ISiK Basis Implementierungsleitfaden
Version 6.0.0-rc - ci-build

Resource Profile: ISiKLebensZustand ( Abstract )

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

Basisprofil für ISiKLebensZustand Observation

Motivation

Viele medizinischen Entscheidungen benötigen Informationen zu den Lebensumständen eines Patienten. Hierzu gehören eine aktuelle Schwangerschaft, Raucherstatus sowie der Alkoholabususstatus. Motivierender Use-Case zur Einführung dieser Profile ist die Arzneitmitteltherapiesicherheit im Krankenhaus - AMTS.

In FHIR werden Untersuchungen, bzw. Beobachtungen als Observation-Ressource repräsentiert.

Dieses Profil ist eine generische, ISiK-spezifische Observation für die Abbildung von Lebenszuständen.
Die folgenden Profile vom Typ Observation sind spezifische Profile im oben genannten Sinn:

  • https://gematik.de/fhir/isik/StructureDefinition/ISiKSchwangerschaftsstatus
  • https://gematik.de/fhir/isik/StructureDefinition/ISiKSchwangerschaftErwarteterEntbindungstermin
  • https://gematik.de/fhir/isik/StructureDefinition/ISiKStillstatus
  • https://gematik.de/fhir/isik/StructureDefinition/ISiKAlkoholAbusus
  • https://gematik.de/fhir/isik/StructureDefinition/ISiKRaucherStatus

Kompatibilität

Für Schwangerschaftsstatus & Erwarteter Geburtstermin wird eine Kompatibilität mit folgenden IPS Profilen angestrebt:

Hinweise zu Inkompatibilitäten können über die Portalseite gemeldet werden.

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 This is an abstract profile. Child profiles: ISiKAlkoholAbusus, ISiKRaucherStatus, ISiKSchwangerschaftErwarteterEntbindungstermin, ISiKSchwangerschaftsstatus, ISiKStillstatus
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 0..* CodeableConcept Kategorie
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... Slices for coding SΣ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:snomed-ct SΣ 0..* ?pkp-2? Code defined by a terminology system
..... coding:loinc SΣ 1..* ?pkp-2? Code defined by a terminology system
... subject SΣ 1..1 Reference(Patient | Group | Device | Location) Patientenbezug
.... reference SΣC 1..1 string Patienten-Link
... encounter SΣ 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference SΣC 1..1 string Encounter-Link
... effective[x] SΣ 1..1 Zeitpunkt/-raum der Beobachtung
.... effectiveDateTime dateTime
.... effectivePeriod Period
... Slices for value[x] SΣC 1..1 Wert der Beobachtung
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]:valueDateTime SΣC 0..1 dateTime Actual result
.... value[x]:valueCodeableConcept SΣC 0..1 CodeableConcept Actual result
... hasMember Σ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... component Σ 0..* BackboneElement Component results
.... 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.

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.component.​code Base example LOINC 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-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 This is an abstract profile. Child profiles: ISiKAlkoholAbusus, ISiKRaucherStatus, ISiKSchwangerschaftErwarteterEntbindungstermin, ISiKSchwangerschaftsstatus, ISiKStillstatus
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
... code S 1..1 CodeableConcept Code
.... Slices for coding S 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:snomed-ct S 0..* ?pkp-2? Code defined by a terminology system
..... coding:loinc S 1..* ?pkp-2? Code defined by a terminology system
... subject S 1..1 Reference(Patient | Group | Device | Location) Patientenbezug
.... reference S 1..1 string Patienten-Link
... encounter S 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference S 1..1 string Encounter-Link
... effective[x] S 1..1 Zeitpunkt/-raum der Beobachtung
.... effectiveDateTime dateTime
.... effectivePeriod Period
... Slices for value[x] S 1..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Wert der Beobachtung
Slice: Unordered, Open by type:$this
.... value[x]:valueDateTime S 0..1 dateTime Actual result
.... value[x]:valueCodeableConcept S 0..1 CodeableConcept Actual result
... hasMember 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... component 0..* BackboneElement Component results

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* Observation This is an abstract profile. Child profiles: ISiKAlkoholAbusus, ISiKRaucherStatus, ISiKSchwangerschaftErwarteterEntbindungstermin, ISiKSchwangerschaftsstatus, ISiKStillstatus
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
Binding: ObservationStatus (required): Codes providing the status of an observation.
... category S 0..* CodeableConcept Kategorie
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
... 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 Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:snomed-ct SΣ 0..* ?pkp-2? Code defined by a terminology system
..... coding:loinc SΣ 1..* ?pkp-2? Code defined by a terminology system
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient | Group | Device | Location) Patientenbezug
.... 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 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) 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] SΣ 1..1 Zeitpunkt/-raum der Beobachtung
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued Σ 0..1 instant Date/Time this version was made available
... performer Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Who is responsible for the observation
... Slices for value[x] SΣC 1..1 Wert der Beobachtung
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]:valueDateTime SΣC 0..1 dateTime Actual result
.... value[x]:valueCodeableConcept SΣC 0..1 CodeableConcept Actual result
... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
... note 0..* Annotation Comments about the observation
... bodySite 0..1 CodeableConcept Observed body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... method 0..1 CodeableConcept How it was done
Binding: ObservationMethods (example): Methods for simple observations.
... specimen 0..1 Reference(Specimen) Specimen used for this observation
... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... 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(4.0.1) Low Range, if relevant
.... high C 0..1 SimpleQuantity(4.0.1) 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
... 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.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.

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

Bedeutung: Kategorie-Code, der die Untersuchung kategorisiert.

Observation.code Code

Bedeutung: Code, der die Untersuchung repräsentiert und kodiert.

Observation.code.coding

Motivation: Jede Lebenszustanduntersuchung MUSS einen LOINC Code enthalten, SnomedCT ist optional

Observation.code.coding:loinc
Observation.code.coding:snomed-ct
Observation.effective[x] Zeitpunkt/-raum der Beobachtung

Bedeutung: Klinisch relevanter Zeitpunkt/Zeitspanne für die Observation.

Observation.encounter Aufenthaltsbezug

Begründung Must-Support: Ein Aufenthaltsbezug der Beobachtung MUSS stets zum Zwecke der Nachvollziehbarkeit und Datenintegrität vorliegen.

Observation.encounter.reference Encounter-Link

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.status Status

Bedeutung: Der Status MUSS insbesondere zur Differenzierung von abgeschlossenen, vorläufigen oder korrigierten Beobachtungen angegeben werden.
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 Patientenbezug

Begründung Must-Support: Ein Patientenbezug der Beobachtung MUSS stets zum Zwecke der Nachvollziehbarkeit und Datenintegrität vorliegen.

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] Wert der Beobachtung

Begründung Must-Support: Erfasster Wert der Observation.

Observation.value[x]:valueCodeableConcept

Begründung Must-Support: Viele Lebenszustände (z. B. Schwangerschaftsstatus, Alkoholabusus, Raucherstatus) werden als kategorisierte Angaben kodiert und erfordern daher ein CodeableConcept.

Observation.value[x]:valueDateTime

Begründung Must-Support: Zeitpunktbezogene Lebenszustände (z. B. erwarteter Entbindungstermin) benötigen eine eindeutige Datumsangabe als Wert.

This structure is derived from Observation

Summary

Mandatory: 6 elements(1 nested mandatory element)
Must-Support: 15 elements

Structures

This structure refers to these other structures:

  • Unable to summarise profile https://gematik.de/fhir/isik/StructureDefinition/ISiKSnomedCTCoding (no profile found)
  • Unable to summarise profile https://gematik.de/fhir/isik/StructureDefinition/ISiKLoincCoding (no profile found)

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.value[x]

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* Observation This is an abstract profile. Child profiles: ISiKAlkoholAbusus, ISiKRaucherStatus, ISiKSchwangerschaftErwarteterEntbindungstermin, ISiKSchwangerschaftsstatus, ISiKStillstatus
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 0..* CodeableConcept Kategorie
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... Slices for coding SΣ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:snomed-ct SΣ 0..* ?pkp-2? Code defined by a terminology system
..... coding:loinc SΣ 1..* ?pkp-2? Code defined by a terminology system
... subject SΣ 1..1 Reference(Patient | Group | Device | Location) Patientenbezug
.... reference SΣC 1..1 string Patienten-Link
... encounter SΣ 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference SΣC 1..1 string Encounter-Link
... effective[x] SΣ 1..1 Zeitpunkt/-raum der Beobachtung
.... effectiveDateTime dateTime
.... effectivePeriod Period
... Slices for value[x] SΣC 1..1 Wert der Beobachtung
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]:valueDateTime SΣC 0..1 dateTime Actual result
.... value[x]:valueCodeableConcept SΣC 0..1 CodeableConcept Actual result
... hasMember Σ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... component Σ 0..* BackboneElement Component results
.... 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.

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.component.​code Base example LOINC 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-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 This is an abstract profile. Child profiles: ISiKAlkoholAbusus, ISiKRaucherStatus, ISiKSchwangerschaftErwarteterEntbindungstermin, ISiKSchwangerschaftsstatus, ISiKStillstatus
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
... code S 1..1 CodeableConcept Code
.... Slices for coding S 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:snomed-ct S 0..* ?pkp-2? Code defined by a terminology system
..... coding:loinc S 1..* ?pkp-2? Code defined by a terminology system
... subject S 1..1 Reference(Patient | Group | Device | Location) Patientenbezug
.... reference S 1..1 string Patienten-Link
... encounter S 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference S 1..1 string Encounter-Link
... effective[x] S 1..1 Zeitpunkt/-raum der Beobachtung
.... effectiveDateTime dateTime
.... effectivePeriod Period
... Slices for value[x] S 1..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Wert der Beobachtung
Slice: Unordered, Open by type:$this
.... value[x]:valueDateTime S 0..1 dateTime Actual result
.... value[x]:valueCodeableConcept S 0..1 CodeableConcept Actual result
... hasMember 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... component 0..* BackboneElement Component results

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* Observation This is an abstract profile. Child profiles: ISiKAlkoholAbusus, ISiKRaucherStatus, ISiKSchwangerschaftErwarteterEntbindungstermin, ISiKSchwangerschaftsstatus, ISiKStillstatus
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
Binding: ObservationStatus (required): Codes providing the status of an observation.
... category S 0..* CodeableConcept Kategorie
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
... 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 Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:snomed-ct SΣ 0..* ?pkp-2? Code defined by a terminology system
..... coding:loinc SΣ 1..* ?pkp-2? Code defined by a terminology system
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient | Group | Device | Location) Patientenbezug
.... 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 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) 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] SΣ 1..1 Zeitpunkt/-raum der Beobachtung
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued Σ 0..1 instant Date/Time this version was made available
... performer Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Who is responsible for the observation
... Slices for value[x] SΣC 1..1 Wert der Beobachtung
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]:valueDateTime SΣC 0..1 dateTime Actual result
.... value[x]:valueCodeableConcept SΣC 0..1 CodeableConcept Actual result
... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
... note 0..* Annotation Comments about the observation
... bodySite 0..1 CodeableConcept Observed body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... method 0..1 CodeableConcept How it was done
Binding: ObservationMethods (example): Methods for simple observations.
... specimen 0..1 Reference(Specimen) Specimen used for this observation
... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... 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(4.0.1) Low Range, if relevant
.... high C 0..1 SimpleQuantity(4.0.1) 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
... 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.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.

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(1 nested mandatory element)
Must-Support: 15 elements

Structures

This structure refers to these other structures:

  • Unable to summarise profile https://gematik.de/fhir/isik/StructureDefinition/ISiKSnomedCTCoding (no profile found)
  • Unable to summarise profile https://gematik.de/fhir/isik/StructureDefinition/ISiKLoincCoding (no profile found)

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.value[x]

 

Other representations of profile: CSV, Excel, Schematron