MII IG ICU
2027.0.0-ballot.3 - Germany

This page is part of the MII IG ICU (v2027.0.0-ballot.3: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Ressourcenprofil: MII PR ICU Score ( Abstrakt )

Offizielle URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/StructureDefinition/mii-pr-icu-score Version: 2027.0.0-ballot.3
Draft Stand: 2026-09-17 Maschinenlesbarer Name: MII_PR_ICU_Score

Parent profile for ICU scoring systems. Scores are represented as Observations with the total score in value[x] and their respective items as components. If subitems of observations have independent medical applications or usage, hasMember can be used to implement these. This profile defines common constraints for all ICU scales and scores including sedation, pain, delirium both pediatric and adult as well as Assessments.

Usages:

You can also check for usages in the FHIR IG Statistics

Formale Ansichten des Profilinhalts

Beschreibung von Profilen, Differentials, Snapshots und deren Repräsentationen.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* Observation This is an abstract profile. Child profiles: MII_PR_ICU_Score_Numerische_Ratingskala, MII_PR_ICU_Score_Visuelle_Analogskala, MII_PR_ICU_Score_Faces_Pain_Scale_Revised, MII_PR_ICU_Score_GCS, MII_PR_ICU_Score_ICDSC, MII_PR_ICU_Score_ZOPA, MII_PR_ICU_Score_SOFA, MII_PR_ICU_Score_CAM_ICU
Measurements and simple assertions
Constraints: obs-6, obs-7, mii-icu-val-xor-dar, mii-icu-enc-or-sub, mii-icu-comp-xor-val
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!Σ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.
.... category:survey S 1..1 CodeableConcept Survey category
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..1 Coding Code defined by a terminology system

Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: survey
...... display 1..1 string Representation defined by the system
Fixed Value: Survey
...... userSelected 0..1 boolean If this coding was chosen directly by the user
.... category:assessment-scale 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..1 Coding Code defined by a terminology system

Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 273249006
...... display 1..1 string Representation defined by the system
Fixed Value: Assessment scales (assessment scale)
...... userSelected 0..1 boolean If this coding was chosen directly by the user
... code ΣC 1..1 CodeableConcept Type of observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.
Constraints: mii-icu-loinc-sct-dgai-ieee11073
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:loinc SΣ 0..1 Coding Code defined by a terminology system
...... system Σ 1..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
...... code SΣ 1..1 code Symbol in syntax defined by the system
..... coding:sct SΣ 0..1 Coding Code defined by a terminology system
...... system Σ 1..1 uri Identity of the terminology system
Required Pattern: http://snomed.info/sct
...... version SΣ 0..1 string Version of the system - if relevant
Required Pattern: http://snomed.info/sct/900000000000207008/version/20260701
...... code SΣ 1..1 code Symbol in syntax defined by the system
..... coding:ieee11073 SΣ 0..1 Coding Code defined by a terminology system
...... system Σ 1..1 uri Identity of the terminology system
Required Pattern: urn:iso:std:iso:11073:10101
...... code SΣ 1..1 code Symbol in syntax defined by the system
... subject SΣ 1..1 Reference(Patient) Patient being assessed
... encounter SΣ 0..1 Reference(Encounter) Healthcare event during which this observation is made
... effective[x] SΣ 1..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 0..1 instant Date/Time this version was made available
... performer SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Who is responsible for the observation
... value[x] SΣC 0..1 Actual result
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueInteger integer
... dataAbsentReason SC 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
... interpretation S 0..1 CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
... device S 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... hasMember SΣ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom SΣ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
... component SΣC 0..* BackboneElement Component results
Constraints: mii-icu-val-xor-dar
.... 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] SΣ 0..1 Actual component result
..... valueQuantity Quantity
..... valueCodeableConcept CodeableConcept
..... valueInteger integer
.... 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:survey Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
Observation.category:assessment-scale Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
Observation.code Base example LOINC Codes 📍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.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()
mii-icu-comp-xor-val error Observation If there is no component or hasMember element then either a value[x] or a data absent reason must be present (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() xor value.exists())
mii-icu-enc-or-sub error Observation Either subject OR encounter exists $this.encounter.exists() or $this.subject.exists()
mii-icu-loinc-sct-dgai-ieee11073 error Observation.code Es muss mindestens ein LOINC, SnomedCT, IEEE-11073 oder DGAI Code vorhanden sein coding.where(system='http://loinc.org').exists() or coding.where(system='http://snomed.info/sct').exists() or coding.where(system='urn:iso:std:iso:11073:10101').exists() or coding.where(system='http://dgai.de').exists()
mii-icu-val-xor-dar error Observation, Observation.component Resource must have either value or dataAbsentReason. value.exists() xor dataAbsentReason.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()

Diese Struktur ist abgeleitet von Observation

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* Observation This is an abstract profile. Child profiles: MII_PR_ICU_Score_Numerische_Ratingskala, MII_PR_ICU_Score_Visuelle_Analogskala, MII_PR_ICU_Score_Faces_Pain_Scale_Revised, MII_PR_ICU_Score_GCS, MII_PR_ICU_Score_ICDSC, MII_PR_ICU_Score_ZOPA, MII_PR_ICU_Score_SOFA, MII_PR_ICU_Score_CAM_ICU
Measurements and simple assertions
Constraints: mii-icu-val-xor-dar, mii-icu-enc-or-sub, mii-icu-comp-xor-val
... status 1..1 code registered | preliminary | final | amended +
... Slices for category S 2..* CodeableConcept Classification of type of observation
Slice: Unordered, Open by pattern:$this
.... category:survey S 1..1 CodeableConcept Survey category
Required Pattern: At least the following
..... coding S 1..1 Coding Code defined by a terminology system
Fixed Value: (Complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: survey
...... display 1..1 string Representation defined by the system
Fixed Value: Survey
.... category:assessment-scale S 1..1 CodeableConcept Classification of type of observation
Required Pattern: At least the following
..... coding S 1..1 Coding Code defined by a terminology system
Fixed Value: (Complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 273249006
...... display 1..1 string Representation defined by the system
Fixed Value: Assessment scales (assessment scale)
... code C 1..1 CodeableConcept Type of observation (code / type)
Constraints: mii-icu-loinc-sct-dgai-ieee11073
.... Slices for coding S 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:loinc S 0..1 Coding Code defined by a terminology system
...... system 1..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
...... code S 1..1 code Symbol in syntax defined by the system
..... coding:sct S 0..1 Coding Code defined by a terminology system
...... system 1..1 uri Identity of the terminology system
Required Pattern: http://snomed.info/sct
...... version S 0..1 string Version of the system - if relevant
Required Pattern: http://snomed.info/sct/900000000000207008/version/20260701
...... code S 1..1 code Symbol in syntax defined by the system
..... coding:ieee11073 S 0..1 Coding Code defined by a terminology system
...... system 1..1 uri Identity of the terminology system
Required Pattern: urn:iso:std:iso:11073:10101
...... code S 1..1 code Symbol in syntax defined by the system
... encounter S 0..1 Reference(Encounter) Healthcare event during which this observation is made
... effective[x] S 1..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued S 0..1 instant Date/Time this version was made available
... performer S 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Who is responsible for the observation
... value[x] S 0..1 Actual result
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueInteger integer
... dataAbsentReason S 0..1 CodeableConcept Why the result is missing
... interpretation S 0..1 CodeableConcept High, low, normal, etc.
... specimen 0..0 Specimen used for this observation
... device S 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... hasMember S 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom S 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
... component SC 0..* BackboneElement Component results
Constraints: mii-icu-val-xor-dar
.... code S 1..1 CodeableConcept Type of component observation (code / type)
.... value[x] S 0..1 Actual component result
..... valueQuantity Quantity
..... valueCodeableConcept CodeableConcept
..... valueInteger integer
.... dataAbsentReason S 0..1 CodeableConcept Why the component result is missing

doco Documentation for this format

Constraints

Id Grade Path(s) Description Expression
mii-icu-comp-xor-val error Observation If there is no component or hasMember element then either a value[x] or a data absent reason must be present (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() xor value.exists())
mii-icu-enc-or-sub error Observation Either subject OR encounter exists $this.encounter.exists() or $this.subject.exists()
mii-icu-loinc-sct-dgai-ieee11073 error Observation.code Es muss mindestens ein LOINC, SnomedCT, IEEE-11073 oder DGAI Code vorhanden sein coding.where(system='http://loinc.org').exists() or coding.where(system='http://snomed.info/sct').exists() or coding.where(system='urn:iso:std:iso:11073:10101').exists() or coding.where(system='http://dgai.de').exists()
mii-icu-val-xor-dar error Observation, Observation.component Resource must have either value or dataAbsentReason. value.exists() xor dataAbsentReason.exists()
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* Observation This is an abstract profile. Child profiles: MII_PR_ICU_Score_Numerische_Ratingskala, MII_PR_ICU_Score_Visuelle_Analogskala, MII_PR_ICU_Score_Faces_Pain_Scale_Revised, MII_PR_ICU_Score_GCS, MII_PR_ICU_Score_ICDSC, MII_PR_ICU_Score_ZOPA, MII_PR_ICU_Score_SOFA, MII_PR_ICU_Score_CAM_ICU
Measurements and simple assertions
Constraints: obs-6, obs-7, mii-icu-val-xor-dar, mii-icu-enc-or-sub, mii-icu-comp-xor-val
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... 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 ?!Σ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.
... Slices for category S 2..* CodeableConcept Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
.... category:survey S 1..1 CodeableConcept Survey category
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..1 Coding Code defined by a terminology system

Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: survey
...... display 1..1 string Representation defined by the system
Fixed Value: Survey
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text Σ 0..1 string Plain text representation of the concept
.... category:assessment-scale 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..1 Coding Code defined by a terminology system

Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 273249006
...... display 1..1 string Representation defined by the system
Fixed Value: Assessment scales (assessment scale)
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text Σ 0..1 string Plain text representation of the concept
... code ΣC 1..1 CodeableConcept Type of observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.
Constraints: mii-icu-loinc-sct-dgai-ieee11073
.... 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 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:loinc SΣ 0..1 Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ 1..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
...... 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
..... coding:sct SΣ 0..1 Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ 1..1 uri Identity of the terminology system
Required Pattern: http://snomed.info/sct
...... version SΣ 0..1 string Version of the system - if relevant
Required Pattern: http://snomed.info/sct/900000000000207008/version/20260701
...... 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
..... coding:ieee11073 SΣ 0..1 Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ 1..1 uri Identity of the terminology system
Required Pattern: urn:iso:std:iso:11073:10101
...... 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 1..1 Reference(Patient) Patient being assessed
... 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) Healthcare event during which this observation is made
... effective[x] SΣ 1..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 0..1 instant Date/Time this version was made available
... performer SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Who is responsible for the observation
... value[x] SΣC 0..1 Actual result
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueInteger integer
... dataAbsentReason SC 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
... interpretation S 0..1 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.
... device S 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) Related resource that belongs to the Observation group
... derivedFrom SΣ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
... component SΣC 0..* BackboneElement Component results
Constraints: mii-icu-val-xor-dar
.... 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] SΣ 0..1 Actual component result
..... valueQuantity Quantity
..... valueCodeableConcept CodeableConcept
..... valueInteger integer
.... 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.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:survey Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
Observation.category:assessment-scale Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
Observation.code Base example LOINC Codes 📍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()
mii-icu-comp-xor-val error Observation If there is no component or hasMember element then either a value[x] or a data absent reason must be present (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() xor value.exists())
mii-icu-enc-or-sub error Observation Either subject OR encounter exists $this.encounter.exists() or $this.subject.exists()
mii-icu-loinc-sct-dgai-ieee11073 error Observation.code Es muss mindestens ein LOINC, SnomedCT, IEEE-11073 oder DGAI Code vorhanden sein coding.where(system='http://loinc.org').exists() or coding.where(system='http://snomed.info/sct').exists() or coding.where(system='urn:iso:std:iso:11073:10101').exists() or coding.where(system='http://dgai.de').exists()
mii-icu-val-xor-dar error Observation, Observation.component Resource must have either value or dataAbsentReason. value.exists() xor dataAbsentReason.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()

Diese Struktur ist abgeleitet von Observation

Summary

Mandatory: 6 elements(6 nested mandatory elements)
Must-Support: 28 elements
Prohibited: 1 element

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Observation.category
  • The element 1 is sliced based on the value of Observation.code.coding

Schlüsselelemente-Ansicht

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* Observation This is an abstract profile. Child profiles: MII_PR_ICU_Score_Numerische_Ratingskala, MII_PR_ICU_Score_Visuelle_Analogskala, MII_PR_ICU_Score_Faces_Pain_Scale_Revised, MII_PR_ICU_Score_GCS, MII_PR_ICU_Score_ICDSC, MII_PR_ICU_Score_ZOPA, MII_PR_ICU_Score_SOFA, MII_PR_ICU_Score_CAM_ICU
Measurements and simple assertions
Constraints: obs-6, obs-7, mii-icu-val-xor-dar, mii-icu-enc-or-sub, mii-icu-comp-xor-val
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!Σ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.
.... category:survey S 1..1 CodeableConcept Survey category
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..1 Coding Code defined by a terminology system

Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: survey
...... display 1..1 string Representation defined by the system
Fixed Value: Survey
...... userSelected 0..1 boolean If this coding was chosen directly by the user
.... category:assessment-scale 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..1 Coding Code defined by a terminology system

Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 273249006
...... display 1..1 string Representation defined by the system
Fixed Value: Assessment scales (assessment scale)
...... userSelected 0..1 boolean If this coding was chosen directly by the user
... code ΣC 1..1 CodeableConcept Type of observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.
Constraints: mii-icu-loinc-sct-dgai-ieee11073
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:loinc SΣ 0..1 Coding Code defined by a terminology system
...... system Σ 1..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
...... code SΣ 1..1 code Symbol in syntax defined by the system
..... coding:sct SΣ 0..1 Coding Code defined by a terminology system
...... system Σ 1..1 uri Identity of the terminology system
Required Pattern: http://snomed.info/sct
...... version SΣ 0..1 string Version of the system - if relevant
Required Pattern: http://snomed.info/sct/900000000000207008/version/20260701
...... code SΣ 1..1 code Symbol in syntax defined by the system
..... coding:ieee11073 SΣ 0..1 Coding Code defined by a terminology system
...... system Σ 1..1 uri Identity of the terminology system
Required Pattern: urn:iso:std:iso:11073:10101
...... code SΣ 1..1 code Symbol in syntax defined by the system
... subject SΣ 1..1 Reference(Patient) Patient being assessed
... encounter SΣ 0..1 Reference(Encounter) Healthcare event during which this observation is made
... effective[x] SΣ 1..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 0..1 instant Date/Time this version was made available
... performer SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Who is responsible for the observation
... value[x] SΣC 0..1 Actual result
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueInteger integer
... dataAbsentReason SC 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
... interpretation S 0..1 CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
... device S 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... hasMember SΣ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom SΣ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
... component SΣC 0..* BackboneElement Component results
Constraints: mii-icu-val-xor-dar
.... 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] SΣ 0..1 Actual component result
..... valueQuantity Quantity
..... valueCodeableConcept CodeableConcept
..... valueInteger integer
.... 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:survey Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
Observation.category:assessment-scale Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
Observation.code Base example LOINC Codes 📍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.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()
mii-icu-comp-xor-val error Observation If there is no component or hasMember element then either a value[x] or a data absent reason must be present (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() xor value.exists())
mii-icu-enc-or-sub error Observation Either subject OR encounter exists $this.encounter.exists() or $this.subject.exists()
mii-icu-loinc-sct-dgai-ieee11073 error Observation.code Es muss mindestens ein LOINC, SnomedCT, IEEE-11073 oder DGAI Code vorhanden sein coding.where(system='http://loinc.org').exists() or coding.where(system='http://snomed.info/sct').exists() or coding.where(system='urn:iso:std:iso:11073:10101').exists() or coding.where(system='http://dgai.de').exists()
mii-icu-val-xor-dar error Observation, Observation.component Resource must have either value or dataAbsentReason. value.exists() xor dataAbsentReason.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-Ansicht

Diese Struktur ist abgeleitet von Observation

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* Observation This is an abstract profile. Child profiles: MII_PR_ICU_Score_Numerische_Ratingskala, MII_PR_ICU_Score_Visuelle_Analogskala, MII_PR_ICU_Score_Faces_Pain_Scale_Revised, MII_PR_ICU_Score_GCS, MII_PR_ICU_Score_ICDSC, MII_PR_ICU_Score_ZOPA, MII_PR_ICU_Score_SOFA, MII_PR_ICU_Score_CAM_ICU
Measurements and simple assertions
Constraints: mii-icu-val-xor-dar, mii-icu-enc-or-sub, mii-icu-comp-xor-val
... status 1..1 code registered | preliminary | final | amended +
... Slices for category S 2..* CodeableConcept Classification of type of observation
Slice: Unordered, Open by pattern:$this
.... category:survey S 1..1 CodeableConcept Survey category
Required Pattern: At least the following
..... coding S 1..1 Coding Code defined by a terminology system
Fixed Value: (Complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: survey
...... display 1..1 string Representation defined by the system
Fixed Value: Survey
.... category:assessment-scale S 1..1 CodeableConcept Classification of type of observation
Required Pattern: At least the following
..... coding S 1..1 Coding Code defined by a terminology system
Fixed Value: (Complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 273249006
...... display 1..1 string Representation defined by the system
Fixed Value: Assessment scales (assessment scale)
... code C 1..1 CodeableConcept Type of observation (code / type)
Constraints: mii-icu-loinc-sct-dgai-ieee11073
.... Slices for coding S 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:loinc S 0..1 Coding Code defined by a terminology system
...... system 1..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
...... code S 1..1 code Symbol in syntax defined by the system
..... coding:sct S 0..1 Coding Code defined by a terminology system
...... system 1..1 uri Identity of the terminology system
Required Pattern: http://snomed.info/sct
...... version S 0..1 string Version of the system - if relevant
Required Pattern: http://snomed.info/sct/900000000000207008/version/20260701
...... code S 1..1 code Symbol in syntax defined by the system
..... coding:ieee11073 S 0..1 Coding Code defined by a terminology system
...... system 1..1 uri Identity of the terminology system
Required Pattern: urn:iso:std:iso:11073:10101
...... code S 1..1 code Symbol in syntax defined by the system
... encounter S 0..1 Reference(Encounter) Healthcare event during which this observation is made
... effective[x] S 1..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued S 0..1 instant Date/Time this version was made available
... performer S 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Who is responsible for the observation
... value[x] S 0..1 Actual result
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueInteger integer
... dataAbsentReason S 0..1 CodeableConcept Why the result is missing
... interpretation S 0..1 CodeableConcept High, low, normal, etc.
... specimen 0..0 Specimen used for this observation
... device S 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... hasMember S 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom S 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
... component SC 0..* BackboneElement Component results
Constraints: mii-icu-val-xor-dar
.... code S 1..1 CodeableConcept Type of component observation (code / type)
.... value[x] S 0..1 Actual component result
..... valueQuantity Quantity
..... valueCodeableConcept CodeableConcept
..... valueInteger integer
.... dataAbsentReason S 0..1 CodeableConcept Why the component result is missing

doco Documentation for this format

Constraints

Id Grade Path(s) Description Expression
mii-icu-comp-xor-val error Observation If there is no component or hasMember element then either a value[x] or a data absent reason must be present (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() xor value.exists())
mii-icu-enc-or-sub error Observation Either subject OR encounter exists $this.encounter.exists() or $this.subject.exists()
mii-icu-loinc-sct-dgai-ieee11073 error Observation.code Es muss mindestens ein LOINC, SnomedCT, IEEE-11073 oder DGAI Code vorhanden sein coding.where(system='http://loinc.org').exists() or coding.where(system='http://snomed.info/sct').exists() or coding.where(system='urn:iso:std:iso:11073:10101').exists() or coding.where(system='http://dgai.de').exists()
mii-icu-val-xor-dar error Observation, Observation.component Resource must have either value or dataAbsentReason. value.exists() xor dataAbsentReason.exists()

Snapshot-AnsichtView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* Observation This is an abstract profile. Child profiles: MII_PR_ICU_Score_Numerische_Ratingskala, MII_PR_ICU_Score_Visuelle_Analogskala, MII_PR_ICU_Score_Faces_Pain_Scale_Revised, MII_PR_ICU_Score_GCS, MII_PR_ICU_Score_ICDSC, MII_PR_ICU_Score_ZOPA, MII_PR_ICU_Score_SOFA, MII_PR_ICU_Score_CAM_ICU
Measurements and simple assertions
Constraints: obs-6, obs-7, mii-icu-val-xor-dar, mii-icu-enc-or-sub, mii-icu-comp-xor-val
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... 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 ?!Σ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.
... Slices for category S 2..* CodeableConcept Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
.... category:survey S 1..1 CodeableConcept Survey category
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..1 Coding Code defined by a terminology system

Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: survey
...... display 1..1 string Representation defined by the system
Fixed Value: Survey
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text Σ 0..1 string Plain text representation of the concept
.... category:assessment-scale 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..1 Coding Code defined by a terminology system

Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 273249006
...... display 1..1 string Representation defined by the system
Fixed Value: Assessment scales (assessment scale)
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text Σ 0..1 string Plain text representation of the concept
... code ΣC 1..1 CodeableConcept Type of observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.
Constraints: mii-icu-loinc-sct-dgai-ieee11073
.... 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 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:loinc SΣ 0..1 Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ 1..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
...... 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
..... coding:sct SΣ 0..1 Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ 1..1 uri Identity of the terminology system
Required Pattern: http://snomed.info/sct
...... version SΣ 0..1 string Version of the system - if relevant
Required Pattern: http://snomed.info/sct/900000000000207008/version/20260701
...... 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
..... coding:ieee11073 SΣ 0..1 Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ 1..1 uri Identity of the terminology system
Required Pattern: urn:iso:std:iso:11073:10101
...... 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 1..1 Reference(Patient) Patient being assessed
... 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) Healthcare event during which this observation is made
... effective[x] SΣ 1..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 0..1 instant Date/Time this version was made available
... performer SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Who is responsible for the observation
... value[x] SΣC 0..1 Actual result
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueInteger integer
... dataAbsentReason SC 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
... interpretation S 0..1 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.
... device S 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) Related resource that belongs to the Observation group
... derivedFrom SΣ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
... component SΣC 0..* BackboneElement Component results
Constraints: mii-icu-val-xor-dar
.... 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] SΣ 0..1 Actual component result
..... valueQuantity Quantity
..... valueCodeableConcept CodeableConcept
..... valueInteger integer
.... 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.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:survey Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
Observation.category:assessment-scale Base preferred Observation Category Codes 📍4.0.1 FHIR Std.
Observation.code Base example LOINC Codes 📍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()
mii-icu-comp-xor-val error Observation If there is no component or hasMember element then either a value[x] or a data absent reason must be present (component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() xor value.exists())
mii-icu-enc-or-sub error Observation Either subject OR encounter exists $this.encounter.exists() or $this.subject.exists()
mii-icu-loinc-sct-dgai-ieee11073 error Observation.code Es muss mindestens ein LOINC, SnomedCT, IEEE-11073 oder DGAI Code vorhanden sein coding.where(system='http://loinc.org').exists() or coding.where(system='http://snomed.info/sct').exists() or coding.where(system='urn:iso:std:iso:11073:10101').exists() or coding.where(system='http://dgai.de').exists()
mii-icu-val-xor-dar error Observation, Observation.component Resource must have either value or dataAbsentReason. value.exists() xor dataAbsentReason.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()

Diese Struktur ist abgeleitet von Observation

Summary

Mandatory: 6 elements(6 nested mandatory elements)
Must-Support: 28 elements
Prohibited: 1 element

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Observation.category
  • The element 1 is sliced based on the value of Observation.code.coding

 

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