ISiK Formularmodul Implementation Guide
Version 6.0.0-rc - ci-build

Resource Profile: ISiKEKG

Official URL: https://gematik.de/fhir/isik/StructureDefinition/ISiKEKG Version: 6.0.0-rc
Active as of 2025-12-17 Computable Name: ISiKEKG

Dieses Profil spezifiziert die Minimalanforderungen für die Bereitstellung von Informationen über kurze, relevante EKG-Ausschnitte eines Patienten im Rahmen der interoperablen Kommunikation gemäß den Vorgaben der ISiK (Interoperable Schnittstelle im Krankenhaus). Es wurde entwickelt, um spezifische klinische Fragestellungen zu unterstützen, bei denen prägnante und gezielte EKG-Daten im Vordergrund stehen. Für vollständige und längere EKG-Aufzeichnungen sind alternative Formate vorgesehen, die für umfangreiche Daten besser geeignet sind.

Motivation

Die Bereitstellung kurzer EKG-Ausschnitte ermöglicht eine präzise und effiziente Unterstützung bei der Diagnose akuter kardiologischer Fragestellungen, der Überwachung von Arrhythmien oder der Beurteilung bestimmter Ereignisse wie ST-Strecken-Veränderungen. Diese fokussierte Darstellung dient der Optimierung klinischer Entscheidungen und der schnellen Verarbeitung relevanter Daten.

In FHIR wird das EKG durch die Observation-Ressource repräsentiert, wobei spezifische Anforderungen für die Darstellung und Kodierung der Daten in diesem Profil berücksichtigt werden.

Kompatibilität

Das Profil ISiKEKG ist vom Profil EkgDE aus den deutschen Basisprofilen abgeleitet.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* EkgDE Measurements and simple assertions
Constraints: obs-6, obs-7
... id SΣ 0..1 id serverseitige, interne ID des Datensatzes
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... category S 1..* CodeableConcept Untersuchungskategorie
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
.... coding Σ 0..* Coding Code defined by a terminology system

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: procedure
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... Slices for coding SΣ 1..* Coding Coding
Slice: Unordered, Open by pattern:$this
..... coding:loinc SΣ 1..1 Coding LOINC Kodierung

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11524-6
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... coding:snomed SΣ 0..* Coding SNOMED CT Kodierung

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 106073009
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
... subject SΣ 1..1 Reference(Patient | Group | Device | Location) Patient
... encounter SΣ 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference SΣC 1..1 string Encounter-Link
... effective[x] SΣC 1..1 dateTime Datum und Uhrzeit der Untersuchung
Constraints: vs-de-1
... performer SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Untersuchender
... dataAbsentReason SC 0..1 CodeableConcept Grund für fehlende Untersuchungsergebnisse
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
... method S 0..1 CodeableConcept Untersuchungsmethode
Binding: ObservationMethods (example): Methods for simple observations.
... device S 0..1 Reference(Device | DeviceMetric) Gerät
... Slices for component SΣ 1..* BackboneElement Vitalparameter-Komponente
Slice: Unordered, Open by pattern:code
.... component:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
...... coding SΣ 0..* Coding Coding
..... value[x] SΣ 0..1 Wert der Komponente
...... valueQuantity Quantity
...... valueCodeableConcept CodeableConcept
...... valueString string
...... valueBoolean boolean
...... valueInteger integer
...... valueRange Range
...... valueRatio Ratio
...... valueSampledData SampledData
...... valueTime time
...... valueDateTime dateTime
...... valuePeriod Period
.... component:ekgLeads SΣ 0..* BackboneElement EKG-Ableitungen
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣ 1..1 CodeableConcept Type of component observation (code / type)
Binding: SNOMED CT codes der EKG Ableitungen (required): Loinc Part Codes identifying the EKG lead
...... coding SΣ 1..* Coding Code defined by a terminology system
..... value[x] SΣ 1..1 SampledData SampledData
...... origin SΣ 1..1 SimpleQuantity Ausgangswert
...... period SΣ 1..1 decimal Messintervall
...... dimensions SΣ 1..1 positiveInt Dimensionen
...... data S 1..1 string Messwerte
.... component:deprecatedLeadCodes Σ 0..* BackboneElement Component results
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣ 1..1 CodeableConcept Type of component observation (code / type)
Binding: EKG/ECG leads (required): Loinc Part Codes identifying the EKG lead
...... coding SΣ 1..* Coding Code defined by a terminology system
..... value[x] SΣ 1..1 SampledData Actual component result
...... origin Σ 1..1 SimpleQuantity Zero value and units
...... period Σ 1..1 decimal Number of milliseconds between samples
...... dimensions Σ 1..1 positiveInt Number of sample points at each time point
...... data 1..1 string Decimal values with spaces, or "E" | "U" | "L"

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Observation.status Base required ObservationStatus 📍4.0.1 FHIR Std.
Observation.category Base preferred Observation Category Codes 📦4.0.1 FHIR Std.
Observation.code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.method Base example Observation Methods 📦4.0.1 FHIR Std.
Observation.component.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component:ekgLeads.​code Base required SNOMED CT codes der EKG Ableitungen 📦1.5.4 de.basisprofil.r4 v1.5
Observation.component:deprecatedLeadCodes.​code Base required EKG/ECG leads 📦1.5.4 de.basisprofil.r4 v1.5

Constraints

Id Grade Path(s) Description Expression
dom-2 error Observation If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Observation If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Observation If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Observation If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Observation A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
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()
vs-de-1 error Observation.effective[x] If Observation.effective[x] has a value then that value shall be precise to the day (($this is dateTime) implies ($this as dateTime).toString().length() >= 10) and ($this.start.exists() implies ($this.start as dateTime).toString().length() >= 10) and ($this.end.exists() implies ($this.end as dateTime).toString().length() >= 10)

This structure is derived from EkgDE

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation 0..* EkgDE Measurements and simple assertions
... id S 0..1 id serverseitige, interne ID des Datensatzes
... meta
.... versionId 0..1 id Eindeutiger Name der serverseitigen Version des Datensatzes
.... lastUpdated 0..1 instant Zeitpunkt der letzten Änderung
... status S 1..1 code Untersuchungsstatus
... code S 1..1 CodeableConcept Code
.... coding S 1..* Coding Coding
.... Slices for coding Content/Rules for all slices
..... coding:loinc S 1..1 Coding LOINC Kodierung
..... coding:snomed S 0..* Coding SNOMED CT Kodierung
... subject S 1..1 Reference(Patient | Group | Device | Location) Patient
... encounter S 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference S 1..1 string Encounter-Link
... effective[x] S 1..1 dateTime Datum und Uhrzeit der Untersuchung
... performer S 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Untersuchender
... dataAbsentReason S 0..1 CodeableConcept Grund für fehlende Untersuchungsergebnisse
... method S 0..1 CodeableConcept Untersuchungsmethode
... device S 0..1 Reference(Device | DeviceMetric) Gerät
... component S 1..* BackboneElement Vitalparameter-Komponente
.... code S 1..1 CodeableConcept Code
..... coding S 0..* Coding Coding
.... value[x] S 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Wert der Komponente
... Slices for component Content/Rules for all slices
.... component:ekgLeads S 0..* BackboneElement EKG-Ableitungen
..... code S 1..1 CodeableConcept Type of component observation (code / type)
...... coding S 1..* Coding Code defined by a terminology system
..... value[x] S 1..1 SampledData SampledData
...... origin S 1..1 SimpleQuantity Ausgangswert
...... period S 1..1 decimal Messintervall
...... dimensions S 1..1 positiveInt Dimensionen
...... data S 1..1 string Messwerte
.... component:deprecatedLeadCodes 0..* BackboneElement Component results
..... code S 1..1 CodeableConcept Type of component observation (code / type)
...... coding S 1..* Coding Code defined by a terminology system
..... value[x] S 1..1 SampledData Actual component result

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* EkgDE Measurements and simple assertions
Constraints: obs-6, obs-7
... id SΣ 0..1 id serverseitige, interne ID des Datensatzes
... meta Σ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Eindeutiger Name der serverseitigen Version des Datensatzes
.... lastUpdated Σ 0..1 instant Zeitpunkt der letzten Änderung
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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 ?!SΣ 1..1 code Untersuchungsstatus
Binding: ObservationStatus (required): Codes providing the status of an observation.
... category S 1..* CodeableConcept Untersuchungskategorie
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: procedure
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 1..* Coding Coding
Slice: Unordered, Open by pattern:$this
..... coding:loinc SΣ 1..1 Coding LOINC Kodierung

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11524-6
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... coding:snomed SΣ 0..* Coding SNOMED CT Kodierung

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 106073009
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient | Group | Device | Location) Patient
... focus Σ 0..* Reference(Resource) What the observation is about, when it is not about the subject of record
... encounter SΣ 0..1 Reference(Encounter) Aufenthaltsbezug
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Encounter-Link
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... effective[x] SΣC 1..1 dateTime Datum und Uhrzeit der Untersuchung
Constraints: vs-de-1
... issued Σ 0..1 instant Date/Time this version was made available
... performer SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Untersuchender
... dataAbsentReason SC 0..1 CodeableConcept Grund für fehlende Untersuchungsergebnisse
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 0..1 CodeableConcept Observed body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... method S 0..1 CodeableConcept Untersuchungsmethode
Binding: ObservationMethods (example): Methods for simple observations.
... specimen 0..1 Reference(Specimen) Specimen used for this observation
... device S 0..1 Reference(Device | DeviceMetric) Gerät
... referenceRange C 0..* BackboneElement Provides guide for interpretation
Constraints: obs-3
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... low C 0..1 SimpleQuantity Low Range, if relevant
.... high C 0..1 SimpleQuantity High Range, if relevant
.... type 0..1 CodeableConcept Reference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
.... appliesTo 0..* CodeableConcept Reference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
.... age 0..1 Range Applicable age range, if relevant
.... text 0..1 string Text based reference range in an observation
... hasMember Σ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
... Slices for component SΣ 1..* BackboneElement Vitalparameter-Komponente
Slice: Unordered, Open by pattern:code
.... component:All Slices Content/Rules for all slices
..... 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 SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 0..* Coding Coding
...... text Σ 0..1 string Plain text representation of the concept
..... value[x] SΣ 0..1 Wert der Komponente
...... valueQuantity Quantity
...... valueCodeableConcept CodeableConcept
...... valueString string
...... valueBoolean boolean
...... valueInteger integer
...... valueRange Range
...... valueRatio Ratio
...... valueSampledData SampledData
...... valueTime time
...... valueDateTime dateTime
...... valuePeriod Period
..... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
..... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
..... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result
.... component:ekgLeads SΣ 0..* BackboneElement EKG-Ableitungen
..... 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 SΣ 1..1 CodeableConcept Type of component observation (code / type)
Binding: SNOMED CT codes der EKG Ableitungen (required): Loinc Part Codes identifying the EKG lead
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 1..* Coding Code defined by a terminology system
...... text Σ 0..1 string Plain text representation of the concept
..... value[x] SΣ 1..1 SampledData SampledData
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... origin SΣ 1..1 SimpleQuantity Ausgangswert
...... period SΣ 1..1 decimal Messintervall
...... factor Σ 0..1 decimal Multiply data by this before adding to origin
...... lowerLimit Σ 0..1 decimal Lower limit of detection
...... upperLimit Σ 0..1 decimal Upper limit of detection
...... dimensions SΣ 1..1 positiveInt Dimensionen
...... data S 1..1 string Messwerte
..... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
..... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
..... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result
.... component:deprecatedLeadCodes 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 SΣ 1..1 CodeableConcept Type of component observation (code / type)
Binding: EKG/ECG leads (required): Loinc Part Codes identifying the EKG lead
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 1..* Coding Code defined by a terminology system
...... text Σ 0..1 string Plain text representation of the concept
..... value[x] SΣ 1..1 SampledData Actual component result
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... origin Σ 1..1 SimpleQuantity Zero value and units
...... period Σ 1..1 decimal Number of milliseconds between samples
...... factor Σ 0..1 decimal Multiply data by this before adding to origin
...... lowerLimit Σ 0..1 decimal Lower limit of detection
...... upperLimit Σ 0..1 decimal Upper limit of detection
...... dimensions Σ 1..1 positiveInt Number of sample points at each time point
...... data 1..1 string Decimal values with spaces, or "E" | "U" | "L"
..... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
..... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
..... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Observation.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Observation.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Observation.language Base preferred Common Languages 📦4.0.1 FHIR Std.
Observation.status Base required ObservationStatus 📍4.0.1 FHIR Std.
Observation.category Base preferred Observation Category Codes 📦4.0.1 FHIR Std.
Observation.code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.encounter.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Observation.dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.interpretation Base extensible Observation Interpretation Codes 📦4.0.1 FHIR Std.
Observation.bodySite Base example SNOMED CT Body Structures 📦4.0.1 FHIR Std.
Observation.method Base example Observation Methods 📦4.0.1 FHIR Std.
Observation.referenceRange.​type Base preferred Observation Reference Range Meaning Codes 📦4.0.1 FHIR Std.
Observation.referenceRange.​appliesTo Base example Observation Reference Range Applies To Codes 📦4.0.1 FHIR Std.
Observation.component.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component.​dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.component.​interpretation Base extensible Observation Interpretation Codes 📦4.0.1 FHIR Std.
Observation.component:ekgLeads.​code Base required SNOMED CT codes der EKG Ableitungen 📦1.5.4 de.basisprofil.r4 v1.5
Observation.component:ekgLeads.​dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.component:ekgLeads.​interpretation Base extensible Observation Interpretation Codes 📦4.0.1 FHIR Std.
Observation.component:deprecatedLeadCodes.​code Base required EKG/ECG leads 📦1.5.4 de.basisprofil.r4 v1.5
Observation.component:deprecatedLeadCodes.​dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.component:deprecatedLeadCodes.​interpretation Base extensible Observation Interpretation Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Observation If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Observation If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Observation If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Observation If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Observation A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
obs-3 error Observation.referenceRange Must have at least a low or a high or text low.exists() or high.exists() or text.exists()
obs-6 error Observation dataAbsentReason SHALL only be present if Observation.value[x] is not present dataAbsentReason.empty() or value.empty()
obs-7 error Observation If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
vs-de-1 error Observation.effective[x] If Observation.effective[x] has a value then that value shall be precise to the day (($this is dateTime) implies ($this as dateTime).toString().length() >= 10) and ($this.start.exists() implies ($this.start as dateTime).toString().length() >= 10) and ($this.end.exists() implies ($this.end as dateTime).toString().length() >= 10)
ElementShort descriptionNotes
Observation.category Untersuchungskategorie

Motivation MS: Dieses Feld erlaubt die Sortierung und Abfrage anhand der Kategorie der Untersuchung
Observation.code Code

Motivation MS: Die Observation wird anhand des Codes identifiziert.
Observation.code.coding Coding

Motivation MS: Semantische Kodierung
Observation.code.coding:loinc LOINC Kodierung

Motivation MS: Kodierung des Vitalparameters mittels LOINC.
Observation.code.coding:snomed SNOMED CT Kodierung

Motivation MS: Kodierung des Vitalparameters mittels SNOMED CT.
Observation.component Vitalparameter-Komponente

Motivation MS: Erfassung der Komponenten eines Vitalparameters
Observation.component.code Code

Motivation MS: Die Komponente wird anhand des Codes identifiziert.
Observation.component.code.coding Coding

Motivation MS: Semantische Kodierung
Observation.component.value[x] Wert der Komponente

Motivation MS: Der Wert der Komponente ist ein Ergebnis der Untersuchung
Observation.component:deprecatedLeadCodes.code
Observation.component:deprecatedLeadCodes.code.coding
Observation.component:deprecatedLeadCodes.value[x]
Observation.component:ekgLeads EKG-Ableitungen

Motivation MS: Die einzelnen Ableitungen des EKG werden als component abgebildet. Begründung: Bei einer EKG Untersuchung werden mehrere Ableitungen gemeinsam erfasst und bilden zusammen das Gesamtbild des EKGs. Siehe auch Observation.component im FHIR R4 Standard.
Observation.component:ekgLeads.code
Observation.component:ekgLeads.code.coding
Observation.component:ekgLeads.value[x] SampledData

Motivation MS: Die EKG-Daten werden mittels des SampledData Datentyps abgebildet.
Observation.component:ekgLeads.value[x].data Messwerte

Motivation MS: Das Feld data enthält die eigentlichen Messwerte der EKG-Daten.
Observation.component:ekgLeads.value[x].dimensions Dimensionen

Motivation MS: Das Feld dimensions gibt die Anzahl der Achsen oder Dimensionen an, die in der Messreihe enthalten sind, und ist notwendig, um die Struktur der Daten korrekt zu verstehen.
Observation.component:ekgLeads.value[x].origin Ausgangswert

Motivation MS: Das Feld origin definiert den Referenzpunkt und die Einheit der Messreihe, um sicherzustellen, dass die gemessenen Werte im richtigen Kontext interpretiert werden können.
Observation.component:ekgLeads.value[x].period Messintervall

Motivation MS: Das Feld period definiert die zeitliche Distanz zwischen zwei aufeinanderfolgenden Messwerten.
Observation.dataAbsentReason Grund für fehlende Untersuchungsergebnisse

Motivation MS: Dieses Feld erlaubt die Angabe von Gründen für fehlende Untersuchungsergebnisse
Observation.device Gerät

Einschränkung der übergreifenden MS-Definition:
Verfügt ein bestätigungsrelevantes System nicht über die Datenstruktur zur Hinterlegung des Geräts, mittels dessen der Parameter erhoben worden ist, so MUSS dieses System die Information NICHT abbilden.

Motivation zum eingeschränkten MS: Dieses Feld stellt präzisierende Angaben zum Zweck der Qualitätsbewertung bereit. Allerdings rechtfertigt der Stand der Umsetzung in gängigen Systemen eine Implementierungspflicht (MS) für die Schnittstelle nicht.
Observation.effective[x] Datum und Uhrzeit der Untersuchung

Motivation MS: Das Datum und die Uhrzeit der Untersuchung sind für die Interpretation der Untersuchungsergebnisse relevant
Observation.encounter Aufenthaltsbezug

Motivation MS: Der Behandlungskontext ist für die Interpretation der Untersuchungsergebnisse relevant
Observation.encounter.reference Encounter-Link

Begründung Pflichtfeld: Die Verlinkung auf eine Encounter-Ressource dient der technischen Zuordnung der Dokumentation zu einem Aufenthalt und ermöglicht wichtige API-Funktionen wie verkettete Suche, (Reverse-)Include etc. WICHTIGER Hinweis für Implementierer: Die Zuordnung MUSS auf einen Encounter der Ebene “Abteilungskontakt” (siehe hierzu Basismodul > UseCases > Abbildung des Konstruktes “Fall”) erfolgen.
Bei der Auswahl des Encounters ist zu beachten, dass unter einer (Abrechnungs-)”Fallnummer” (hier: Encounter.account) unter Umständen mehrere Encounter gruppiert sein können (z.B. stationärer Besuch mit mehreren vor- und nachstationären Aufenthalten.) Im ISik Kontext MUSS die referenzierte Ressource konform zu ISiKKontaktGesundheitseinrichtung sein. Jenseits von ISiK KÖNNEN weitere Instanzen mit anderen Profilen referenziert werden.
Observation.id serverseitige, interne ID des Datensatzes

bedingtes Pflichtfeld/bedingtes MS: Alle von einem Server bereitgestellten Ressourcen MÜSSEN über eine id verfügen. Von Clients erzeugte Ressourcen, die im Kontext einer CREATE-Interaktion übermittelt werden, MÜSSEN NICHT über eine idverfügen.
Observation.method Untersuchungsmethode

Einschränkung der übergreifenden MS-Definition:
Verfügt ein bestätigungsrelevantes System nicht über die Datenstruktur zur Hinterlegung der Untersuchungsmethode, so MUSS dieses System die Information NICHT abbilden

Motivation zum eingeschränkten MS: Dieses Feld stellt präzisierende Angaben zum Zweck der Qualitätsbewertung bereit. Allerdings rechtfertigt der Stand der Umsetzung in gängigen Systemen eine Implementierungspflicht (MS) für die Schnittstelle nicht.
Observation.performer Untersuchender

Motivation MS: Dieses Feld stellt präzisierende Angaben zum Zweck der Qualitätsbewertung bereit
Observation.status Untersuchungsstatus

WICHTIGER Hinweis für Implementierer:

  • Alle server-seitigen Implementierungen MÜSSEN in der Lage sein, die systemintern möglichen Statuswerte korrekt in FHIR abzubilden, mindestens jedoch final.
  • Alle client-seitigen Implementierungen MÜSSEN in der Lage sein, sämtliche Status-Codes zu interpretieren und dem Anwender in angemessener Form darstellen zu können, beispielsweise durch Ausblenden/Durchstreichen von Ressourcen mit dem status entered-in-error und Ausgrauen von Ressourcen, die einen Plan- oder Entwurfs-Status haben.
Observation.subject Patient

Motivation MS: Die Verlinkung auf eine Patienten-Ressource dient der technischen Zuordnung der Dokumentation zu einem Patienten und ermöglicht wichtige API-Funktionen wie verkettete Suche, (Reverse-)Include etc. Im ISik Kontext MUSS die referenzierte Ressource konform zu ISiKPatient sein. Jenseits von ISiK KÖNNEN weitere Instanzen mit anderen Profilen referenziert werden.

This structure is derived from EkgDE

Summary

Mandatory: 0 element(1 nested mandatory element)
Must-Support: 30 elements

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* EkgDE Measurements and simple assertions
Constraints: obs-6, obs-7
... id SΣ 0..1 id serverseitige, interne ID des Datensatzes
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... category S 1..* CodeableConcept Untersuchungskategorie
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
.... coding Σ 0..* Coding Code defined by a terminology system

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: procedure
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... Slices for coding SΣ 1..* Coding Coding
Slice: Unordered, Open by pattern:$this
..... coding:loinc SΣ 1..1 Coding LOINC Kodierung

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11524-6
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... coding:snomed SΣ 0..* Coding SNOMED CT Kodierung

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 106073009
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
... subject SΣ 1..1 Reference(Patient | Group | Device | Location) Patient
... encounter SΣ 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference SΣC 1..1 string Encounter-Link
... effective[x] SΣC 1..1 dateTime Datum und Uhrzeit der Untersuchung
Constraints: vs-de-1
... performer SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Untersuchender
... dataAbsentReason SC 0..1 CodeableConcept Grund für fehlende Untersuchungsergebnisse
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
... method S 0..1 CodeableConcept Untersuchungsmethode
Binding: ObservationMethods (example): Methods for simple observations.
... device S 0..1 Reference(Device | DeviceMetric) Gerät
... Slices for component SΣ 1..* BackboneElement Vitalparameter-Komponente
Slice: Unordered, Open by pattern:code
.... component:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
...... coding SΣ 0..* Coding Coding
..... value[x] SΣ 0..1 Wert der Komponente
...... valueQuantity Quantity
...... valueCodeableConcept CodeableConcept
...... valueString string
...... valueBoolean boolean
...... valueInteger integer
...... valueRange Range
...... valueRatio Ratio
...... valueSampledData SampledData
...... valueTime time
...... valueDateTime dateTime
...... valuePeriod Period
.... component:ekgLeads SΣ 0..* BackboneElement EKG-Ableitungen
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣ 1..1 CodeableConcept Type of component observation (code / type)
Binding: SNOMED CT codes der EKG Ableitungen (required): Loinc Part Codes identifying the EKG lead
...... coding SΣ 1..* Coding Code defined by a terminology system
..... value[x] SΣ 1..1 SampledData SampledData
...... origin SΣ 1..1 SimpleQuantity Ausgangswert
...... period SΣ 1..1 decimal Messintervall
...... dimensions SΣ 1..1 positiveInt Dimensionen
...... data S 1..1 string Messwerte
.... component:deprecatedLeadCodes Σ 0..* BackboneElement Component results
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣ 1..1 CodeableConcept Type of component observation (code / type)
Binding: EKG/ECG leads (required): Loinc Part Codes identifying the EKG lead
...... coding SΣ 1..* Coding Code defined by a terminology system
..... value[x] SΣ 1..1 SampledData Actual component result
...... origin Σ 1..1 SimpleQuantity Zero value and units
...... period Σ 1..1 decimal Number of milliseconds between samples
...... dimensions Σ 1..1 positiveInt Number of sample points at each time point
...... data 1..1 string Decimal values with spaces, or "E" | "U" | "L"

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Observation.status Base required ObservationStatus 📍4.0.1 FHIR Std.
Observation.category Base preferred Observation Category Codes 📦4.0.1 FHIR Std.
Observation.code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.method Base example Observation Methods 📦4.0.1 FHIR Std.
Observation.component.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component:ekgLeads.​code Base required SNOMED CT codes der EKG Ableitungen 📦1.5.4 de.basisprofil.r4 v1.5
Observation.component:deprecatedLeadCodes.​code Base required EKG/ECG leads 📦1.5.4 de.basisprofil.r4 v1.5

Constraints

Id Grade Path(s) Description Expression
dom-2 error Observation If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Observation If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Observation If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Observation If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Observation A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
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()
vs-de-1 error Observation.effective[x] If Observation.effective[x] has a value then that value shall be precise to the day (($this is dateTime) implies ($this as dateTime).toString().length() >= 10) and ($this.start.exists() implies ($this.start as dateTime).toString().length() >= 10) and ($this.end.exists() implies ($this.end as dateTime).toString().length() >= 10)

Differential View

This structure is derived from EkgDE

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation 0..* EkgDE Measurements and simple assertions
... id S 0..1 id serverseitige, interne ID des Datensatzes
... meta
.... versionId 0..1 id Eindeutiger Name der serverseitigen Version des Datensatzes
.... lastUpdated 0..1 instant Zeitpunkt der letzten Änderung
... status S 1..1 code Untersuchungsstatus
... code S 1..1 CodeableConcept Code
.... coding S 1..* Coding Coding
.... Slices for coding Content/Rules for all slices
..... coding:loinc S 1..1 Coding LOINC Kodierung
..... coding:snomed S 0..* Coding SNOMED CT Kodierung
... subject S 1..1 Reference(Patient | Group | Device | Location) Patient
... encounter S 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference S 1..1 string Encounter-Link
... effective[x] S 1..1 dateTime Datum und Uhrzeit der Untersuchung
... performer S 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Untersuchender
... dataAbsentReason S 0..1 CodeableConcept Grund für fehlende Untersuchungsergebnisse
... method S 0..1 CodeableConcept Untersuchungsmethode
... device S 0..1 Reference(Device | DeviceMetric) Gerät
... component S 1..* BackboneElement Vitalparameter-Komponente
.... code S 1..1 CodeableConcept Code
..... coding S 0..* Coding Coding
.... value[x] S 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Wert der Komponente
... Slices for component Content/Rules for all slices
.... component:ekgLeads S 0..* BackboneElement EKG-Ableitungen
..... code S 1..1 CodeableConcept Type of component observation (code / type)
...... coding S 1..* Coding Code defined by a terminology system
..... value[x] S 1..1 SampledData SampledData
...... origin S 1..1 SimpleQuantity Ausgangswert
...... period S 1..1 decimal Messintervall
...... dimensions S 1..1 positiveInt Dimensionen
...... data S 1..1 string Messwerte
.... component:deprecatedLeadCodes 0..* BackboneElement Component results
..... code S 1..1 CodeableConcept Type of component observation (code / type)
...... coding S 1..* Coding Code defined by a terminology system
..... value[x] S 1..1 SampledData Actual component result

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* EkgDE Measurements and simple assertions
Constraints: obs-6, obs-7
... id SΣ 0..1 id serverseitige, interne ID des Datensatzes
... meta Σ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Eindeutiger Name der serverseitigen Version des Datensatzes
.... lastUpdated Σ 0..1 instant Zeitpunkt der letzten Änderung
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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 ?!SΣ 1..1 code Untersuchungsstatus
Binding: ObservationStatus (required): Codes providing the status of an observation.
... category S 1..* CodeableConcept Untersuchungskategorie
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: procedure
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 1..* Coding Coding
Slice: Unordered, Open by pattern:$this
..... coding:loinc SΣ 1..1 Coding LOINC Kodierung

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11524-6
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... coding:snomed SΣ 0..* Coding SNOMED CT Kodierung

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 106073009
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient | Group | Device | Location) Patient
... focus Σ 0..* Reference(Resource) What the observation is about, when it is not about the subject of record
... encounter SΣ 0..1 Reference(Encounter) Aufenthaltsbezug
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Encounter-Link
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... effective[x] SΣC 1..1 dateTime Datum und Uhrzeit der Untersuchung
Constraints: vs-de-1
... issued Σ 0..1 instant Date/Time this version was made available
... performer SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Untersuchender
... dataAbsentReason SC 0..1 CodeableConcept Grund für fehlende Untersuchungsergebnisse
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 0..1 CodeableConcept Observed body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... method S 0..1 CodeableConcept Untersuchungsmethode
Binding: ObservationMethods (example): Methods for simple observations.
... specimen 0..1 Reference(Specimen) Specimen used for this observation
... device S 0..1 Reference(Device | DeviceMetric) Gerät
... referenceRange C 0..* BackboneElement Provides guide for interpretation
Constraints: obs-3
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... low C 0..1 SimpleQuantity Low Range, if relevant
.... high C 0..1 SimpleQuantity High Range, if relevant
.... type 0..1 CodeableConcept Reference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
.... appliesTo 0..* CodeableConcept Reference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
.... age 0..1 Range Applicable age range, if relevant
.... text 0..1 string Text based reference range in an observation
... hasMember Σ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
... Slices for component SΣ 1..* BackboneElement Vitalparameter-Komponente
Slice: Unordered, Open by pattern:code
.... component:All Slices Content/Rules for all slices
..... 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 SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 0..* Coding Coding
...... text Σ 0..1 string Plain text representation of the concept
..... value[x] SΣ 0..1 Wert der Komponente
...... valueQuantity Quantity
...... valueCodeableConcept CodeableConcept
...... valueString string
...... valueBoolean boolean
...... valueInteger integer
...... valueRange Range
...... valueRatio Ratio
...... valueSampledData SampledData
...... valueTime time
...... valueDateTime dateTime
...... valuePeriod Period
..... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
..... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
..... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result
.... component:ekgLeads SΣ 0..* BackboneElement EKG-Ableitungen
..... 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 SΣ 1..1 CodeableConcept Type of component observation (code / type)
Binding: SNOMED CT codes der EKG Ableitungen (required): Loinc Part Codes identifying the EKG lead
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 1..* Coding Code defined by a terminology system
...... text Σ 0..1 string Plain text representation of the concept
..... value[x] SΣ 1..1 SampledData SampledData
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... origin SΣ 1..1 SimpleQuantity Ausgangswert
...... period SΣ 1..1 decimal Messintervall
...... factor Σ 0..1 decimal Multiply data by this before adding to origin
...... lowerLimit Σ 0..1 decimal Lower limit of detection
...... upperLimit Σ 0..1 decimal Upper limit of detection
...... dimensions SΣ 1..1 positiveInt Dimensionen
...... data S 1..1 string Messwerte
..... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
..... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
..... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result
.... component:deprecatedLeadCodes 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 SΣ 1..1 CodeableConcept Type of component observation (code / type)
Binding: EKG/ECG leads (required): Loinc Part Codes identifying the EKG lead
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 1..* Coding Code defined by a terminology system
...... text Σ 0..1 string Plain text representation of the concept
..... value[x] SΣ 1..1 SampledData Actual component result
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... origin Σ 1..1 SimpleQuantity Zero value and units
...... period Σ 1..1 decimal Number of milliseconds between samples
...... factor Σ 0..1 decimal Multiply data by this before adding to origin
...... lowerLimit Σ 0..1 decimal Lower limit of detection
...... upperLimit Σ 0..1 decimal Upper limit of detection
...... dimensions Σ 1..1 positiveInt Number of sample points at each time point
...... data 1..1 string Decimal values with spaces, or "E" | "U" | "L"
..... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
..... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
..... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Observation.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Observation.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Observation.language Base preferred Common Languages 📦4.0.1 FHIR Std.
Observation.status Base required ObservationStatus 📍4.0.1 FHIR Std.
Observation.category Base preferred Observation Category Codes 📦4.0.1 FHIR Std.
Observation.code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.encounter.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Observation.dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.interpretation Base extensible Observation Interpretation Codes 📦4.0.1 FHIR Std.
Observation.bodySite Base example SNOMED CT Body Structures 📦4.0.1 FHIR Std.
Observation.method Base example Observation Methods 📦4.0.1 FHIR Std.
Observation.referenceRange.​type Base preferred Observation Reference Range Meaning Codes 📦4.0.1 FHIR Std.
Observation.referenceRange.​appliesTo Base example Observation Reference Range Applies To Codes 📦4.0.1 FHIR Std.
Observation.component.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component.​dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.component.​interpretation Base extensible Observation Interpretation Codes 📦4.0.1 FHIR Std.
Observation.component:ekgLeads.​code Base required SNOMED CT codes der EKG Ableitungen 📦1.5.4 de.basisprofil.r4 v1.5
Observation.component:ekgLeads.​dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.component:ekgLeads.​interpretation Base extensible Observation Interpretation Codes 📦4.0.1 FHIR Std.
Observation.component:deprecatedLeadCodes.​code Base required EKG/ECG leads 📦1.5.4 de.basisprofil.r4 v1.5
Observation.component:deprecatedLeadCodes.​dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.component:deprecatedLeadCodes.​interpretation Base extensible Observation Interpretation Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Observation If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Observation If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Observation If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Observation If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Observation A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
obs-3 error Observation.referenceRange Must have at least a low or a high or text low.exists() or high.exists() or text.exists()
obs-6 error Observation dataAbsentReason SHALL only be present if Observation.value[x] is not present dataAbsentReason.empty() or value.empty()
obs-7 error Observation If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
vs-de-1 error Observation.effective[x] If Observation.effective[x] has a value then that value shall be precise to the day (($this is dateTime) implies ($this as dateTime).toString().length() >= 10) and ($this.start.exists() implies ($this.start as dateTime).toString().length() >= 10) and ($this.end.exists() implies ($this.end as dateTime).toString().length() >= 10)

This structure is derived from EkgDE

Summary

Mandatory: 0 element(1 nested mandatory element)
Must-Support: 30 elements

 

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