||
| Patient.address.period | 0 | 1 | Y | Period |
Time period when address was/is in use | Time period when address was/is in use. | MS[0..1] | |||
| Patient.maritalStatus | 0 | 1 | CodeableConcept |
Marital (civil) status of a patient | This field contains a patient's most recent marital (civil) status. | extensible | Marital Status Codes | http://hl7.org/fhir/ValueSet/marital-status | NR | |
| Patient.multipleBirth[x] | 0 | 1 | boolean integer |
Whether patient is part of a multiple birth | Indicates whether the patient is part of a multiple (boolean) or indicates the actual birth order (integer). | NR | ||||
| Patient.photo | 0 | * | Attachment |
Image of the patient | Image of the patient. | NR | ||||
| Patient.contact | 0 | * | BackboneElement |
A contact party (e.g. guardian, partner, friend) for the patient | A contact party (e.g. guardian, partner, friend) for the patient. | MS[0..*] | ||||
| Patient.contact.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NR | ||||
| Patient.contact.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NR | ||||
| Patient.contact.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
u877i | ||||
| Patient.contact.relationship | 0 | * | CodeableConcept |
The kind of relationship | The nature of the relationship between the patient and the contact person. | extensible | The nature of the relationship between a patient and a contact person for that patient. | http://hl7.org/fhir/ValueSet/patient-contactrelationship | MS[0..*] | |
| Patient.contact.name | 0 | 1 | HumanName |
A name associated with the contact person | A name associated with the contact person. | MS[0..1] | ||||
| Patient.contact.telecom | 0 | * | ContactPoint |
A contact detail for the person | A contact detail for the person, e.g. a telephone number or an email address. | MS[0..*] | ||||
| Patient.contact.address | 0 | 1 | Address |
Address for the contact person | Address for the contact person. | MS[0..1] | ||||
| Patient.contact.gender | 0 | 1 | code |
male | female | other | unknown | Administrative Gender - the gender that the contact person is considered to have for administration and record keeping purposes. | required | The gender of a person used for administrative purposes. | http://hl7.org/fhir/ValueSet/administrative-gender|4.0.1 | NR | |
| Patient.contact.organization | 0 | 1 | Reference(Organization) |
Organization that is associated with the contact | Organization on behalf of which the contact is acting or for which the contact is working. | NR | ||||
| Patient.contact.period | 0 | 1 | Period |
The period during which this contact person or organization is valid to be contacted relating to this patient | The period during which this contact person or organization is valid to be contacted relating to this patient. | MS[0..1) | ||||
| Patient.communication | 0 | * | Y | BackboneElement |
A language which may be used to communicate with the patient about his or her health | A language which may be used to communicate with the patient about his or her health. | MS[0..*] | |||
| Patient.communication.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NR | ||||
| Patient.communication.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NR | ||||
| Patient.communication.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | ||||
| Patient.communication.language | 1 | 1 | Y | CodeableConcept |
The language which can be used to communicate with the patient about his or her health | The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England English. | extensible | http://hl7.org/fhir/us/core/ValueSet/simple-language | R [1..1] | |
| Patient.communication.preferred | 0 | 1 | boolean |
Language preference indicator | Indicates whether or not the patient prefers this language (over other languages he masters up a certain level). | MS[0..1] | ||||
| Patient.generalPractitioner | 0 | * | Reference(Organization|Practitioner|PractitionerRole) |
Patient's nominated primary care provider | Patient's nominated care provider. | NR | ||||
| Patient.managingOrganization | 0 | 1 | Reference(Organization) |
Organization that is the custodian of the patient record | Organization that is the custodian of the patient record. | [0..1] | ||||
| Patient.link | 0 | * | BackboneElement |
Link to another patient resource that concerns the same actual person | Link to another patient resource that concerns the same actual patient. | MS[0..*] | ||||
| Patient.link.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | [0..*] | ||||
| Patient.link.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | [0..*] | ||||
| Patient.link.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
[0..*] | ||||
| Patient.link.other | 1 | 1 | Reference(Patient|RelatedPerson) |
The other patient or related person resource that the link refers to | The other patient resource that the link refers to. | R [1..1] | ||||
| Patient.link.type | 1 | 1 | code |
replaced-by | replaces | refer | seealso | The type of link between this patient resource and another patient resource. | required | LinkType | http://hl7.org/fhir/ValueSet/link-type|4.0.1 | R [1..1] |
| Back to TOC | ||||||||||||
| FHIR Path | Min | Max | Must Support? | Type(s) | Short | Definition | Comments | Requirements | Binding Strength | Binding Description | Binding Value Set | Cross Measure Requirements |
| Procedure | 0 | * | An action that is being or was performed on a patient | The US Core Condition Profile is based upon the core FHIR Procedure Resource and created to meet the 2015 Edition Common Clinical Data Set 'Procedures' requirements. | MS [0..*] | |||||||
| Procedure.id | 0 | 1 | string |
Logical id of this artifact | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | R [1..1] | |||||
| Procedure.meta | 0 | 1 | Meta |
Metadata about the resource | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | NRT | ||||||
| Procedure.implicitRules | 0 | 1 | uri |
A set of rules under which this content was created | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. | NRT | |||||
| Procedure.language | 0 | 1 | code |
Language of the resource content | The base language in which the resource is written. | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). | preferred | A human language. | http://hl7.org/fhir/ValueSet/languages | NRT | ||
| Procedure.text | 0 | 1 | Narrative |
Text summary of the resource, for human interpretation | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. | NRT | |||||
| Procedure.contained | 0 | * | Resource |
Contained, inline Resources | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. | NRT | |||||
| Procedure.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | |||||
| Procedure.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension). | NRT | ||||
| Procedure.identifier | 0 | * | Identifier |
External Identifiers for this procedure | Business identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server. | This is a business identifier, not a resource identifier (see [discussion](http://hl7.org/fhir/R4/resource.html#identifiers)). 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. For example, multiple Patient and Person resource instances might share the same social insurance number. | Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers. | NRT | ||||
| Procedure.instantiatesCanonical | 0 | * | canonical(PlanDefinition|ActivityDefinition|Measure|OperationDefinition|Questionnaire) |
Instantiates FHIR protocol or definition | The URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure. | NR | ||||||
| Procedure.instantiatesUri | 0 | * | uri |
Instantiates external protocol or definition | The URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure. | This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier. | NR | |||||
| Procedure.basedOn | 0 | * | Reference(CarePlan|ServiceRequest) |
A request for this procedure | A reference to a resource that contains details of the request for this procedure. | NR | ||||||
| Procedure.partOf | 0 | * | Reference(Procedure|Observation|MedicationAdministration) |
Part of referenced event | A larger event of which this particular procedure is a component or step. | The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration). | NR | |||||
| Procedure.status | 1 | 1 | Y | code |
preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown | A code specifying the state of the procedure. Generally, this will be the in-progress or completed state. | The "unknown" code is not to be used to convey other statuses. The "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. |
required | http://hl7.org/fhir/R4/ValueSet/event-status | R [1..1] | ||
| Procedure.statusReason | 0 | 1 | CodeableConcept |
Reason for current status | Captures the reason for the current state of the procedure. | This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here. | example | A code that identifies the reason a procedure was not performed. | http://hl7.org/fhir/ValueSet/procedure-not-performed-reason | NR | ||
| Procedure.category | 0 | 1 | CodeableConcept |
Classification of the procedure | A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). | example | A code that classifies a procedure for searching, sorting and display purposes. | http://hl7.org/fhir/ValueSet/procedure-category | NR | |||
| Procedure.code | 1 | 1 | Y | CodeableConcept |
Identification of the procedure | The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy"). | 0..1 to account for primarily narrative only resources. | extensible | Codes describing the type of Procedure | http://hl7.org/fhir/us/core/STU3.1.1/ValueSet-us-core-procedure-code | R [1..1] | |
| Procedure.subject | 1 | 1 | Y | Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient) |
Who the procedure was performed on | The person, animal or group on which the procedure was performed. | R [1..1] | |||||
| Procedure.encounter | 0 | 1 | Reference(Encounter) |
Encounter created as part of | The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated. | This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. | MS [0..1] | |||||
| Procedure.performed[x] | 1 | 1 | Y | dateTime Period string Age Range |
When the procedure was performed | Estimated or actual date, date-time, period, or age when the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured. | Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone. | R [1..1] | ||||
| Procedure.recorder | 0 | 1 | Reference(Patient|RelatedPerson|Practitioner|PractitionerRole) |
Who recorded the procedure | Individual who recorded the record and takes responsibility for its content. | NR | ||||||
| Procedure.asserter | 0 | 1 | Reference(Patient|RelatedPerson|Practitioner|PractitionerRole) |
Person who asserts this procedure | Individual who is making the procedure statement. | NR | ||||||
| Procedure.performer | 0 | * | BackboneElement |
The people who performed the procedure | Limited to "real" people rather than equipment. | NR | ||||||
| Procedure.performer.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||||
| Procedure.performer.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | |||||
| Procedure.performer.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension). | NRT | ||||
| Procedure.performer.function | 0 | 1 | CodeableConcept |
Type of performance | Distinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist. | Allows disambiguation of the types of involvement of different performers. | example | A code that identifies the role of a performer of the procedure. | http://hl7.org/fhir/ValueSet/performer-role | NR | ||
| Procedure.performer.actor | 1 | 1 | Reference(Practitioner|PractitionerRole|Organization|Patient|RelatedPerson|Device) |
The reference to the practitioner | The practitioner who was involved in the procedure. | A reference to Device supports use cases, such as pacemakers. | NR | |||||
| Procedure.performer.onBehalfOf | 0 | 1 | Reference(Organization) |
Organization the device or practitioner was acting for | The organization the device or practitioner was acting on behalf of. | Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action. | NR | |||||
| Procedure.location | 0 | 1 | Reference(Location) |
Where the procedure happened | The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant. | Ties a procedure to where the records are likely kept. | MS [0..1] | |||||
| Procedure.reasonCode | 0 | * | CodeableConcept |
Coded reason procedure performed | The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text. | Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure. | example | A code that identifies the reason a procedure is required. | http://hl7.org/fhir/ValueSet/procedure-reason | MS [0..*] | ||
| Procedure.reasonReference | 0 | * | Reference(Condition|Observation|Procedure|DiagnosticReport|DocumentReference) |
The justification that the procedure was performed | The justification of why the procedure was performed. | It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as an epidural). Other examples include endoscopy for dilatation and biopsy (a combination of diagnostic and therapeutic use). Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure. |
MS [0..*] | |||||
| Procedure.bodySite | 0 | * | CodeableConcept |
Target body sites | Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion. | If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension [procedure-targetbodystructure](http://hl7.org/fhir/R4/extension-procedure-targetbodystructure.html). | example | Codes describing anatomical locations. May include laterality. | http://hl7.org/fhir/ValueSet/body-site | MS [0..*] | ||
| Procedure.outcome | 0 | 1 | CodeableConcept |
The result of procedure | The outcome of the procedure - did it resolve the reasons for the procedure being performed? | If outcome contains narrative text only, it can be captured using the CodeableConcept.text. | example | An outcome of a procedure - whether it was resolved or otherwise. | http://hl7.org/fhir/ValueSet/procedure-outcome | NR | ||
| Procedure.report | 0 | * | Reference(DiagnosticReport|DocumentReference|Composition) |
Any report resulting from the procedure | This could be a histology result, pathology report, surgical report, etc. | There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports. | NR | |||||
| Procedure.complication | 0 | * | CodeableConcept |
Complication following the procedure | Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the notes, which will typically describe the procedure itself rather than any 'post procedure' issues. | If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text. | example | Codes describing complications that resulted from a procedure. | http://hl7.org/fhir/ValueSet/condition-code | NR | ||
| Procedure.complicationDetail | 0 | * | Reference(Condition) |
A condition that is a result of the procedure | Any complications that occurred during the procedure, or in the immediate post-performance period. | This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure. | NR | |||||
| Procedure.followUp | 0 | * | CodeableConcept |
Instructions for follow up | If the procedure required specific follow up - e.g. removal of sutures. The follow up may be represented as a simple note or could potentially be more complex, in which case the CarePlan resource can be used. | example | Specific follow up required for a procedure e.g. removal of sutures. | http://hl7.org/fhir/ValueSet/procedure-followup | NR | |||
| Procedure.note | 0 | * | Annotation |
Additional information about the procedure | Any other notes and comments about the procedure. | NR | ||||||
| Procedure.focalDevice | 0 | * | BackboneElement |
Manipulated, implanted, or removed device | A device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure. | NR | ||||||
| Procedure.focalDevice.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | ||||||
| Procedure.focalDevice.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | NRT | |||||
| Procedure.focalDevice.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension). | NRT | ||||
| Procedure.focalDevice.action | 0 | 1 | CodeableConcept |
Kind of change to device | The kind of change that happened to the device during the procedure. | preferred | A kind of change that happened to the device during the procedure. | http://hl7.org/fhir/ValueSet/device-action | NR | |||
| Procedure.focalDevice.manipulated | 1 | 1 | Reference(Device) |
Device that was changed | The device that was manipulated (changed) during the procedure. | NR | ||||||
| Procedure.usedReference | 0 | * | Reference(Device|Medication|Substance) |
Items used during procedure | Identifies medications, devices and any other substance used as part of the procedure. | For devices actually implanted or removed, use Procedure.device. | Used for tracking contamination, etc. | NR | ||||
| Procedure.usedCode | 0 | * | CodeableConcept |
Coded items used during the procedure | Identifies coded items that were used as part of the procedure. | For devices actually implanted or removed, use Procedure.device. | example | Codes describing items used during a procedure. | http://hl7.org/fhir/R4/ValueSet/device-kind | NR |
| Back to TOC | |||||||||
| Path | Min | Max | Type(s) | Short | Definition | Binding Strength | Binding Description | Binding Value Set | Cross Measure Requirements |
| ServiceRequest | 0 | * | A request for a service to be performed | A record of a request for service such as diagnostic investigations, treatments, or operations to be performed. | MS [0..*] | ||||
| ServiceRequest.id | 0 | 1 | id |
Logical id of this artifact | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | R [1..1] | |||
| ServiceRequest.meta | 0 | 1 | Meta |
Metadata about the resource | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | NRT | |||
| ServiceRequest.implicitRules | 0 | 1 | uri |
A set of rules under which this content was created | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | NRT | |||
| ServiceRequest.language | 0 | 1 | code |
Language of the resource content | The base language in which the resource is written. | preferred | Common Languages | http://hl7.org/fhir/ValueSet/languages | NRT |
| ServiceRequest.text | 0 | 1 | Narrative |
Text summary of the resource, for human interpretation | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | NRT | |||
| ServiceRequest.contained | 0 | * | Resource |
Contained, inline Resources | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | NRT | |||
| ServiceRequest.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | |||
| ServiceRequest.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | |||
| ServiceRequest.identifier | 0 | * | Identifier |
Identifiers assigned to this order | Identifiers assigned to this order instance by the orderer and/or the receiver and/or order fulfiller. | NRT | |||
| ServiceRequest.instantiatesCanonical | 0 | * | canonical(ActivityDefinition|PlanDefinition) |
Instantiates FHIR protocol or definition | The URL pointing to a FHIR-defined protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. | NR | |||
| ServiceRequest.instantiatesUri | 0 | * | uri |
Instantiates external protocol or definition | The URL pointing to an externally maintained protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. | NR | |||
| ServiceRequest.basedOn | 0 | * | Reference(CarePlan|ServiceRequest|MedicationRequest) |
What request fulfills | Plan/proposal/order fulfilled by this request. | NR | |||
| ServiceRequest.replaces | 0 | * | Reference(ServiceRequest) |
What request replaces | The request takes the place of the referenced completed or terminated request(s). | NR | |||
| ServiceRequest.requisition | 0 | 1 | Identifier |
Composite Request ID | A shared identifier common to all service requests that were authorized more or less simultaneously by a single author, representing the composite or group identifier. | NR | |||
| ServiceRequest.status | 1 | 1 | code |
draft | active | on-hold | revoked | completed | entered-in-error | unknown | The status of the order. | required | RequestStatus | http://hl7.org/fhir/ValueSet/request-status | R [1..1] |
| ServiceRequest.intent | 1 | 1 | code |
proposal | plan | directive | order | original-order | reflex-order | filler-order | instance-order | option | Whether the request is a proposal, plan, an original order or a reflex order. | required | RequestIntent | http://hl7.org/fhir/ValueSet/request-intent | R [1..1] |
| ServiceRequest.category | 0 | * | CodeableConcept |
Classification of service | A code that classifies the service for searching, sorting and display purposes (e.g. "Surgical Procedure"). | example | Service Request Category Codes | http://hl7.org/fhir/ValueSet/servicerequest-category | MS [0..*] |
| ServiceRequest.priority | 0 | 1 | code |
routine | urgent | asap | stat | Indicates how quickly the ServiceRequest should be addressed with respect to other requests. | required | Request priority | http://hl7.org/fhir/ValueSet/request-priority | MS [0…1] |
| ServiceRequest.doNotPerform | 0 | 1 | boolean |
True if service/procedure should not be performed | Set this to true if the record is saying that the service/procedure should NOT be performed. | MS [0..1] | |||
| ServiceRequest.code | 0 | 1 | CodeableConcept |
What is being requested/ordered | A code that identifies a particular service (i.e., procedure, diagnostic investigation, or panel of investigations) that have been requested. | example | Procedure Codes (SNOMED CT) | http://hl7.org/fhir/ValueSet/procedure-code | MS [0..1] |
| ServiceRequest.orderDetail | 0 | * | CodeableConcept |
Additional order information | Additional details and instructions about the how the services are to be delivered. For example, and order for a urinary catheter may have an order detail for an external or indwelling catheter, or an order for a bandage may require additional instructions specifying how the bandage should be applied. | example | Service Request Order Details Codes | http://hl7.org/fhir/ValueSet/servicerequest-orderdetail | NR |
| ServiceRequest.quantity[x] | 0 | 1 | Quantity RatioRange |
Service amount | An amount of service being requested which can be a quantity ( for example $1,500 home modification), a ratio ( for example, 20 half day visits per month), or a range (2.0 to 1.8 Gy per fraction). | NR | |||
| ServiceRequest.subject | 1 | 1 | Reference(Patient|Group|Location|Device) |
Individual or Entity the service is ordered for | On whom or what the service is to be performed. This is usually a human patient, but can also be requested on animals, groups of humans or animals, devices such as dialysis machines, or even locations (typically for environmental scans). | R [1..1] | |||
| ServiceRequest.encounter | 0 | 1 | Reference(Encounter) |
Encounter in which the request was created | An encounter that provides additional information about the healthcare context in which this request is made. | MS [0..1] | |||
| ServiceRequest.occurrence[x] | 0 | 1 | dateTime Period Timing |
When service should occur | The date/time at which the requested service should occur. | MS [0..1] | |||
| ServiceRequest.asNeeded[x] | 0 | 1 | boolean CodeableConcept |
Preconditions for service | If a CodeableConcept is present, it indicates the pre-condition for performing the service. For example "pain", "on flare-up", etc. | example | SNOMED CT Medication As Needed Reason Codes | http://hl7.org/fhir/ValueSet/medication-as-needed-reason | MS [0..1] |
| ServiceRequest.authoredOn | 0 | 1 | dateTime |
Date request signed | When the request transitioned to being actionable. | R [1..1] | |||
| ServiceRequest.requester | 0 | 1 | Reference(Practitioner|PractitionerRole|Organization|Patient|RelatedPerson|Device) |
Who/what is requesting service | The individual who initiated the request and has responsibility for its activation. | NR | |||
| ServiceRequest.performerType | 0 | 1 | CodeableConcept |
Performer role | Desired type of performer for doing the requested service. | example | Participant Roles | http://terminology.hl7.org/ValueSet/action-participant-role | NR |
| ServiceRequest.performer | 0 | * | Reference(Practitioner|PractitionerRole|Organization|CareTeam|HealthcareService|Patient|Device|RelatedPerson) |
Requested performer | The desired performer for doing the requested service. For example, the surgeon, dermatopathologist, endoscopist, etc. | NR | |||
| ServiceRequest.locationCode | 0 | * | CodeableConcept |
Requested location | The preferred location(s) where the procedure should actually happen in coded or free text form. E.g. at home or nursing day care center. | example | V3 Value SetServiceDeliveryLocationRoleType | http://terminology.hl7.org/ValueSet/v3-ServiceDeliveryLocationRoleType | NR |
| ServiceRequest.locationReference | 0 | * | Reference(Location) |
Requested location | A reference to the the preferred location(s) where the procedure should actually happen. E.g. at home or nursing day care center. | NR | |||
| ServiceRequest.reasonCode | 0 | * | CodeableConcept |
Explanation/Justification for procedure or service | An explanation or justification for why this service is being requested in coded or textual form. This is often for billing purposes. May relate to the resources referred to in `supportingInfo`. | example | Procedure Reason Codes | http://hl7.org/fhir/ValueSet/procedure-reason | NR |
| ServiceRequest.reasonReference | 0 | * | Reference(Condition|Observation|DiagnosticReport|DocumentReference) |
Explanation/Justification for service or service | Indicates another resource that provides a justification for why this service is being requested. May relate to the resources referred to in `supportingInfo`. | MS [0..*] | |||
| ServiceRequest.insurance | 0 | * | Reference(Coverage|ClaimResponse) |
Associated insurance coverage | Insurance plans, coverage extensions, pre-authorizations and/or pre-determinations that may be needed for delivering the requested service. | NR | |||
| ServiceRequest.supportingInfo | 0 | * | Reference(Resource) |
Additional clinical information | Additional clinical information about the patient or specimen that may influence the services or their interpretations. This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as "ask at order entry questions (AOEs)". This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the amount of inspired oxygen for blood gas measurements. | NR | |||
| ServiceRequest.specimen | 0 | * | Reference(Specimen) |
Procedure Samples | One or more specimens that the laboratory procedure will use. | MS [0..*] | |||
| ServiceRequest.bodySite | 0 | * | CodeableConcept |
Location on Body | Anatomic location where the procedure should be performed. This is the target site. | example | SNOMED CT Body Structures | http://hl7.org/fhir/ValueSet/body-site | NR |
| ServiceRequest.note | 0 | * | Annotation |
Comments | Any other notes and comments made about the service request. For example, internal billing notes. | NR | |||
| ServiceRequest.patientInstruction | 0 | 1 | string |
Patient or consumer-oriented instructions | Instructions in terms that are understood by the patient or consumer. | NR | |||
| ServiceRequest.relevantHistory | 0 | * | Reference(Provenance) |
Request provenance | Key events in the history of the request. | NR |
| Back to TOC | |||||||||
| Path |
Min | Max | Type(s) | Short | Definition | Binding Strength | Binding Description | Binding Value Set | Cross Measure Requirements |
| Specimen | 0 | * | Sample for analysis | A sample to be used for analysis. | MS [0..*] | ||||
| Specimen.id | 0 | 1 | id |
Logical id of this artifact | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | R [1..1] | |||
| Specimen.meta | 0 | 1 | Meta |
Metadata about the resource | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | NRT | |||
| Specimen.implicitRules | 0 | 1 | uri |
A set of rules under which this content was created | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | NRT | |||
| Specimen.language | 0 | 1 | code |
Language of the resource content | The base language in which the resource is written. | preferred | Common Languages | http://hl7.org/fhir/ValueSet/languages | NRT |
| Specimen.text | 0 | 1 | Narrative |
Text summary of the resource, for human interpretation | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | NR | |||
| Specimen.contained | 0 | * | Resource |
Contained, inline Resources | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | NR | |||
| Specimen.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NR | |||
| Specimen.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | |||
| Specimen.identifier | 0 | * | Identifier |
External Identifier | Id for specimen. | MS [0..*] | |||
| Specimen.accessionIdentifier | 0 | 1 | Identifier |
Identifier assigned by the lab | The identifier assigned by the lab when accessioning specimen(s). This is not necessarily the same as the specimen identifier, depending on local lab procedures. | MS [0..1] | |||
| Specimen.status | 0 | 1 | code |
available | unavailable | unsatisfactory | entered-in-error | The availability of the specimen. | required | SpecimenStatus | http://hl7.org/fhir/ValueSet/specimen-status | NR |
| Specimen.type | 0 | 1 | CodeableConcept |
Kind of material that forms the specimen | The kind of material that forms the specimen. | example | V2 Specimen Type | http://terminology.hl7.org/ValueSet/v2-0487 | R [1..1] |
| Specimen.subject | 0 | 1 | Reference(Patient|Group|Device|Substance|Location) |
Where the specimen came from. This may be from patient(s), from a location (e.g., the source of an environmental sample), or a sampling of a substance or a device | Where the specimen came from. This may be from patient(s), from a location (e.g., the source of an environmental sample), or a sampling of a substance or a device. | MS [0..1] | |||
| Specimen.receivedTime | 0 | 1 | dateTime |
The time when specimen was received for processing | Time when specimen was received for processing or testing. | NR | |||
| Specimen.parent | 0 | * | Reference(Specimen) |
Specimen from which this specimen originated | Reference to the parent (source) specimen which is used when the specimen was either derived from or a component of another specimen. | NR | |||
| Specimen.request | 0 | * | Reference(ServiceRequest) |
Why the specimen was collected | Details concerning a service request that required a specimen to be collected. | NR | |||
| Specimen.collection | 0 | 1 | BackboneElement |
Collection details | Details concerning the specimen collection. | R [1..1] | |||
| Specimen.collection.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | |||
| Specimen.collection.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | |||
| Specimen.collection.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | |||
| Specimen.collection.collector | 0 | 1 | Reference(Practitioner|PractitionerRole) |
Who collected the specimen | Person who collected the specimen. | NR | |||
| Specimen.collection.collected[x] | 0 | 1 | dateTime Period |
Collection time | Time when specimen was collected from subject - the physiologically relevant time. | R [1..1] |
|||
| Specimen.collection.duration | 0 | 1 | Duration |
How long it took to collect specimen | The span of time over which the collection of a specimen occurred. | NR | |||
| Specimen.collection.quantity | 0 | 1 | Quantity {SimpleQuantity} |
The quantity of specimen collected | The quantity of specimen collected; for instance the volume of a blood sample, or the physical measurement of an anatomic pathology sample. | NR | |||
| Specimen.collection.method | 0 | 1 | CodeableConcept |
Technique used to perform collection | A coded value specifying the technique that is used to perform the procedure. | example | FHIR Specimen Collection Method | http://hl7.org/fhir/ValueSet/specimen-collection-method | NR |
| Specimen.collection.bodySite | 0 | 1 | CodeableConcept |
Anatomical collection site | Anatomical location from which the specimen was collected (if subject is a patient). This is the target site. This element is not used for environmental specimens. | example | SNOMED CT Body Structures | http://hl7.org/fhir/R4/valueset-body-site.html | R [1..1] |
| Specimen.collection.fastingStatus[x] | 0 | 1 | CodeableConcept Duration |
Whether or how long patient abstained from food and/or drink | Abstinence or reduction from some or all food, drink, or both, for a period of time prior to sample collection. | extensible | v2 Relevant Clinical Inforrmation | http://terminology.hl7.org/ValueSet/v2-0916 | |
| Specimen.processing | 0 | * | BackboneElement |
Processing and processing step details | Details concerning processing and processing steps for the specimen. | ||||
| Specimen.processing.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | |||
| Specimen.processing.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | |||
| Specimen.processing.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | |||
| Specimen.processing.description | 0 | 1 | string |
Textual description of procedure | Textual description of procedure. | ||||
| Specimen.processing.procedure | 0 | 1 | CodeableConcept |
Indicates the treatment step applied to the specimen | A coded value specifying the procedure used to process the specimen. | example | Specimen processing procedure | http://hl7.org/fhir/ValueSet/specimen-processing-procedure | |
| Specimen.processing.additive | 0 | * | Reference(Substance) |
Material used in the processing step | Material used in the processing step. | ||||
| Specimen.processing.time[x] | 0 | 1 | dateTime Period |
Date and time of specimen processing | A record of the time or period when the specimen processing occurred. For example the time of sample fixation or the period of time the sample was in formalin. | ||||
| Specimen.container | 0 | * | BackboneElement |
Direct container of specimen (tube/slide, etc.) | The container holding the specimen. The recursive nature of containers; i.e. blood in tube in tray in rack is not addressed here. | ||||
| Specimen.container.id | 0 | 1 | string |
Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | NRT | |||
| Specimen.container.extension | 0 | * | Extension |
Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | NRT | |||
| Specimen.container.modifierExtension | 0 | * | Extension |
Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
NRT | |||
| Specimen.container.identifier | 0 | * | Identifier |
Id for the container | Id for container. There may be multiple; a manufacturer's bar code, lab assigned identifier, etc. The container ID may differ from the specimen id in some circumstances. | NRT | |||
| Specimen.container.description | 0 | 1 | string |
Textual description of the container | Textual description of the container. | ||||
| Specimen.container.type | 0 | 1 | CodeableConcept |
Kind of container directly associated with specimen | The type of container associated with the specimen (e.g. slide, aliquot, etc.). | example | Specimen container | http://hl7.org/fhir/ValueSet/specimen-container-type | |
| Specimen.container.capacity | 0 | 1 | Quantity {SimpleQuantity} |
Container volume or size | The capacity (volume or other measure) the container may contain. | ||||
| Specimen.container.specimenQuantity | 0 | 1 | Quantity {SimpleQuantity} |
Quantity of specimen within container | The quantity of specimen in the container; may be volume, dimensions, or other appropriate measurements, depending on the specimen type. | ||||
| Specimen.container.additive[x] | 0 | 1 | CodeableConcept Reference(Substance) |
Additive associated with container | Introduced substance to preserve, maintain or enhance the specimen. Examples: Formalin, Citrate, EDTA. | example | v2 Additive | http://terminology.hl7.org/ValueSet/v2-0371 | |
| Specimen.condition | 0 | * | CodeableConcept |
State of the specimen | A mode or state of being that describes the nature of the specimen. | extensible | v2 Specimen Condition | http://terminology.hl7.org/ValueSet/v2-0493 | |
| Specimen.note | 0 | * | Annotation |
Comments | To communicate any details or issues about the specimen or during the specimen collection. (for example: broken vial, sent with patient, frozen). |
| Property | Value |
| URL | http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition |
| Version | 4.1.0 |
| Name | USCoreCondition |
| Title | US Core Condition Profile |
| Status | active |
| Experimental | false |
| Date | 2020-06-27 |
| Publisher | HL7 International - Cross-Group Projects |
| Contact | No display for ContactDetail |
| Jurisdiction | United States of America |
| Description | Defines constraints and extensions on the Condition resource for the minimal set of data to query and retrieve problems and health concerns information. |
| Purpose | |
| Copyright | Used by permission of HL7 International, all rights reserved Creative Commons License |
| FHIR Version | 4.0.1 |
| Kind | resource |
| Type | Condition |
| Base Definition | http://hl7.org/fhir/StructureDefinition/Condition |
| Abstract | false |
| Derivation | constraint |
| Property | Value |
| URL | http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition |
| Version | 4.1.0 |
| Name | USCoreCondition |
| Title | US Core Condition Profile |
| Status | active |
| Experimental | false |
| Date | 2020-06-27 |
| Publisher | HL7 International - Cross-Group Projects |
| Contact | No display for ContactDetail |
| Jurisdiction | United States of America |
| Description | Defines constraints and extensions on the Condition resource for the minimal set of data to query and retrieve problems and health concerns information. |
| Purpose | |
| Copyright | Used by permission of HL7 International, all rights reserved Creative Commons License |
| FHIR Version | 4.0.1 |
| Kind | resource |
| Type | Condition |
| Base Definition | http://hl7.org/fhir/StructureDefinition/Condition |
| Abstract | false |
| Derivation | constraint |
| Property | Value |
| URL | http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference |
| Version | 4.1.0 |
| Name | USCoreDocumentReferenceProfile |
| Title | US Core DocumentReference Profile |
| Status | active |
| Experimental | false |
| Date | 2020-07-02 |
| Publisher | HL7 International - Cross-Group Projects |
| Contact | No display for ContactDetail |
| Jurisdiction | United States of America |
| Description | The document reference profile used in US Core. |
| Purpose | |
| Copyright | Used by permission of HL7 International, all rights reserved Creative Commons License |
| FHIR Version | 4.0.1 |
| Kind | resource |
| Type | DocumentReference |
| Base Definition | http://hl7.org/fhir/StructureDefinition/DocumentReference |
| Abstract | false |
| Derivation | constraint |
| Property | Value |
| URL | http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter |
| Version | 4.1.0 |
| Name | USCoreEncounterProfile |
| Title | US Core Encounter Profile |
| Status | active |
| Experimental | false |
| Date | 2019-05-21 |
| Publisher | HL7 International - Cross-Group Projects |
| Contact | No display for ContactDetail |
| Jurisdiction | United States of America |
| Description | The Encounter referenced in the US Core profiles. |
| Purpose | |
| Copyright | Used by permission of HL7 International, all rights reserved Creative Commons License |
| FHIR Version | 4.0.1 |
| Kind | resource |
| Type | Encounter |
| Base Definition | http://hl7.org/fhir/StructureDefinition/Encounter |
| Abstract | false |
| Derivation | constraint |
| Property | Value |
| URL | http://hl7.org/fhir/us/core/StructureDefinition/us-core-immunization |
| Version | 4.1.0 |
| Name | USCoreImmunizationProfile |
| Title | US Core Immunization Profile |
| Status | active |
| Experimental | false |
| Date | 2019-08-26 |
| Publisher | HL7 International - Cross-Group Projects |
| Contact | No display for ContactDetail |
| Jurisdiction | United States of America |
| Description | Defines constraints and extensions on the Immunization resource for the minimal set of data to query and retrieve patient's immunization information. |
| Purpose | |
| Copyright | Used by permission of HL7 International, all rights reserved Creative Commons License |
| FHIR Version | 4.0.1 |
| Kind | resource |
| Type | Immunization |
| Base Definition | http://hl7.org/fhir/StructureDefinition/Immunization |
| Abstract | false |
| Derivation | constraint |
| Property | Value |
| URL | http://hl7.org/fhir/us/core/StructureDefinition/us-core-location |
| Version | 4.1.0 |
| Name | USCoreLocation |
| Title | US Core Location Profile |
| Status | active |
| Experimental | false |
| Date | 2019-05-21 |
| Publisher | HL7 International - Cross-Group Projects |
| Contact | No display for ContactDetail |
| Jurisdiction | United States of America |
| Description | Defines basic constraints and extensions on the Location resource for use with other US Core resources |
| Purpose | |
| Copyright | Used by permission of HL7 International, all rights reserved Creative Commons License |
| FHIR Version | 4.0.1 |
| Kind | resource |
| Type | Location |
| Base Definition | http://hl7.org/fhir/StructureDefinition/Location |
| Abstract | false |
| Derivation | constraint |
| Property | Value |
| URL | http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication |
| Version | 4.1.0 |
| Name | USCoreMedicationProfile |
| Title | US Core Medication Profile |
| Status | active |
| Experimental | false |
| Date | 2019-05-21 |
| Publisher | HL7 International - Cross-Group Projects |
| Contact | No display for ContactDetail |
| Jurisdiction | United States of America |
| Description | Defines constraints and extensions on the Medication resource for the minimal set of data to query and retrieve patient retrieving patient's medication information. |
| Purpose | |
| Copyright | Used by permission of HL7 International, all rights reserved Creative Commons License |
| FHIR Version | 4.0.1 |
| Kind | resource |
| Type | Medication |
| Base Definition | http://hl7.org/fhir/StructureDefinition/Medication |
| Abstract | false |
| Derivation | constraint |
| Property | Value |
| URL | http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest |
| Version | 4.1.0 |
| Name | USCoreMedicationRequestProfile |
| Title | US Core MedicationRequest Profile |
| Status | active |
| Experimental | false |
| Date | 2020-06-26 |
| Publisher | HL7 International - Cross-Group Projects |
| Contact | No display for ContactDetail |
| Jurisdiction | United States of America |
| Description | Defines constraints and extensions on the MedicationRequest resource for the minimal set of data to query and retrieve prescription information. |
| Purpose | |
| Copyright | Used by permission of HL7 International, all rights reserved Creative Commons License |
| FHIR Version | 4.0.1 |
| Kind | resource |
| Type | MedicationRequest |
| Base Definition | http://hl7.org/fhir/StructureDefinition/MedicationRequest |
| Abstract | false |
| Derivation | constraint |
| Property | Value |
| URL | http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab |
| Version | 4.1.0 |
| Name | USCoreLaboratoryResultObservationProfile |
| Title | US Core Laboratory Result Observation Profile |
| Status | active |
| Experimental | false |
| Date | 2020-06-27 |
| Publisher | HL7 International - Cross-Group Projects |
| Contact | No display for ContactDetail |
| Jurisdiction | United States of America |
| Description | Defines constraints and extensions on the Observation resource for the minimal set of data to query and retrieve laboratory test results |
| Purpose | |
| Copyright | Used by permission of HL7 International, all rights reserved Creative Commons License |
| FHIR Version | 4.0.1 |
| Kind | resource |
| Type | Observation |
| Base Definition | http://hl7.org/fhir/StructureDefinition/Observation |
| Abstract | false |
| Derivation | constraint |
| Property | Value |
| URL | http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure |
| Version | 4.1.0 |
| Name | USCoreProcedureProfile |
| Title | US Core Procedure Profile |
| Status | active |
| Experimental | false |
| Date | 2020-06-29 |
| Publisher | HL7 International - Cross-Group Projects |
| Contact | No display for ContactDetail |
| Jurisdiction | United States of America |
| Description | Defines constraints and extensions on the Procedure resource for the minimal set of data to query and retrieve patient's procedure information. This profile can be used to record a service or intervention that is or was performed on or for a patient. |
| Purpose | |
| Copyright | Used by permission of HL7 International, all rights reserved Creative Commons License |
| FHIR Version | 4.0.1 |
| Kind | resource |
| Type | Procedure |
| Base Definition | http://hl7.org/fhir/StructureDefinition/Procedure |
| Abstract | false |
| Derivation | constraint |
| Property | Value |
| URL | http://hl7.org/fhir/us/core/StructureDefinition/us-core-servicerequest |
| Version | 4.1.0 |
| Name | USCoreServiceRequest |
| Title | US Core Service Request |
| Status | active |
| Experimental | |
| Date | 2018-08-22T00:00:00+00:00 |
| Publisher | HL7 International - Cross-Group Projects |
| Contact | No display for ContactDetail |
| Jurisdiction | United States of America |
| Description | Defines constraints and extensions on the ServiceRequest resource for the minimal set of data to query and retrieve orders associated with diagnostic and clinical tests and clinical interventions for a patient |
| Purpose | |
| Copyright | Used by permission of HL7 International, all rights reserved Creative Commons License |
| FHIR Version | 4.0.1 |
| Kind | resource |
| Type | ServiceRequest |
| Base Definition | http://hl7.org/fhir/StructureDefinition/ServiceRequest |
| Abstract | false |
| Derivation | constraint |
| Property | Value |
| URL | http://hl7.org/fhir/StructureDefinition/Coverage |
| Version | 4.3.0 |
| Name | Coverage |
| Title | |
| Status | draft |
| Experimental | false |
| Date | 2022-05-28T12:47:40+10:00 |
| Publisher | Health Level Seven International (Financial Management) |
| Contact | No display for ContactDetail |
| Contact | No display for ContactDetail |
| Description | Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment. |
| Purpose | Coverage provides a link between covered parties (patients) and the payors of their healthcare costs (both insurance and self-pay). |
| Copyright | |
| FHIR Version | 4.3.0 |
| Kind | resource |
| Type | Coverage |
| Base Definition | http://hl7.org/fhir/StructureDefinition/DomainResource |
| Abstract | false |
| Derivation | specialization |
| Property | Value |
| URL | http://hl7.org/fhir/StructureDefinition/MedicationAdministration |
| Version | 4.3.0 |
| Name | MedicationAdministration |
| Title | |
| Status | draft |
| Experimental | false |
| Date | 2022-05-28T12:47:40+10:00 |
| Publisher | Health Level Seven International (Pharmacy) |
| Contact | No display for ContactDetail |
| Contact | No display for ContactDetail |
| Description | Describes the event of a patient consuming or otherwise being administered a medication. This may be as simple as swallowing a tablet or it may be a long running infusion. Related resources tie this event to the authorizing prescription, and the specific encounter between patient and health care practitioner. |
| Purpose | |
| Copyright | |
| FHIR Version | 4.3.0 |
| Kind | resource |
| Type | MedicationAdministration |
| Base Definition | http://hl7.org/fhir/StructureDefinition/DomainResource |
| Abstract | false |
| Derivation | specialization |
| Property | Value |
| URL | http://hl7.org/fhir/StructureDefinition/Observation |
| Version | 4.3.0 |
| Name | Observation |
| Title | |
| Status | active |
| Experimental | false |
| Date | 2022-05-28T12:47:40+10:00 |
| Publisher | Health Level Seven International (Orders and Observations) |
| Contact | No display for ContactDetail |
| Contact | No display for ContactDetail |
| Description | Measurements and simple assertions made about a patient, device or other subject. |
| Purpose | Observations are a key aspect of healthcare. This resource is used to capture those that do not require more sophisticated mechanisms. |
| Copyright | |
| FHIR Version | 4.3.0 |
| Kind | resource |
| Type | Observation |
| Base Definition | http://hl7.org/fhir/StructureDefinition/DomainResource |
| Abstract | false |
| Derivation | specialization |
| Property | Value |
| URL | http://hl7.org/fhir/StructureDefinition/Specimen |
| Version | 4.3.0 |
| Name | Specimen |
| Title | |
| Status | draft |
| Experimental | false |
| Date | 2022-05-28T12:47:40+10:00 |
| Publisher | Health Level Seven International (Orders and Observations) |
| Contact | No display for ContactDetail |
| Contact | No display for ContactDetail |
| Description | A sample to be used for analysis. |
| Purpose | |
| Copyright | |
| FHIR Version | 4.3.0 |
| Kind | resource |
| Type | Specimen |
| Base Definition | http://hl7.org/fhir/StructureDefinition/DomainResource |
| Abstract | false |
| Derivation | specialization |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |