HSAI FHIR Implementation Guide
0.1.0 - CI Build Netherlands

HSAI FHIR Implementation Guide - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

## Resource Profile: CDT Observation

Official URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/cdt-observation | Version: 0.1.0
Active as of 2026-02-09 | Computable Name: CDTObservation

Observation profile created by the Clinical Data Transformer (CDT) tool for international use

Usage:

- This Resource Profile is not used by any profiles in this Implementation Guide

### Formal Views of Profile Content

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

- Differential Table
- Key Elements Table
- Snapshot Table
- Statistics/References
- All

This structure is derived from Observation

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation |  | 0..* | Observation | Measurements and simple assertions
Slices for extension |  | 3..* | Extension | Extension Slice: Unordered, Open by value:url
extension:textSource | S | 1..1 | string | Text Source Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-source
extension:textIndexStart | S | 1..1 | integer | Text Index Start Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-start
extension:textIndexEnd | S | 1..1 | integer | Text Index End Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-end
identifier | S | 1..* | Identifier | Business Identifier for observation
system |  | 0..1 | uri | The namespace for the identifier value Required Pattern: https://cdt-beta.healthsage.ai/fhir/identifier/hsai-cdt
value |  | 1..1 | string | The value that is unique
status | S | 1..1 | code | registered | preliminary | final | amended +
value |  | 0..1 | string | Primitive value for code Required Pattern: final
code | S | 1..1 | CodeableConcept | Type of observation (code / type) Binding: CDT Observation Value Set (required)
coding |  |  |  |
system |  | 1..1 | uri | Identity of the terminology system Required Pattern: http://snomed.info/sct
version |  | 1..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system
display |  | 1..1 | string | Representation defined by the system
subject | S | 1..1 | Reference(Patient | Group | Device | Location) | Who and/or what the observation is about
effective[x] | S | 0..1 |  | Clinically relevant time/time-period for observation
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
bodySite | S | 0..1 | CodeableConcept | Body site laterality (left, right, bilateral) Binding: CDT Body Side Value Set (required)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Observation.code | required | CDTObservationVS `https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-observation-vs` from this IG
Observation.bodySite | required | CDTBodySideValueSet `https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-body-side-vs` from this IG

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management 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
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
Slices for extension |  | 3..* | Extension | Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:textSource | S | 1..1 | string | Text Source Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-source ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:textIndexStart | S | 1..1 | integer | Text Index Start Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-start ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:textIndexEnd | S | 1..1 | integer | Text Index End Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-end ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier | S Σ | 1..* | Identifier | Business Identifier for observation ele-1: All FHIR elements must have a @value or children
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . ele-1: All FHIR elements must have a @value or children
system | Σ | 0..1 | uri | The namespace for the identifier value ele-1: All FHIR elements must have a @value or children Required Pattern: https://cdt-beta.healthsage.ai/fhir/identifier/hsai-cdt
value | Σ | 1..1 | string | The value that is unique ele-1: All FHIR elements must have a @value or children Example General: 123456
status | ?!S Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. ele-1: All FHIR elements must have a @value or children
value |  | 0..1 | string | Primitive value for code Required Pattern: final
code | S Σ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: CDT Observation Value Set (required) ele-1: All FHIR elements must have a @value or children
subject | S Σ | 1..1 | Reference(Patient | Group | Device | Location) | Who and/or what the observation is about ele-1: All FHIR elements must have a @value or children
effective[x] | S Σ | 0..1 |  | Clinically relevant time/time-period for observation ele-1: All FHIR elements must have a @value or children
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
bodySite | S | 0..1 | CodeableConcept | Body site laterality (left, right, bilateral) Binding: CDT Body Side Value Set (required) ele-1: All FHIR elements must have a @value or children
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
Observation.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Observation.status | required | ObservationStatus `http://hl7.org/fhir/ValueSet/observation-status|4.0.1` from the FHIR Standard
Observation.code | required | CDTObservationVS `https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-observation-vs` from this IG
Observation.bodySite | required | CDTBodySideValueSet `https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-body-side-vs` from this IG

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() |

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
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
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 Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 3..* | Extension | Extension Slice: Unordered, Open by value:url
extension:textSource | S | 1..1 | string | Text Source Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-source
extension:textIndexStart | S | 1..1 | integer | Text Index Start Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-start
extension:textIndexEnd | S | 1..1 | integer | Text Index End Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-end
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ | 1..* | Identifier | Business Identifier for observation
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system | Σ | 0..1 | uri | The namespace for the identifier value Required Pattern: https://cdt-beta.healthsage.ai/fhir/identifier/hsai-cdt
value | Σ | 1..1 | string | The value that is unique Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
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 | ?!S Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation.
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional content defined by implementations
value |  | 0..1 | string | Primitive value for code Required Pattern: final
category |  | 0..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
code | S Σ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: CDT Observation Value Set (required)
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 | Σ | 0..* | 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 | Σ | 1..1 | string | Version of the system - if relevant
code | Σ | 1..1 | code | Symbol in syntax defined by the system
display | Σ | 1..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 | S Σ | 1..1 | Reference(Patient | Group | Device | Location) | 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 | Σ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made
effective[x] | S Σ | 0..1 |  | Clinically relevant time/time-period for observation
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | Σ | 0..1 | instant | Date/Time this version was made available
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation
value[x] | Σ C | 0..1 |  | Actual 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 result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation |  | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note |  | 0..* | Annotation | Comments about the observation
bodySite | S | 0..1 | CodeableConcept | Body site laterality (left, right, bilateral) Binding: CDT Body Side Value Set (required)
method |  | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations.
specimen |  | 0..1 | Reference(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 | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | 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
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
Observation.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` from the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Observation.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Observation.identifier.type | extensible | Identifier Type Codes `http://hl7.org/fhir/ValueSet/identifier-type` from the FHIR Standard
Observation.status | required | ObservationStatus `http://hl7.org/fhir/ValueSet/observation-status|4.0.1` from the FHIR Standard
Observation.category | preferred | ObservationCategoryCodes `http://hl7.org/fhir/ValueSet/observation-category` from the FHIR Standard
Observation.code | required | CDTObservationVS `https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-observation-vs` from this IG
Observation.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` from the FHIR Standard
Observation.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` from the FHIR Standard
Observation.bodySite | required | CDTBodySideValueSet `https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-body-side-vs` from this IG
Observation.method | example | ObservationMethods `http://hl7.org/fhir/ValueSet/observation-methods` from the FHIR Standard
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes `http://hl7.org/fhir/ValueSet/referencerange-meaning` from the FHIR Standard
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes `http://hl7.org/fhir/ValueSet/referencerange-appliesto` from the FHIR Standard
Observation.component.code | example | LOINCCodes (a valid code from LOINC) `http://hl7.org/fhir/ValueSet/observation-codes` from the FHIR Standard
Observation.component.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` from the FHIR Standard
Observation.component.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` from the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() |

This structure is derived from Observation

Summary

Mandatory: 6 elements(4 nested mandatory elements)
Must-Support: 9 elements

Extensions

This structure refers to these extensions:

- https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-source
- https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-start
- https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-end

Differential View

This structure is derived from Observation

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation |  | 0..* | Observation | Measurements and simple assertions
Slices for extension |  | 3..* | Extension | Extension Slice: Unordered, Open by value:url
extension:textSource | S | 1..1 | string | Text Source Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-source
extension:textIndexStart | S | 1..1 | integer | Text Index Start Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-start
extension:textIndexEnd | S | 1..1 | integer | Text Index End Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-end
identifier | S | 1..* | Identifier | Business Identifier for observation
system |  | 0..1 | uri | The namespace for the identifier value Required Pattern: https://cdt-beta.healthsage.ai/fhir/identifier/hsai-cdt
value |  | 1..1 | string | The value that is unique
status | S | 1..1 | code | registered | preliminary | final | amended +
value |  | 0..1 | string | Primitive value for code Required Pattern: final
code | S | 1..1 | CodeableConcept | Type of observation (code / type) Binding: CDT Observation Value Set (required)
coding |  |  |  |
system |  | 1..1 | uri | Identity of the terminology system Required Pattern: http://snomed.info/sct
version |  | 1..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system
display |  | 1..1 | string | Representation defined by the system
subject | S | 1..1 | Reference(Patient | Group | Device | Location) | Who and/or what the observation is about
effective[x] | S | 0..1 |  | Clinically relevant time/time-period for observation
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
bodySite | S | 0..1 | CodeableConcept | Body site laterality (left, right, bilateral) Binding: CDT Body Side Value Set (required)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Observation.code | required | CDTObservationVS `https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-observation-vs` from this IG
Observation.bodySite | required | CDTBodySideValueSet `https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-body-side-vs` from this IG

Key Elements View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management 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
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
Slices for extension |  | 3..* | Extension | Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:textSource | S | 1..1 | string | Text Source Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-source ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:textIndexStart | S | 1..1 | integer | Text Index Start Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-start ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:textIndexEnd | S | 1..1 | integer | Text Index End Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-end ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier | S Σ | 1..* | Identifier | Business Identifier for observation ele-1: All FHIR elements must have a @value or children
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . ele-1: All FHIR elements must have a @value or children
system | Σ | 0..1 | uri | The namespace for the identifier value ele-1: All FHIR elements must have a @value or children Required Pattern: https://cdt-beta.healthsage.ai/fhir/identifier/hsai-cdt
value | Σ | 1..1 | string | The value that is unique ele-1: All FHIR elements must have a @value or children Example General: 123456
status | ?!S Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. ele-1: All FHIR elements must have a @value or children
value |  | 0..1 | string | Primitive value for code Required Pattern: final
code | S Σ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: CDT Observation Value Set (required) ele-1: All FHIR elements must have a @value or children
subject | S Σ | 1..1 | Reference(Patient | Group | Device | Location) | Who and/or what the observation is about ele-1: All FHIR elements must have a @value or children
effective[x] | S Σ | 0..1 |  | Clinically relevant time/time-period for observation ele-1: All FHIR elements must have a @value or children
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
bodySite | S | 0..1 | CodeableConcept | Body site laterality (left, right, bilateral) Binding: CDT Body Side Value Set (required) ele-1: All FHIR elements must have a @value or children
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
Observation.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Observation.status | required | ObservationStatus `http://hl7.org/fhir/ValueSet/observation-status|4.0.1` from the FHIR Standard
Observation.code | required | CDTObservationVS `https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-observation-vs` from this IG
Observation.bodySite | required | CDTBodySideValueSet `https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-body-side-vs` from this IG

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() |

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
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
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 Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 3..* | Extension | Extension Slice: Unordered, Open by value:url
extension:textSource | S | 1..1 | string | Text Source Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-source
extension:textIndexStart | S | 1..1 | integer | Text Index Start Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-start
extension:textIndexEnd | S | 1..1 | integer | Text Index End Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-end
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ | 1..* | Identifier | Business Identifier for observation
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system | Σ | 0..1 | uri | The namespace for the identifier value Required Pattern: https://cdt-beta.healthsage.ai/fhir/identifier/hsai-cdt
value | Σ | 1..1 | string | The value that is unique Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
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 | ?!S Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation.
id |  | 0..1 | string | xml:id (or equivalent in JSON)
extension |  | 0..* | Extension | Additional content defined by implementations
value |  | 0..1 | string | Primitive value for code Required Pattern: final
category |  | 0..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
code | S Σ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: CDT Observation Value Set (required)
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 | Σ | 0..* | 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 | Σ | 1..1 | string | Version of the system - if relevant
code | Σ | 1..1 | code | Symbol in syntax defined by the system
display | Σ | 1..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 | S Σ | 1..1 | Reference(Patient | Group | Device | Location) | 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 | Σ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made
effective[x] | S Σ | 0..1 |  | Clinically relevant time/time-period for observation
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | Σ | 0..1 | instant | Date/Time this version was made available
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation
value[x] | Σ C | 0..1 |  | Actual 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 result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation |  | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note |  | 0..* | Annotation | Comments about the observation
bodySite | S | 0..1 | CodeableConcept | Body site laterality (left, right, bilateral) Binding: CDT Body Side Value Set (required)
method |  | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations.
specimen |  | 0..1 | Reference(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 | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | 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
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
Observation.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` from the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Observation.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Observation.identifier.type | extensible | Identifier Type Codes `http://hl7.org/fhir/ValueSet/identifier-type` from the FHIR Standard
Observation.status | required | ObservationStatus `http://hl7.org/fhir/ValueSet/observation-status|4.0.1` from the FHIR Standard
Observation.category | preferred | ObservationCategoryCodes `http://hl7.org/fhir/ValueSet/observation-category` from the FHIR Standard
Observation.code | required | CDTObservationVS `https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-observation-vs` from this IG
Observation.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` from the FHIR Standard
Observation.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` from the FHIR Standard
Observation.bodySite | required | CDTBodySideValueSet `https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-body-side-vs` from this IG
Observation.method | example | ObservationMethods `http://hl7.org/fhir/ValueSet/observation-methods` from the FHIR Standard
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes `http://hl7.org/fhir/ValueSet/referencerange-meaning` from the FHIR Standard
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes `http://hl7.org/fhir/ValueSet/referencerange-appliesto` from the FHIR Standard
Observation.component.code | example | LOINCCodes (a valid code from LOINC) `http://hl7.org/fhir/ValueSet/observation-codes` from the FHIR Standard
Observation.component.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` from the FHIR Standard
Observation.component.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` from the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Observation | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() |

This structure is derived from Observation

Summary

Mandatory: 6 elements(4 nested mandatory elements)
Must-Support: 9 elements

Extensions

This structure refers to these extensions:

- https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-source
- https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-start
- https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-end

Other representations of profile: CSV, Excel, Schematron