AGHA.FHIR.GENCLIPR\Finding

Genomics Clinical Picture Repository Implementation Guide
0.1.0 - ci-build

Genomics Clinical Picture Repository Implementation Guide - Local Development build (v0.1.0). See the Directory of published versions

Resource Profile: Finding

Official URL: http://aehrc.github.io/genclipr-fhir-ig/StructureDefinition/Finding				Version: 0.1.0
Active as of 2022-03-21				Computable Name: Finding
Copyright/Legal: Australian Genomics

An observation about a patient that can be normal or abnormal and is expressed in a way that its action is reduced to a single concept (see pattern 3 in http://hl7.org/fhir/R4/observation.html#code-interop).

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

Text Summary
Differential Table
Snapshot Table
Snapshot Table (Must Support)
All

This structure is derived from Observation

Summary

Mandatory: 3 elements
Must-Support: 3 elements
Prohibited: 3 elements

Structures

This structure refers to these other structures:

This structure is derived from Observation

Name	Flags	Card.	Type	Description & Constraints
Observation		0..*	Observation	Measurements and simple assertions
category	S	1..*	CodeableConcept	Classification of type of observation
code		1..1	CodeableConcept	Type of observation (code / type) Binding: Abnormal Clinical Findings Value Set (required)
subject		1..1	Reference(Deidentified Patient)	Who and/or what the observation is about
focus		0..0
encounter		1..1	Reference(Genomics Clinical Picture Repository Encounter)	Healthcare event during which this observation is made
effective[x]	S	0..1		Clinically relevant time/time-period for observation
effectiveDateTime			dateTime
effectivePeriod			Period
value[x]		0..1	Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period	Actual result Binding: Presence Value Set (required)
bodySite	S	0..1	CodeableConcept	Observed body part Binding: SNOMEDCTBodyStructures (required)
referenceRange		0..0
hasMember		0..0
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Observation	I	0..*	Observation	Measurements and simple assertions
id	Σ	0..1	string	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language.
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	Business Identifier for observation
basedOn	Σ	0..*	Reference(CarePlan \| DeviceRequest \| ImmunizationRecommendation \| MedicationRequest \| NutritionOrder \| ServiceRequest)	Fulfills plan, proposal or order
partOf	Σ	0..*	Reference(MedicationAdministration \| MedicationDispense \| MedicationStatement \| Procedure \| Immunization \| ImagingStudy)	Part of referenced event
status	?!Σ	1..1	code	registered \| preliminary \| final \| amended + Binding: ObservationStatus (required): Codes providing the status of an observation.
category	S	1..*	CodeableConcept	Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
code	Σ	1..1	CodeableConcept	Type of observation (code / type) Binding: Abnormal Clinical Findings Value Set (required)
subject	Σ	1..1	Reference(Deidentified Patient)	Who and/or what the observation is about
encounter	Σ	1..1	Reference(Genomics Clinical Picture Repository Encounter)	Healthcare event during which this observation is made
effective[x]	SΣ	0..1		Clinically relevant time/time-period for observation
effectiveDateTime			dateTime
effectivePeriod			Period
issued	Σ	0..1	instant	Date/Time this version was made available
performer	Σ	0..*	Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam \| Patient \| RelatedPerson)	Who is responsible for the observation
value[x]	ΣI	0..1		Actual result Binding: Presence Value Set (required)
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	I	0..1	CodeableConcept	Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note		0..*	Annotation	Comments about the observation
bodySite	S	0..1	CodeableConcept	Observed body part Binding: SNOMEDCTBodyStructures (required)
method		0..1	CodeableConcept	How it was done Binding: ObservationMethods (example): Methods for simple observations.
specimen		0..1	Reference(Specimen)	Specimen used for this observation
device		0..1	Reference(Device \| DeviceMetric)	(Measurement) Device
derivedFrom	Σ	0..*	Reference(DocumentReference \| ImagingStudy \| Media \| QuestionnaireResponse \| Observation \| MolecularSequence)	Related measurements the observation is made from
component	Σ	0..*	BackboneElement	Component results
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	1..1	CodeableConcept	Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
value[x]	Σ	0..1		Actual component result
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	I	0..1	CodeableConcept	Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
referenceRange		0..*	See referenceRange (Observation)	Provides guide for interpretation of component result
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Observation	I	0..*	Observation	Measurements and simple assertions
category		1..*	CodeableConcept	Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
effective[x]	Σ	0..1		Clinically relevant time/time-period for observation
effectiveDateTime			dateTime
effectivePeriod			Period
bodySite		0..1	CodeableConcept	Observed body part Binding: SNOMEDCTBodyStructures (required)
Documentation for this format

This structure is derived from Observation

Summary

Mandatory: 3 elements
Must-Support: 3 elements
Prohibited: 3 elements

Structures

This structure refers to these other structures:

Differential View

This structure is derived from Observation

Name	Flags	Card.	Type	Description & Constraints
Observation		0..*	Observation	Measurements and simple assertions
category	S	1..*	CodeableConcept	Classification of type of observation
code		1..1	CodeableConcept	Type of observation (code / type) Binding: Abnormal Clinical Findings Value Set (required)
subject		1..1	Reference(Deidentified Patient)	Who and/or what the observation is about
focus		0..0
encounter		1..1	Reference(Genomics Clinical Picture Repository Encounter)	Healthcare event during which this observation is made
effective[x]	S	0..1		Clinically relevant time/time-period for observation
effectiveDateTime			dateTime
effectivePeriod			Period
value[x]		0..1	Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period	Actual result Binding: Presence Value Set (required)
bodySite	S	0..1	CodeableConcept	Observed body part Binding: SNOMEDCTBodyStructures (required)
referenceRange		0..0
hasMember		0..0
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Observation	I	0..*	Observation	Measurements and simple assertions
id	Σ	0..1	string	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language.
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	Business Identifier for observation
basedOn	Σ	0..*	Reference(CarePlan \| DeviceRequest \| ImmunizationRecommendation \| MedicationRequest \| NutritionOrder \| ServiceRequest)	Fulfills plan, proposal or order
partOf	Σ	0..*	Reference(MedicationAdministration \| MedicationDispense \| MedicationStatement \| Procedure \| Immunization \| ImagingStudy)	Part of referenced event
status	?!Σ	1..1	code	registered \| preliminary \| final \| amended + Binding: ObservationStatus (required): Codes providing the status of an observation.
category	S	1..*	CodeableConcept	Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
code	Σ	1..1	CodeableConcept	Type of observation (code / type) Binding: Abnormal Clinical Findings Value Set (required)
subject	Σ	1..1	Reference(Deidentified Patient)	Who and/or what the observation is about
encounter	Σ	1..1	Reference(Genomics Clinical Picture Repository Encounter)	Healthcare event during which this observation is made
effective[x]	SΣ	0..1		Clinically relevant time/time-period for observation
effectiveDateTime			dateTime
effectivePeriod			Period
issued	Σ	0..1	instant	Date/Time this version was made available
performer	Σ	0..*	Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam \| Patient \| RelatedPerson)	Who is responsible for the observation
value[x]	ΣI	0..1		Actual result Binding: Presence Value Set (required)
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	I	0..1	CodeableConcept	Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note		0..*	Annotation	Comments about the observation
bodySite	S	0..1	CodeableConcept	Observed body part Binding: SNOMEDCTBodyStructures (required)
method		0..1	CodeableConcept	How it was done Binding: ObservationMethods (example): Methods for simple observations.
specimen		0..1	Reference(Specimen)	Specimen used for this observation
device		0..1	Reference(Device \| DeviceMetric)	(Measurement) Device
derivedFrom	Σ	0..*	Reference(DocumentReference \| ImagingStudy \| Media \| QuestionnaireResponse \| Observation \| MolecularSequence)	Related measurements the observation is made from
component	Σ	0..*	BackboneElement	Component results
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	1..1	CodeableConcept	Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
value[x]	Σ	0..1		Actual component result
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	I	0..1	CodeableConcept	Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
referenceRange		0..*	See referenceRange (Observation)	Provides guide for interpretation of component result
Documentation for this format

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

Path	Conformance	ValueSet
Observation.language	preferred	CommonLanguages Max Binding: AllLanguages
Observation.status	required	ObservationStatus
Observation.category	preferred	ObservationCategoryCodes
Observation.code	required	AbnormalClinicalFindings
Observation.value[x]	required	PresenceValues
Observation.dataAbsentReason	extensible	DataAbsentReason
Observation.interpretation	extensible	ObservationInterpretationCodes
Observation.bodySite	required	SNOMEDCTBodyStructures
Observation.method	example	ObservationMethods
Observation.referenceRange.type	preferred	ObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesTo	example	ObservationReferenceRangeAppliesToCodes
Observation.component.code	example	LOINCCodes
Observation.component.dataAbsentReason	extensible	DataAbsentReason
Observation.component.interpretation	extensible	ObservationInterpretationCodes

Constraints

Id	Grade	Path	Details	Requirements
dom-2	error	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Observation	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference \| %resource.descendants().as(canonical) \| %resource.descendants().as(uri) \| %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Observation	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Observation	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	Best Practice	Observation	A resource should have narrative for robust management : text.`div`.exists()
obs-6	error	Observation	dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty()
obs-7	error	Observation	If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
ele-1	error	Observation.meta	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.implicitRules	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.language	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.text	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Observation.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Observation.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Observation.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Observation.identifier	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.basedOn	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.partOf	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.status	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.category	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.code	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.subject	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.encounter	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.effective[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.issued	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.performer	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.value[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.dataAbsentReason	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.interpretation	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.note	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.bodySite	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.method	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.specimen	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.device	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.referenceRange.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Observation.referenceRange.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Observation.referenceRange.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Observation.referenceRange.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Observation.referenceRange.low	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.referenceRange.high	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.referenceRange.type	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.referenceRange.appliesTo	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.referenceRange.age	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.referenceRange.text	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.derivedFrom	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.component	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.component.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Observation.component.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Observation.component.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Observation.component.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Observation.component.code	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.component.value[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.component.dataAbsentReason	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.component.interpretation	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Observation.component.referenceRange	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())

IG © 2021+ The Australian e-Health Research Centre. Package agha.fhir.genclipr#0.1.0 based on FHIR 4.0.1. Generated 2022-03-21
Links: Table of Contents | QA Report