Resumen Digital de Atención en Salud (RDA)
0.7.2 - STU1
Colombia
Resumen Digital de Atención en Salud (RDA) - Local Development build (v0.7.2) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Canonical URL: https://fhir.minsalud.gov.co/rda/StructureDefinition/ObservationClarificationNoteRDA | Version: 0.7.2 | |||
| Active as of 2025-12-29 | Computable Name: ObservationClarificationNoteRDA | |||
Copyright/Legal: Ministerio de Salud y Protección Social, CC BY-NC-SA 4.0, 2025+ |
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Perfil FHIR de notas aclaratorias, para su intercambio en un documento RDA en Colombia.
Una nota aclaratoria en la historia clínica es una anotación formal para corregir, ampliar o explicar información errónea o incompleta en un registro anterior, asegurando la integridad y exactitud del registro clínico, sin borrar lo escrito, y siempre priorizando la seguridad del paciente y la transparencia, indicando claramente el motivo de la corrección.
Las notas aclaratorias son vitales para la precisión y legalidad de la Historia Clínica, debiendo ser diligenciadas siguiendo los principios de claridad, veracidad y confidencialidad establecidos por la normativa colombiana, especialmente para sistemas digitales.
El perfil ObservationClarificationNoteRDA define las restricciones y extensiones aplicables al recurso Observation para representar la nota aclaratoria sobre un documento RDA (Composition), previamente enviado a la plataforma de interoperabilidad de Historia Clínica Electrónica en Colombia.
El recurso Observation en FHIR se utiliza para registrar mediciones, evaluaciones o aserciones clínicas. En este caso, se adapta para registrar una Nota aclaratoria.
Este perfil forma parte del Resumen Digital de Atención (RDA) y contribuye a la interoperabilidad de la información ocupacional en el ecosistema de salud colombiano.
Observation siguiendo el perfil descrito en esta página.Bundle tipo transaction que contenga los recursos Observation correspondientes. Ver ejemplo de Bundle con notas aclaratorias.
Este perfil define las restricciones y extensiones aplicables al recurso Observation, con el objetivo de representar una nota aclaratoria posterior al reporte de un encuentro de atención en salud.
Se aplica dentro del contexto de la interoperabilidad de la Historia Clínica Electrónica en Colombia, particularmente en el escenario de intercambio del Resumen Digital de Atención (RDA).
Ha sido diseñado a partir de los lineamientos normativos definidos por el Ministerio de Salud y Protección Social, y está armonizado con la Guía de Implementación FHIR Core Colombia.
Este perfil está diseñado para ser implementado por:
Se espera que sea utilizado principalmente en el escenario de intercambio del Resumen Digital de Atención (RDA).
En Colombia, la normativa sobre notas aclaratorias clínicas se basa en la integridad y claridad de la historia clínica, regida principalmente por la Resolución 1995 de 1999 y el Decreto 441 de 2022, junto con la Ley Estatutaria 1581 de 2012 (protección de datos) y la Ley 2015 de 2020 (HCE), exigiendo que las notas sean legibles, sin tachones, con fecha, hora, nombre y firma, y que las aclaraciones se hagan sin borrar lo anterior, sino complementando o corrigiendo, usando formatos específicos para asegurar la trazabilidad y transparencia, fundamentales para la continuidad de la atención y auditorías.
Este perfil se basa en:
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Path | Conformance | ValueSet / Code | URI |
| Observation.status | required | Fixed Value: finalhttp://hl7.org/fhir/ValueSet/observation-status|4.0.1From the FHIR Standard | |
| Observation.code | example | LOINCCodes(a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesFrom the FHIR Standard | |
| Observation.component.code | example | LOINCCodes(a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesFrom 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 Filter: ![]() ![]() |
|---|---|---|---|---|
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0..* | Observation | Measurements and simple assertions | |
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1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to Fixed Value: https://fhir.minsalud.gov.co/rda/StructureDefinition/ObservationClarificationNoteRDA | |
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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1..1 | code | registered | preliminary | final | amended + Fixed Value: final | |
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0..0 | |||
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1..1 | CodeableConcept | Tipo de observación | |
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1..1 | Coding | Sistema de codificación para el tipo de observación | |
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1..1 | uri | Sistema de codificación Fixed Value: http://snomed.info/sct | |
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1..1 | code | Código de la observación Fixed Value: 445664008 | |
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1..1 | string | Descripción del código de la observación Fixed Value: informe enmendado | |
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1..1 | string | Texto descriptivo del tipo de observación Fixed Value: Nota aclaratoria | |
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S | 1..1 | Reference(Paciente (Patient) RDA) | Paciente asociado a la observación |
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1..* | Reference(Resource) | Recurso focal de la nota aclaratoria Slice: Unordered, Open by value:id | |
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1..1 | Reference(Resumen Digital de Atención en Salud de Consulta (RDA Consulta) | Resumen Digital de Atención en Salud de Urgencias (RDA Urgencias) | Resumen Digital de Atención en Salud de Hospitalización (RDA Hospitalización)) | Referencia al documento RDA (Composition) del evento de atención | |
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1..1 | string | Unique id for inter-element referencing Fixed Value: CompositionRDA | |
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S | 0..1 | string | Literal reference, Relative, internal or absolute URL |
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0..* | Reference(Diagnóstico de condición de salud (Condition) RDA | Alergia o intolerancia (AllergyIntolerance) RDA | Administración de medicamentos (MedicationAdministration) RDA | Prescripción de Medicamentos (MedicationRequest) RDA | Prescripción de administración de medicamentos (MedicationRequest) RDA | Procedimiento realizado (Procedure) RDA | Procedimiento realizado (Procedure) RDA | Incapacidad (Observation) RDA | Ocupación del paciente en el momento del encuentro de atención (Observation) RDA | Factor de riesgo (RiskAssessment) RDA | Resultado de procedimiento (Observation) RDA | Orden de procedimiento o tecnología en salud (ServiceRequest) RDA | Recurso (Resource) RDA | Clasificación del Triage durante el encuentro de atención de urgencias (Observation) RDA) | Referencia a otros recursos FHIR | |
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1..1 | string | Unique id for inter-element referencing Required Pattern: Resource-1 | |
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S | 0..1 | string | Literal reference, Relative, internal or absolute URL |
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S | 0..1 | Reference(Encuentro de atención de urgencias en salud (Encounter) RDA | Encuentro de hospitalización (Encounter) RDA | Encuentro de atención ambulatoria (Encounter) RDA) | Encuentro de atención en salud asociado a la observación |
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S | 1..1 | dateTime | Fecha y hora de la nota aclaratoria |
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0..0 | |||
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1..1 | Reference(Profesional de salud (Practitioner) RDA) | Profesional de salud que realiza la nota aclaratoria | |
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S | 0..1 | string | Literal reference, Relative, internal or absolute URL |
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S | 1..1 | string | Texto de la nota aclaratoria |
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
|---|---|---|---|---|---|---|---|---|
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C | 0..* | Observation | Measurements and simple assertions Constraints: obs-6, obs-7 | ||||
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Σ | 0..1 | id | Logical id of this artifact | ||||
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Σ | 0..1 | Meta | Metadata about the resource | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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Σ | 0..1 | id | Version specific identifier | ||||
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Σ | 0..1 | instant | When the resource version last changed | ||||
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Σ | 0..1 | uri | Identifies where the resource comes from | ||||
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Σ | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to Fixed Value: https://fhir.minsalud.gov.co/rda/StructureDefinition/ObservationClarificationNoteRDA | ||||
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Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
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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". | ||||
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?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
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0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
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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 | |||||
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0..* | Resource | Contained, inline Resources | |||||
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?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: final | ||||
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Σ | 1..1 | CodeableConcept | Tipo de observación Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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Σ | 1..1 | Coding | Sistema de codificación para el tipo de observación | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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Σ | 1..1 | uri | Sistema de codificación Fixed Value: http://snomed.info/sct | ||||
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Σ | 0..1 | string | Version of the system - if relevant | ||||
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Σ | 1..1 | code | Código de la observación Fixed Value: 445664008 | ||||
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Σ | 1..1 | string | Descripción del código de la observación Fixed Value: informe enmendado | ||||
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Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
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Σ | 1..1 | string | Texto descriptivo del tipo de observación Fixed Value: Nota aclaratoria | ||||
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SΣ | 1..1 | Reference(Paciente (Patient) RDA) | Paciente asociado a la observación | ||||
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Σ | 1..* | Reference(Resource) | Recurso focal de la nota aclaratoria Slice: Unordered, Open by value:id | ||||
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Σ | 1..1 | Reference(Resumen Digital de Atención en Salud de Consulta (RDA Consulta) | Resumen Digital de Atención en Salud de Urgencias (RDA Urgencias) | Resumen Digital de Atención en Salud de Hospitalización (RDA Hospitalización)) | Referencia al documento RDA (Composition) del evento de atención | ||||
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1..1 | string | Unique id for inter-element referencing Fixed Value: CompositionRDA | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
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Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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Σ | 0..* | Reference(Diagnóstico de condición de salud (Condition) RDA | Alergia o intolerancia (AllergyIntolerance) RDA | Administración de medicamentos (MedicationAdministration) RDA | Prescripción de Medicamentos (MedicationRequest) RDA | Prescripción de administración de medicamentos (MedicationRequest) RDA | Procedimiento realizado (Procedure) RDA | Procedimiento realizado (Procedure) RDA | Incapacidad (Observation) RDA | Ocupación del paciente en el momento del encuentro de atención (Observation) RDA | Factor de riesgo (RiskAssessment) RDA | Resultado de procedimiento (Observation) RDA | Orden de procedimiento o tecnología en salud (ServiceRequest) RDA | Recurso (Resource) RDA | Clasificación del Triage durante el encuentro de atención de urgencias (Observation) RDA) | Referencia a otros recursos FHIR | ||||
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1..1 | string | Unique id for inter-element referencing Required Pattern: Resource-1 | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
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Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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SΣ | 0..1 | Reference(Encuentro de atención de urgencias en salud (Encounter) RDA | Encuentro de hospitalización (Encounter) RDA | Encuentro de atención ambulatoria (Encounter) RDA) | Encuentro de atención en salud asociado a la observación | ||||
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SΣ | 1..1 | dateTime | Fecha y hora de la nota aclaratoria | ||||
![]() ![]() |
Σ | 1..1 | Reference(Profesional de salud (Practitioner) RDA) | Profesional de salud que realiza la nota aclaratoria | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() |
SΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
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Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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SΣC | 1..1 | string | Texto de la nota aclaratoria | ||||
Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Observation.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsFrom the FHIR Standard | ||||
| Observation.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tagsFrom the FHIR Standard | ||||
| Observation.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesFrom the FHIR Standard
| ||||
| Observation.status | required | Fixed Value: finalhttp://hl7.org/fhir/ValueSet/observation-status|4.0.1From the FHIR Standard | ||||
| Observation.code | example | LOINCCodes(a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesFrom the FHIR Standard | ||||
| Observation.focus:CompositionRDA.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesFrom the FHIR Standard | ||||
| Observation.focus:Resource.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesFrom the FHIR Standard | ||||
| Observation.performer.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesFrom the FHIR Standard | ||||
| Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaningFrom the FHIR Standard | ||||
| Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliestoFrom the FHIR Standard | ||||
| Observation.component.code | example | LOINCCodes(a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesFrom the FHIR Standard | ||||
| Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonFrom the FHIR Standard | ||||
| Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationFrom 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
Summary
Mandatory: 12 elements(2 nested mandatory elements)
Must-Support: 7 elements
Fixed: 7 elements
Prohibited: 18 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Key Elements View
| Path | Conformance | ValueSet / Code | URI |
| Observation.status | required | Fixed Value: finalhttp://hl7.org/fhir/ValueSet/observation-status|4.0.1From the FHIR Standard | |
| Observation.code | example | LOINCCodes(a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesFrom the FHIR Standard | |
| Observation.component.code | example | LOINCCodes(a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesFrom 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 Filter: ![]() ![]() |
|---|---|---|---|---|
![]() |
0..* | Observation | Measurements and simple assertions | |
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||||
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1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to Fixed Value: https://fhir.minsalud.gov.co/rda/StructureDefinition/ObservationClarificationNoteRDA | |
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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1..1 | code | registered | preliminary | final | amended + Fixed Value: final | |
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0..0 | |||
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1..1 | CodeableConcept | Tipo de observación | |
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1..1 | Coding | Sistema de codificación para el tipo de observación | |
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1..1 | uri | Sistema de codificación Fixed Value: http://snomed.info/sct | |
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1..1 | code | Código de la observación Fixed Value: 445664008 | |
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1..1 | string | Descripción del código de la observación Fixed Value: informe enmendado | |
![]() ![]() ![]() |
1..1 | string | Texto descriptivo del tipo de observación Fixed Value: Nota aclaratoria | |
![]() ![]() |
S | 1..1 | Reference(Paciente (Patient) RDA) | Paciente asociado a la observación |
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1..* | Reference(Resource) | Recurso focal de la nota aclaratoria Slice: Unordered, Open by value:id | |
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1..1 | Reference(Resumen Digital de Atención en Salud de Consulta (RDA Consulta) | Resumen Digital de Atención en Salud de Urgencias (RDA Urgencias) | Resumen Digital de Atención en Salud de Hospitalización (RDA Hospitalización)) | Referencia al documento RDA (Composition) del evento de atención | |
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1..1 | string | Unique id for inter-element referencing Fixed Value: CompositionRDA | |
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S | 0..1 | string | Literal reference, Relative, internal or absolute URL |
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0..* | Reference(Diagnóstico de condición de salud (Condition) RDA | Alergia o intolerancia (AllergyIntolerance) RDA | Administración de medicamentos (MedicationAdministration) RDA | Prescripción de Medicamentos (MedicationRequest) RDA | Prescripción de administración de medicamentos (MedicationRequest) RDA | Procedimiento realizado (Procedure) RDA | Procedimiento realizado (Procedure) RDA | Incapacidad (Observation) RDA | Ocupación del paciente en el momento del encuentro de atención (Observation) RDA | Factor de riesgo (RiskAssessment) RDA | Resultado de procedimiento (Observation) RDA | Orden de procedimiento o tecnología en salud (ServiceRequest) RDA | Recurso (Resource) RDA | Clasificación del Triage durante el encuentro de atención de urgencias (Observation) RDA) | Referencia a otros recursos FHIR | |
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1..1 | string | Unique id for inter-element referencing Required Pattern: Resource-1 | |
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S | 0..1 | string | Literal reference, Relative, internal or absolute URL |
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S | 0..1 | Reference(Encuentro de atención de urgencias en salud (Encounter) RDA | Encuentro de hospitalización (Encounter) RDA | Encuentro de atención ambulatoria (Encounter) RDA) | Encuentro de atención en salud asociado a la observación |
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S | 1..1 | dateTime | Fecha y hora de la nota aclaratoria |
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0..0 | |||
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1..1 | Reference(Profesional de salud (Practitioner) RDA) | Profesional de salud que realiza la nota aclaratoria | |
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S | 0..1 | string | Literal reference, Relative, internal or absolute URL |
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S | 1..1 | string | Texto de la nota aclaratoria |
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
|---|---|---|---|---|---|---|---|---|
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C | 0..* | Observation | Measurements and simple assertions Constraints: obs-6, obs-7 | ||||
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Σ | 0..1 | id | Logical id of this artifact | ||||
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Σ | 0..1 | Meta | Metadata about the resource | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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Σ | 0..1 | id | Version specific identifier | ||||
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Σ | 0..1 | instant | When the resource version last changed | ||||
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Σ | 0..1 | uri | Identifies where the resource comes from | ||||
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Σ | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to Fixed Value: https://fhir.minsalud.gov.co/rda/StructureDefinition/ObservationClarificationNoteRDA | ||||
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Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
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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". | ||||
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?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
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0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
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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 | |||||
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0..* | Resource | Contained, inline Resources | |||||
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?!Σ | 1..1 | code | registered | preliminary | final | amended + Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: final | ||||
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Σ | 1..1 | CodeableConcept | Tipo de observación Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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Σ | 1..1 | Coding | Sistema de codificación para el tipo de observación | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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Σ | 1..1 | uri | Sistema de codificación Fixed Value: http://snomed.info/sct | ||||
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Σ | 0..1 | string | Version of the system - if relevant | ||||
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Σ | 1..1 | code | Código de la observación Fixed Value: 445664008 | ||||
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Σ | 1..1 | string | Descripción del código de la observación Fixed Value: informe enmendado | ||||
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Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
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Σ | 1..1 | string | Texto descriptivo del tipo de observación Fixed Value: Nota aclaratoria | ||||
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SΣ | 1..1 | Reference(Paciente (Patient) RDA) | Paciente asociado a la observación | ||||
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Σ | 1..* | Reference(Resource) | Recurso focal de la nota aclaratoria Slice: Unordered, Open by value:id | ||||
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Σ | 1..1 | Reference(Resumen Digital de Atención en Salud de Consulta (RDA Consulta) | Resumen Digital de Atención en Salud de Urgencias (RDA Urgencias) | Resumen Digital de Atención en Salud de Hospitalización (RDA Hospitalización)) | Referencia al documento RDA (Composition) del evento de atención | ||||
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1..1 | string | Unique id for inter-element referencing Fixed Value: CompositionRDA | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
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Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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Σ | 0..* | Reference(Diagnóstico de condición de salud (Condition) RDA | Alergia o intolerancia (AllergyIntolerance) RDA | Administración de medicamentos (MedicationAdministration) RDA | Prescripción de Medicamentos (MedicationRequest) RDA | Prescripción de administración de medicamentos (MedicationRequest) RDA | Procedimiento realizado (Procedure) RDA | Procedimiento realizado (Procedure) RDA | Incapacidad (Observation) RDA | Ocupación del paciente en el momento del encuentro de atención (Observation) RDA | Factor de riesgo (RiskAssessment) RDA | Resultado de procedimiento (Observation) RDA | Orden de procedimiento o tecnología en salud (ServiceRequest) RDA | Recurso (Resource) RDA | Clasificación del Triage durante el encuentro de atención de urgencias (Observation) RDA) | Referencia a otros recursos FHIR | ||||
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1..1 | string | Unique id for inter-element referencing Required Pattern: Resource-1 | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
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Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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SΣ | 0..1 | Reference(Encuentro de atención de urgencias en salud (Encounter) RDA | Encuentro de hospitalización (Encounter) RDA | Encuentro de atención ambulatoria (Encounter) RDA) | Encuentro de atención en salud asociado a la observación | ||||
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SΣ | 1..1 | dateTime | Fecha y hora de la nota aclaratoria | ||||
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Σ | 1..1 | Reference(Profesional de salud (Practitioner) RDA) | Profesional de salud que realiza la nota aclaratoria | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
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Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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SΣC | 1..1 | string | Texto de la nota aclaratoria | ||||
Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Observation.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsFrom the FHIR Standard | ||||
| Observation.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tagsFrom the FHIR Standard | ||||
| Observation.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesFrom the FHIR Standard
| ||||
| Observation.status | required | Fixed Value: finalhttp://hl7.org/fhir/ValueSet/observation-status|4.0.1From the FHIR Standard | ||||
| Observation.code | example | LOINCCodes(a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesFrom the FHIR Standard | ||||
| Observation.focus:CompositionRDA.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesFrom the FHIR Standard | ||||
| Observation.focus:Resource.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesFrom the FHIR Standard | ||||
| Observation.performer.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesFrom the FHIR Standard | ||||
| Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodeshttp://hl7.org/fhir/ValueSet/referencerange-meaningFrom the FHIR Standard | ||||
| Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodeshttp://hl7.org/fhir/ValueSet/referencerange-appliestoFrom the FHIR Standard | ||||
| Observation.component.code | example | LOINCCodes(a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesFrom the FHIR Standard | ||||
| Observation.component.dataAbsentReason | extensible | DataAbsentReasonhttp://hl7.org/fhir/ValueSet/data-absent-reasonFrom the FHIR Standard | ||||
| Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationFrom 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
Summary
Mandatory: 12 elements(2 nested mandatory elements)
Must-Support: 7 elements
Fixed: 7 elements
Prohibited: 18 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron