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
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:
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
Name | Flags | Card. | Type | Description & Constraints![]() |
---|---|---|---|---|
![]() ![]() |
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 |
![]() ![]() ![]() |
?!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 |
![]() ![]() ![]() |
?! | 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 |
![]() ![]() ![]() |
?!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 |
![]() ![]() ![]() |
0..* | CodeableConcept | Classification of type of observation Binding: ValueSetObservationCategory (MY Core) (preferred) ele-1: All FHIR elements must have a @value or children | |
![]() ![]() ![]() |
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 |
![]() ![]() ![]() |
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 |
![]() ![]() ![]() |
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 |
![]() ![]() ![]() |
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 |
![]() |
Path | Conformance | ValueSet | URI |
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | |
Observation.category | preferred | ValueSetObservationCategoryMyCorehttp://fhir.hie.moh.gov.my/ValueSet/observation-category-my-core from this IG | |
Observation.code | preferred | ValueSetObservationPanelMyCorehttp://fhir.hie.moh.gov.my/ValueSet/observation-panel-my-core from this IG | |
Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard |
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() |
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints![]() |
---|---|---|---|---|
![]() ![]() |
Observation | |||
![]() ![]() ![]() |
0..* | CodeableConcept | Classification of type of observation Binding: ValueSetObservationCategory (MY Core) (preferred) | |
![]() ![]() ![]() |
1..1 | CodeableConcept | Observation panel codes for HIE Binding: ValueSetObservationPanel (MY Core) (preferred): Observation panel codes for HIE | |
![]() ![]() ![]() |
1..1 | Reference(Patient | Group | Device | Location) | Who and/or what the observation is about | |
![]() ![]() ![]() |
0..1 | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation | |
![]() ![]() ![]() |
0..0 | |||
![]() ![]() ![]() |
0..0 | |||
![]() ![]() ![]() |
0..0 | |||
![]() ![]() ![]() |
1..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | |
![]() ![]() ![]() |
0..0 | |||
![]() |
Path | Conformance | ValueSet | URI |
Observation.category | preferred | ValueSetObservationCategoryMyCorehttp://fhir.hie.moh.gov.my/ValueSet/observation-category-my-core from this IG | |
Observation.code | preferred | ValueSetObservationPanelMyCorehttp://fhir.hie.moh.gov.my/ValueSet/observation-panel-my-core from this IG |
Name | Flags | Card. | Type | Description & Constraints![]() | ||||
---|---|---|---|---|---|---|---|---|
![]() ![]() |
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 | ||||
![]() ![]() ![]() |
Σ | 0..1 | id | Logical id of this artifact | ||||
![]() ![]() ![]() |
Σ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
![]() ![]() ![]() |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
![]() ![]() ![]() |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
![]() ![]() ![]() |
0..* | Resource | Contained, inline Resources | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
![]() ![]() ![]() |
Σ | 0..* | Identifier | Business Identifier for observation | ||||
![]() ![]() ![]() |
Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | ||||
![]() ![]() ![]() |
Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
![]() ![]() ![]() |
?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
![]() ![]() ![]() |
0..* | CodeableConcept | Classification of type of observation Binding: ValueSetObservationCategory (MY Core) (preferred) | |||||
![]() ![]() ![]() |
Σ | 1..1 | CodeableConcept | Observation panel codes for HIE Binding: ValueSetObservationPanel (MY Core) (preferred): Observation panel codes for HIE | ||||
![]() ![]() ![]() |
Σ | 1..1 | Reference(Patient | Group | Device | Location) | Who and/or what the observation is about | ||||
![]() ![]() ![]() |
Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
![]() ![]() ![]() |
Σ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made | ||||
![]() ![]() ![]() |
Σ | 0..1 | Clinically relevant time/time-period for observation | |||||
![]() ![]() ![]() ![]() |
dateTime | |||||||
![]() ![]() ![]() ![]() |
Period | |||||||
![]() ![]() ![]() ![]() |
Timing | |||||||
![]() ![]() ![]() ![]() |
instant | |||||||
![]() ![]() ![]() |
Σ | 0..1 | instant | Date/Time this version was made available | ||||
![]() ![]() ![]() |
Σ | 0..1 | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation | ||||
![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
![]() ![]() ![]() |
0..* | Annotation | Comments about the observation | |||||
![]() ![]() ![]() |
0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
![]() ![]() ![]() |
0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |||||
![]() ![]() ![]() |
0..1 | Reference(Specimen) | Specimen used for this observation | |||||
![]() ![]() ![]() |
0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
![]() ![]() ![]() |
Σ | 1..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
![]() ![]() ![]() |
Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
![]() |
Path | Conformance | ValueSet | URI | |||
Observation.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard
| ||||
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | ||||
Observation.category | preferred | ValueSetObservationCategoryMyCorehttp://fhir.hie.moh.gov.my/ValueSet/observation-category-my-core from this IG | ||||
Observation.code | preferred | ValueSetObservationPanelMyCorehttp://fhir.hie.moh.gov.my/ValueSet/observation-panel-my-core from this IG | ||||
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methods from the FHIR Standard | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaning from the FHIR Standard | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://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 | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard |
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() |
This structure is derived from Observation
Key Elements View
Name | Flags | Card. | Type | Description & Constraints![]() |
---|---|---|---|---|
![]() ![]() |
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 |
![]() ![]() ![]() |
?!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 |
![]() ![]() ![]() |
?! | 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 |
![]() ![]() ![]() |
?!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 |
![]() ![]() ![]() |
0..* | CodeableConcept | Classification of type of observation Binding: ValueSetObservationCategory (MY Core) (preferred) ele-1: All FHIR elements must have a @value or children | |
![]() ![]() ![]() |
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 |
![]() ![]() ![]() |
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 |
![]() ![]() ![]() |
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 |
![]() ![]() ![]() |
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 |
![]() |
Path | Conformance | ValueSet | URI |
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | |
Observation.category | preferred | ValueSetObservationCategoryMyCorehttp://fhir.hie.moh.gov.my/ValueSet/observation-category-my-core from this IG | |
Observation.code | preferred | ValueSetObservationPanelMyCorehttp://fhir.hie.moh.gov.my/ValueSet/observation-panel-my-core from this IG | |
Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard |
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() |
Differential View
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints![]() |
---|---|---|---|---|
![]() ![]() |
Observation | |||
![]() ![]() ![]() |
0..* | CodeableConcept | Classification of type of observation Binding: ValueSetObservationCategory (MY Core) (preferred) | |
![]() ![]() ![]() |
1..1 | CodeableConcept | Observation panel codes for HIE Binding: ValueSetObservationPanel (MY Core) (preferred): Observation panel codes for HIE | |
![]() ![]() ![]() |
1..1 | Reference(Patient | Group | Device | Location) | Who and/or what the observation is about | |
![]() ![]() ![]() |
0..1 | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation | |
![]() ![]() ![]() |
0..0 | |||
![]() ![]() ![]() |
0..0 | |||
![]() ![]() ![]() |
0..0 | |||
![]() ![]() ![]() |
1..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | |
![]() ![]() ![]() |
0..0 | |||
![]() |
Path | Conformance | ValueSet | URI |
Observation.category | preferred | ValueSetObservationCategoryMyCorehttp://fhir.hie.moh.gov.my/ValueSet/observation-category-my-core from this IG | |
Observation.code | preferred | ValueSetObservationPanelMyCorehttp://fhir.hie.moh.gov.my/ValueSet/observation-panel-my-core from this IG |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints![]() | ||||
---|---|---|---|---|---|---|---|---|
![]() ![]() |
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 | ||||
![]() ![]() ![]() |
Σ | 0..1 | id | Logical id of this artifact | ||||
![]() ![]() ![]() |
Σ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
![]() ![]() ![]() |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
![]() ![]() ![]() |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
![]() ![]() ![]() |
0..* | Resource | Contained, inline Resources | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
![]() ![]() ![]() |
Σ | 0..* | Identifier | Business Identifier for observation | ||||
![]() ![]() ![]() |
Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order | ||||
![]() ![]() ![]() |
Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
![]() ![]() ![]() |
?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
![]() ![]() ![]() |
0..* | CodeableConcept | Classification of type of observation Binding: ValueSetObservationCategory (MY Core) (preferred) | |||||
![]() ![]() ![]() |
Σ | 1..1 | CodeableConcept | Observation panel codes for HIE Binding: ValueSetObservationPanel (MY Core) (preferred): Observation panel codes for HIE | ||||
![]() ![]() ![]() |
Σ | 1..1 | Reference(Patient | Group | Device | Location) | Who and/or what the observation is about | ||||
![]() ![]() ![]() |
Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
![]() ![]() ![]() |
Σ | 0..1 | Reference(Encounter) | Healthcare event during which this observation is made | ||||
![]() ![]() ![]() |
Σ | 0..1 | Clinically relevant time/time-period for observation | |||||
![]() ![]() ![]() ![]() |
dateTime | |||||||
![]() ![]() ![]() ![]() |
Period | |||||||
![]() ![]() ![]() ![]() |
Timing | |||||||
![]() ![]() ![]() ![]() |
instant | |||||||
![]() ![]() ![]() |
Σ | 0..1 | instant | Date/Time this version was made available | ||||
![]() ![]() ![]() |
Σ | 0..1 | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation | ||||
![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
![]() ![]() ![]() |
0..* | Annotation | Comments about the observation | |||||
![]() ![]() ![]() |
0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
![]() ![]() ![]() |
0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |||||
![]() ![]() ![]() |
0..1 | Reference(Specimen) | Specimen used for this observation | |||||
![]() ![]() ![]() |
0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
![]() ![]() ![]() |
Σ | 1..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
![]() ![]() ![]() |
Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
![]() |
Path | Conformance | ValueSet | URI | |||
Observation.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard
| ||||
Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard | ||||
Observation.category | preferred | ValueSetObservationCategoryMyCorehttp://fhir.hie.moh.gov.my/ValueSet/observation-category-my-core from this IG | ||||
Observation.code | preferred | ValueSetObservationPanelMyCorehttp://fhir.hie.moh.gov.my/ValueSet/observation-panel-my-core from this IG | ||||
Observation.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Observation.method | example | ObservationMethodshttp://hl7.org/fhir/ValueSet/observation-methods from the FHIR Standard | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaning from the FHIR Standard | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://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 | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard |
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() |
This structure is derived from Observation
Other representations of profile: CSV, Excel, Schematron
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. |
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.
|
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 |
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 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 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 |
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 |
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"
.