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

Resource Profile: ISiKLaboruntersuchung

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

Dieses Profil ermöglicht die Abbildung von Informationen zur Laboruntersuchungen eines Patienten in ISiK Szenarien. Es dient primär als Vorlage, von der spezifische Laboruntersuchungs-Profile abgeleitet werden, kann aber grundsätzlich auch zur Repräsentation von nicht weiter ausspezifizierten Laboruntersuchungen genutzt werden.

Viele medizinischen Entscheidungen benötigen Informationen zu den Laboruntersuchungen eines Patienten. Hierzu gehören z.B. aktuelle Nierenfunktionswerte, Leberwerte, Blutbildwerte oder Hormone aus Schilddrüse. Jede dieser Untersuchungen wird durch bestimmte [[https://loinc.org/ LOINC]] oder [[http://snomed.info/sct SNOMED CT]] Codes bezeichnet. Der angegebene Wert ist durch genaue Einheitenangaben in [[http://unitsofmeasure.org UCUM]] zu konkretitiseren. Motivierender Use-Case zur Einführung dieser Profile ist die Arzneitmitteltherapiesicherheit im Krankenhaus - AMTS.

In FHIR werden Untersuchungen, bzw. Beobachtungen als Observation-Ressource repräsentiert. Zugehörige Codes und Einheiten sind den entsprechenden Valuessets zu entnehmen.

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..* Observation 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 Kategorie der Laboruntersuchung
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.

Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... 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: laboratory
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept Gegenstand der Untersuchung (Laborparameter)
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... Slices for coding SΣ 1..* Coding Kodierung des Laborparameters
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system SΣ 1..1 uri System, aus dem der Code für den Laborparameter stammt (z. B. LOINC)
...... code SΣ 1..1 code Code des Laborparameters entsprechend dem verwendeten System
...... display SΣ 0..1 string Anzeige-/Bezeichnungstext für den Laborparameter-Code
..... coding:loinc SΣ 1..* 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://loinc.org
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri System, aus dem der Code für den Laborparameter stammt (z. B. LOINC)
...... code SΣ 1..1 code Code des Laborparameters entsprechend dem verwendeten System
...... display SΣ 0..1 string Anzeige-/Bezeichnungstext für den Laborparameter-Code
.... text SΣ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Referenz auf den Patienten
.... reference SΣC 0..1 string Patienten-Link
... encounter SΣ 0..1 Reference(Encounter) Referenz auf den Abteilungskontakt
.... reference SΣC 0..1 string Literal reference, Relative, internal or absolute URL
... Slices for effective[x] SΣ 0..1 Zeitpunkt der Untersuchung
Slice: Unordered, Open by type:$this
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
.... effective[x]:effectiveDateTime SΣ 0..1 dateTime Clinically relevant time/time-period for observation
... issued SΣ 0..1 instant Zeitpunkt der Verfügbarkeit des Untersuchungsergebnisses
... Slices for value[x] SΣC 0..1 Festgestellter (Mess)Wert für den Laborparameter
Slice: Unordered, Open by type:$this
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
.... value[x]:valueQuantity SΣC 0..1 Quantity Messwert in quantitativer Form
..... value SΣ 1..1 decimal Der numerische Messwert
..... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
..... unit SΣ 0..1 string Einheit des Messwertes (z. B. mg/dL)
..... system SΣC 1..1 uri Kodiersystem für die Einheit (UCUM)
Required Pattern: http://unitsofmeasure.org
..... code SΣ 1..1 code UCUM-Code der Einheit
... dataAbsentReason SC 0..1 CodeableConcept Angabe eines Grundes weshalb kein Ergebniss der Laboruntersuchung vorliegt
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
... interpretation S 0..* CodeableConcept Interpretation oder Bewertung des Messergebnisses (z.B. „hoch“, „niedrig“, „normal“)
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
... note S 0..* Annotation Freitextnotiz oder Kommentar zur Beobachtung (z. B. Hinweise des Labors)
... method S 0..1 CodeableConcept How it was done
Binding: ObservationMethods (example): Methods for simple observations.
... specimen S 0..1 Reference(Specimen) Specimen used for this observation
.... reference SΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... identifier SΣ 0..1 Identifier Logical reference, when literal reference is not known
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... system SΣ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SΣ 1..1 string The value that is unique
Example General: 123456
... device S 0..1 Reference(Device | DeviceMetric) Verwendetes Gerät oder Instrument zur Durchführung der Untersuchung
... referenceRange SC 0..* BackboneElement Referenzbereich zur Interpretation des Messergebnisses (z. B. Normalwerte)
Constraints: obs-3
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... low SC 0..1 SimpleQuantity(4.0.1) Untergrenze des Referenzbereichs
..... value SΣ 1..1 decimal Numerical value (with implicit precision)
..... unit SΣ 0..1 string Unit representation
..... system SΣC 1..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
..... code SΣ 1..1 code Coded form of the unit
.... high SC 0..1 SimpleQuantity(4.0.1) Obergrenze des Referenzbereichs
..... value SΣ 1..1 decimal Numerical value (with implicit precision)
..... unit SΣ 0..1 string Unit representation
..... system SΣC 1..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
..... code SΣ 1..1 code Coded form of the unit
.... type S 0..1 CodeableConcept Art des Referenzbereichs (z. B. normal, kritisch)
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
..... coding SΣ 0..* Coding Code defined by a terminology system
...... system SΣ 1..1 uri Identity of the terminology system
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 0..1 string Representation defined by the system
..... text SΣ 0..1 string Plain text representation of the concept
.... appliesTo S 0..* CodeableConcept Für wen der Referenzbereich gilt (z. B. Geschlecht, Alter)
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
..... coding SΣ 0..* Coding Kodierte Angabe zur Zielgruppe
...... system SΣ 1..1 uri Identity of the terminology system
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 0..1 string Representation defined by the system
..... text SΣ 0..1 string Plain text representation of the concept
.... age S 0..1 Range Altersbereich, für den der Referenzbereich gilt
..... low SΣ 0..1 SimpleQuantity(4.0.1) Low limit
..... high SΣ 0..1 SimpleQuantity(4.0.1) High limit
.... text S 0..1 string Freitextbeschreibung des Referenzbereichs

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.value[x]:valueQuantity.​comparator Base required QuantityComparator 📍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.method Base example Observation Methods 📍4.0.1 FHIR Std.
Observation.specimen.​identifier.use Base required IdentifierUse 📍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.

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()

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation 0..* Observation 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 Status der Laboruntersuchung
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: laboratory
... code S 1..1 CodeableConcept Gegenstand der Untersuchung (Laborparameter)
.... Slices for coding S 1..* Coding Kodierung des Laborparameters
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system S 1..1 uri System, aus dem der Code für den Laborparameter stammt (z. B. LOINC)
...... code S 1..1 code Code des Laborparameters entsprechend dem verwendeten System
...... display S 0..1 string Anzeige-/Bezeichnungstext für den Laborparameter-Code
..... coding:loinc S 1..* Coding Code defined by a terminology system

Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
.... text S 0..1 string Plain text representation of the concept
... subject S 1..1 Reference(Patient) Referenz auf den Patienten
.... reference S 0..1 string Patienten-Link
... encounter S 0..1 Reference(Encounter) Referenz auf den Abteilungskontakt
.... reference S 0..1 string Literal reference, Relative, internal or absolute URL
... Slices for effective[x] S 0..1 dateTime, Period, Timing, instant Zeitpunkt der Untersuchung
Slice: Unordered, Open by type:$this
.... effective[x]:effectiveDateTime S 0..1 dateTime Clinically relevant time/time-period for observation
... issued S 0..1 instant Zeitpunkt der Verfügbarkeit des Untersuchungsergebnisses
... Slices for value[x] S 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Festgestellter (Mess)Wert für den Laborparameter
Slice: Unordered, Open by type:$this
.... value[x]:valueQuantity S 0..1 Quantity Messwert in quantitativer Form
..... value S 1..1 decimal Der numerische Messwert
..... unit S 0..1 string Einheit des Messwertes (z. B. mg/dL)
..... system S 1..1 uri Kodiersystem für die Einheit (UCUM)
Required Pattern: http://unitsofmeasure.org
..... code S 1..1 code UCUM-Code der Einheit
... dataAbsentReason S 0..1 CodeableConcept Angabe eines Grundes weshalb kein Ergebniss der Laboruntersuchung vorliegt
... interpretation S 0..* CodeableConcept Interpretation oder Bewertung des Messergebnisses (z.B. „hoch“, „niedrig“, „normal“)
... note S 0..* Annotation Freitextnotiz oder Kommentar zur Beobachtung (z. B. Hinweise des Labors)
... method S 0..1 CodeableConcept How it was done
... specimen S 0..1 Reference(Specimen) Specimen used for this observation
.... reference S 0..1 string Literal reference, Relative, internal or absolute URL
.... identifier S 0..1 Identifier Logical reference, when literal reference is not known
..... system S 1..1 uri The namespace for the identifier value
..... value S 1..1 string The value that is unique
... device S 0..1 Reference(Device | DeviceMetric) Verwendetes Gerät oder Instrument zur Durchführung der Untersuchung
... referenceRange S 0..* BackboneElement Referenzbereich zur Interpretation des Messergebnisses (z. B. Normalwerte)
.... low S 0..1 SimpleQuantity(4.0.1) Untergrenze des Referenzbereichs
..... value S 1..1 decimal Numerical value (with implicit precision)
..... unit S 0..1 string Unit representation
..... system S 1..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
..... code S 1..1 code Coded form of the unit
.... high S 0..1 SimpleQuantity(4.0.1) Obergrenze des Referenzbereichs
..... value S 1..1 decimal Numerical value (with implicit precision)
..... unit S 0..1 string Unit representation
..... system S 1..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
..... code S 1..1 code Coded form of the unit
.... type S 0..1 CodeableConcept Art des Referenzbereichs (z. B. normal, kritisch)
..... coding S 0..* Coding Code defined by a terminology system
...... system S 1..1 uri Identity of the terminology system
...... code S 1..1 code Symbol in syntax defined by the system
...... display S 0..1 string Representation defined by the system
..... text S 0..1 string Plain text representation of the concept
.... appliesTo S 0..* CodeableConcept Für wen der Referenzbereich gilt (z. B. Geschlecht, Alter)
..... coding S 0..* Coding Kodierte Angabe zur Zielgruppe
...... system S 1..1 uri Identity of the terminology system
...... code S 1..1 code Symbol in syntax defined by the system
...... display S 0..1 string Representation defined by the system
..... text S 0..1 string Plain text representation of the concept
.... age S 0..1 Range Altersbereich, für den der Referenzbereich gilt
..... low S 0..1 SimpleQuantity(4.0.1) Low limit
..... high S 0..1 SimpleQuantity(4.0.1) High limit
.... text S 0..1 string Freitextbeschreibung des Referenzbereichs

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* Observation 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 Status der Laboruntersuchung
Binding: ObservationStatus (required): Codes providing the status of an observation.
... category S 1..* CodeableConcept Kategorie der Laboruntersuchung
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.

Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... 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: laboratory
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept Gegenstand der Untersuchung (Laborparameter)
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 Kodierung des Laborparameters
Slice: Unordered, Open by pattern:$this
..... coding: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
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri System, aus dem der Code für den Laborparameter stammt (z. B. LOINC)
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Code des Laborparameters entsprechend dem verwendeten System
...... display SΣ 0..1 string Anzeige-/Bezeichnungstext für den Laborparameter-Code
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:loinc SΣ 1..* 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://loinc.org
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri System, aus dem der Code für den Laborparameter stammt (z. B. LOINC)
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Code des Laborparameters entsprechend dem verwendeten System
...... display SΣ 0..1 string Anzeige-/Bezeichnungstext für den Laborparameter-Code
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text SΣ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Referenz auf den Patienten
.... 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 0..1 string Patienten-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
... 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) Referenz auf den Abteilungskontakt
.... 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 0..1 string Literal reference, Relative, internal or absolute URL
.... 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
... Slices for effective[x] SΣ 0..1 Zeitpunkt der Untersuchung
Slice: Unordered, Open by type:$this
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
.... effective[x]:effectiveDateTime SΣ 0..1 dateTime Clinically relevant time/time-period for observation
... issued SΣ 0..1 instant Zeitpunkt der Verfügbarkeit des Untersuchungsergebnisses
... performer Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Who is responsible for the observation
... Slices for value[x] SΣC 0..1 Festgestellter (Mess)Wert für den Laborparameter
Slice: Unordered, Open by type:$this
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
.... value[x]:valueQuantity SΣC 0..1 Quantity Messwert in quantitativer Form
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... value SΣ 1..1 decimal Der numerische Messwert
..... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
..... unit SΣ 0..1 string Einheit des Messwertes (z. B. mg/dL)
..... system SΣC 1..1 uri Kodiersystem für die Einheit (UCUM)
Required Pattern: http://unitsofmeasure.org
..... code SΣ 1..1 code UCUM-Code der Einheit
... dataAbsentReason SC 0..1 CodeableConcept Angabe eines Grundes weshalb kein Ergebniss der Laboruntersuchung vorliegt
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
... interpretation S 0..* CodeableConcept Interpretation oder Bewertung des Messergebnisses (z.B. „hoch“, „niedrig“, „normal“)
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
... note S 0..* Annotation Freitextnotiz oder Kommentar zur Beobachtung (z. B. Hinweise des Labors)
... bodySite 0..1 CodeableConcept Observed body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... method S 0..1 CodeableConcept How it was done
Binding: ObservationMethods (example): Methods for simple observations.
... specimen S 0..1 Reference(Specimen) Specimen used for this observation
.... 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 0..1 string Literal reference, Relative, internal or absolute URL
.... 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 SΣ 0..1 Identifier Logical reference, when literal reference is not known
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
..... system SΣ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SΣ 1..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
.... display Σ 0..1 string Text alternative for the resource
... device S 0..1 Reference(Device | DeviceMetric) Verwendetes Gerät oder Instrument zur Durchführung der Untersuchung
... referenceRange SC 0..* BackboneElement Referenzbereich zur Interpretation des Messergebnisses (z. B. Normalwerte)
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 SC 0..1 SimpleQuantity(4.0.1) Untergrenze des Referenzbereichs
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... value SΣ 1..1 decimal Numerical value (with implicit precision)
..... unit SΣ 0..1 string Unit representation
..... system SΣC 1..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
..... code SΣ 1..1 code Coded form of the unit
.... high SC 0..1 SimpleQuantity(4.0.1) Obergrenze des Referenzbereichs
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... value SΣ 1..1 decimal Numerical value (with implicit precision)
..... unit SΣ 0..1 string Unit representation
..... system SΣC 1..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
..... code SΣ 1..1 code Coded form of the unit
.... type S 0..1 CodeableConcept Art des Referenzbereichs (z. B. normal, kritisch)
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
..... 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 Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... text SΣ 0..1 string Plain text representation of the concept
.... appliesTo S 0..* CodeableConcept Für wen der Referenzbereich gilt (z. B. Geschlecht, Alter)
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
..... 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 Kodierte Angabe zur Zielgruppe
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... text SΣ 0..1 string Plain text representation of the concept
.... age S 0..1 Range Altersbereich, für den der Referenzbereich gilt
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... low SΣ 0..1 SimpleQuantity(4.0.1) Low limit
..... high SΣ 0..1 SimpleQuantity(4.0.1) High limit
.... text S 0..1 string Freitextbeschreibung des Referenzbereichs
... 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
... 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 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.subject.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Observation.encounter.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Observation.value[x]:valueQuantity.​comparator Base required QuantityComparator 📍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.specimen.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Observation.specimen.​identifier.use Base required IdentifierUse 📍4.0.1 FHIR Std.
Observation.specimen.​identifier.type Base extensible IdentifierType 📍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.

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()
ElementShort descriptionNotes
Observation.category Kategorie der Laboruntersuchung

Begründung MS: Ermöglicht das Filtern, Sortieren und Gruppieren von Befunden. Für Laboruntersuchungen ist die Kategorie zwingend mit dem entsprechenden Code (z. B. LOINC-Kategorie „laboratory“) zu befüllen.
Observation.code Gegenstand der Untersuchung (Laborparameter)

Begründung MS: Der Code identifiziert, was gemessen wurde, und ist damit das zentrale Element der Observation. Ohne .code ist kein eindeutiger sowie maschinell auswertbarer klinischer Kontext dokumentiert.
Observation.code.coding Kodierung des Laborparameters
Observation.code.coding.code Code des Laborparameters entsprechend dem verwendeten System
Observation.code.coding.display Anzeige-/Bezeichnungstext für den Laborparameter-Code
Observation.code.coding.system System, aus dem der Code für den Laborparameter stammt (z. B. LOINC)
Observation.code.coding:loinc
Observation.code.text
Observation.dataAbsentReason Angabe eines Grundes weshalb kein Ergebniss der Laboruntersuchung vorliegt

Begründung Must Support: Nicht alle geplanten oder dokumentierten Untersuchungen liefern auch tatsächlich ein Ergebnis. In solchen Fällen ist es wichtig, nicht nur auf das Fehlen eines Wertes zu reagieren, sondern den Grund strukturiert anzugeben. dataAbsentReason ermöglicht diese präzise Aussage und verhindert Fehlinterpretationen
Observation.device Verwendetes Gerät oder Instrument zur Durchführung der Untersuchung

Begründung Must Support: Das verwendete Mess- oder Analysegerät kann einen entscheidenden Einfluss auf die Genauigkeit, Validität und Vergleichbarkeit von Untersuchungsergebnissen haben.
Observation.effective[x] Zeitpunkt der Untersuchung

Begründung Must Support: Das Element effective[x] ist zentral, um die Beobachtung - insbesondere bei Laborbefunden - zeitlich korrekt einzuordnen. Es stellt sicher, dass Systeme erkennen können, wann eine Untersuchung durchgeführt oder ein Zustand beobachtet wurde. Dies ist entscheidend für:

  • die klinische Relevanz des Ergebnisses (z.B. aktueller vs. älterer Befund),
  • Verlaufsauswertungen und Trendanalysen,
  • zeitlich abhängige Entscheidungsunterstützung,
  • eine valide Anzeige im zeitlichen Kontext des Patientenaufenthalts.
Observation.effective[x]:effectiveDateTime
Observation.encounter Referenz auf den Abteilungskontakt

Begründung MS: Dient der Einordnung in den klinischen Verlauf und ermöglicht Kontextinformationen wie Aufnahmediagnose oder behandelnde Abteilung.
Observation.encounter.reference

Begründung MS: 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. 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.interpretation Interpretation oder Bewertung des Messergebnisses (z.B. „hoch“, „niedrig“, „normal“)

Begründung MS: Unterstützt die klinische Interpretation, insbesondere bei komplexen Parametern und automatisierten Auswertungen.
Observation.issued Zeitpunkt der Verfügbarkeit des Untersuchungsergebnisses

Begründung MS: Relevant zur Nachvollziehbarkeit und Validierung von Befunden, z.B. wann eine Entscheidung darauf basierte.
Observation.method

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

Motivation zum eingeschränkten MS: Die Untersuchungsmethode einer Laboruntersuchung ist eine relevante medizinische Information: Unterschiedliche Methoden können unterschiedliche Resultate liefern. Die Methode ist daher für Transparenz und Vergleichbarkeit entscheidend. Da diese Information aktuell häufig nicht übergeben wird, wird das MS eingeschränkt. Es ist dennoch wünschenswert, dass die Probe in der Zukunft übergeben wird.
Observation.note Freitextnotiz oder Kommentar zur Beobachtung (z. B. Hinweise des Labors)

Begründung MS: Dient zur Dokumentation abweichender Umstände, Freitextbefundung oder ergänzender Laborkommentare.
Observation.referenceRange Referenzbereich zur Interpretation des Messergebnisses (z. B. Normalwerte)

Begründung MS: Referenzbereiche erlauben die sofortige klinische Bewertung eines Wertes
Observation.referenceRange.age Altersbereich, für den der Referenzbereich gilt
Observation.referenceRange.age.high
Observation.referenceRange.age.low
Observation.referenceRange.appliesTo Für wen der Referenzbereich gilt (z. B. Geschlecht, Alter)
Observation.referenceRange.appliesTo.coding Kodierte Angabe zur Zielgruppe
Observation.referenceRange.appliesTo.coding.code
Observation.referenceRange.appliesTo.coding.display
Observation.referenceRange.appliesTo.coding.system
Observation.referenceRange.appliesTo.text
Observation.referenceRange.high Obergrenze des Referenzbereichs
Observation.referenceRange.high.code
Observation.referenceRange.high.system
Observation.referenceRange.high.unit
Observation.referenceRange.high.value
Observation.referenceRange.low Untergrenze des Referenzbereichs
Observation.referenceRange.low.code
Observation.referenceRange.low.system
Observation.referenceRange.low.unit
Observation.referenceRange.low.value
Observation.referenceRange.text Freitextbeschreibung des Referenzbereichs
Observation.referenceRange.type Art des Referenzbereichs (z. B. normal, kritisch)
Observation.referenceRange.type.coding
Observation.referenceRange.type.coding.code
Observation.referenceRange.type.coding.display
Observation.referenceRange.type.coding.system
Observation.referenceRange.type.text
Observation.specimen

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

Motivation zum eingeschränkten MS: Die Probe (z. B. Serum, Urin) ist zentral für die korrekte Bewertung des Ergebnisses. Die Unterscheidung von Materialtypen ist oft diagnostisch ausschlaggebend. Da die Information aktuell jedoch häufig nicht übergeben wird, wird das MS eingeschränkt. Es ist dennoch wünschenswert, dass die Probe in der Zukunft übergeben wird
Observation.specimen.identifier
Observation.specimen.identifier.system
Observation.specimen.identifier.value
Observation.specimen.reference
Observation.status Status der Laboruntersuchung

Begründung MS: Der Status ist unerlässlich für die korrekte Interpretation einer Untersuchung. WICHTIGER Hinweis für Implementierer:

  • Alle server-seitigen Implementierungen MÜSSEN in der Lage sein, die systemintern möglichen Statuswerte korrekt in FHIR abzubilden, mindestens jedoch die Werte final und unknown.
  • 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 Prozeduren mit dem status entered-in-error und Ausgrauen von Untersuchungen, die noch nicht stattgefunden haben, o.ä.
Observation.subject Referenz auf den Patienten

Begründung MS: Die Verknüpfung zur Patientin oder zum Patienten ist zwingend notwendig für jegliche klinische Verwertbarkeit.
Observation.subject.reference Patienten-Link

Begründung 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.
Observation.value[x] Festgestellter (Mess)Wert für den Laborparameter

Begründung MS: Der gemessene Wert stellt die zentrale Aussage der Observation dar. Ohne value besitzt die Observation keine medizinische Relevanz.
Observation.value[x]:valueQuantity Messwert in quantitativer Form

Begründung MS: Standardisierte, codierte Einheiten sind für Vergleichbarkeit, Umrechnung und automatische Plausibilisierung erforderlich.
Observation.value[x]:valueQuantity.code UCUM-Code der Einheit
Observation.value[x]:valueQuantity.system Kodiersystem für die Einheit (UCUM)
Observation.value[x]:valueQuantity.unit Einheit des Messwertes (z. B. mg/dL)
Observation.value[x]:valueQuantity.value Der numerische Messwert

This structure is derived from Observation

Summary

Mandatory: 6 elements(15 nested mandatory elements)
Must-Support: 60 elements

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Observation.code.coding
  • The element 1 is sliced based on the value of Observation.effective[x]
  • The element 1 is sliced based on the value of Observation.value[x]

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* Observation 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 Kategorie der Laboruntersuchung
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.

Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... 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: laboratory
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept Gegenstand der Untersuchung (Laborparameter)
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... Slices for coding SΣ 1..* Coding Kodierung des Laborparameters
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system SΣ 1..1 uri System, aus dem der Code für den Laborparameter stammt (z. B. LOINC)
...... code SΣ 1..1 code Code des Laborparameters entsprechend dem verwendeten System
...... display SΣ 0..1 string Anzeige-/Bezeichnungstext für den Laborparameter-Code
..... coding:loinc SΣ 1..* 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://loinc.org
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri System, aus dem der Code für den Laborparameter stammt (z. B. LOINC)
...... code SΣ 1..1 code Code des Laborparameters entsprechend dem verwendeten System
...... display SΣ 0..1 string Anzeige-/Bezeichnungstext für den Laborparameter-Code
.... text SΣ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Referenz auf den Patienten
.... reference SΣC 0..1 string Patienten-Link
... encounter SΣ 0..1 Reference(Encounter) Referenz auf den Abteilungskontakt
.... reference SΣC 0..1 string Literal reference, Relative, internal or absolute URL
... Slices for effective[x] SΣ 0..1 Zeitpunkt der Untersuchung
Slice: Unordered, Open by type:$this
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
.... effective[x]:effectiveDateTime SΣ 0..1 dateTime Clinically relevant time/time-period for observation
... issued SΣ 0..1 instant Zeitpunkt der Verfügbarkeit des Untersuchungsergebnisses
... Slices for value[x] SΣC 0..1 Festgestellter (Mess)Wert für den Laborparameter
Slice: Unordered, Open by type:$this
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
.... value[x]:valueQuantity SΣC 0..1 Quantity Messwert in quantitativer Form
..... value SΣ 1..1 decimal Der numerische Messwert
..... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
..... unit SΣ 0..1 string Einheit des Messwertes (z. B. mg/dL)
..... system SΣC 1..1 uri Kodiersystem für die Einheit (UCUM)
Required Pattern: http://unitsofmeasure.org
..... code SΣ 1..1 code UCUM-Code der Einheit
... dataAbsentReason SC 0..1 CodeableConcept Angabe eines Grundes weshalb kein Ergebniss der Laboruntersuchung vorliegt
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
... interpretation S 0..* CodeableConcept Interpretation oder Bewertung des Messergebnisses (z.B. „hoch“, „niedrig“, „normal“)
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
... note S 0..* Annotation Freitextnotiz oder Kommentar zur Beobachtung (z. B. Hinweise des Labors)
... method S 0..1 CodeableConcept How it was done
Binding: ObservationMethods (example): Methods for simple observations.
... specimen S 0..1 Reference(Specimen) Specimen used for this observation
.... reference SΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... identifier SΣ 0..1 Identifier Logical reference, when literal reference is not known
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... system SΣ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SΣ 1..1 string The value that is unique
Example General: 123456
... device S 0..1 Reference(Device | DeviceMetric) Verwendetes Gerät oder Instrument zur Durchführung der Untersuchung
... referenceRange SC 0..* BackboneElement Referenzbereich zur Interpretation des Messergebnisses (z. B. Normalwerte)
Constraints: obs-3
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... low SC 0..1 SimpleQuantity(4.0.1) Untergrenze des Referenzbereichs
..... value SΣ 1..1 decimal Numerical value (with implicit precision)
..... unit SΣ 0..1 string Unit representation
..... system SΣC 1..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
..... code SΣ 1..1 code Coded form of the unit
.... high SC 0..1 SimpleQuantity(4.0.1) Obergrenze des Referenzbereichs
..... value SΣ 1..1 decimal Numerical value (with implicit precision)
..... unit SΣ 0..1 string Unit representation
..... system SΣC 1..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
..... code SΣ 1..1 code Coded form of the unit
.... type S 0..1 CodeableConcept Art des Referenzbereichs (z. B. normal, kritisch)
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
..... coding SΣ 0..* Coding Code defined by a terminology system
...... system SΣ 1..1 uri Identity of the terminology system
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 0..1 string Representation defined by the system
..... text SΣ 0..1 string Plain text representation of the concept
.... appliesTo S 0..* CodeableConcept Für wen der Referenzbereich gilt (z. B. Geschlecht, Alter)
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
..... coding SΣ 0..* Coding Kodierte Angabe zur Zielgruppe
...... system SΣ 1..1 uri Identity of the terminology system
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 0..1 string Representation defined by the system
..... text SΣ 0..1 string Plain text representation of the concept
.... age S 0..1 Range Altersbereich, für den der Referenzbereich gilt
..... low SΣ 0..1 SimpleQuantity(4.0.1) Low limit
..... high SΣ 0..1 SimpleQuantity(4.0.1) High limit
.... text S 0..1 string Freitextbeschreibung des Referenzbereichs

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.value[x]:valueQuantity.​comparator Base required QuantityComparator 📍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.method Base example Observation Methods 📍4.0.1 FHIR Std.
Observation.specimen.​identifier.use Base required IdentifierUse 📍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.

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()

Differential View

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation 0..* Observation 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 Status der Laboruntersuchung
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: laboratory
... code S 1..1 CodeableConcept Gegenstand der Untersuchung (Laborparameter)
.... Slices for coding S 1..* Coding Kodierung des Laborparameters
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system S 1..1 uri System, aus dem der Code für den Laborparameter stammt (z. B. LOINC)
...... code S 1..1 code Code des Laborparameters entsprechend dem verwendeten System
...... display S 0..1 string Anzeige-/Bezeichnungstext für den Laborparameter-Code
..... coding:loinc S 1..* Coding Code defined by a terminology system

Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
.... text S 0..1 string Plain text representation of the concept
... subject S 1..1 Reference(Patient) Referenz auf den Patienten
.... reference S 0..1 string Patienten-Link
... encounter S 0..1 Reference(Encounter) Referenz auf den Abteilungskontakt
.... reference S 0..1 string Literal reference, Relative, internal or absolute URL
... Slices for effective[x] S 0..1 dateTime, Period, Timing, instant Zeitpunkt der Untersuchung
Slice: Unordered, Open by type:$this
.... effective[x]:effectiveDateTime S 0..1 dateTime Clinically relevant time/time-period for observation
... issued S 0..1 instant Zeitpunkt der Verfügbarkeit des Untersuchungsergebnisses
... Slices for value[x] S 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Festgestellter (Mess)Wert für den Laborparameter
Slice: Unordered, Open by type:$this
.... value[x]:valueQuantity S 0..1 Quantity Messwert in quantitativer Form
..... value S 1..1 decimal Der numerische Messwert
..... unit S 0..1 string Einheit des Messwertes (z. B. mg/dL)
..... system S 1..1 uri Kodiersystem für die Einheit (UCUM)
Required Pattern: http://unitsofmeasure.org
..... code S 1..1 code UCUM-Code der Einheit
... dataAbsentReason S 0..1 CodeableConcept Angabe eines Grundes weshalb kein Ergebniss der Laboruntersuchung vorliegt
... interpretation S 0..* CodeableConcept Interpretation oder Bewertung des Messergebnisses (z.B. „hoch“, „niedrig“, „normal“)
... note S 0..* Annotation Freitextnotiz oder Kommentar zur Beobachtung (z. B. Hinweise des Labors)
... method S 0..1 CodeableConcept How it was done
... specimen S 0..1 Reference(Specimen) Specimen used for this observation
.... reference S 0..1 string Literal reference, Relative, internal or absolute URL
.... identifier S 0..1 Identifier Logical reference, when literal reference is not known
..... system S 1..1 uri The namespace for the identifier value
..... value S 1..1 string The value that is unique
... device S 0..1 Reference(Device | DeviceMetric) Verwendetes Gerät oder Instrument zur Durchführung der Untersuchung
... referenceRange S 0..* BackboneElement Referenzbereich zur Interpretation des Messergebnisses (z. B. Normalwerte)
.... low S 0..1 SimpleQuantity(4.0.1) Untergrenze des Referenzbereichs
..... value S 1..1 decimal Numerical value (with implicit precision)
..... unit S 0..1 string Unit representation
..... system S 1..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
..... code S 1..1 code Coded form of the unit
.... high S 0..1 SimpleQuantity(4.0.1) Obergrenze des Referenzbereichs
..... value S 1..1 decimal Numerical value (with implicit precision)
..... unit S 0..1 string Unit representation
..... system S 1..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
..... code S 1..1 code Coded form of the unit
.... type S 0..1 CodeableConcept Art des Referenzbereichs (z. B. normal, kritisch)
..... coding S 0..* Coding Code defined by a terminology system
...... system S 1..1 uri Identity of the terminology system
...... code S 1..1 code Symbol in syntax defined by the system
...... display S 0..1 string Representation defined by the system
..... text S 0..1 string Plain text representation of the concept
.... appliesTo S 0..* CodeableConcept Für wen der Referenzbereich gilt (z. B. Geschlecht, Alter)
..... coding S 0..* Coding Kodierte Angabe zur Zielgruppe
...... system S 1..1 uri Identity of the terminology system
...... code S 1..1 code Symbol in syntax defined by the system
...... display S 0..1 string Representation defined by the system
..... text S 0..1 string Plain text representation of the concept
.... age S 0..1 Range Altersbereich, für den der Referenzbereich gilt
..... low S 0..1 SimpleQuantity(4.0.1) Low limit
..... high S 0..1 SimpleQuantity(4.0.1) High limit
.... text S 0..1 string Freitextbeschreibung des Referenzbereichs

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* Observation 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 Status der Laboruntersuchung
Binding: ObservationStatus (required): Codes providing the status of an observation.
... category S 1..* CodeableConcept Kategorie der Laboruntersuchung
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.

Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... 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: laboratory
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept Gegenstand der Untersuchung (Laborparameter)
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 Kodierung des Laborparameters
Slice: Unordered, Open by pattern:$this
..... coding: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
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri System, aus dem der Code für den Laborparameter stammt (z. B. LOINC)
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Code des Laborparameters entsprechend dem verwendeten System
...... display SΣ 0..1 string Anzeige-/Bezeichnungstext für den Laborparameter-Code
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:loinc SΣ 1..* 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://loinc.org
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri System, aus dem der Code für den Laborparameter stammt (z. B. LOINC)
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Code des Laborparameters entsprechend dem verwendeten System
...... display SΣ 0..1 string Anzeige-/Bezeichnungstext für den Laborparameter-Code
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text SΣ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Referenz auf den Patienten
.... 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 0..1 string Patienten-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
... 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) Referenz auf den Abteilungskontakt
.... 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 0..1 string Literal reference, Relative, internal or absolute URL
.... 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
... Slices for effective[x] SΣ 0..1 Zeitpunkt der Untersuchung
Slice: Unordered, Open by type:$this
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
.... effective[x]:effectiveDateTime SΣ 0..1 dateTime Clinically relevant time/time-period for observation
... issued SΣ 0..1 instant Zeitpunkt der Verfügbarkeit des Untersuchungsergebnisses
... performer Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Who is responsible for the observation
... Slices for value[x] SΣC 0..1 Festgestellter (Mess)Wert für den Laborparameter
Slice: Unordered, Open by type:$this
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
.... value[x]:valueQuantity SΣC 0..1 Quantity Messwert in quantitativer Form
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... value SΣ 1..1 decimal Der numerische Messwert
..... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
..... unit SΣ 0..1 string Einheit des Messwertes (z. B. mg/dL)
..... system SΣC 1..1 uri Kodiersystem für die Einheit (UCUM)
Required Pattern: http://unitsofmeasure.org
..... code SΣ 1..1 code UCUM-Code der Einheit
... dataAbsentReason SC 0..1 CodeableConcept Angabe eines Grundes weshalb kein Ergebniss der Laboruntersuchung vorliegt
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
... interpretation S 0..* CodeableConcept Interpretation oder Bewertung des Messergebnisses (z.B. „hoch“, „niedrig“, „normal“)
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
... note S 0..* Annotation Freitextnotiz oder Kommentar zur Beobachtung (z. B. Hinweise des Labors)
... bodySite 0..1 CodeableConcept Observed body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... method S 0..1 CodeableConcept How it was done
Binding: ObservationMethods (example): Methods for simple observations.
... specimen S 0..1 Reference(Specimen) Specimen used for this observation
.... 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 0..1 string Literal reference, Relative, internal or absolute URL
.... 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 SΣ 0..1 Identifier Logical reference, when literal reference is not known
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
..... system SΣ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SΣ 1..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
.... display Σ 0..1 string Text alternative for the resource
... device S 0..1 Reference(Device | DeviceMetric) Verwendetes Gerät oder Instrument zur Durchführung der Untersuchung
... referenceRange SC 0..* BackboneElement Referenzbereich zur Interpretation des Messergebnisses (z. B. Normalwerte)
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 SC 0..1 SimpleQuantity(4.0.1) Untergrenze des Referenzbereichs
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... value SΣ 1..1 decimal Numerical value (with implicit precision)
..... unit SΣ 0..1 string Unit representation
..... system SΣC 1..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
..... code SΣ 1..1 code Coded form of the unit
.... high SC 0..1 SimpleQuantity(4.0.1) Obergrenze des Referenzbereichs
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... value SΣ 1..1 decimal Numerical value (with implicit precision)
..... unit SΣ 0..1 string Unit representation
..... system SΣC 1..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
..... code SΣ 1..1 code Coded form of the unit
.... type S 0..1 CodeableConcept Art des Referenzbereichs (z. B. normal, kritisch)
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
..... 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 Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... text SΣ 0..1 string Plain text representation of the concept
.... appliesTo S 0..* CodeableConcept Für wen der Referenzbereich gilt (z. B. Geschlecht, Alter)
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
..... 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 Kodierte Angabe zur Zielgruppe
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display SΣ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... text SΣ 0..1 string Plain text representation of the concept
.... age S 0..1 Range Altersbereich, für den der Referenzbereich gilt
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... low SΣ 0..1 SimpleQuantity(4.0.1) Low limit
..... high SΣ 0..1 SimpleQuantity(4.0.1) High limit
.... text S 0..1 string Freitextbeschreibung des Referenzbereichs
... 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
... 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 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.subject.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Observation.encounter.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Observation.value[x]:valueQuantity.​comparator Base required QuantityComparator 📍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.specimen.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Observation.specimen.​identifier.use Base required IdentifierUse 📍4.0.1 FHIR Std.
Observation.specimen.​identifier.type Base extensible IdentifierType 📍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.

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()

This structure is derived from Observation

Summary

Mandatory: 6 elements(15 nested mandatory elements)
Must-Support: 60 elements

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Observation.code.coding
  • The element 1 is sliced based on the value of Observation.effective[x]
  • The element 1 is sliced based on the value of Observation.value[x]

 

Other representations of profile: CSV, Excel, Schematron