臺灣核心實作指引(TW Core IG)
0.3.0 - Trial Use

This page is part of the 臺灣核心實作指引(TW Core IG) (v0.3.0: Releases) 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

Resource Profile: TW Core Observation Clinical Result

Official URL: https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Observation-clinical-result-twcore Version: 0.3.0
Active as of 2024-10-15 Computable Name: TWCoreObservationClinicalResult

此臺灣核心-臨床檢驗檢查(TW Core Observation Clinical Result) Profile說明本IG如何進一步定義FHIR的Observation Resource以呈現臨床檢驗檢查資料。

Usage:

Formal Views of Profile Content

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

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
tw-core-4: If there is no component or hasMember element then either a value[x] or a data absent reason must be present.
... basedOn 0..* Reference(TW Core CarePlan | DeviceRequest | ImmunizationRecommendation | TW Core MedicationRequest | NutritionOrder | TW Core ServiceRequest) Fulfills plan, proposal or order
... partOf 0..* Reference(MedicationAdministration | TW Core MedicationDispense | TW Core MedicationStatement | TW Core Procedure | TW Core Immunization | TW Core ImagingStudy) Part of referenced event
... status S 1..1 code registered | preliminary | final | amended +
.... category:twcore S 0..* CodeableConcept Classification of type of observation
Binding: 臺灣衛福部資訊處Observation Clinical Result類型值集 (required): 此slice綁定的值集之綁定強度雖為最高強度「要求使用(Requird)」,但因slice之特性,其不會限制僅能填此值集中的代碼,故在實作時也可使用其他值集的代碼。


... code S 1..1 CodeableConceptTW 概念(Concept)— 參照一個專門術語或只是文字表述
Binding: LOINCCodes (extensible)
... subject S 1..1 Reference(TW Core Patient | TW Core Location | Group | Device) Who and/or what the observation is about
... encounter S 0..1 Reference(TW Core Encounter) Healthcare event during which this observation is made
... effective[x] SC 0..1 Clinically relevant time/time-period for observation
tw-core-3: Datetime must be at least to day.
.... effectiveDateTime dateTime S
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... performer 0..* Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | TW Core CareTeam) Who is responsible for the observation
... value[x] SC 0..1 Actual result
tw-core-5: SHALL use UCUM for coded quantity units.
.... valueQuantity Quantity S
.... valueCodeableConcept CodeableConcept S
.... valueString string S
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
... dataAbsentReason S 0..1 CodeableConceptTW 概念(Concept)— 參照一個專門術語或只是文字表述
... specimen 0..1 Reference(TW Core Specimen) Specimen used for this observation
... hasMember 0..* Reference(Observation | TW Core QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom 0..* Reference(TW Core DocumentReference | TW Core ImagingStudy | TW Core Media | TW Core QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.category:twcorerequiredTWObservationClinicalResultCategory
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/observation-clinical-result-category
from this IG
Observation.codeextensibleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
tw-core-3errorObservation.effective[x]Datetime must be at least to day.
: $this is dateTime implies $this.toString().length() >= 10
tw-core-4errorObservationIf 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() or value.exists())
tw-core-5errorObservation.value[x]SHALL use UCUM for coded quantity units.
: ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org'
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
tw-core-4: If there is no component or hasMember element then either a value[x] or a data absent reason must be present.
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... basedOn Σ 0..* Reference(TW Core CarePlan | DeviceRequest | ImmunizationRecommendation | TW Core MedicationRequest | NutritionOrder | TW Core ServiceRequest) Fulfills plan, proposal or order
... status ?!SΣ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category S 1..* CodeableConceptTW Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:twcore S 0..* CodeableConcept Classification of type of observation
Binding: 臺灣衛福部資訊處Observation Clinical Result類型值集 (required): 此slice綁定的值集之綁定強度雖為最高強度「要求使用(Requird)」,但因slice之特性,其不會限制僅能填此值集中的代碼,故在實作時也可使用其他值集的代碼。


... code S 1..1 CodeableConceptTW 概念(Concept)— 參照一個專門術語或只是文字表述
Binding: LOINCCodes (extensible)
... subject SΣ 1..1 Reference(TW Core Patient | TW Core Location | Group | Device) Who and/or what the observation is about
... encounter SΣ 0..1 Reference(TW Core Encounter) Healthcare event during which this observation is made
... effective[x] SΣC 0..1 Clinically relevant time/time-period for observation
tw-core-3: Datetime must be at least to day.
.... effectiveDateTime dateTime
... performer Σ 0..* Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | TW Core CareTeam) Who is responsible for the observation
... value[x] SΣC 0..1 Actual result
tw-core-5: SHALL use UCUM for coded quantity units.
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
... dataAbsentReason S 0..1 CodeableConceptTW 概念(Concept)— 參照一個專門術語或只是文字表述
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... specimen 0..1 Reference(TW Core Specimen) Specimen used for this observation
... hasMember Σ 0..* Reference(Observation | TW Core QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom Σ 0..* Reference(TW Core DocumentReference | TW Core ImagingStudy | TW Core Media | TW Core QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:twcorerequiredTWObservationClinicalResultCategory
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/observation-clinical-result-category
from this IG
Observation.codeextensibleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorObservationIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorObservationIf 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-4errorObservationIf 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-5errorObservationIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceObservationA resource should have narrative for robust management
: text.`div`.exists()
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-6errorObservationdataAbsentReason SHALL only be present if Observation.value[x] is not present
: dataAbsentReason.empty() or value.empty()
obs-7errorObservationIf 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()
tw-core-3errorObservation.effective[x]Datetime must be at least to day.
: $this is dateTime implies $this.toString().length() >= 10
tw-core-4errorObservationIf 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() or value.exists())
tw-core-5errorObservation.value[x]SHALL use UCUM for coded quantity units.
: ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org'
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
tw-core-4: If there is no component or hasMember element then either a value[x] or a data absent reason must be present.
... 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
... 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(TW Core CarePlan | DeviceRequest | ImmunizationRecommendation | TW Core MedicationRequest | NutritionOrder | TW Core ServiceRequest) Fulfills plan, proposal or order
... partOf Σ 0..* Reference(MedicationAdministration | TW Core MedicationDispense | TW Core MedicationStatement | TW Core Procedure | TW Core Immunization | TW Core ImagingStudy) Part of referenced event
... status ?!SΣ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category S 1..* CodeableConceptTW Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:twcore S 0..* CodeableConcept Classification of type of observation
Binding: 臺灣衛福部資訊處Observation Clinical Result類型值集 (required): 此slice綁定的值集之綁定強度雖為最高強度「要求使用(Requird)」,但因slice之特性,其不會限制僅能填此值集中的代碼,故在實作時也可使用其他值集的代碼。


... code S 1..1 CodeableConceptTW 概念(Concept)— 參照一個專門術語或只是文字表述
Binding: LOINCCodes (extensible)
... subject SΣ 1..1 Reference(TW Core Patient | TW Core Location | Group | Device) Who and/or what the observation is about
... focus Σ 0..* Reference(Resource) What the observation is about, when it is not about the subject of record
... encounter SΣ 0..1 Reference(TW Core Encounter) Healthcare event during which this observation is made
... effective[x] SΣC 0..1 Clinically relevant time/time-period for observation
tw-core-3: Datetime must be at least to day.
.... effectiveDateTime dateTime S
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... issued Σ 0..1 instant Date/Time this version was made available
... performer Σ 0..* Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | TW Core CareTeam) Who is responsible for the observation
... value[x] SΣC 0..1 Actual result
tw-core-5: SHALL use UCUM for coded quantity units.
.... valueQuantity Quantity S
.... valueCodeableConcept CodeableConcept S
.... valueString string S
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
... dataAbsentReason S 0..1 CodeableConceptTW 概念(Concept)— 參照一個專門術語或只是文字表述
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 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.

... specimen 0..1 Reference(TW Core Specimen) Specimen used for this observation
... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... referenceRange C 0..* BackboneElement Provides guide for interpretation
obs-3: Must have at least a low or a high or text
.... 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 Low Range, if relevant
.... high C 0..1 SimpleQuantity 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 Σ 0..* Reference(Observation | TW Core QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom Σ 0..* Reference(TW Core DocumentReference | TW Core ImagingStudy | TW Core Media | TW Core QuestionnaireResponse | Observation | MolecularSequence) 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 Σ 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
..... valueBoolean boolean
..... valueInteger integer
..... valueRange Range
..... valueRatio Ratio
..... valueSampledData SampledData
..... valueTime time
..... valueDateTime dateTime
..... valuePeriod Period
.... dataAbsentReason C 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

PathConformanceValueSetURI
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:twcorerequiredTWObservationClinicalResultCategory
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/observation-clinical-result-category
from this IG
Observation.codeextensibleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Observation.methodexampleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
http://hl7.org/fhir/ValueSet/referencerange-meaning
from the FHIR Standard
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
http://hl7.org/fhir/ValueSet/referencerange-appliesto
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorObservationIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorObservationIf 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-4errorObservationIf 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-5errorObservationIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceObservationA resource should have narrative for robust management
: text.`div`.exists()
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()
obs-6errorObservationdataAbsentReason SHALL only be present if Observation.value[x] is not present
: dataAbsentReason.empty() or value.empty()
obs-7errorObservationIf 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()
tw-core-3errorObservation.effective[x]Datetime must be at least to day.
: $this is dateTime implies $this.toString().length() >= 10
tw-core-4errorObservationIf 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() or value.exists())
tw-core-5errorObservation.value[x]SHALL use UCUM for coded quantity units.
: ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org'

This structure is derived from Observation

Summary

Mandatory: 2 elements
Must-Support: 9 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

Differential View

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
tw-core-4: If there is no component or hasMember element then either a value[x] or a data absent reason must be present.
... basedOn 0..* Reference(TW Core CarePlan | DeviceRequest | ImmunizationRecommendation | TW Core MedicationRequest | NutritionOrder | TW Core ServiceRequest) Fulfills plan, proposal or order
... partOf 0..* Reference(MedicationAdministration | TW Core MedicationDispense | TW Core MedicationStatement | TW Core Procedure | TW Core Immunization | TW Core ImagingStudy) Part of referenced event
... status S 1..1 code registered | preliminary | final | amended +
.... category:twcore S 0..* CodeableConcept Classification of type of observation
Binding: 臺灣衛福部資訊處Observation Clinical Result類型值集 (required): 此slice綁定的值集之綁定強度雖為最高強度「要求使用(Requird)」,但因slice之特性,其不會限制僅能填此值集中的代碼,故在實作時也可使用其他值集的代碼。


... code S 1..1 CodeableConceptTW 概念(Concept)— 參照一個專門術語或只是文字表述
Binding: LOINCCodes (extensible)
... subject S 1..1 Reference(TW Core Patient | TW Core Location | Group | Device) Who and/or what the observation is about
... encounter S 0..1 Reference(TW Core Encounter) Healthcare event during which this observation is made
... effective[x] SC 0..1 Clinically relevant time/time-period for observation
tw-core-3: Datetime must be at least to day.
.... effectiveDateTime dateTime S
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... performer 0..* Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | TW Core CareTeam) Who is responsible for the observation
... value[x] SC 0..1 Actual result
tw-core-5: SHALL use UCUM for coded quantity units.
.... valueQuantity Quantity S
.... valueCodeableConcept CodeableConcept S
.... valueString string S
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
... dataAbsentReason S 0..1 CodeableConceptTW 概念(Concept)— 參照一個專門術語或只是文字表述
... specimen 0..1 Reference(TW Core Specimen) Specimen used for this observation
... hasMember 0..* Reference(Observation | TW Core QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom 0..* Reference(TW Core DocumentReference | TW Core ImagingStudy | TW Core Media | TW Core QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.category:twcorerequiredTWObservationClinicalResultCategory
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/observation-clinical-result-category
from this IG
Observation.codeextensibleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
tw-core-3errorObservation.effective[x]Datetime must be at least to day.
: $this is dateTime implies $this.toString().length() >= 10
tw-core-4errorObservationIf 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() or value.exists())
tw-core-5errorObservation.value[x]SHALL use UCUM for coded quantity units.
: ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org'

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
tw-core-4: If there is no component or hasMember element then either a value[x] or a data absent reason must be present.
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... basedOn Σ 0..* Reference(TW Core CarePlan | DeviceRequest | ImmunizationRecommendation | TW Core MedicationRequest | NutritionOrder | TW Core ServiceRequest) Fulfills plan, proposal or order
... status ?!SΣ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category S 1..* CodeableConceptTW Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:twcore S 0..* CodeableConcept Classification of type of observation
Binding: 臺灣衛福部資訊處Observation Clinical Result類型值集 (required): 此slice綁定的值集之綁定強度雖為最高強度「要求使用(Requird)」,但因slice之特性,其不會限制僅能填此值集中的代碼,故在實作時也可使用其他值集的代碼。


... code S 1..1 CodeableConceptTW 概念(Concept)— 參照一個專門術語或只是文字表述
Binding: LOINCCodes (extensible)
... subject SΣ 1..1 Reference(TW Core Patient | TW Core Location | Group | Device) Who and/or what the observation is about
... encounter SΣ 0..1 Reference(TW Core Encounter) Healthcare event during which this observation is made
... effective[x] SΣC 0..1 Clinically relevant time/time-period for observation
tw-core-3: Datetime must be at least to day.
.... effectiveDateTime dateTime
... performer Σ 0..* Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | TW Core CareTeam) Who is responsible for the observation
... value[x] SΣC 0..1 Actual result
tw-core-5: SHALL use UCUM for coded quantity units.
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
... dataAbsentReason S 0..1 CodeableConceptTW 概念(Concept)— 參照一個專門術語或只是文字表述
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... specimen 0..1 Reference(TW Core Specimen) Specimen used for this observation
... hasMember Σ 0..* Reference(Observation | TW Core QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom Σ 0..* Reference(TW Core DocumentReference | TW Core ImagingStudy | TW Core Media | TW Core QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:twcorerequiredTWObservationClinicalResultCategory
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/observation-clinical-result-category
from this IG
Observation.codeextensibleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorObservationIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorObservationIf 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-4errorObservationIf 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-5errorObservationIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceObservationA resource should have narrative for robust management
: text.`div`.exists()
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-6errorObservationdataAbsentReason SHALL only be present if Observation.value[x] is not present
: dataAbsentReason.empty() or value.empty()
obs-7errorObservationIf 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()
tw-core-3errorObservation.effective[x]Datetime must be at least to day.
: $this is dateTime implies $this.toString().length() >= 10
tw-core-4errorObservationIf 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() or value.exists())
tw-core-5errorObservation.value[x]SHALL use UCUM for coded quantity units.
: ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org'

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
tw-core-4: If there is no component or hasMember element then either a value[x] or a data absent reason must be present.
... 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
... 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(TW Core CarePlan | DeviceRequest | ImmunizationRecommendation | TW Core MedicationRequest | NutritionOrder | TW Core ServiceRequest) Fulfills plan, proposal or order
... partOf Σ 0..* Reference(MedicationAdministration | TW Core MedicationDispense | TW Core MedicationStatement | TW Core Procedure | TW Core Immunization | TW Core ImagingStudy) Part of referenced event
... status ?!SΣ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category S 1..* CodeableConceptTW Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:twcore S 0..* CodeableConcept Classification of type of observation
Binding: 臺灣衛福部資訊處Observation Clinical Result類型值集 (required): 此slice綁定的值集之綁定強度雖為最高強度「要求使用(Requird)」,但因slice之特性,其不會限制僅能填此值集中的代碼,故在實作時也可使用其他值集的代碼。


... code S 1..1 CodeableConceptTW 概念(Concept)— 參照一個專門術語或只是文字表述
Binding: LOINCCodes (extensible)
... subject SΣ 1..1 Reference(TW Core Patient | TW Core Location | Group | Device) Who and/or what the observation is about
... focus Σ 0..* Reference(Resource) What the observation is about, when it is not about the subject of record
... encounter SΣ 0..1 Reference(TW Core Encounter) Healthcare event during which this observation is made
... effective[x] SΣC 0..1 Clinically relevant time/time-period for observation
tw-core-3: Datetime must be at least to day.
.... effectiveDateTime dateTime S
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... issued Σ 0..1 instant Date/Time this version was made available
... performer Σ 0..* Reference(TW Core Practitioner | TW Core Organization | TW Core Patient | TW Core PractitionerRole | TW Core CareTeam) Who is responsible for the observation
... value[x] SΣC 0..1 Actual result
tw-core-5: SHALL use UCUM for coded quantity units.
.... valueQuantity Quantity S
.... valueCodeableConcept CodeableConcept S
.... valueString string S
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
... dataAbsentReason S 0..1 CodeableConceptTW 概念(Concept)— 參照一個專門術語或只是文字表述
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 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.

... specimen 0..1 Reference(TW Core Specimen) Specimen used for this observation
... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... referenceRange C 0..* BackboneElement Provides guide for interpretation
obs-3: Must have at least a low or a high or text
.... 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 Low Range, if relevant
.... high C 0..1 SimpleQuantity 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 Σ 0..* Reference(Observation | TW Core QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom Σ 0..* Reference(TW Core DocumentReference | TW Core ImagingStudy | TW Core Media | TW Core QuestionnaireResponse | Observation | MolecularSequence) 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 Σ 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
..... valueBoolean boolean
..... valueInteger integer
..... valueRange Range
..... valueRatio Ratio
..... valueSampledData SampledData
..... valueTime time
..... valueDateTime dateTime
..... valuePeriod Period
.... dataAbsentReason C 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

PathConformanceValueSetURI
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:twcorerequiredTWObservationClinicalResultCategory
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/observation-clinical-result-category
from this IG
Observation.codeextensibleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Observation.methodexampleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
http://hl7.org/fhir/ValueSet/referencerange-meaning
from the FHIR Standard
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
http://hl7.org/fhir/ValueSet/referencerange-appliesto
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorObservationIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorObservationIf 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-4errorObservationIf 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-5errorObservationIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceObservationA resource should have narrative for robust management
: text.`div`.exists()
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()
obs-6errorObservationdataAbsentReason SHALL only be present if Observation.value[x] is not present
: dataAbsentReason.empty() or value.empty()
obs-7errorObservationIf 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()
tw-core-3errorObservation.effective[x]Datetime must be at least to day.
: $this is dateTime implies $this.toString().length() >= 10
tw-core-4errorObservationIf 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() or value.exists())
tw-core-5errorObservation.value[x]SHALL use UCUM for coded quantity units.
: ofType(Quantity).system.empty() or ofType(Quantity).system = 'http://unitsofmeasure.org'

This structure is derived from Observation

Summary

Mandatory: 2 elements
Must-Support: 9 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

 

Other representations of profile: CSV, Excel, Schematron

Notes:

以下概述了此Profile所需的RESTful FHIR互動功能。有關TW Core IG支援的RESTful互動功能的完整清單,請參閱TW Core Server能力聲明

必須支援以下查詢參數:

  1. 必須(SHALL) 支援透過查詢參數 patientcategory 查詢所有Observation:
    (如何透過reference查詢)
    (如何透過token查詢)
    GET [base]/Observation?patient={Type/}[id]&category=https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/category-code-tw|laboratory

    例子:
    (1) GET [base]/Observation?patient=Patient/pat-example&category=https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/category-code-tw|laboratory

  2. 必須(SHALL) 支援透過查詢參數 patientcode 查詢所有Observation:
    (如何透過reference查詢)
    (如何透過token查詢)
    GET [base]/Observation?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}

    例子:
    (1) GET [base]/Observation?patient=Patient/pat-example&code=http://loinc.org|44974-4,http://loinc.org|44963-7,http://loinc.org|8601-7

  3. 必須(SHALL) 支援透過查詢參數 patientcategorydate 查詢所有Observation:
    (如何透過reference查詢)
    (如何透過token查詢)
    (如何透過date查詢)
    GET [base]/Observation?patient={Type/}[id]&category=https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/category-code-tw|laboratory&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

    例子:
    (1) GET [base]/Observation?patient=Patient/pat-example&category=https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/category-code-tw|laboratory&date=ge2020-01-01T00:00:00Z

建議應該支援以下查詢參數:

  1. 建議應該(SHOULD) 支援透過查詢參數 patientcategorystatus 查詢所有Observation:
    (如何透過reference查詢)
    (如何透過token查詢)
    GET [base]/Observation?patient={Type/}[id]&category=https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/category-code-tw|laboratoryh&status={system|}[code]{,{system|}[code],...}

    例子:
    (1) GET [base]/Observation?patient=Patient/pat-example&category=https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/category-code-tw|laboratory&status=final

  2. 建議應該(SHOULD) 支援透過查詢參數 patientcategory_lastUpdated 查詢所有Observation:
    (如何透過reference查詢)
    (如何透過token查詢)
    (如何透過date查詢)
    GET [base]/Observation?patient={Type/}[id]&category={system|}[code]&_lastUpdated={gt|lt|ge|le}[date]{&_lastUpdated={gt|lt|ge|le}[date]&...}

    例子:
    (1) GET [base]/Observation?patient=Patient/pat-example&category=https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/category-code-tw|laboratory&_lastUpdated=ge2024-01-01T00:00:00Z

  3. 支援透過查詢參數 patientcodedate 查詢所有Observation:
    (如何透過reference查詢)
    (如何透過token查詢)
    (如何透過date查詢)
    GET [base]/Observation?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

    例子:
    (1) GET [base]/Observation?patient=Patient/pat-example&code=http://loinc.org|8867-4,http://loinc.org|85354-9,http://loinc.org|96607-7&date=ge2020-01-01T00:00:00Z