MediRecords FHIR Implementation Guide
1.3.0 - release


Resource Profile: Medirecords Generic Clinical Observation

Defining URL:https://fhir.medirecords.com/StructureDefinition/mr-observation-clinical
Version:1.3.0
Name:MRObservationClinical
Title:Medirecords Generic Clinical Observation
Status:Active as of 2023-12-21 01:01:27+0000
Definition:

Medirecords Clinical Observation to record general clinical observations of a patient in context

Source Resource:XML / JSON / Turtle

The official URL for this profile is: 

https://fhir.medirecords.com/StructureDefinition/mr-observation-clinical

Formal Views of Profile Content

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

This structure is derived from Observation

Summary

Mandatory: 3 elements (3 nested mandatory elements)
Must-Support: 14 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Observation.effective[x] is sliced based on the value of type:$this

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
​.. Observation C0..*ObservationMeasurements and simple assertions
inv-mr-observation-clinical-01: Observation.component.dataAbasentReason SHALL only be present if Observation.component.value is not present
inv-mr-observation-clinical-02: Observation.component SHALL have an Observation.component.dataAbsentReason if Observation.component.value is not present
​... meta
​.... lastUpdated S0..1instantWhen the resource version last changed
​.... profile 1..*canonical(StructureDefinition)Profiles this resource claims to conform to
​... status S1..1coderegistered | preliminary | final | amended +
Required Pattern: final
​... category
​.... coding S1..1CodingCode defined by a terminology system
​.... coding S0..*CodingCode defined by a terminology system
​.... text 0..1stringClinical observation Parameter name
​... subject S1..1Reference(MediRecords Core Patient)Who and/or what the observation is about
​... encounter S0..1Reference(MediRecords Core Encounter)Healthcare event during which this observation is made
​... effective[x] 1..1dateTimeClinically relevant time/time-period for observation
Slice: Unordered, Open by type:$this
​... effectiveDateTime S1..1dateTimeClinically relevant time/time-period for observation
​... performer S0..1Reference(MediRecords Core Practitioner)Who is responsible for the observation
​... value[x] S0..1Actual result
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueDateTimedateTime
​... bodySite S0..1CodeableConceptObserved body part
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
​... hasMember S0..*Reference(Observation)Related resource that belongs to the Observation group
​... component
​.... code
​..... coding S0..*CodingCode defined by a terminology system
​..... text 0..1stringClinical observation Parameter name
​.... value[x] S0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueDateTimedateTime
​.... dataAbsentReason
​..... coding S1..1CodingCode defined by a terminology system

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationMeasurements and simple assertions
inv-mr-observation-clinical-01: Observation.component.dataAbasentReason SHALL only be present if Observation.component.value is not present
inv-mr-observation-clinical-02: Observation.component SHALL have an Observation.component.dataAbsentReason if Observation.component.value is not present
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated SΣ0..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile Σ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ0..*CodingTags 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 ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

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


Required Pattern: final
... category 0..*CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ1..1CodingCode defined by a terminology system
.... text Σ0..1stringPlain text representation of the concept
... code Σ1..1CodeableConceptType of observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ0..*CodingCode defined by a terminology system
.... text Σ0..1stringClinical observation Parameter name
... subject SΣ1..1Reference(MediRecords Core Patient)Who and/or what the observation is about
... focus ΣTU0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter SΣ0..1Reference(MediRecords Core Encounter)Healthcare event during which this observation is made
... Slices for effective[x] Σ1..1dateTimeClinically relevant time/time-period for observation
Slice: Unordered, Closed by type:$this
.... effective[x]:effectiveDateTime SΣ1..1dateTimeClinically relevant time/time-period for observation
... issued Σ0..1instantDate/Time this version was made available
... performer SΣ0..1Reference(MediRecords Core Practitioner)Who is responsible for the observation
... value[x] SΣC0..1Actual result
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueDateTimedateTime
... dataAbsentReason C0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..*AnnotationComments about the observation
... bodySite S0..1CodeableConceptObserved body part
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
... method 0..1CodeableConceptHow it was done
Binding: ObservationMethods (example): Methods for simple observations.

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

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


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember SΣ0..*Reference(Observation)Related resource that belongs to the Observation group
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component Σ0..*BackboneElementComponent results
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣ0..*CodingCode defined by a terminology system
..... text Σ0..1stringClinical observation Parameter name
.... value[x] SΣ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueDateTimedateTime
.... dataAbsentReason C0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣ1..1CodingCode defined by a terminology system
..... text Σ0..1stringPlain text representation of the concept
.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


.... referenceRange 0..*See referenceRange (Observation)Provides guide for interpretation of component result

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
​.. Observation C0..*ObservationMeasurements and simple assertions
inv-mr-observation-clinical-01: Observation.component.dataAbasentReason SHALL only be present if Observation.component.value is not present
inv-mr-observation-clinical-02: Observation.component SHALL have an Observation.component.dataAbsentReason if Observation.component.value is not present
​... meta Σ0..1MetaMetadata about the resource
​.... lastUpdated Σ0..1instantWhen the resource version last changed
​... status ?!Σ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.


Required Pattern: final
​... category 0..*CodeableConceptClassification of type of observation
​.... coding Σ1..1CodingCode defined by a terminology system
​.... coding Σ0..*CodingCode defined by a terminology system
​... subject Σ1..1Reference(MediRecords Core Patient)Who and/or what the observation is about
​... encounter Σ0..1Reference(MediRecords Core Encounter)Healthcare event during which this observation is made
​... effective[x]:effectiveDateTime Σ1..1dateTimeClinically relevant time/time-period for observation
​... performer Σ0..1Reference(MediRecords Core Practitioner)Who is responsible for the observation
​... value[x] ΣC0..1Actual result
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueDateTimedateTime
​... bodySite 0..1CodeableConceptObserved body part
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
​... hasMember Σ0..*Reference(Observation)Related resource that belongs to the Observation group
​... component Σ0..*BackboneElementComponent results
​.... code Σ1..1CodeableConceptType of component observation (code / type)
​..... coding Σ0..*CodingCode defined by a terminology system
​.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueDateTimedateTime
​.... dataAbsentReason C0..1CodeableConceptWhy the component result is missing
​..... coding Σ1..1CodingCode defined by a terminology system

doco Documentation for this format

This structure is derived from Observation

Summary

Mandatory: 3 elements (3 nested mandatory elements)
Must-Support: 14 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Observation.effective[x] is sliced based on the value of type:$this

Differential View

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
​.. Observation C0..*ObservationMeasurements and simple assertions
inv-mr-observation-clinical-01: Observation.component.dataAbasentReason SHALL only be present if Observation.component.value is not present
inv-mr-observation-clinical-02: Observation.component SHALL have an Observation.component.dataAbsentReason if Observation.component.value is not present
​... meta
​.... lastUpdated S0..1instantWhen the resource version last changed
​.... profile 1..*canonical(StructureDefinition)Profiles this resource claims to conform to
​... status S1..1coderegistered | preliminary | final | amended +
Required Pattern: final
​... category
​.... coding S1..1CodingCode defined by a terminology system
​.... coding S0..*CodingCode defined by a terminology system
​.... text 0..1stringClinical observation Parameter name
​... subject S1..1Reference(MediRecords Core Patient)Who and/or what the observation is about
​... encounter S0..1Reference(MediRecords Core Encounter)Healthcare event during which this observation is made
​... effective[x] 1..1dateTimeClinically relevant time/time-period for observation
Slice: Unordered, Open by type:$this
​... effectiveDateTime S1..1dateTimeClinically relevant time/time-period for observation
​... performer S0..1Reference(MediRecords Core Practitioner)Who is responsible for the observation
​... value[x] S0..1Actual result
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueDateTimedateTime
​... bodySite S0..1CodeableConceptObserved body part
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
​... hasMember S0..*Reference(Observation)Related resource that belongs to the Observation group
​... component
​.... code
​..... coding S0..*CodingCode defined by a terminology system
​..... text 0..1stringClinical observation Parameter name
​.... value[x] S0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueDateTimedateTime
​.... dataAbsentReason
​..... coding S1..1CodingCode defined by a terminology system

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationMeasurements and simple assertions
inv-mr-observation-clinical-01: Observation.component.dataAbasentReason SHALL only be present if Observation.component.value is not present
inv-mr-observation-clinical-02: Observation.component SHALL have an Observation.component.dataAbsentReason if Observation.component.value is not present
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated SΣ0..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile Σ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ0..*CodingTags 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 ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

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


Required Pattern: final
... category 0..*CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ1..1CodingCode defined by a terminology system
.... text Σ0..1stringPlain text representation of the concept
... code Σ1..1CodeableConceptType of observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ0..*CodingCode defined by a terminology system
.... text Σ0..1stringClinical observation Parameter name
... subject SΣ1..1Reference(MediRecords Core Patient)Who and/or what the observation is about
... focus ΣTU0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter SΣ0..1Reference(MediRecords Core Encounter)Healthcare event during which this observation is made
... Slices for effective[x] Σ1..1dateTimeClinically relevant time/time-period for observation
Slice: Unordered, Closed by type:$this
.... effective[x]:effectiveDateTime SΣ1..1dateTimeClinically relevant time/time-period for observation
... issued Σ0..1instantDate/Time this version was made available
... performer SΣ0..1Reference(MediRecords Core Practitioner)Who is responsible for the observation
... value[x] SΣC0..1Actual result
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueDateTimedateTime
... dataAbsentReason C0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..*AnnotationComments about the observation
... bodySite S0..1CodeableConceptObserved body part
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
... method 0..1CodeableConceptHow it was done
Binding: ObservationMethods (example): Methods for simple observations.

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

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


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember SΣ0..*Reference(Observation)Related resource that belongs to the Observation group
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component Σ0..*BackboneElementComponent results
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣ0..*CodingCode defined by a terminology system
..... text Σ0..1stringClinical observation Parameter name
.... value[x] SΣ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueDateTimedateTime
.... dataAbsentReason C0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣ1..1CodingCode defined by a terminology system
..... text Σ0..1stringPlain text representation of the concept
.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


.... referenceRange 0..*See referenceRange (Observation)Provides guide for interpretation of component result

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
Observation.meta.securityextensibleAll Security Labels
Observation.meta.tagexampleCommonTags
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Observation.statusrequiredPattern: final
Observation.categorypreferredObservationCategoryCodes
Observation.codeexampleLOINCCodes (a valid code from LOINC)
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySitepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
obs-3errorObservation.referenceRangeMust have at least a low or a high or text
: low.exists() or high.exists() or text.exists()