My Health Record FHIR IG
1.3.0 - active Australia flag

My Health Record FHIR IG - Local Development build (v1.3.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: ADHA Core Observation

Official URL: http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-observation-core-1 Version: 1.3.0
Active as of 2024-10-25 Computable Name: ADHAObservationCore

Copyright/Legal: Copyright © 2022 Australian Digital Health Agency - All rights reserved. This content is licensed under a Creative Commons Attribution 4.0 International License. See https://creativecommons.org/licenses/by/4.0/.

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.

Usage:

Formal Views of Profile Content

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

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements 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 S 1..1 code registered | preliminary | final | amended +
... category S 1..* CodeableConcept Classification of type of observation
... code S 1..1 CodeableConcept Type of observation (code / type)
... encounter S 0..1 Reference(ADHA Core Encounter) Healthcare event during which this observation is made
... effective[x] SC 1..1 dateTime, Period, Timing, instant Clinically relevant time/time-period for observation
inv-dh-obs-07: Date shall be at least to day
... performer SC 1..* 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] SC 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Actual result
... dataAbsentReason SC 0..1 CodeableConcept Why the result is missing
... interpretation S 0..* CodeableConcept High, low, normal, etc.
... note S 0..* Annotation Comments about the observation
... bodySite SC 0..1 CodeableConcept Observed body part
Binding: Body Site . (extensible)
inv-dh-obs-04: If a coded body site is provided, at least one code shall be from SNOMED CT
... method S 0..1 CodeableConcept How it was done
... hasMember S 0..* Reference(ADHA Core Observation) Related resource that belongs to the Observation group
... component S 0..* BackboneElement Component results
.... code S 1..1 CodeableConcept Type of component observation (code / type)
.... value[x] S 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Actual component result
.... dataAbsentReason S 0..1 CodeableConcept Why the component result is missing
.... interpretation S 0..* CodeableConcept High, low, normal, etc.

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.bodySiteextensibleBodySite .
https://healthterminologies.gov.au/fhir/ValueSet/body-site-1

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-obs-01errorObservation.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-obs-03errorObservation.performerAt least reference or display or a valid identifier shall be present
: reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-obs-04errorObservation.bodySiteIf a coded body site is provided, at least one code shall be from SNOMED CT
: coding.exists() implies coding.where(system='http://snomed.info/sct').exists()
inv-dh-obs-05errorObservationIf there is no component or hasMember element then at least value or data absent reason shall be present
: (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists())
inv-dh-obs-07errorObservation.effective[x]Date shall be at least to day
: $this is DateTime implies $this.toString().length() >= 10

 

Other representations of profile: CSV, Excel, Schematron