MII IG Modul Patho
2027.0.0-ballot - Germany

MII IG Modul Patho - Local Development build (v2027.0.0-ballot) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: MII PR Patho Finding

Official URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-finding Version: 2027.0.0-ballot
Active as of 2026-09-14 Computable Name: MII_PR_Patho_Finding

The MII PR Patho Finding profile of the Observation resource represents atomic coded examination results as a hasMember or derivedFrom reference for a profile of type MII PR Patho Section Grouper. This profile can form nested constructs to capture "child observations" that further specify a single observation. PathoFindings may be provided by the pathology information system via Questionnaire / QuestionnaireResponse resources (see HL7 Implementation Guide Structured Data Capture), or QuestionnaireResponse resources are referenced. Each MII PR Patho Finding should reference the specimen on which the observation was made.

Special case:

For specific observation constructs, especially from the oncology basic data set (oBDS) (TNM, histological tumor type, etc.), observation profiles of the MII Oncology extension module may also be used. For observations on immunohistochemical stains, in-situ hybridizations, PCR tests, methylation tests and NGS examinations, observation profiles of the MII Molecular Tumor Board extension module or the MII Molecular Genetic Report extension module should be used.

Further examples

Further extensive examples with complete narratives can be found in the Prostate Cancer Spec IG.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots, and their representations.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* MII_PR_Patho_Base_Observation Measurements and simple assertions
Constraints: obs-6, obs-7
... id SΣ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
.... lastUpdated SΣ 0..1 instant When the resource version last changed
.... profile SΣ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... identifier SΣ 0..* Identifier Identifier
... basedOn SΣ 0..* Reference(ServiceRequest) Examination request
... status ?!SΣ 1..1 code Status
Binding: ObservationStatus (required): Codes providing the status of an observation.
... Slices for category S 2..* CodeableConcept Category
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
.... category:laboratory-category S 1..1 CodeableConcept Classification of type of observation
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
..... text 0..1 string Plain text representation of the concept
..... coding SΣ 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
...... version 0..1 string Version of the system - if relevant
...... 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 Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: laboratory
.... category:section-type S 1..1 CodeableConcept Observation report section
Binding: MII VS Patho Section Types [LOINC] (required)
... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... coding SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (preferred)
..... system SΣ 1..1 uri Identity of the terminology system
..... code SΣ 1..1 code Symbol in syntax defined by the system
... subject SΣ 0..1 Reference(Patient) Patient
... effective[x] SΣ 0..1 dateTime Observation time
... value[x] SΣC 0..1 Value
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueRange Range
.... valueRatio Ratio
... bodySite S 0..1 CodeableConcept Body site
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
.... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:sct SΣ 0..1 Coding Code defined by a terminology system
Binding: MII VS Biobank BodyStructures SCT (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... 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 Identity of the terminology system
Fixed Value: http://snomed.info/sct
... method S 0..1 CodeableConcept Method
Binding: ObservationMethods (example): Methods for simple observations.
... specimen S 0..1 Reference(Specimen) Specimen
... hasMember SΣ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Associated individual observation
... Slices for derivedFrom SΣ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Derived from
Slice: Unordered, Open by type:$this.resolve()
.... derivedFrom:attached-image SΣ 0..* Reference(MII PR Patho Attached Image) Related measurements the observation is made from
.... derivedFrom:dicom-image SΣ 0..* Reference(ImagingStudy) Related measurements the observation is made from
... component Σ 0..* BackboneElement Component results
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code SΣ 1..1 CodeableConcept Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... dataAbsentReason SC 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

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.category:laboratory-category Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
Observation.category:section-type Base required MII VS Patho Section Types [LOINC] 📦2027.0.0-ballot This IG
Observation.code Base example LOINC Codes 📍4.0.1 FHIR Std.
Observation.code.coding Base preferred MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Observation.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
Observation.bodySite.​coding:sct Base required MII VS Biobank BodyStructures SCT 📦2027.0.0-ballot This IG
Observation.method Base example Observation Methods 📍4.0.1 FHIR Std.
Observation.component.​code Base example LOINC Codes 📍4.0.1 FHIR Std.
Observation.component.​dataAbsentReason Base extensible DataAbsentReason 📍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()

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation 0..* MII_PR_Patho_Base_Observation Measurements and simple assertions
... identifier 0..* Identifier Identifier
... basedOn 0..* Reference(ServiceRequest) Examination request
... status 1..1 code Status
... Slices for category Content/Rules for all slices
.... category:section-type S 1..1 CodeableConcept Observation report section
Binding: MII VS Patho Section Types [LOINC] (required)
... code 1..1 CodeableConcept Code
... subject 0..1 Reference(Patient) Patient
... effective[x] 0..1 dateTime Observation time
... value[x] S 0..1 Value
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueRange Range
.... valueRatio Ratio
... bodySite 0..1 CodeableConcept Body site
... method 0..1 CodeableConcept Method
... specimen 0..1 Reference(Specimen) Specimen
... hasMember 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Associated individual observation
... derivedFrom 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Derived from

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Observation.category:section-type Base required MII VS Patho Section Types [LOINC] 📦2027.0.0-ballot This IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* MII_PR_Patho_Base_Observation Measurements and simple assertions
Constraints: obs-6, obs-7
... id SΣ 0..1 id Logical id of this artifact
... 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 Version specific identifier
.... lastUpdated SΣ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile SΣ 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 SΣ 0..* Identifier Identifier
... basedOn SΣ 0..* Reference(ServiceRequest) Examination request
... 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.
... Slices for category S 2..* CodeableConcept Category
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
.... category:laboratory-category S 1..1 CodeableConcept Classification of type of observation
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
Slice: Unordered, Open by value:url
..... coding SΣ 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
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: laboratory
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... text Σ 0..1 string Plain text representation of the concept
.... category:section-type S 1..1 CodeableConcept Observation report section
Binding: MII VS Patho Section Types [LOINC] (required)
... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (preferred)
..... 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 Σ 0..1 string Representation defined by the system
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 0..1 Reference(Patient) Patient
... focus Σ 0..* Reference(Resource) What the observation is about, when it is not about the subject of record
... encounter Σ 0..1 Reference(Encounter) Healthcare event during which this observation is made
... effective[x] SΣ 0..1 dateTime Observation time
... 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
... value[x] SΣC 0..1 Value
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueRange Range
.... valueRatio Ratio
... 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 S 0..1 CodeableConcept Body site
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
.... 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 Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:sct SΣ 0..1 Coding Code defined by a terminology system
Binding: MII VS Biobank BodyStructures SCT (required)

Required Pattern: At least the following
...... 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
Fixed Value: http://snomed.info/sct
...... version Σ 0..1 string Version of the system - if relevant
...... code Σ 0..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... method S 0..1 CodeableConcept Method
Binding: ObservationMethods (example): Methods for simple observations.
... specimen S 0..1 Reference(Specimen) Specimen
... 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 SΣ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Associated individual observation
... Slices for derivedFrom SΣ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Derived from
Slice: Unordered, Open by type:$this.resolve()
.... derivedFrom:attached-image SΣ 0..* Reference(MII PR Patho Attached Image) Related measurements the observation is made from
.... derivedFrom:dicom-image SΣ 0..* Reference(ImagingStudy) 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 SΣ 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
..... valueRatio Ratio
.... dataAbsentReason SC 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.category:laboratory-category Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
Observation.category:section-type Base required MII VS Patho Section Types [LOINC] 📦2027.0.0-ballot This IG
Observation.code Base example LOINC Codes 📍4.0.1 FHIR Std.
Observation.code.coding Base preferred MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
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.bodySite.​coding:sct Base required MII VS Biobank BodyStructures SCT 📦2027.0.0-ballot This IG
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()

Summary

Mandatory: 1 element
Must-Support: 2 elements

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* MII_PR_Patho_Base_Observation Measurements and simple assertions
Constraints: obs-6, obs-7
... id SΣ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
.... lastUpdated SΣ 0..1 instant When the resource version last changed
.... profile SΣ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... identifier SΣ 0..* Identifier Identifier
... basedOn SΣ 0..* Reference(ServiceRequest) Examination request
... status ?!SΣ 1..1 code Status
Binding: ObservationStatus (required): Codes providing the status of an observation.
... Slices for category S 2..* CodeableConcept Category
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
.... category:laboratory-category S 1..1 CodeableConcept Classification of type of observation
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
..... text 0..1 string Plain text representation of the concept
..... coding SΣ 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
...... version 0..1 string Version of the system - if relevant
...... 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 Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: laboratory
.... category:section-type S 1..1 CodeableConcept Observation report section
Binding: MII VS Patho Section Types [LOINC] (required)
... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... coding SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (preferred)
..... system SΣ 1..1 uri Identity of the terminology system
..... code SΣ 1..1 code Symbol in syntax defined by the system
... subject SΣ 0..1 Reference(Patient) Patient
... effective[x] SΣ 0..1 dateTime Observation time
... value[x] SΣC 0..1 Value
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueRange Range
.... valueRatio Ratio
... bodySite S 0..1 CodeableConcept Body site
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
.... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:sct SΣ 0..1 Coding Code defined by a terminology system
Binding: MII VS Biobank BodyStructures SCT (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... 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 Identity of the terminology system
Fixed Value: http://snomed.info/sct
... method S 0..1 CodeableConcept Method
Binding: ObservationMethods (example): Methods for simple observations.
... specimen S 0..1 Reference(Specimen) Specimen
... hasMember SΣ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Associated individual observation
... Slices for derivedFrom SΣ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Derived from
Slice: Unordered, Open by type:$this.resolve()
.... derivedFrom:attached-image SΣ 0..* Reference(MII PR Patho Attached Image) Related measurements the observation is made from
.... derivedFrom:dicom-image SΣ 0..* Reference(ImagingStudy) Related measurements the observation is made from
... component Σ 0..* BackboneElement Component results
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code SΣ 1..1 CodeableConcept Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... dataAbsentReason SC 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

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.category:laboratory-category Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
Observation.category:section-type Base required MII VS Patho Section Types [LOINC] 📦2027.0.0-ballot This IG
Observation.code Base example LOINC Codes 📍4.0.1 FHIR Std.
Observation.code.coding Base preferred MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Observation.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
Observation.bodySite.​coding:sct Base required MII VS Biobank BodyStructures SCT 📦2027.0.0-ballot This IG
Observation.method Base example Observation Methods 📍4.0.1 FHIR Std.
Observation.component.​code Base example LOINC Codes 📍4.0.1 FHIR Std.
Observation.component.​dataAbsentReason Base extensible DataAbsentReason 📍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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation 0..* MII_PR_Patho_Base_Observation Measurements and simple assertions
... identifier 0..* Identifier Identifier
... basedOn 0..* Reference(ServiceRequest) Examination request
... status 1..1 code Status
... Slices for category Content/Rules for all slices
.... category:section-type S 1..1 CodeableConcept Observation report section
Binding: MII VS Patho Section Types [LOINC] (required)
... code 1..1 CodeableConcept Code
... subject 0..1 Reference(Patient) Patient
... effective[x] 0..1 dateTime Observation time
... value[x] S 0..1 Value
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueRange Range
.... valueRatio Ratio
... bodySite 0..1 CodeableConcept Body site
... method 0..1 CodeableConcept Method
... specimen 0..1 Reference(Specimen) Specimen
... hasMember 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Associated individual observation
... derivedFrom 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Derived from

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Observation.category:section-type Base required MII VS Patho Section Types [LOINC] 📦2027.0.0-ballot This IG

Snapshot ViewView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* MII_PR_Patho_Base_Observation Measurements and simple assertions
Constraints: obs-6, obs-7
... id SΣ 0..1 id Logical id of this artifact
... 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 Version specific identifier
.... lastUpdated SΣ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile SΣ 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 SΣ 0..* Identifier Identifier
... basedOn SΣ 0..* Reference(ServiceRequest) Examination request
... 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.
... Slices for category S 2..* CodeableConcept Category
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
.... category:laboratory-category S 1..1 CodeableConcept Classification of type of observation
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
Slice: Unordered, Open by value:url
..... coding SΣ 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
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: laboratory
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... text Σ 0..1 string Plain text representation of the concept
.... category:section-type S 1..1 CodeableConcept Observation report section
Binding: MII VS Patho Section Types [LOINC] (required)
... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (preferred)
..... 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 Σ 0..1 string Representation defined by the system
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 0..1 Reference(Patient) Patient
... focus Σ 0..* Reference(Resource) What the observation is about, when it is not about the subject of record
... encounter Σ 0..1 Reference(Encounter) Healthcare event during which this observation is made
... effective[x] SΣ 0..1 dateTime Observation time
... 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
... value[x] SΣC 0..1 Value
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueRange Range
.... valueRatio Ratio
... 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 S 0..1 CodeableConcept Body site
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
.... 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 Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:sct SΣ 0..1 Coding Code defined by a terminology system
Binding: MII VS Biobank BodyStructures SCT (required)

Required Pattern: At least the following
...... 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
Fixed Value: http://snomed.info/sct
...... version Σ 0..1 string Version of the system - if relevant
...... code Σ 0..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... method S 0..1 CodeableConcept Method
Binding: ObservationMethods (example): Methods for simple observations.
... specimen S 0..1 Reference(Specimen) Specimen
... 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 SΣ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Associated individual observation
... Slices for derivedFrom SΣ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Derived from
Slice: Unordered, Open by type:$this.resolve()
.... derivedFrom:attached-image SΣ 0..* Reference(MII PR Patho Attached Image) Related measurements the observation is made from
.... derivedFrom:dicom-image SΣ 0..* Reference(ImagingStudy) 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 SΣ 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
..... valueRatio Ratio
.... dataAbsentReason SC 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.category:laboratory-category Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
Observation.category:section-type Base required MII VS Patho Section Types [LOINC] 📦2027.0.0-ballot This IG
Observation.code Base example LOINC Codes 📍4.0.1 FHIR Std.
Observation.code.coding Base preferred MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
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.bodySite.​coding:sct Base required MII VS Biobank BodyStructures SCT 📦2027.0.0-ballot This IG
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()

Summary

Mandatory: 1 element
Must-Support: 2 elements

 

Other representations of profile: CSV, Excel, Schematron