Kenya ePrescription FHIR Implementation Guide
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Kenya ePrescription 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: Kenya Morphology / Histology Observation

Official URL: https://prescription.intellisoftkenya.com/StructureDefinition/ke-morphology-observation Version: 0.1.0
Draft as of 2026-04-13 Computable Name: KEMorphologyObservation

Copyright/Legal: Copyright 2025+ IntelliSOFT Kenya. This content is licensed under Creative Commons Attribution 4.0 International (CC-BY-4.0). Terminology content from the Kenya Pharmacy and Poisons Board (PPB) via Open Concept Lab (OCL) is subject to separate terms.

Profile on Observation for recording tumour morphology (histology/ICD-O-3) results in the Kenya oncology IG.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* Observation Measurements and simple assertions
Constraints: obs-6, obs-7
... id SΣ 1..1 id Logical id of this artifact
... meta SΣ 1..1 Meta Metadata about the resource
.... profile SΣ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to.
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... identifier SΣ 0..* Identifier Business Identifier for observation
... status ?!SΣ 1..1 code Observation status — default 'final'
Binding: ObservationStatus (required)
... category S 1..* CodeableConcept Category — default 'laboratory'
Binding: ObservationCategoryCodes (required)
... code SΣ 1..1 CodeableConcept LOINC or local code identifying the morphology observation
Binding: LOINCCodes (required)
... subject SΣ 1..1 Reference(Patient) Who and/or what the observation is about
... focus SΣ 1..* Reference(Condition) The oncology condition this morphology observation relates to
... encounter SΣ 0..1 Reference(Encounter) Healthcare event during which this observation is made
... Slices for effective[x] SΣ 1..1 Clinically relevant time/time-period for observation
Slice: Unordered, Closed by type:$this
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effective[x]:effectiveDateTime SΣ 0..1 dateTime Clinically relevant time/time-period for observation
.... effective[x]:effectivePeriod SΣ 0..1 Period Clinically relevant time/time-period for observation
... performer SΣ 1..* Reference(Practitioner | PractitionerRole | Organization) Pathologist or performing lab
... value[x] SΣC 1..1 CodeableConcept ICD-O-3 morphology code or SNOMED CT finding
... bodySite S 0..1 CodeableConcept Observed body part
Binding: SNOMEDCTBodyStructures (required)
... method S 1..1 CodeableConcept Method of morphology determination (biopsy, cytology, etc.)
Binding: Observation Methods ValueSet (required)

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Observation.status Base required ObservationStatus 📦4.0.1 FHIR Std.
Observation.category Base required Observation Category Codes 📦4.0.1 FHIR Std.
Observation.code Base required LOINC Codes 📦4.0.1 FHIR Std.
Observation.bodySite Base required SNOMED CT Body Structures 📦4.0.1 FHIR Std.
Observation.method Base required Observation Methods ValueSet 📦0.1.0 This IG

Constraints

Id Grade Path(s) Description Expression
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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation 0..* Observation Measurements and simple assertions
... id S 1..1 id Logical id of this artifact
... meta S 1..1 Meta Metadata about the resource
.... profile S 1..* canonical(StructureDefinition) Profiles this resource claims to conform to.
... identifier S 0..* Identifier Business Identifier for observation
... category S 1..* CodeableConcept Category — default 'laboratory'
Binding: ObservationCategoryCodes (required)
... code S 1..1 CodeableConcept LOINC or local code identifying the morphology observation
Binding: LOINCCodes (required)
... subject S 1..1 Reference(Patient) Who and/or what the observation is about
... focus S 1..* Reference(Condition) The oncology condition this morphology observation relates to
... encounter S 0..1 Reference(Encounter) Healthcare event during which this observation is made
... Slices for effective[x] S 1..1 Clinically relevant time/time-period for observation
Slice: Unordered, Open by type:$this
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effective[x]:effectiveDateTime S 0..1 dateTime Clinically relevant time/time-period for observation
.... effective[x]:effectivePeriod S 0..1 Period Clinically relevant time/time-period for observation
... performer S 1..* Reference(Practitioner | PractitionerRole | Organization) Pathologist or performing lab
... value[x] S 1..1 CodeableConcept ICD-O-3 morphology code or SNOMED CT finding
... bodySite S 0..1 CodeableConcept Observed body part
Binding: SNOMEDCTBodyStructures (required)
... method S 1..1 CodeableConcept Method of morphology determination (biopsy, cytology, etc.)
Binding: Observation Methods ValueSet (required)

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Observation.status Base required ObservationStatus 📦4.0.1 FHIR Std.
Observation.category Base required Observation Category Codes 📦4.0.1 FHIR Std.
Observation.code Base required LOINC Codes 📦4.0.1 FHIR Std.
Observation.bodySite Base required SNOMED CT Body Structures 📦4.0.1 FHIR Std.
Observation.method Base required Observation Methods ValueSet 📦0.1.0 This IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* Observation Measurements and simple assertions
Constraints: obs-6, obs-7
... id SΣ 1..1 id Logical id of this artifact
... meta SΣ 1..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile SΣ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to.
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 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 ?!SΣ 1..1 code Observation status — default 'final'
Binding: ObservationStatus (required)
... category S 1..* CodeableConcept Category — default 'laboratory'
Binding: ObservationCategoryCodes (required)
... code SΣ 1..1 CodeableConcept LOINC or local code identifying the morphology observation
Binding: LOINCCodes (required)
... subject SΣ 1..1 Reference(Patient) Who and/or what the observation is about
... focus SΣ 1..* Reference(Condition) The oncology condition this morphology observation relates to
... encounter SΣ 0..1 Reference(Encounter) Healthcare event during which this observation is made
... Slices for effective[x] SΣ 1..1 Clinically relevant time/time-period for observation
Slice: Unordered, Closed by type:$this
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effective[x]:effectiveDateTime SΣ 0..1 dateTime Clinically relevant time/time-period for observation
.... effective[x]:effectivePeriod SΣ 0..1 Period Clinically relevant time/time-period for observation
... issued Σ 0..1 instant Date/Time this version was made available
... performer SΣ 1..* Reference(Practitioner | PractitionerRole | Organization) Pathologist or performing lab
... value[x] SΣC 1..1 CodeableConcept ICD-O-3 morphology code or SNOMED CT finding
... 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 Observed body part
Binding: SNOMEDCTBodyStructures (required)
... method S 1..1 CodeableConcept Method of morphology determination (biopsy, cytology, etc.)
Binding: Observation Methods ValueSet (required)
... 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
Constraints: obs-3
.... 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(4.0.1) Low Range, if relevant
.... high C 0..1 SimpleQuantity(4.0.1) 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Observation.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Observation.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Observation.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Observation.status Base required ObservationStatus 📦4.0.1 FHIR Std.
Observation.category Base required Observation Category Codes 📦4.0.1 FHIR Std.
Observation.code Base required LOINC Codes 📦4.0.1 FHIR Std.
Observation.dataAbsentReason Base extensible DataAbsentReason 📍4.0.1 FHIR Std.
Observation.interpretation Base extensible Observation Interpretation Codes 📍4.0.1 FHIR Std.
Observation.bodySite Base required SNOMED CT Body Structures 📦4.0.1 FHIR Std.
Observation.method Base required Observation Methods ValueSet 📦0.1.0 This IG
Observation.referenceRange.​type Base preferred Observation Reference Range Meaning Codes 📍4.0.1 FHIR Std.
Observation.referenceRange.​appliesTo Base example Observation Reference Range Applies To Codes 📍4.0.1 FHIR Std.
Observation.component.​code Base example LOINC Codes 📍4.0.1 FHIR Std.
Observation.component.​dataAbsentReason Base extensible DataAbsentReason 📍4.0.1 FHIR Std.
Observation.component.​interpretation Base extensible Observation Interpretation Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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: 10 elements
Must-Support: 17 elements

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Observation.effective[x]

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* Observation Measurements and simple assertions
Constraints: obs-6, obs-7
... id SΣ 1..1 id Logical id of this artifact
... meta SΣ 1..1 Meta Metadata about the resource
.... profile SΣ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to.
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... identifier SΣ 0..* Identifier Business Identifier for observation
... status ?!SΣ 1..1 code Observation status — default 'final'
Binding: ObservationStatus (required)
... category S 1..* CodeableConcept Category — default 'laboratory'
Binding: ObservationCategoryCodes (required)
... code SΣ 1..1 CodeableConcept LOINC or local code identifying the morphology observation
Binding: LOINCCodes (required)
... subject SΣ 1..1 Reference(Patient) Who and/or what the observation is about
... focus SΣ 1..* Reference(Condition) The oncology condition this morphology observation relates to
... encounter SΣ 0..1 Reference(Encounter) Healthcare event during which this observation is made
... Slices for effective[x] SΣ 1..1 Clinically relevant time/time-period for observation
Slice: Unordered, Closed by type:$this
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effective[x]:effectiveDateTime SΣ 0..1 dateTime Clinically relevant time/time-period for observation
.... effective[x]:effectivePeriod SΣ 0..1 Period Clinically relevant time/time-period for observation
... performer SΣ 1..* Reference(Practitioner | PractitionerRole | Organization) Pathologist or performing lab
... value[x] SΣC 1..1 CodeableConcept ICD-O-3 morphology code or SNOMED CT finding
... bodySite S 0..1 CodeableConcept Observed body part
Binding: SNOMEDCTBodyStructures (required)
... method S 1..1 CodeableConcept Method of morphology determination (biopsy, cytology, etc.)
Binding: Observation Methods ValueSet (required)

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Observation.status Base required ObservationStatus 📦4.0.1 FHIR Std.
Observation.category Base required Observation Category Codes 📦4.0.1 FHIR Std.
Observation.code Base required LOINC Codes 📦4.0.1 FHIR Std.
Observation.bodySite Base required SNOMED CT Body Structures 📦4.0.1 FHIR Std.
Observation.method Base required Observation Methods ValueSet 📦0.1.0 This IG

Constraints

Id Grade Path(s) Description Expression
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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation 0..* Observation Measurements and simple assertions
... id S 1..1 id Logical id of this artifact
... meta S 1..1 Meta Metadata about the resource
.... profile S 1..* canonical(StructureDefinition) Profiles this resource claims to conform to.
... identifier S 0..* Identifier Business Identifier for observation
... category S 1..* CodeableConcept Category — default 'laboratory'
Binding: ObservationCategoryCodes (required)
... code S 1..1 CodeableConcept LOINC or local code identifying the morphology observation
Binding: LOINCCodes (required)
... subject S 1..1 Reference(Patient) Who and/or what the observation is about
... focus S 1..* Reference(Condition) The oncology condition this morphology observation relates to
... encounter S 0..1 Reference(Encounter) Healthcare event during which this observation is made
... Slices for effective[x] S 1..1 Clinically relevant time/time-period for observation
Slice: Unordered, Open by type:$this
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effective[x]:effectiveDateTime S 0..1 dateTime Clinically relevant time/time-period for observation
.... effective[x]:effectivePeriod S 0..1 Period Clinically relevant time/time-period for observation
... performer S 1..* Reference(Practitioner | PractitionerRole | Organization) Pathologist or performing lab
... value[x] S 1..1 CodeableConcept ICD-O-3 morphology code or SNOMED CT finding
... bodySite S 0..1 CodeableConcept Observed body part
Binding: SNOMEDCTBodyStructures (required)
... method S 1..1 CodeableConcept Method of morphology determination (biopsy, cytology, etc.)
Binding: Observation Methods ValueSet (required)

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Observation.status Base required ObservationStatus 📦4.0.1 FHIR Std.
Observation.category Base required Observation Category Codes 📦4.0.1 FHIR Std.
Observation.code Base required LOINC Codes 📦4.0.1 FHIR Std.
Observation.bodySite Base required SNOMED CT Body Structures 📦4.0.1 FHIR Std.
Observation.method Base required Observation Methods ValueSet 📦0.1.0 This IG

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* Observation Measurements and simple assertions
Constraints: obs-6, obs-7
... id SΣ 1..1 id Logical id of this artifact
... meta SΣ 1..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile SΣ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to.
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 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 ?!SΣ 1..1 code Observation status — default 'final'
Binding: ObservationStatus (required)
... category S 1..* CodeableConcept Category — default 'laboratory'
Binding: ObservationCategoryCodes (required)
... code SΣ 1..1 CodeableConcept LOINC or local code identifying the morphology observation
Binding: LOINCCodes (required)
... subject SΣ 1..1 Reference(Patient) Who and/or what the observation is about
... focus SΣ 1..* Reference(Condition) The oncology condition this morphology observation relates to
... encounter SΣ 0..1 Reference(Encounter) Healthcare event during which this observation is made
... Slices for effective[x] SΣ 1..1 Clinically relevant time/time-period for observation
Slice: Unordered, Closed by type:$this
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effective[x]:effectiveDateTime SΣ 0..1 dateTime Clinically relevant time/time-period for observation
.... effective[x]:effectivePeriod SΣ 0..1 Period Clinically relevant time/time-period for observation
... issued Σ 0..1 instant Date/Time this version was made available
... performer SΣ 1..* Reference(Practitioner | PractitionerRole | Organization) Pathologist or performing lab
... value[x] SΣC 1..1 CodeableConcept ICD-O-3 morphology code or SNOMED CT finding
... 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 Observed body part
Binding: SNOMEDCTBodyStructures (required)
... method S 1..1 CodeableConcept Method of morphology determination (biopsy, cytology, etc.)
Binding: Observation Methods ValueSet (required)
... 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
Constraints: obs-3
.... 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(4.0.1) Low Range, if relevant
.... high C 0..1 SimpleQuantity(4.0.1) 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Observation.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Observation.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Observation.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Observation.status Base required ObservationStatus 📦4.0.1 FHIR Std.
Observation.category Base required Observation Category Codes 📦4.0.1 FHIR Std.
Observation.code Base required LOINC Codes 📦4.0.1 FHIR Std.
Observation.dataAbsentReason Base extensible DataAbsentReason 📍4.0.1 FHIR Std.
Observation.interpretation Base extensible Observation Interpretation Codes 📍4.0.1 FHIR Std.
Observation.bodySite Base required SNOMED CT Body Structures 📦4.0.1 FHIR Std.
Observation.method Base required Observation Methods ValueSet 📦0.1.0 This IG
Observation.referenceRange.​type Base preferred Observation Reference Range Meaning Codes 📍4.0.1 FHIR Std.
Observation.referenceRange.​appliesTo Base example Observation Reference Range Applies To Codes 📍4.0.1 FHIR Std.
Observation.component.​code Base example LOINC Codes 📍4.0.1 FHIR Std.
Observation.component.​dataAbsentReason Base extensible DataAbsentReason 📍4.0.1 FHIR Std.
Observation.component.​interpretation Base extensible Observation Interpretation Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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: 10 elements
Must-Support: 17 elements

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Observation.effective[x]

 

Other representations of profile: CSV, Excel, Schematron