2025 OMB FHIR RPS Data Dictionary

2025 OMB FHIR RPS Data Dictionary_Updated_8_23_2024.xlsx

[NCEZID] The National Healthcare Safety Network (NHSN)

2025 OMB FHIR RPS Data Dictionary

OMB: 0920-0666

Document [xlsx]
Download: xlsx | pdf

Overview

TOC - Daily
Abbreviations
FHIR DD Change Log
Dx Rpt Lab-US Core
Encounter-US Core
Lab Result Observation-US Core
Location-US Core
Medication-US Core
MedicationAdministration-R4
MedicationRequest-US Core
Observation-R4
Patient-US Core
Procedure-US Core
Service Request-R4
Specimen-R4
R4 Valuesets
Unused References
Metadata


Sheet 1: TOC - Daily

Table of Contents - Resources & Profiles Standard CDC NHSN dQM IG Profile - Daily
RPS
Diagnostic Report (Lab) - US Core US Core v3.1.1 Respiratory Pathogen Surveillance Event Laboratory Diagnostic Report MS
Encounter-US Core US Core v3.1.1 Respiratory Pathogen Surveillance Event Report Encounter R
Laboratory Result Observation - US Core US Core v3.1.1 Respiratory Pathogen Surveillance Event Lab Observation MS
Location-US Core US Core v3.1.1 Respiratory Pathogen Surveillance Event Location R
Medication-US Core US Core v3.1.1 Respiratory Pathogen Surveillance Event Medication MS
MedicationAdministration FHIR R4 v4.0.1 Respiratory Pathogen Surveillance Event MedicationAdministration MS
MedicationRequest-US Core US Core v3.1.1 Respiratory Pathogen Surveillance Event Report MedicationRequest MS
Observation FHIR R4 v4.0.1 in progress
MS
Patient - US Core US Core v3.1.1 Cross-Measure Patient Profile R
Procedure - US Core US Core v3.1.1 Respiratory Pathogen Surveillance Event Procedure MS
Service Request FHIR R4 v4.0.1 Respiratory Pathogen Surveillance Event ServiceRequest MS
Specimen FHIR R4 v4.0.1 Respiratory Pathogen Surveillance Event Specimen 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






FHIR R4:


http://hl7.org/fhir/R4/downloads.html






Link to Change Log






Sheet 2: Abbreviations

Details FHIR Master Data Dictionary
Version of Document: 1.00
Date of Document 2/9/2024
Draft Purpose This FHIR Master Data Dictionary documents the NHSN specific measure requirements to inform the development of the CDC NHSN dQM IG for daily measures.
Authors dQM Leads, Protocol Leads
Scope All daily NHSN measures
Abbreviation Name Details Comments
MS Must Support If available, it will be queried by NHSNLink for measure calculation or risk adjustment. Must be designated as MS or R if wanted in the Silver table.
Required Required to be queried by NHSNLink for the NHSN Application to determine initial population. Must be designated as MS or R if wanted in the Silver table.
NR Not Required Queried by NHSNLink but not required to calculate the measures. Elements designated as NR will go into the Bronze table but will not progress to Silver.
NRT Not Required by Technical Team Queried by NHSNLink but determined by the technical team as not needed. NRT elements will not be copied to Bronze and will only exist in the bundle itself, which are archived by NHSN.
AI Action Item In the change log tab, the dQM leads will indicate if an update requires an action item. If an AI is identified, a Jira ticket is typically assigned to a responsible party.
CQL Clinical Quality Language CQL is machine-readable and structured on the FHIR data model.
The NHSN dQM CQL defines the following items:
• The initial population eligible for the measure
• Line-level data required to calculate measure metrics
• Additional line-level data for stratification, risk adjustment, social determinants of health, and patient matching
FHIR bundle validation will occur against the CDC NHSN dQM IG, version 3.1.1 of US Core Profiles, and version 4.0.1 of FHIR R4.
Key for use of colors, fonts, and tabs
Red Font Cardinality differs from FHIR R4 or US Core standards or conformance is more constrained against FHIR R4 or US Core profiles.

Bold Font In the FHIR Resource tabs, it indicates the parent data elements.

Teal Tab FHIR R4 v.4.0.1 Profiles

Maroon Tab US Core v.3.1.1 Profiles

NHSN Technical Guidance
Mark all {Resource}.{dataElement}.identifiers as NRT.
Mark all {Resource}.contained as NRT.
Mark all {Resource}.meta as NRT.
Mark all {Resource}.text as NRT.

Sheet 3: FHIR DD Change Log

Date of Request Measure Name Data Element Changed From Changed To
4/18/2023 All Measures {Resource}.language NR NRT
4/18/2023 All Measures {Resource}.implicitRules NR NRT
4/18/2023 All Measures {Resource}.Identifier.period MS[0..1] in Encounte Resource NRT only in Technical column
4/18/2023 All Measures {Resource}.Identifier.assigner NR NRT
4/18/2023 All Measures Encounter.EpisodeOfCare MS [0..1] NRT only in Technical column
4/18/2023 All Measures Encounter.BasedOn NR NRT
4/18/2023 All Measures Encounter.serviceProvider NR NRT
4/18/2023 All Measures Encounter.appointment NR NRT
4/18/2023 All Measures Condition.recorder NR NRT
4/18/2023 All Measures Condition.asserter NR NRT
4/18/2023 All Measures Coverage.type NR NRT
4/18/2023 All Measures Coverage.dependent NR NRT
4/18/2023 All Measures Coverage.costToBeneficiary NR NRT
4/18/2023 All Measures Observation.category.extension NR NRT
4/18/2023 All Measures Medication.ingredient.isActive NR NRT
4/18/2023 All Measures MedicationRequest.statusReason NR NRT
4/18/2023 All Measures MedicationRequest.supportingInformation NR NRT
4/18/2023 All Measures MedicationRequest.performer NR NRT
4/18/2023 All Measures MedicationRequest.performerType NR NRT
4/18/2023 All Measures MedicationRequest.instantiatesCanonical MS [0..1] NRT only in Technical column
4/18/2023 All Measures MedicationRequest.instantiatesUri NR NRT
4/18/2023 All Measures MedicationRequest.basedOn NR NRT
4/18/2023 All Measures MedicationRequest.groupIdentifier NR NRT
4/18/2023 All Measures MedicationRequest.insurance NR NRT
4/18/2023 All Measures MedicationRequest.note NR NRT
4/18/2023 All Measures MedicationRequest.dosageInstruction.sequence NR NRT
4/18/2023 All Measures MedicationRequest.dosageInstruction.additionalInstruction NR NRT
4/18/2023 All Measures MedicationRequest.dosageInstruction.site MS[0..1] for Hypo and CDI/HOB NRT only in Technical column
4/18/2023 All Measures MedicationRequest.dosageInstruction.maxDosePerPeriod NR NRT
4/18/2023 All Measures MedicationRequest.dosageInstruction.maxDosePerAdministration NR NRT
4/18/2023 All Measures MedicationRequest.dosageInstruction.maxDosePerLifetime NR NRT
4/18/2023 All Measures MedicationRequest.substitution NR NRT
4/18/2023 All Measures MedicationRequest.dispenseRequest NR NRT
4/18/2023 All Measures MedicationRequest.priorPrescription NR NRT
4/18/2023 All Measures MedicationRequest.detectedIssue NR NRT
4/18/2023 All Measures MedicationRequest.eventHistory NR NRT
5/2/2023 All measures MedicationRequest.requester Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner|http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|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-relatedperson|Device) Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile)
5/8/2023 HT-CDI/HOB and RPS MedicationRequest.reasonReference NR MS [0..*]
5/8/2023 HT-CDI/HOB and RPS MedicationRequest.instantiatesCanonical NRT MS [0..*]
5/8/2023 HT-CDI/HOB and RPS MedicationRequest.instantiatesUri NRT MS [0..*]
5/15/2023 All measures Medication.ingredient.itemCodeableConcept
Medication.ingredient.itemReference
MS [0..1] Removed from table
5/15/2023 All measures NA NA N/A
5/15/2023 All measures Condition.onset.onsetDateTime
Condition.onset.onsetAge
Condition.onset.Period
Condition.onset.Range
Condition.onset.String

NR Removed from table
5/15/2023 All measures Condition.abatement.onsetDateTime
Condition.abatement.onsetAge
Condition.abatement.Period
Condition.abatement.Range
Condition.abatement.String


N/A Removed from table
5/16/2023 All measures DiagnosticReport.effective.effectiveDateTime
DiagnosticReport.effective.Period
NR N/A
5/22/2023 All measures Observation.category NR R [1..*] Link to Lab Result Observation tab
6/21/2023 All measures Location resource designation in TOC MS R
6/28/2023 All Measures Medication.code


7/5/2023 All Measures TOC, dQM Measure Lead/Back-up Clinical Analyst Row N/A Updated
7/10/2023 All measures Specimen.subject NR MS [0..1]
7/10/2023 All measures Specimen.collection MS [0..1] R [1..1]
7/10/2023 All measures Specimen.collection.id NR NRT
7/10/2023 All measures Specimen.collection.extension NR NRT
7/10/2023 All measures Specimen.collection.modifierExtension NR NRT
7/31/2023 All measures MedicationAdministration.context NR MS [0..1]
7/31/2023 All measures MedicationAdministration.request NR MS [0..1]
7/31/2023 All measures Condition.clinicalStatus NA added a note to FHIR Definition column G
7/31/2023 All measures Condition.verificationStatus NA added a note to FHIR Definition column G
8/1/2023 All measures Patient.contact.modifierExtension [0..1] NRT
8/1/2023 All measures Patient.communication.modifierExtension [0..1] NRT
8/1/2023 All measures Patient.identifier.period NRT - in technical column removed
8/1/2023 All measures Specimen.processing.modifierExtension NR NRT
8/1/2023 All measures Specimen.container.modifierExtension NR NRT
8/1/2023 All measures Specimen.container.identifier NR NRT
8/1/2023 All measures Specimen.text NR NRT
8/1/2023 All measures Specimen.contained NR NRT
8/1/2023 All measures Specimen.extension NR NRT
8/1/2023 All measures Specimen.processing.id NR NRT
8/1/2023 All measures Specimen.processing.extension NR NRT
8/1/2023 All measures Specimen.container.id NR NRT
8/1/2023 All measures Specimen.container.extension NR NRT
8/1/2023 N/A N/A Y or N removed
8/1/2023 All measures Specimen.meta NR NRT
8/1/2023 All measures Specimen.modifierExtension NR NRT
8/1/2023 All measures Specimen.collection.id NR NRT
8/1/2023 All measures Specimen.collection.extension NR NRT
8/1/2023 All measures Specimen.collection.modifierExtension NR NRT
8/1/2023 All measures (Abbreviation Tab) NA NA
8/1/2023 All measures Condition.meta NR NRT
8/1/2023 All measures Condition.text NR NRT
8/1/2023 All measures Condition.contained NR NRT
8/1/2023 All measures Condition.extension NR NRT
8/1/2023 All measures Condition.modifierExtension NR NRT
8/1/2023 All measures Condition.identifier NR NRT
8/1/2023 All measures Condition.stage.id NR NRT
8/1/2023 All measures Condition.stage.extension NR NRT
8/1/2023 All measures Condition.stage.modifierExtension NR NRT
8/1/2023 All measures Condition.evidence.id NR NRT
8/1/2023 All measures Condition.evidence.extension NR NRT
8/1/2023 All measures Condition.evidence.modifierExtension NR NRT
8/1/2023 All measures Coverage.meta NR NRT
8/1/2023 All measures Coverage.text NR NRT
8/1/2023 All measures Coverage.contained NR NRT
8/1/2023 All measures Coverage.extension NR NRT
8/1/2023 All measures Coverage.modifierExtension NR NRT
8/1/2023 All measures Coverage.identifier NR NRT
8/1/2023 All measures Coverage.class.id NR NRT
8/1/2023 All measures Coverage.class.extension NR NRT
8/1/2023 All measures Coverage.class.modifierExtension NR NRT
8/1/2023 All measures DiagnosticReport.meta NR NRT
8/1/2023 All measures DiagnosticReport.implicitRules NR NRT
8/1/2023 All measures DiagnosticReport.language NR NRT
8/1/2023 All measures DiagnosticReport.contained NR NRT
8/1/2023 All measures DiagnosticReport.extension NR NRT
8/1/2023 All measures DiagnosticReport.modifierExtension NR NRT
8/1/2023 All measures DiagnosticReport.identifier NR NRT
8/1/2023 All measures DiagnosticReport.category:LaboratorySlice.id NR NRT
8/1/2023 All measures DiagnosticReport.category:LaboratorySlice.id.extension NR NRT
8/1/2023 All measures DiagnosticReport.category:LaboratorySlice.coding.id NR NRT
8/1/2023 All measures DiagnosticReport.media.id NR NRT
8/1/2023 All measures DiagnosticReport.media.extension NR NRT
8/1/2023 All measures DiagnosticReport.media.modifierExtension NR NRT
8/1/2023 All measures DocumentReference.meta NR NRT
8/1/2023 All measures DocumentReference.text NR NRT
8/1/2023 All measures DocumentReference.contained NR NRT
8/1/2023 All measures DocumentReference.extension NR NRT
8/1/2023 All measures DocumentReference.modifierExtension NR NRT
8/1/2023 All measures DocumentReference.masterIdentifier NR NRT
8/1/2023 All measures DocumentReference.identifier NR NRT
8/1/2023 All measures DocumentReference.relatesTo.id NR NRT
8/1/2023 All measures DocumentReference.relatesTo.extension NR NRT
8/1/2023 All measures DocumentReference.relatesTo.modifierExtension NR NRT
8/1/2023 All measures DocumentReference.content.id NR NRT
8/1/2023 All measures DocumentReference.content.extension NR NRT
8/1/2023 All measures DocumentReference.content.modifierExtension NR NRT
8/1/2023 All measures DocumentReference.content.attachment.id NR NRT
8/1/2023 All measures DocumentReference.content.attachment.extension NR NRT
8/1/2023 All measures DocumentReference.content.attachment.language NR NRT
8/1/2023 All measures DocumentReference.context.id NR NRT
8/1/2023 All measures DocumentReference.context.extension NR NRT
8/1/2023 All measures DocumentReference.context.modifierExtension NR NRT
8/1/2023 All measures Encounter.meta NR NRT
8/1/2023 All measures Encounter.text NR NRT
8/1/2023 All measures Encounter.contained NR NRT
8/1/2023 All measures Encounter.extension NR NRT
8/1/2023 All measures Encounter.modifierExtension NR NRT
8/1/2023 All measures Encounter.identifier.id NR NRT
8/1/2023 All measures Encounter.identifier.extension NR NRT
8/1/2023 All measures Encounter.statusHistory.id NR NRT
8/1/2023 All measures Encounter.statusHistory.extension NR NRT
8/1/2023 All measures Encounter.statusHistory.modifierExtension NR NRT
8/1/2023 All measures Encounter.classHistory.id NR NRT
8/1/2023 All measures Encounter.classHistory.extension NR NRT
8/1/2023 All measures Encounter.classHistory.modifierExtension NR NRT
8/1/2023 All measures Encounter.participant.id NR NRT
8/1/2023 All measures Encounter.participant.extension NR NRT
8/1/2023 All measures Encounter.participant.modifierExtension NR NRT
8/1/2023 All measures Encounter.diagnosis.id NR NRT
8/1/2023 All measures Encounter.diagnosis.extension NR NRT
8/1/2023 All measures Encounter.diagnosis.modifierExtension NR NRT
8/1/2023 All measures Encounter.diagnosis.condition NR NRT
8/1/2023 All measures Encounter.hospitalization.id NR NRT
8/1/2023 All measures Encounter.hospitalization.extension NR NRT
8/1/2023 All measures Encounter.hospitalization.modifierExtension NR NRT
8/1/2023 All measures Encounter.location.id NR NRT
8/1/2023 All measures Encounter.location.extension NR NRT
8/1/2023 All measures Encounter.location.modifierExtension NR NRT
8/1/2023 All measures Immunization.meta NR NRT
8/1/2023 All measures Immunization.implicitRules NR NRT
8/1/2023 All measures Immunization.language NR NRT
8/1/2023 All measures Immunization.text NR NRT
8/1/2023 All measures Immunization.contained NR NRT
8/1/2023 All measures Immunization.extension NR NRT
8/1/2023 All measures Immunization.modifierExtension NR NRT
8/1/2023 All measures Immunization.performer.id NR NRT
8/1/2023 All measures Immunization.performer.extension NR NRT
8/1/2023 All measures Immunization.performer.modifierExtension NR NRT
8/1/2023 All measures Immunization.education.id NR NRT
8/1/2023 All measures Immunization.education.extension NR NRT
8/1/2023 All measures Immunization.education.modifierExtension NR NRT
8/1/2023 All measures Immunization.reaction.id NR NRT
8/1/2023 All measures Immunization.reaction.extension NR NRT
8/1/2023 All measures Immunization.reaction.modifierExtension NR NRT
8/1/2023 All measures Immunization.protocolApplied.id NR NRT
8/1/2023 All measures Immunization.protocolApplied.extension NR NRT
8/1/2023 All measures Immunization.protocolApplied.modifierExtension NR NRT
8/1/2023 All measures Device.meta NR NRT
8/1/2023 All measures Device.implicitRules NR NRT
8/1/2023 All measures Device.language NR NRT
8/1/2023 All measures Device.text NR NRT
8/1/2023 All measures Device.contained NR NRT
8/1/2023 All measures Device.extension NR NRT
8/1/2023 All measures Device.modifierExtension NR NRT
8/1/2023 All measures Device.identifier NR NRT
8/1/2023 All measures Device.deviceName.id NR NRT
8/1/2023 All measures Device.deviceName.extension NR NRT
8/1/2023 All measures Device.deviceName.modifierExtension NR NRT
8/1/2023 All measures Device.specialization.id NR NRT
8/1/2023 All measures Device.specialization.extension NR NRT
8/1/2023 All measures Device.specialization.modifierExtension NR NRT
8/1/2023 All measures Device.version.id NR NRT
8/1/2023 All measures Device.version.extension NR NRT
8/1/2023 All measures Device.version.modifierExtension NR NRT
8/1/2023 All measures Device.property.id NR NRT
8/1/2023 All measures Device.property.extension NR NRT
8/1/2023 All measures Device.property.modifierExtension NR NRT
8/1/2023 All measures Observation.meta NR NRT
8/1/2023 All measures Observation.text NR NRT
8/1/2023 All measures Observation.contained NR NRT
8/1/2023 All measures Observation.extension NR NRT
8/1/2023 All measures Observation.modifierExtension NR NRT
8/1/2023 All measures Observation.identifier NR NRT
8/1/2023 All measures Observation.category.id NR NRT
8/1/2023 All measures Observation.referenceRange.id NR NRT
8/1/2023 All measures Observation.referenceRange.extension NR NRT
8/1/2023 All measures Observation.referenceRange.modifierExtension NR NRT
8/1/2023 All measures Observation.component.id NR NRT
8/1/2023 All measures Observation.component.extension NR NRT
8/1/2023 All measures Observation.component.modifierExtension NR NRT
8/1/2023 All measures Location.meta NR NRT
8/1/2023 All measures Location.text NR NRT
8/1/2023 All measures Location.contained NR NRT
8/1/2023 All measures Location.extension NR NRT
8/1/2023 All measures Location.modifierExtension NR NRT
8/1/2023 All measures Location.address.id NR NRT
8/1/2023 All measures Location.address.extension NR NRT
8/1/2023 All measures Location.position.id NR NRT
8/1/2023 All measures Location.position.extension NR NRT
8/1/2023 All measures Location.position.modifierExtension NR NRT
8/1/2023 All measures Location.hoursOfOperation.id NR NRT
8/1/2023 All measures Location.hoursOfOperation.extension NR NRT
8/1/2023 All measures Location.hoursOfOperation.modifierExtension NR NRT
8/1/2023 All measures Medication.meta NR NRT
8/1/2023 All measures Medication.text NR NRT
8/1/2023 All measures Medication.contained NR NRT
8/1/2023 All measures Medication.extension NR NRT
8/1/2023 All measures Medication.modifierExtension NR NRT
8/1/2023 All measures Medication.identifier NR NRT
8/1/2023 All measures Medication.ingredient.id NR NRT
8/1/2023 All measures Medication.ingredient.extension NR NRT
8/1/2023 All measures Medication.ingredient.modifierExtension NR NRT
8/1/2023 All measures Medication.batch.id NR NRT
8/1/2023 All measures Medication.batch.extension NR NRT
8/1/2023 All measures Medication.batch.modifierExtension NR NRT
8/1/2023 All measures MedicationAdministration.meta NR NRT
8/1/2023 All measures MedicationAdministration.text NR NRT
8/1/2023 All measures MedicationAdministration.contained NR NRT
8/1/2023 All measures MedicationAdministration.extension NR NRT
8/1/2023 All measures MedicationAdministration.modifierExtension NR NRT
8/1/2023 All measures MedicationAdministration.identifier NR NRT
8/1/2023 All measures MedicationAdministration.performer.id NR NRT
8/1/2023 All measures MedicationAdministration.performer.extension NR NRT
8/1/2023 All measures MedicationAdministration.performer.modifierExtension NR NRT
8/1/2023 All measures MedicationAdministration.dosage.modifierExtension NR NRT
8/1/2023 All measures MedicationRequest.meta NR NRT
8/1/2023 All measures MedicationRequest.text NR NRT
8/1/2023 All measures MedicationRequest.contained NR NRT
8/1/2023 All measures MedicationRequest.extension NR NRT
8/1/2023 All measures MedicationRequest.modifierExtension NR NRT
8/1/2023 All measures MedicationRequest.identifier NR NRT
8/1/2023 All measures MedicationRequest.substitution.id NR NRT
8/1/2023 All measures MedicationRequest.substitution.extension NR NRT
8/1/2023 All measures MedicationRequest.substitution.modifierExtension NR NRT
8/1/2023 All measures Observation.meta NR NRT
8/1/2023 All measures Observation.text NR NRT
8/1/2023 All measures Observation.contained NR NRT
8/1/2023 All measures Observation.extension NR NRT
8/1/2023 All measures Observation.modifierExtension NR NRT
8/1/2023 All measures Observation.identifier NR NRT
8/1/2023 All measures Observation.referenceRange.id NR NRT
8/1/2023 All measures Observation.referenceRange.extension NR NRT
8/1/2023 All measures Observation.referenceRange.modifierExtension NR NRT
8/1/2023 All measures Procedure.meta NR NRT
8/1/2023 All measures Procedure.text NR NRT
8/1/2023 All measures Procedure.contained NR NRT
8/1/2023 All measures Procedure.extension NR NRT
8/1/2023 All measures Procedure.modifierExtension NR NRT
8/1/2023 All measures Procedure.identifier NR NRT
8/1/2023 All measures Procedure.performer.id NR NRT
8/1/2023 All measures Procedure.performer.extension NR NRT
8/1/2023 All measures Procedure.performer.modifierExtension NR NRT
8/1/2023 All measures Procedure.focalDevice.id NR NRT
8/1/2023 All measures Procedure.focalDevice.extension NR NRT
8/1/2023 All measures Procedure.focalDevice.modifierExtension NR NRT
8/1/2023 All measures ServiceRequest.meta NR NRT
8/1/2023 All measures ServiceRequest.text NR NRT
8/1/2023 All measures ServiceRequest.contained NR NRT
8/1/2023 All measures ServiceRequest.extension NR NRT
8/1/2023 All measures ServiceRequest.modifierExtension NR NRT
8/1/2023 All measures ServiceRequest.identifier NR NRT
8/2/2023 All measures Patient.meta NR NRT
8/2/2023 All measures Patient.implicitRules NR NRT
8/2/2023 All measures Patient.language NR NRT
8/2/2023 All measures Patient.text NR NRT
8/2/2023 All measures Patient.contained NR NRT
8/2/2023 All measures Patient.modifierExtension NR NRT
8/2/2023 All measures Patient.telecom.id NR NRT
8/2/2023 All measures Patient.telecom.extension NR NRT
8/7/2023 All measures MedicationRequest.dosageInstruction.site NRT blank
8/7/2023 RPS Encounter.diagnosis MS NRT
8/7/2023 RPS Encounter.diagnosis.condition NRT NR
8/7/2023 RPS MedicationRequest.reasonReference MS NR
8/7/2023 RPS Encounter.diagnosis.use NRT NR
8/7/2023 RPS Encounter.diagnosis.rank NRT NR
8/7/2023 RPS Encounter.status R [1..1]

Constrain CQL to triaged | in-progress | finished
R [1..1]

Constrain CQL to triaged | in-progress | onleave | finished

8/7/2023 Cross Measure Technical Team Requirements Review column Encounter.diagnosis.condition NRT (left blank)
8/14/2023 RPS MedicationRequest.dosageInstruction.text MS [0..1] NR
9/6/2023 All Resource Tabs, New Cross-Measure dQM Alignment, monthly column added NA NA NA
10/2/2023 Cross-Measure dQM aligment, monthly All data element aligment analysis NA NA
10/2/2023 Cross-Measure dQM aligment, monthly All data element aligment analysis NA NA
10/3/2023 TOC Tab NHSN IG - Cross Measure, Monthly Column NA NA
10/4/2023` TOC and all Resource Tabs Added an "ACH dQM" column with requirements


1010/2023 TOC Medication and Medication Request Resources in ACH dQM


10/25/2023 ACH, VTE, LOS/MEN, CDI/HOB, Hypo, RPS Observation.component.code MS [1..1] R [1..1]
11/6/2023 RPS Medication.status NR MS [0..*]
11/6/2023 RPS Specimen.status NR MS [0..1]
11/6/2023 RPS Observation - Vital Signs Resource/Profile NA NA
11/6/2023 RPS Encounter.status R [1..1]

Constrain CQL to triaged | in-progress | onleave | finished
R [1..1]

The following constraints are written into the CQL:
'in-progress', 'finished', 'triaged', 'onleave', 'entered-in-error'

11/7/2023 All Patient.extension (gender identity) MS [0..1] MS [0..*]
11/21/2023 All applicable measures Encounter.type http://hl7.org/fhir/us/core/ValueSet/us-core-encounter-type https://hl7.org/fhir/us/core/STU3.1.1/ValueSet-us-core-encounter-type.html
11/21/2023 All applicable measures Encounter.diagnosis.use http://hl7.org/fhir/ValueSet/diagnosis-role https://hl7.org/fhir/R4/valueset-diagnosis-role.html
11/21/2023 All applicable measures Encounter.hospitalization.admitSource http://hl7.org/fhir/ValueSet/encounter-admit-source https://hl7.org/fhir/R4/valueset-encounter-admit-source.html
11/21/2023 All applicable measures Encounter.location.status http://hl7.org/fhir/ValueSet/encounter-location-status https://hl7.org/fhir/R4/valueset-encounter-location-status.html
11/21/2023 All applicable measures Device.status http://hl7.org/fhir/ValueSet/device-status|4.0.1 https://hl7.org/fhir/R4/valueset-device-status.html
11/21/2023 All applicable measures Device.deviceName.type http://hl7.org/fhir/ValueSet/device-nametype|4.0.1 https://hl7.org/fhir/R4/valueset-device-nametype.html
11/21/2023 All applicable measures Observation.category http://hl7.org/fhir/ValueSet/observation-category https://hl7.org/fhir/R4/valueset-observation-category.html
11/21/2023 All applicable measures Observation.interpretation http://hl7.org/fhir/ValueSet/observation-interpretation https://hl7.org/fhir/R4/valueset-observation-interpretation.html
11/21/2023 All applicable measures Observation.component.interpretation http://hl7.org/fhir/ValueSet/observation-interpretation https://hl7.org/fhir/R4/valueset-observation-interpretation.html
12/13/2023 All Implantable Device (US Core)
Device.owner
N/A N/A
12/13/2023 All Implantable Device (UsCore)
Device.contact
N/A N/A
12/13/2023 All Implantable Device (UsCore)
Device.location
N/A N/A
12/13/2023 All Implantable Device (UsCore)
Device.url
N/A N/A
12/13/2023 All Implantable Device (UsCore)
Device.note
N/A N/A
12/13/2023 All Implantable Device (UsCore)
Device.safety
N/A N/A
12/13/2023 All Implantable Device (UsCore)
Device.parent
N/A N/A
12/13/2023 All Observation Vital Signs (R4)
Observation.component.referenceRange.low
N/A N/A
12/13/2023 All Observation Vital Signs (R4)
Observation.component.referenceRange.high
N/A N/A
12/13/2023 All Observation Vital Signs (R4)
Observation.component.referenceRange.type
N/A N/A
12/13/2023 All Observation Vital Signs (R4)
Observation.component.referenceRange.appliesTo
N/A N/A
12/13/2023 All Observation Vital Signs (R4)
Observation.component.referenceRange.age
N/A N/A
12/13/2023 All Observation Vital Signs (R4)
Observation.component. referenceRange.text
N/A N/A
12/22/2023 RPS Observation.code R [1..1]

R [1..1]

The following constraints are written into the CQL:
• "COVID_19 (Tests for SARS_CoV_2 Nucleic Acid)"
• "COVID_19 (Tests for SARS_CoV_2 Antigen)"
• "Influenza (Tests for influenza A or B virus Nucleic Acid)"
• "Influenza (Tests for influenza A or B virus Antigen)"
• " RSV (Tests for RSV Nucleic Acid)"
• "RSV (Tests for RSV Antigen)"

12/22/2023 RPS Observation.value[x] MS [0..1]

(could have a null if lab result/status is not yet finalized)
MS [0..1]

(could have a null if lab result/status is not yet finalized)

The following value set constraints are written into the CQL:
• "COVID_19 (Organism or Substance in Lab Results)"
• "Influenza (influenza A or B virus in Lab Results)"
• "RSV (Organism or Substance in Lab Results)"
• "LIVD SARS CoV2 Test Result Codes"

12/22/2023 RPS Medication.code R [1..1]
R [1..1]

The following value set constraints are written into the CQL:
• "Anakinra"
• "Baloxavir"
• "Bamlanivimab"
• "Baricitinib"
• "Bebtelovimab"
• "Casirivimab / Imdevimab"
• "Casirivimab"
• "COVID19 RxNorm Value Set for Tocilizumab"
• "Etesevimab"
• "Imdevimab"
• "Molnupiravir"
• "Nirmatrelvir / Ritonavir"
• "Oseltamivir"
• "Peramivir"
• "Remdesivir"
• "Sarilumab"
• "Sotrovimab"
• "Tofacitinib"
• "Zanamivir"

1/2/2024 HT-CDI/HOB, LOS/MEN, VTE, RPS Observation.value[x] MS [0..1]

(could have a null if lab result/status is not yet finalized)
MS [0..1]


1/2/2024 ACH, HT-CDI/HOB, Hypo, LOS/MEN, VTE, RPS Location.alias MS [0..*] MS [0..*]
1/2/2024 ACH, HT-CDI/HOB, Hypo, LOS/MEN, VTE, RPS Medication MS [0..*]
MS [0..*]

1/2/2024 ACH, HT-CDI/HOB, Hypo, LOS/MEN, VTE, RPS Medication.form MS [0..1] MS [0..1]
1/2/2024 ACH, HT-CDI/HOB, Hypo, LOS/MEN, VTE, RPS Medication.amount MS [0..1] MS [0..1]
1/2/2024 ACH, HT-CDI/HOB, Hypo, LOS/MEN, VTE, RPS Medication.ingredient MS [0..*] MS [0..*]
1/4/2024 All measures Observation.encounter (Lab Result Observation) MS [0..1] MS [0..1]
1/4/2024 ACH, HT-CDI/HOB, LOS/MEN, VTE, RPS DiagnosticReport.specimen MS [0..*] MS [0..*]
1/4/2024 All measures Location.partOf MS [0..1] MS [0..1]
1/4/2024 All measures MedicationAdministration MS [0..*] MS [0..*]
1/4/2024 All measures MedicationAdministration.statusReason MS [0..*] MS [0..*]
1/4/2024 All measures MedicationAdministration.category MS [0..*] MS [0..*]
1/4/2024 All measures MedicationAdministration.reasonCode MS [0..*] MS [0..*]
1/4/2024 All measures MedicationAdministration.reasonReference MS [0..*] MS [0..*]
1/4/2024 All measures MedicationRequest.dosageInstruction.method MS [0..1] MS [0..1]
1/4/2024 All measures MedicationRequest.dosageInstruction.doseAndRate MS [0..*] MS [0..*]
1/4/2024 All measures MedicationRequest.dosageInstruction.doseAndRate.type MS [0..1] MS [0..1]
1/4/2024 All measures MedicationRequest.dosageInstruction.doseAndRate.dose[x] MS [0..1] MS [0..1]
1/4/2024 All measures MedicationRequest.dosageInstruction.doseAndRate.rate[x] MS [0..1] MS [0..1]
1/4/2024 ACH, HT-CDI/HOB, LOS/MEN, VTE, RPS Procedure MS [0..*]

MS [0..*]
1/4/2024 ACH, HT-CDI/HOB, LOS/MEN, VTE, RPS Procedure.encounter MS[0..1] MS [0..1]
1/4/2024 ACH, HT-CDI/HOB, LOS/MEN, VTE, RPS Procedure.location MS [0..1] MS [0..1]
1/4/2024 All measures ServiceRequest MS [0..*] MS [0..*]
1/4/2024 All measures ServiceRequest.category MS [0..*] MS [0..*]
1/4/2024 All measures ServiceRequest.priority MS [0..1] MS [0…1]
1/4/2024 All measures ServiceRequest.doNotPerform MS [0..1] MS [0..1]
1/4/2024 All measures ServiceRequest.code MS [0..1] MS [0..1]
1/4/2024 All measures ServiceRequest.encounter MS [0..1] MS [0..1]
1/4/2024 All measures ServiceRequest.occurrence[x] MS [0..1] MS [0..1]
1/4/2024 All measures ServiceRequest.asNeeded[x] MS [0..1] MS [0..1]
1/4/2024 All measures ServiceRequest.reasonReference MS [0..*] MS [0..*]
1/4/2024 All measures ServiceRequest.specimen MS [0..*] MS [0..*]
1/4/2024 RPS MedicationRequest.basedOn MS [0..*]
NRT
1/19/2024 RPS DiagnosticReport.performer 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)
Reference(US Core Practitioner Profile | US Core Organization Profile)
1/19/2024 RPS DiagnosticReport.result Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab)
Reference(US Core Laboratory Result Observation Profile)

1/24/2024 ACH, CDI/HOB, LOS/MEN, VTE, RPS Diagnostic Report- Lab
DiagnosticReport.text
NR NRT
1/24/2024 ALL Location.identifier NR NRT
1/29/2024 ALL location.managingOrg MS NR
1/29/2024 ALL patient.managingOrganization MS NR
1/29/2024 RPS DiagnosticReport.performer MS [0..*] NR
1/30/2024 ALL DiagnosticReport.media.link NR NRT
1/30/2024 ALL DiagnosticReport.media.comment NR NRT
1/30/2024 ALL MedicationRequest.substitution.allowed[x]
NR NRT
1/30/2024 ALL MedicationRequest.substitution.reason NR NRT
2/8/2024 RPS Added Observation R4 Resource NA NA
2/9/2024 HT-CDI/HOB, LOS/MEN, RPS, VTE DiagnosticReport.presentedForm NR NRT
2/9/2024 RPS NA NA NA
6/17/2024 RPS MedicationRequest.requester R[1..1] NR

Sheet 4: Dx Rpt Lab-US Core

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 RPS
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.


NRT
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]

The following constraints are written into the CQL: 'final','registered','preliminary','partial'
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).


MS [0..1]
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(US Core Practitioner Profile | US Core Organization Profile) 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(US Core Laboratory Result Observation Profile)
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).



NRT
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.


NRT
DiagnosticReport.media.link 1 1
Reference(Media)
Reference to the image source Reference to the image source.



NRT
DiagnosticReport.conclusion 0 1
string
Clinical conclusion (interpretation) of test results Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report.



MS [0..1]
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 MS [0..*]
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.


NRT

Sheet 5: Encounter-US Core

Back to TOC









FHIR Path
Min Max Must Support? Data Type(s) FHIR Short Description FHIR Definition Binding Strength Binding Description FHIR Binding Value Set RPS
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..*]
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 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
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 https://hl7.org/fhir/R4/valueset-encounter-status.html R [1..1]

The following constraints are written into the CQL:
'in-progress', 'finished', 'triaged', 'onleave', 'entered-in-error'
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 R [1..1]

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.


R [1..1]
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]

The following constraints are written into the CQL: 'inpatient acute', 'inpatient encounter', 'observation encounter', 'inpatient non-acute', 'short stay'
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 https://hl7.org/fhir/us/core/STU3.1.1/ValueSet-us-core-encounter-type.html R [1..*]

The following constraints are written into the CQL:
"Observation Services": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1111.143'
"Encounter Inpatient": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307'
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.


NR
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.


NR
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 https://hl7.org/fhir/R4/valueset-diagnosis-role.html NR
Encounter.diagnosis.rank 0 1
positiveInt
Ranking of the diagnosis (for each role type) Ranking of the diagnosis (for each role type).


NR
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.


MS [0..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 https://hl7.org/fhir/R4/valueset-encounter-admit-source.html 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 NR
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]

CQL is constrained to codes within the HL7 "Discharge Disposition" value set.
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..*]

The following constraints are written into the CQL:
Inpatient, Emergency, and Observation Locations 2.16.840.1.113762.1.4.1046.265

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 NR
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

Sheet 6: Lab Result Observation-US Core

Back to TOC









FHIR Path Min Max Must Support? Data Type(s) FHIR Short Description FHIR Definition Binding Strength Binding Description (Value Set Name) Binding Value Set RPS
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 https://hl7.org/fhir/R4/valueset-observation-category.html R [1..*]
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:Laboratory.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:Laboratory.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:Laboratory.coding 1 * Y Coding Code defined by a terminology system A reference to a code defined by a terminology system.


NR
Observation.category:Laboratory.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:Laboratory.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:Laboratory.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:Laboratory.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:Laboratory.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:Laboratory.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:Laboratory.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:Laboratory.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]
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 NR
Observation.interpretation 0 *
CodeableConcept
High, low, normal, etc. A categorical assessment of an observation value. For example, high, low, normal. extensible ObservationInterpretationCodes https://hl7.org/fhir/R4/valueset-observation-interpretation.html 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.


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.


MS [0..*]
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 https://hl7.org/fhir/R4/valueset-observation-interpretation.html 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























Sheet 7: Location-US Core

Back to TOC









FHIR Path Min Max Must Support Data Type(s) FHIR Short Description FHIR Definition Binding Strength Binding Description Binding Value Set RPS
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.


NRT
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 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 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 NR
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.


NR
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 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

Sheet 8: Medication-US Core

Back to TOC









FHIR Path
Min Max Must Support? Data Type(s) FHIR Short Description FHIR Definition Binding Strength Binding Description Binding Value Set RPS
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 MS [0..*]
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

Sheet 9: MedicationAdministration-R4

Back to TOC








FHIRPath Min Max Data Type(s) FHIR Short Description FHIR Definition Binding Strength Binding Description (Value Set Name) Binding Value Set RPS
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.


NR
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 NR
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 NR
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.


NR
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

Sheet 10: MedicationRequest-US Core

Back to TOC










FHIR Path Min Max Must Support? Data Type(s) FHIR Short Description FHIR Definition Comments Binding Strength Binding Description Binding Value Set RPS
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. 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]
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. 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
MedicationRequest.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 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. 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
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. 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
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. 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
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).
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
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. This is a business identifier, not a resource identifier.


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. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. required medicationrequest Status http://hl7.org/fhir/ValueSet/medicationrequest-status R [1..1]

CQL is constrained to 'completed'
MedicationRequest.statusReason 0 1
CodeableConcept
Reason for current status+F14 Captures the reason for the current state of the MedicationRequest. This is generally only used for "exception" statuses such as "suspended" or "cancelled". The reason why the MedicationRequest was created at all is captured in reasonCode, not here. example medicationRequest Status Reason Codes http://hl7.org/fhir/ValueSet/medicationrequest-status-reason NRT
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. It is expected that the type of requester will be restricted for different stages of a MedicationRequest. For example, Proposals can be created by a patient, relatedPerson, Practitioner or Device. Plans can be created by Practitioners, Patients, RelatedPersons and Devices. Original orders can be created by a Practitioner only.

An instance-order is an instantiation of a request or order and may be used to populate Medication Administration Record.

This element is labeled as a modifier because the intent alters when and how the resource is actually applicable.
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)). The category can be used to include where the medication is expected to be consumed or other types of requests. 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. If do not perform is not specified, the request is a positive request e.g. "do perform".


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. If only a code is specified, then it needs to be a code for a specific product. If more information is required, then the use of the Medication resource is recommended. For example, if you require form or lot number or if the medication is compounded or extemporaneously prepared, then you must reference the Medication resource. 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. The subject on a medication request is mandatory. For the secondary use case where the actual subject is not provided, there still must be an anonymized subject specified.


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. 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." If there is a need to link to episodes of care they will be handled with an extension.


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.



NR
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. If specified without indicating a performer, this indicates that the performer must be of the specified type. If specified with a performer then it indicates the requirements of the performer if the designated performer is not available. 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. This could be a diagnosis code. If a full condition record exists or additional detail is needed, use reasonReference. 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. This is a reference to a condition or observation that is the reason for the medication order. If only a code exists, use reasonCode.


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. can include a version number (FHIR based)


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. This attribute should not be confused with the protocol of the medication. example Medication request course of therapy codes http://hl7.org/fhir/R4/ValueSet/medicationrequest-course-of-therapy NR
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. There are examples where a medication request may include the option of an oral dose or an Intravenous or Intramuscular dose. For example, "Ondansetron 8mg orally or IV twice a day as needed for nausea" or "Compazine® (prochlorperazine) 5-10mg PO or 25mg PR bid prn nausea or vomiting". In these cases, two medication requests would be created that could be grouped together. The decision on which dose and route of administration to use is based on the patient's condition at the time the dose is needed.


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. 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
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).
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
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.



NR
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"). Information about administration or preparation of the medication (e.g. "infuse as rapidly as possibly via intraperitoneal port" or "immediately following drug x") should be populated in dosage.text. 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. This attribute might not always be populated while the Dosage.text is expected to be populated. If both are populated, then the Dosage.text should reflect the content of the Dosage.timing.


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). Can express "as needed" without a reason by setting the Boolean = True. In this case the CodeableConcept is not populated. Or you can express "as needed" with a reason by including the CodeableConcept. In this case the Boolean is assumed to be True. If you set the Boolean to False, then the dose is given according to the schedule and is not "prn" or "as needed". 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. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension [bodySite](http://hl7.org/fhir/R4/extension-bodysite.html). May be a summary code, or a reference to a very precise definition of the location, or both. 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. Terminologies used often pre-coordinate this term with the route and or form of administration. 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. 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
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. Note that this specifies the quantity of the specified medication, not the quantity for each active ingredient(s). Each ingredient amount can be communicated in the Medication resource. For example, if one wants to communicate that a tablet was 375 mg, where the dose was one tablet, you can use the Medication resource to document that the tablet was comprised of 375 mg of drug XYZ. Alternatively if the dose was 375 mg, then you may only need to use the Medication resource to indicate this was a tablet. If the example were an IV such as dopamine and you wanted to communicate that 400mg of dopamine was mixed in 500 ml of some IV solution, then this would all be communicated in the Medication resource. If the administration is not intended to be instantaneous (rate is present or timing has a duration), this can be specified to convey the total amount to be administered over the period of time as indicated by the schedule e.g. 500 ml in dose, with timing used to convey that this should be done over 4 hours.


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. It is possible to supply both a rate and a doseQuantity to provide full details about how the medication is to be administered and supplied. If the rate is intended to change over time, depending on local rules/regulations, each change should be captured as a new version of the MedicationRequest with an updated rate, or captured with a new MedicationRequest with the new rate._x000D__x000D_It is possible to specify a rate over time (for example, 100 ml/hour) using either the rateRatio and rateQuantity. The rateQuantity approach requires systems to have the capability to parse UCUM grammer where ml/hour is included rather than a specific ratio where the time is specified as the denominator. Where a rate such as 500ml over 2 hours is specified, the use of rateRatio may be more semantically correct than specifying using a rateQuantity of 250 mg/hour.


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. This is intended for use as an adjunct to the dosage when there is an upper cap. For example "2 tablets every 4 hours to a maximum of 8/day".


NRT
MedicationRequest.dosageInstruction.maxDosePerAdministration 0 1
Quantity {SimpleQuantity}
Upper limit on medication per administration Upper limit on medication per administration. This is intended for use as an adjunct to the dosage when there is an upper cap. For example, a body surface area related dose with a maximum amount, such as 1.5 mg/m2 (maximum 2 mg) IV over 5 – 10 minutes would have doseQuantity of 1.5 mg/m2 and maxDosePerAdministration of 2 mg.


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. 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
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).
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
MedicationRequest.dispenseRequest.initialFill 0 1
BackboneElement
First fill details Indicates the quantity or duration for the first dispense of the medication. If populating this element, either the quantity or the duration must be included.


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. 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
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).
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
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). It reflects the prescribers' perspective for the validity of the prescription. Dispenses must not be made against the prescription outside of this period. The lower-bound of the Dispensing Window signifies the earliest date that the prescription can be filled for the first time. If an upper-bound is not specified then the Prescription is open-ended or will default to a stale-date based on regulations.


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. If displaying "number of authorized fills", add 1 to this number.


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. In some situations, this attribute may be used instead of quantity to identify the amount supplied by how long it is expected to last, rather than the physical quantity issued, e.g. 90 days supply of medication (based on an ordered dosage). When possible, it is always better to specify quantity, as this tends to be more precise. expectedSupplyDuration will always be an estimate that can be influenced by external factors.


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. 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
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).
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
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. This element is labeled as a modifier because whether substitution is allow or not, it cannot be ignored. example ActSubstanceAdminSubstitutionCode http://terminology.hl7.org/ValueSet/v3-ActSubstanceAdminSubstitutionCode NRT
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 NRT
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. This element can include a detected issue that has been identified either by a decision support system or by a clinician and may include information on the steps that were taken to address the issue. 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. This might not include provenances for all versions of the request – only those deemed “relevant” or important. This SHALL NOT include the provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the provenance that points to this version using _revinclude All Provenances should have some historical version of this Request as their subject.). Y

NRT

Sheet 11: Observation-R4

Back to TOC








FHIR Path Min Max Data Type(s) FHIR Short Description FHIR Definition Binding Strength Binding Description (Value Set Name) Binding Value Set RPS
Observation 0 * DomainResource Measurements and simple assertions Measurements and simple assertions made about a patient, device or other subject.


MS [0..*]
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.


MS[0..*]
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 MS [0..*]
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 NR
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 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/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

Sheet 12: Patient-US Core

Back to TOC









FHIR Path Min Max Must Support? Data Type(s) FHIR Short Description FHIR Definition Binding Strength Binding Description Binding Value Set cross-setting for all measures
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.. *]
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).



NRT
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.


NR
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.


MS [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.


MS [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).



MS [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]

Sheet 13: Procedure-US Core

Back to TOC










FHIR Path Min Max Must Support? Data Type(s) FHIR Short Description FHIR Definition Comments Binding Strength Binding Description Binding Value Set RPS
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.


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.


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").
extensible Codes describing the type of Procedure https://hl7.org/fhir/us/core/STU3.1.1/ValueSet-us-core-procedure-code.html 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.


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.
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.



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.



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.



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 NR
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.



NR
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 NR
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.



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.


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.


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

Sheet 14: Service Request-R4

Back to TOC








FHIR Path Min Max Data Type(s) FHIR Short Description FHIR Definition Binding Strength Binding Description Binding Value Set RPS
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 https://hl7.org/fhir/R4/valueset-servicerequest-orderdetail.html 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

Sheet 15: Specimen-R4

Back to TOC








FHIR Path
Min Max Data Type(s) FHIR Short Description FHIR Definition Binding Strength Binding Description Binding Value Set RPS
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.


NRT
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.


NRT
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.


NRT
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 MS[0..1]
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 NR
Specimen.processing 0 * BackboneElement
Processing and processing step details Details concerning processing and processing steps for the specimen.


NR
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.


NR
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 https://hl7.org/fhir/R4/valueset-specimen-processing-procedure.html NR
Specimen.processing.additive 0 * Reference(Substance)
Material used in the processing step Material used in the processing step.


NR
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.


NR
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.


NR
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.


NR
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 NR
Specimen.container.capacity 0 1 Quantity {SimpleQuantity}
Container volume or size The capacity (volume or other measure) the container may contain.


NR
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.


NR
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 NR
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 NR
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).


NR

Sheet 16: R4 Valuesets

Back to TOC






Valueset Name Canonical URL Description Multiple Code Systems? CodeSystem Used Measures Used In Used in Data Returned from Site Resource/Element Used in
Discharge disposition http://terminology.hl7.org/ValueSet/encounter-discharge-disposition This value set defines a set of codes that can be used to where the patient left the hospital. No http://terminology.hl7.org/CodeSystem/discharge-disposition Hypo, RPS None Encounter.hospitalization.dischargeDisposition
Inpatient, Emergency, and Observation Locations http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1046.265 Set of codes that describe locations within a hospital No https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/hsloc.html Hypo, CDI/HOB, RPS None Location.type
Encounter Inpatient http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307 The purpose of this value set is to represent concepts of inpatient hospitalization encounters. No http://snomed.info/sct Hypo, CDI/HOB, RPS None Encounter.type
Observation Services http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1111.143 The purpose of this value set is to represent concepts for encounters for observation in the inpatient setting. No http://snomed.info/sct Hypo, CDI/HOB, RPS None Encounter.type
COVID_19 (Tests for SARS_CoV_2 Nucleic Acid) http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1146.1142 [Threaded comment] Your version of Excel allows you to read this threaded comment; however, any edits to it will get removed if the file is opened in a newer version of Excel. Learn more: https://go.microsoft.com/fwlink/?linkid=870924 Comment: None of the value sets in this row and below have official descriptions. Leaving blank
No http://loinc.org RPS
Observation.code, DiagnosticReport.code, ServiceRequest.code
COVID_19 (Tests for SARS_CoV_2 Antigen) http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1146.1158
No http://loinc.org RPS
Observation.code, DiagnosticReport.code, ServiceRequest.code
Influenza (Tests for influenza A or B virus Nucleic Acid) http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1146.336
No http://loinc.org RPS
Observation.code, DiagnosticReport.code, ServiceRequest.code
Influenza (Tests for influenza A or B virus Antigen) http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1146.337
No http://loinc.org RPS
Observation.code, DiagnosticReport.code, ServiceRequest.code
RSV (Tests for RSV Antigen) http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1146.1311
No http://loinc.org RPS
Observation.code, DiagnosticReport.code, ServiceRequest.code
RSV (Tests for RSV Nucleic Acid) http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1146.1312
No http://loinc.org RPS
Observation.code, DiagnosticReport.code, ServiceRequest.code
Baricitinib http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3616.200.110.102.2046
No http://www.nlm.nih.gov/research/umls/rxnorm RPS
MedicationRequest.medication, MedicationAdministration.medication, Medication.code
Anakinra http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3616.200.110.102.2054
No http://www.nlm.nih.gov/research/umls/rxnorm RPS
MedicationRequest.medication, MedicationAdministration.medication, Medication.code
Sarilumab http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3616.200.110.102.2084
No http://www.nlm.nih.gov/research/umls/rxnorm RPS
MedicationRequest.medication, MedicationAdministration.medication, Medication.code
COVID19 RxNorm Value Set for Tocilizumab http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3616.200.110.102.2087
No http://www.nlm.nih.gov/research/umls/rxnorm RPS
MedicationRequest.medication, MedicationAdministration.medication, Medication.code
Casirivimab http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3616.200.110.102.2097
No http://www.nlm.nih.gov/research/umls/rxnorm RPS
MedicationRequest.medication, MedicationAdministration.medication, Medication.code
Imdevimab http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3616.200.110.102.2098
No http://www.nlm.nih.gov/research/umls/rxnorm RPS
MedicationRequest.medication, MedicationAdministration.medication, Medication.code
Bamlanivimab http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3616.200.110.102.2099
No http://www.nlm.nih.gov/research/umls/rxnorm RPS
MedicationRequest.medication, MedicationAdministration.medication, Medication.code
Etesevimab http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3616.200.110.102.2100
No http://www.nlm.nih.gov/research/umls/rxnorm RPS
MedicationRequest.medication, MedicationAdministration.medication, Medication.code
Sotrovimab http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3616.200.110.102.2101
No http://www.nlm.nih.gov/research/umls/rxnorm RPS
MedicationRequest.medication, MedicationAdministration.medication, Medication.code
Tofacitinib http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3616.200.110.102.2102
No http://www.nlm.nih.gov/research/umls/rxnorm RPS
MedicationRequest.medication, MedicationAdministration.medication, Medication.code
Casirivimab / Imdevimab http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3616.200.110.102.2103
No http://www.nlm.nih.gov/research/umls/rxnorm RPS
MedicationRequest.medication, MedicationAdministration.medication, Medication.code
Molnupiravir http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3616.200.110.102.2119
No http://www.nlm.nih.gov/research/umls/rxnorm RPS
MedicationRequest.medication, MedicationAdministration.medication, Medication.code
Remdesivir http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3616.200.110.102.2081
No http://www.nlm.nih.gov/research/umls/rxnorm RPS
MedicationRequest.medication, MedicationAdministration.medication, Medication.code
Nirmatrelvir / Ritonavir http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3616.200.110.102.2104
No http://www.nlm.nih.gov/research/umls/rxnorm RPS
MedicationRequest.medication, MedicationAdministration.medication, Medication.code
Bebtelovimab http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3616.200.110.102.2105
No http://www.nlm.nih.gov/research/umls/rxnorm RPS
MedicationRequest.medication, MedicationAdministration.medication, Medication.code
Baloxavir http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1190.85
No http://www.nlm.nih.gov/research/umls/rxnorm RPS
MedicationRequest.medication, MedicationAdministration.medication, Medication.code
Peramivir http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1190.86
No http://www.nlm.nih.gov/research/umls/rxnorm RPS
MedicationRequest.medication, MedicationAdministration.medication, Medication.code
Zanamivir http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1190.87
No http://www.nlm.nih.gov/research/umls/rxnorm RPS
MedicationRequest.medication, MedicationAdministration.medication, Medication.code
Oseltamivir http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3616.200.110.102.2078
No http://www.nlm.nih.gov/research/umls/rxnorm RPS
MedicationRequest.medication, MedicationAdministration.medication, Medication.code
Transmission Based Precaution Types http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.10.20.22.5.300
No http://snomed.info/sct RPS
Procedure.code

Sheet 17: Unused References

Reference Name FHIR Data Element
Clinical Impression Condition.stage.assessment
RelatedPerson Coverage.policyHolder
RelatedPerson Coverage.subscriber
Related Person Coverage.payor
Contract Coverage.contract
US Core Practitioner Encounter.participant.individual
ImmunizationRecommendation Encounter.reasonReference
Account Encounter.account
CarePlan Observation.basedOn (Lab Result Observation)
DeviceRequest Observation.basedOn (Lab Result Observation)
ImmunizationRecommendation Observation.basedOn (Lab Result Observation)
NutritionOrder Observation.basedOn (Lab Result Observation)
MedicationDispense Observation.partOf (Lab Result Observation)
MedicationStatement Observation.partOf (Lab Result Observation)
Immunization Observation.partOf (Lab Result Observation)
ImagingStudy Observation.partOf (Lab Result Observation)
Practitioner Observation.performer (Lab Result Observation)
PractitionerRole Observation.performer (Lab Result Observation)
CareTeam Observation.performer (Lab Result Observation)
RelatedPerson Observation.performer (Lab Result Observation)
DeviceMetric Observation.device (Lab Result Observation)
QuestionnaireResponse Observation.hasMember (Lab Result Observation)
MolecularSequence Observation.hasMember (Lab Result Observation)
DocumentReference Observation.derivedFrom (Lab Result Observation)
ImagingStudy Observation.derivedFrom (Lab Result Observation)
Media Observation.derivedFrom (Lab Result Observation)
QuestionnaireResponse Observation.derivedFrom (Lab Result Observation)
MolecularSequence Observation.derivedFrom (Lab Result Observation)
Endpoint Location.endpoint
Group MedicationAdministration.subject
Practitioner MedicationAdministration.performer.actor
PractitionerRole MedicationAdministration.performer.actor
RelatedPerson MedicationAdministration.performer.actor
Provenance MedicationAdministration.eventHistory
CarePlan Observation.basedOn (Observation-Vital Signs R4)
ImmunizationRecommendation Observation.basedOn (Observation-Vital Signs R4)
NutritionOrder Observation.basedOn (Observation-Vital Signs R4)
MedicationDispense Observation.partOf (Observation-Vital Signs R4)
MedicationStatement Observation.partOf (Observation-Vital Signs R4)
Immunization Observation.partOf (Observation-Vital Signs R4)
ImagingStudy Observation.partOf (Observation-Vital Signs R4)
QuestonnaireResponse Observation.hasMember(Observation-Vital Signs R4)
MolecularSequence Observation.hasMember(Observation-Vital Signs R4)
CarePlan ServiceRequest.basedOn 
Group ServiceRequest.subject
Practitioner ServiceRequest.requester
PractitionerRole ServiceRequest.requester
RelatedPerson ServiceRequest.requester
Practitioner ServiceRequest.performer
PractitionerRole ServiceRequest.performer
CareTeam ServiceRequest.performer
HealthcareService ServiceRequest.performer
RelatedPerson ServiceRequest.performer
ClaimResponse ServiceRequest.insurance
Provenance ServiceRequest.relevantHistory
Substance Specimen.container.additive[x]

Sheet 18: Metadata

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 Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

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