HL7 FHIR Malaysia Core (MY Core) Implementation Guide
2.0.0 - ci-build

HL7 FHIR Malaysia Core (MY Core) Implementation Guide - Local Development build (v2.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: Observation Panel (MY Core)

Official URL: http://fhir.hie.moh.gov.my/StructureDefinition/Observation-panel-my-core Version: 2.0.0
Active as of 2024-02-12 Computable Name: ObservationPanelMyCore

This profile is derived from the base FHIR Observation resource, to define the different observation panel codes for the HIE in Malaysian Ministry of Health facilities.

This MY Core IG uses a similar concept used in FHIR Observation Vital Sign profile where an Observation resource is used to store specific bedside measurements and subjective point-in-time assessment parameters. By having a base panel to anchor each related Observation parameter, each Observation record will then by itself be an individual record that is independent yet still have reference to each of their respective point-in-time record via a single panel.

Below is an overview diagram for the Vital Sign Panel:

Imaging

Usage:

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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
... status ?!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
... code Σ 1..1 CodeableConcept Observation panel codes for HIE
Binding: ValueSetObservationPanel (MY Core) (preferred): Observation panel codes for HIE


ele-1: All FHIR elements must have a @value or children
... subject 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
... performer Σ 0..1 Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Who is responsible for the observation
ele-1: All FHIR elements must have a @value or children
... hasMember Σ 1..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
ele-1: All FHIR elements must have a @value or children

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.categorypreferredValueSetObservationCategoryMyCore
http://fhir.hie.moh.gov.my/ValueSet/observation-category-my-core
from this IG
Observation.codepreferredValueSetObservationPanelMyCore
http://fhir.hie.moh.gov.my/ValueSet/observation-panel-my-core
from this IG
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
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()

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation Observation
... category 0..* CodeableConcept Classification of type of observation
Binding: ValueSetObservationCategory (MY Core) (preferred)
... code 1..1 CodeableConcept Observation panel codes for HIE
Binding: ValueSetObservationPanel (MY Core) (preferred): Observation panel codes for HIE

... subject 1..1 Reference(Patient | Group | Device | Location) Who and/or what the observation is about
... value[x] 0..0
... interpretation 0..0
... referenceRange 0..0
... hasMember 1..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... component 0..0

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.categorypreferredValueSetObservationCategoryMyCore
http://fhir.hie.moh.gov.my/ValueSet/observation-category-my-core
from this IG
Observation.codepreferredValueSetObservationPanelMyCore
http://fhir.hie.moh.gov.my/ValueSet/observation-panel-my-core
from this IG
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
... 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(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Fulfills plan, proposal or order
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Part of referenced event
... status ?!Σ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... category 0..* CodeableConcept Classification of type of observation
Binding: ValueSetObservationCategory (MY Core) (preferred)
... code Σ 1..1 CodeableConcept Observation panel codes for HIE
Binding: ValueSetObservationPanel (MY Core) (preferred): Observation panel codes for HIE

... subject 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] Σ 0..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... issued Σ 0..1 instant Date/Time this version was made available
... performer Σ 0..1 Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Who is responsible for the observation
... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... 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(Specimen) Specimen used for this observation
... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... hasMember Σ 1..* 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredValueSetObservationCategoryMyCore
http://fhir.hie.moh.gov.my/ValueSet/observation-category-my-core
from this IG
Observation.codepreferredValueSetObservationPanelMyCore
http://fhir.hie.moh.gov.my/ValueSet/observation-panel-my-core
from this IG
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
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-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()

This structure is derived from Observation

Summary

Mandatory: 2 elements
Prohibited: 4 elements

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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
... status ?!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
... code Σ 1..1 CodeableConcept Observation panel codes for HIE
Binding: ValueSetObservationPanel (MY Core) (preferred): Observation panel codes for HIE


ele-1: All FHIR elements must have a @value or children
... subject 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
... performer Σ 0..1 Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Who is responsible for the observation
ele-1: All FHIR elements must have a @value or children
... hasMember Σ 1..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
ele-1: All FHIR elements must have a @value or children

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.categorypreferredValueSetObservationCategoryMyCore
http://fhir.hie.moh.gov.my/ValueSet/observation-category-my-core
from this IG
Observation.codepreferredValueSetObservationPanelMyCore
http://fhir.hie.moh.gov.my/ValueSet/observation-panel-my-core
from this IG
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
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()

Differential View

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation Observation
... category 0..* CodeableConcept Classification of type of observation
Binding: ValueSetObservationCategory (MY Core) (preferred)
... code 1..1 CodeableConcept Observation panel codes for HIE
Binding: ValueSetObservationPanel (MY Core) (preferred): Observation panel codes for HIE

... subject 1..1 Reference(Patient | Group | Device | Location) Who and/or what the observation is about
... value[x] 0..0
... interpretation 0..0
... referenceRange 0..0
... hasMember 1..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... component 0..0

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.categorypreferredValueSetObservationCategoryMyCore
http://fhir.hie.moh.gov.my/ValueSet/observation-category-my-core
from this IG
Observation.codepreferredValueSetObservationPanelMyCore
http://fhir.hie.moh.gov.my/ValueSet/observation-panel-my-core
from this IG

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
... 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(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Fulfills plan, proposal or order
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Part of referenced event
... status ?!Σ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... category 0..* CodeableConcept Classification of type of observation
Binding: ValueSetObservationCategory (MY Core) (preferred)
... code Σ 1..1 CodeableConcept Observation panel codes for HIE
Binding: ValueSetObservationPanel (MY Core) (preferred): Observation panel codes for HIE

... subject 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] Σ 0..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... issued Σ 0..1 instant Date/Time this version was made available
... performer Σ 0..1 Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Who is responsible for the observation
... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... 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(Specimen) Specimen used for this observation
... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... hasMember Σ 1..* 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredValueSetObservationCategoryMyCore
http://fhir.hie.moh.gov.my/ValueSet/observation-category-my-core
from this IG
Observation.codepreferredValueSetObservationPanelMyCore
http://fhir.hie.moh.gov.my/ValueSet/observation-panel-my-core
from this IG
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
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-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()

This structure is derived from Observation

Summary

Mandatory: 2 elements
Prohibited: 4 elements

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Mandatory Data Elements

This structure defines these elements as mandatory data fields:

Element Description
Observation.status The status of the Observation Panel, e.g. final, amended.
Observation.code Coding for the type of Observation Panel as defined by ValueSetObservationPanel (MY Core) (see below).
Observation.subject References the Patient who is the subject of the Observation.
Observation.performer References the resource who made the Observation entry, e.g. Practitioner, Patient, RelatedPerson.
Observation.hasMember References the resource(s) that is part of this Observation Panel, e.g. Observation, QuestionnaireResponse.

Omitted Elements

This structure omits these elements:

Element Description
Observation.value As this resource defines an Observation Panel and not the Observation reading itself, this element is not relevant.
Observation.intepretation As this resource defines an Observation Panel and not the Observation reading itself, this element is not relevant.
Observation.referenceRange As this resource defines an Observation Panel and not the Observation reading itself, this element is not relevant.
Observation.component The element Observation.hasMember is used to reference component resources of the Observation Panel instead.

Panel Charting

Vital Sign Panel

Vital Sign Panel code Observation.code.coding.code=85353-1 (from CodeSystem https://loinc.org).

Component Profile Code CodeSystem
Respiratory Rate ObservationRespiRate (MY Core) 9279-1 https://loinc.org
Oxygen Saturation ObservationOxygenSat (MY Core) 59408-5 https://loinc.org
Heart Rate ObservationHeartRate (MY Core) 8867-4 https://loinc.org
Body Temperature ObservationBodyTemp (MY Core) 8310-5 https://loinc.org
Systolic Blood Pressure ObservationSystolicBP (MY Core) 8480-6 https://loinc.org
Diastolic Blood Pressure ObservationDiastolicBP (MY Core) 8462-4 https://loinc.org
Pain Score ObservationPainScore (MY Core) 72514-3 https://loinc.org

Vital Sign Panel Sample Data


Anthropometry Panel

Anthropometry Panel code Observation.code.coding.code=55418-8 (from CodeSystem https://loinc.org).

Component Profile Code CodeSystem
Weight ObservationWeight (MY Core) 29463-7 https://loinc.org
Height ObservationHeight (MY Core) 8302-2 https://loinc.org
Waist ObservationWaist (MY Core) 8280-0 https://loinc.org
Head Circumference ObservationHeadCircumference (MY Core) 9843-4 https://loinc.org
Chest Circumference ObservationChestCircumference (MY Core) 8279-2 https://loinc.org
BMI ObservationBMI (MY Core) 39156-5 https://loinc.org

Anthropometry Panel Sample Data


Child Anthropometry Panel

Child Anthropometry Panel code Observation.code.coding.code=0001 (from CodeSystem http://fhir.hie.moh.gov.my/CodeSystem/observation-panel-my-core).

Component Profile Code CodeSystem
Weight ObservationWeight (MY Core) 29463-7 https://loinc.org
Height ObservationHeight (MY Core) 8302-2 https://loinc.org
Waist ObservationWaist (MY Core) 8280-0 https://loinc.org
Head Circumference ObservationHeadCircumference (MY Core) 9843-4 https://loinc.org
Chest Circumference ObservationChestCircumference (MY Core) 8279-2 https://loinc.org
BMI ObservationBMI (MY Core) 39156-5 https://loinc.org

Anthropometry Child Panel Sample Data


Glucose Panel

Glucose Panel code Observation.code.coding.code=41653-7 (from CodeSystem https://loinc.org).

Component Profile Code CodeSystem
Random Glucose ObservationRandomGlucose (MY Core) 271061004 http://snomed.info/sct
Fasting Glucose ObservationFastingGlucose (MY Core) 271062006 http://snomed.info/sct

Glucose Panel Sample Data

Dental Chart

Dental Chart code Observation.code.coding.code=32885-6 (from CodeSystem https://loinc.org).

Component Profile Code CodeSystem
Dentition ObservationDentalChart (MY Core) Code based on CodeSystemDentitian (MY Core) http://fhir.hie.moh.gov.my/CodeSystem/dentitian-my-core

Dental Chart Sample Data



Self Entry Panel

If an Observation record is captured as a self-entry (referring to the Patient making entries themselves) HIE will differentiate it based on the panel-defined performer.reference resource type . A self entry will have the Patient themselves as the performer. For example:

If a Practitioner made the Observation entry, the performer.reference will be:

  • performer.reference="PractitionerRole/7c991944-13d0-419d-b228-e1a6cea6c1a4/_history/3".

If a Patient themselves made the entry, the performer.reference will be:

  • performer.reference="Patient/9b5742e0-bdec-4c1c-94bc-746875264d59".

Self Entry Sample Data