Australian Digital Health Agency FHIR Implementation Guide 1.0.0

Australian Digital Health Agency FHIR Implementation Guide. This is the current published version. It is based on FHIR® version 4.0.1. See the Directory of published versions for a list of available versions.

StructureDefinition: ADHA Core Observation [Active]

The purpose of this profile is to provide a core representation of a generic observation for the electronic exchange of health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia.

This profile identifies the additional constraints, extensions, and value sets that build on and extend Observation that are supported.

Where a more specific Observation profile is applicable, e.g. diagnostic result or vital signs, an implementation SHALL ensure the resource conforms to that specific profile.

This profile is designed to set a core Observation standard for:

  • Query for a generic observation for a patient
  • Record or update a generic observation belonging to a patient

Profile specific guidance

  • Observation.category provides an efficient way of supporting system interactions, e.g. restricting searches. Implementers need to understand that data categorisation is somewhat subjective. The categorisation applied by the source may not align with a receiver’s expectations.
  • Antenatal observations will represent the pregnant individual as Observation.subject and the fetus as Observation.focus.

Boundaries and relationships

This profile is referenced by ADHA Core Encounter, ADHA Core Observation, and ADHA Core Procedure.

Formal Views of Profile Content

The official URL for this profile is: 

http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-observation-core-1

The purpose of this profile is to provide a core representation of a generic observation for the electronic exchange of health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia.

This profile builds on Observation.

This profile was published on 2023-04-14 04:02:01+0000 as a active by Australian Digital Health Agency.

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationMeasurements and simple assertions
inv-dh-obs-05: If there is no component or hasMember element then at least value or data absent reason shall be present
... status S1..1coderegistered | preliminary | final | amended +
... category S1..*CodeableConceptClassification of type of observation
... code S1..1CodeableConceptType of observation (code / type)
... subject SC1..1Reference(ADHA Core Patient)Who and/or what the observation is about
inv-dh-obs-01: At least reference or a valid identifier shall be present
... encounter S0..1Reference(ADHA Core Encounter)Healthcare event during which this observation is made
... effective[x] SC1..1dateTime, Period, Timing, instantClinically relevant time/time-period for observation
inv-dh-obs-07: Date shall be at least to day
... performer SC1..*Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA Core Patient | ADHA Authoring RelatedPerson)Who is responsible for the observation
inv-dh-obs-03: At least reference or display or a valid identifier shall be present
... value[x] SC0..1Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, PeriodActual result
... dataAbsentReason SC0..1CodeableConceptWhy the result is missing
... interpretation S0..*CodeableConceptHigh, low, normal, etc.
... note S0..*AnnotationComments about the observation
... bodySite SC0..1CodeableConceptObserved body part
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible)
inv-dh-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT
... method S0..1CodeableConceptHow it was done
... hasMember S0..*Reference(ADHA Core Observation)Related resource that belongs to the Observation group
... component S0..*BackboneElementComponent results
.... code S1..1CodeableConceptType of component observation (code / type)
.... value[x] S0..1Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, PeriodActual component result
.... dataAbsentReason S0..1CodeableConceptWhy the component result is missing
.... interpretation S0..*CodeableConceptHigh, low, normal, etc.

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationMeasurements and simple assertions
inv-dh-obs-05: If there is no component or hasMember element then at least value or data absent reason shall be present
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!SΣ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... category S1..*CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


... code SΣ1..1CodeableConceptType of observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

... subject SΣC1..1Reference(ADHA Core Patient)Who and/or what the observation is about
inv-dh-obs-01: At least reference or a valid identifier shall be present
... focus Σ0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter SΣ0..1Reference(ADHA Core Encounter)Healthcare event during which this observation is made
... effective[x] SΣC1..1Clinically relevant time/time-period for observation
inv-dh-obs-07: Date shall be at least to day
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
.... effectiveTimingTiming
.... effectiveInstantinstant
... issued Σ0..1instantDate/Time this version was made available
... performer SΣC1..*Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA Core Patient | ADHA Authoring RelatedPerson)Who is responsible for the observation
inv-dh-obs-03: At least reference or display or a valid identifier shall be present
... value[x] SΣC0..1Actual result
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
... dataAbsentReason SC0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation S0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note S0..*AnnotationComments about the observation
... bodySite SC0..1CodeableConceptObserved body part
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible)
inv-dh-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT
... method S0..1CodeableConceptHow it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange C0..*BackboneElementProvides guide for interpretation
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low C0..1SimpleQuantityLow Range, if relevant
.... high C0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember SΣ0..*Reference(ADHA Core Observation)Related resource that belongs to the Observation group
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component SΣ0..*BackboneElementComponent results
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code SΣ1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] SΣ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason SC0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation S0..*CodeableConceptHigh, 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

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationMeasurements and simple assertions
inv-dh-obs-05: If there is no component or hasMember element then at least value or data absent reason shall be present
... status S1..1coderegistered | preliminary | final | amended +
... category S1..*CodeableConceptClassification of type of observation
... code S1..1CodeableConceptType of observation (code / type)
... subject SC1..1Reference(ADHA Core Patient)Who and/or what the observation is about
inv-dh-obs-01: At least reference or a valid identifier shall be present
... encounter S0..1Reference(ADHA Core Encounter)Healthcare event during which this observation is made
... effective[x] SC1..1dateTime, Period, Timing, instantClinically relevant time/time-period for observation
inv-dh-obs-07: Date shall be at least to day
... performer SC1..*Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA Core Patient | ADHA Authoring RelatedPerson)Who is responsible for the observation
inv-dh-obs-03: At least reference or display or a valid identifier shall be present
... value[x] SC0..1Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, PeriodActual result
... dataAbsentReason SC0..1CodeableConceptWhy the result is missing
... interpretation S0..*CodeableConceptHigh, low, normal, etc.
... note S0..*AnnotationComments about the observation
... bodySite SC0..1CodeableConceptObserved body part
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible)
inv-dh-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT
... method S0..1CodeableConceptHow it was done
... hasMember S0..*Reference(ADHA Core Observation)Related resource that belongs to the Observation group
... component S0..*BackboneElementComponent results
.... code S1..1CodeableConceptType of component observation (code / type)
.... value[x] S0..1Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, PeriodActual component result
.... dataAbsentReason S0..1CodeableConceptWhy the component result is missing
.... interpretation S0..*CodeableConceptHigh, low, normal, etc.

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationMeasurements and simple assertions
inv-dh-obs-05: If there is no component or hasMember element then at least value or data absent reason shall be present
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!SΣ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... category S1..*CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


... code SΣ1..1CodeableConceptType of observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

... subject SΣC1..1Reference(ADHA Core Patient)Who and/or what the observation is about
inv-dh-obs-01: At least reference or a valid identifier shall be present
... focus Σ0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter SΣ0..1Reference(ADHA Core Encounter)Healthcare event during which this observation is made
... effective[x] SΣC1..1Clinically relevant time/time-period for observation
inv-dh-obs-07: Date shall be at least to day
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
.... effectiveTimingTiming
.... effectiveInstantinstant
... issued Σ0..1instantDate/Time this version was made available
... performer SΣC1..*Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA Core Patient | ADHA Authoring RelatedPerson)Who is responsible for the observation
inv-dh-obs-03: At least reference or display or a valid identifier shall be present
... value[x] SΣC0..1Actual result
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
... dataAbsentReason SC0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation S0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note S0..*AnnotationComments about the observation
... bodySite SC0..1CodeableConceptObserved body part
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible)
inv-dh-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT
... method S0..1CodeableConceptHow it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange C0..*BackboneElementProvides guide for interpretation
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low C0..1SimpleQuantityLow Range, if relevant
.... high C0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember SΣ0..*Reference(ADHA Core Observation)Related resource that belongs to the Observation group
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component SΣ0..*BackboneElementComponent results
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code SΣ1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] SΣ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason SC0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation S0..*CodeableConceptHigh, 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

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron

 

Terminology Bindings

PathConformanceValueSet
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Observation.statusrequiredObservationStatus
Observation.categorypreferredObservationCategoryCodes
Observation.codeexampleLOINCCodes (a valid code from LOINC)
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySiteextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes

Search Parameters

None defined.