Arbeitsgruppe WeST
Version 1.0.0-kommentierung - ci-build

Resource Profile: KBV_PR_WEST_Observation_Anamnese

Official URL: https://fhir.kbv.de/StructureDefinition/KBV_PR_WEST_Observation_Anamnese Version: 1.0.0-kommentierung
Draft as of 2026-03-11 Computable Name: KBV_PR_WEST_Observation_Anamnese

Copyright/Legal: Im folgenden Profil können Codes aus den Code-Systemen SNOMED CT®, LOINC, Ucum, ATC, ICD-10-GM, ICD-10-WHO, OPS, Alpha-ID/Alpha-ID-SE und ICF enthalten sein, die dem folgenden Urheberrecht unterliegen: This material includes SNOMED CT® Clinical Terms® (SNOMED CT® CT®) which is used by permission of SNOMED CT® International. All rights reserved. SNOMED CT® CT®, was originally created by The College of American Pathologists. SNOMED CT® and SNOMED CT® CT are registered trademarks of SNOMED CT® International. Implementers of these artefacts must have the appropriate SNOMED CT® CT Affiliate license. This material contains content from LOINC (http://LOINC.org). LOINC is copyright © 1995-2020, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license at http://LOINC.org/license. LOINC® is a registered United States trademark of Regenstrief Institute, Inc. This product includes all or a portion of the UCUM table, UCUM codes, and UCUM definitions or is derived from it, subject to a license from Regenstrief Institute, Inc. and The UCUM Organization. Your use of the UCUM table, UCUM codes, UCUM definitions also is subject to this license, a copy of which is available at http://unitsofmeasure.org. The current complete UCUM table, UCUM Specification are available for download at http://unitsofmeasure.org. The UCUM table and UCUM codes are copyright © 1995-2009, Regenstrief Institute, Inc. and the Unified Codes for Units of Measures (UCUM) Organization. All rights reserved. THE UCUM TABLE (IN ALL FORMATS), UCUM DEFINITIONS, AND SPECIFICATION ARE PROVIDED ‘AS IS.’ ANY EXPRESS OR IMPLIED WARRANTIES ARE DISCLAIMED, INCLUDING, BUT NOT LIMITED TO, THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. Dieses Material enthält Inhalte aus ATC. Die Erstellung erfolgte unter Verwendung der Datenträger der amtlichen Fassung der ATC-Klassifikation mit DDD des Bundesinstituts für Arzneimittel und Medizinprodukte (BfArM). Dieses Material enthält Inhalte aus ICD-10-GM, ICD-10-WHO, OPS Alpha-ID ans Alpha-ID-SE. Die Erstellung erfolgt unter Verwendung der maschinenlesbaren Fassung des Bundesinstituts für Arzneimittel und Medizinprodukte (BfArM). Dieses Material enthält Inhalte aus ICF. Die Erstellung erfolgt unter Verwendung der maschinenlesbaren Fassung des Deutschen Instituts für Medizinische Dokumentation und Information (DIMDI). ICF-Kodes, -Begriffe und -Texte © Weltgesundheitsorganisation, übersetzt und herausgegeben durch das Deutsche Institut für Medizinische Dokumentation und Information von der International classification of functioning, disability and health - ICF, herausgegeben durch die Weltgesundheitsorganisation.

In dieser Ressource wird die generische Form einer Anamnese abgebilet.

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(4.0.1) Anamnese
Constraints: obs-6, obs-7
... id Σ 1..1 id Logical id of this artifact
... meta SΣ 1..1 Meta Metadata about the resource
.... Slices for profile SΣ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
Slice: Unordered, Open by value:$this
..... profile:mioProfile SΣ 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to

Fixed Value: https://fhir.kbv.de/StructureDefinition/KBV_PR_WEST_Observation_Anamnese|1.0.0-kommentierung
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... status ?!SΣ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.
Fixed Value: final
... code SΣ 1..1 CodeableConcept Observation Anamnese
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... Slices for coding SΣ 1..2 Coding Code defined by a terminology system
Slice: Unordered, Closed by value:system
..... coding:snomed SΣ 1..1 Coding Code defined by a terminology system
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: 365854008
...... display SΣ 0..1 string Representation defined by the system
Required Pattern: History finding
..... coding:loinc SΣ 0..1 Coding Code defined by a terminology system
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: 10164-2
...... display SΣ 0..1 string Representation defined by the system
Required Pattern: History of Present illness Narrative
... subject SΣ 1..1 Reference(KBV_PR_WEST_Patient(1.0.0-kommentierung)) Patientenbezug
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
... encounter SΣ 0..1 Reference(KBV_PR_WEST_Encounter(1.0.0-kommentierung)) Begegnung
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
... Slices for effective[x] SΣ 0..1 dateTime Clinically relevant time/time-period for observation
Slice: Unordered, Closed by type:$this
.... effective[x]:effectiveDateTime Σ 0..1 dateTime Aufnahmezeitpunkt
... performer Σ 0..* Reference(KBV_PR_WEST_Practitioner(1.0.0-kommentierung) | KBV_PR_WEST_PractitionerRole(1.0.0-kommentierung)) Who is responsible for the observation
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... Slices for value[x] SΣC 1..1 string Actual result
Slice: Unordered, Closed by type:$this
.... value[x]:valueString SΣC 1..1 string Beschreibung

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Observation.status Base required ObservationStatus 📍4.0.1 FHIR Std.
Observation.code Base example LOINC Codes 📍4.0.1 FHIR Std.
Observation.component.​code Base example LOINC 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-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(4.0.1) Anamnese
... id 1..1 id Logical id of this artifact
... meta S 1..1 Meta Metadata about the resource
.... versionId 0..0 Version specific identifier
.... lastUpdated 0..0 When the resource version last changed
.... source 0..0 Identifies where the resource comes from
.... Slices for profile S 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
Slice: Unordered, Open by value:$this
..... profile:mioProfile S 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to
Fixed Value: https://fhir.kbv.de/StructureDefinition/KBV_PR_WEST_Observation_Anamnese|1.0.0-kommentierung
... text 0..0 Text summary of the resource, for human interpretation
... identifier 0..0 Business Identifier for observation
... basedOn 0..0 Fulfills plan, proposal or order
... partOf 0..0 Part of referenced event
... status S 1..1 code registered | preliminary | final | amended +
Fixed Value: final
... category 0..0 Classification of type of observation
... code S 1..1 CodeableConcept Observation Anamnese
.... Slices for coding S 1..2 Coding Code defined by a terminology system
Slice: Unordered, Closed by value:system
..... coding:snomed S 1..1 Coding Code defined by a terminology system
...... system S 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... code S 1..1 code Symbol in syntax defined by the system
Fixed Value: 365854008
...... display S 0..1 string Representation defined by the system
Required Pattern: History finding
...... userSelected 0..0 If this coding was chosen directly by the user
..... coding:loinc S 0..1 Coding Code defined by a terminology system
...... system S 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... code S 1..1 code Symbol in syntax defined by the system
Fixed Value: 10164-2
...... display S 0..1 string Representation defined by the system
Required Pattern: History of Present illness Narrative
...... userSelected 0..0 If this coding was chosen directly by the user
.... text 0..0 Plain text representation of the concept
... subject S 1..1 Reference(KBV_PR_WEST_Patient(1.0.0-kommentierung)) Patientenbezug
.... reference S 1..1 string Literal reference, Relative, internal or absolute URL
.... type 0..0 Type the reference refers to (e.g. "Patient")
.... identifier 0..0 Logical reference, when literal reference is not known
.... display 0..0 Text alternative for the resource
... focus 0..0 What the observation is about, when it is not about the subject of record
... encounter S 0..1 Reference(KBV_PR_WEST_Encounter(1.0.0-kommentierung)) Begegnung
.... reference S 1..1 string Literal reference, Relative, internal or absolute URL
.... type 0..0 Type the reference refers to (e.g. "Patient")
.... identifier 0..0 Logical reference, when literal reference is not known
.... display 0..0 Text alternative for the resource
... Slices for effective[x] S 0..1 dateTime Clinically relevant time/time-period for observation
Slice: Unordered, Closed by type:$this
.... effective[x]:effectiveDateTime 0..1 dateTime Aufnahmezeitpunkt
... issued 0..0 Date/Time this version was made available
... performer 0..* Reference(KBV_PR_WEST_Practitioner(1.0.0-kommentierung) | KBV_PR_WEST_PractitionerRole(1.0.0-kommentierung)) Who is responsible for the observation
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... type 0..0 Type the reference refers to (e.g. "Patient")
.... identifier 0..0 Logical reference, when literal reference is not known
.... display 0..0 Text alternative for the resource
... Slices for value[x] S 1..1 string Actual result
Slice: Unordered, Closed by type:$this
.... value[x]:valueString S 1..1 string Beschreibung
... dataAbsentReason 0..0 Why the result is missing
... interpretation 0..0 High, low, normal, etc.
... note 0..0 Comments about the observation
... bodySite 0..0 Observed body part
... method 0..0 How it was done
... specimen 0..0 Specimen used for this observation
... device 0..0 (Measurement) Device
... referenceRange 0..0 Provides guide for interpretation
... hasMember 0..0 Related resource that belongs to the Observation group
... derivedFrom 0..0 Related measurements the observation is made from
... component 0..0 Component results

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* Observation(4.0.1) Anamnese
Constraints: obs-6, obs-7
... id Σ 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
.... Slices for profile SΣ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
Slice: Unordered, Open by value:$this
..... profile:mioProfile SΣ 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to

Fixed Value: https://fhir.kbv.de/StructureDefinition/KBV_PR_WEST_Observation_Anamnese|1.0.0-kommentierung
.... 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
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.
Fixed Value: final
... code SΣ 1..1 CodeableConcept Observation Anamnese
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 1..2 Coding Code defined by a terminology system
Slice: Unordered, Closed by value:system
..... coding:snomed SΣ 1..1 Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: 365854008
...... display SΣ 0..1 string Representation defined by the system
Required Pattern: History finding
..... coding:loinc SΣ 0..1 Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: 10164-2
...... display SΣ 0..1 string Representation defined by the system
Required Pattern: History of Present illness Narrative
... subject SΣ 1..1 Reference(KBV_PR_WEST_Patient(1.0.0-kommentierung)) Patientenbezug
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
... encounter SΣ 0..1 Reference(KBV_PR_WEST_Encounter(1.0.0-kommentierung)) Begegnung
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
... Slices for effective[x] SΣ 0..1 dateTime Clinically relevant time/time-period for observation
Slice: Unordered, Closed by type:$this
.... effective[x]:effectiveDateTime Σ 0..1 dateTime Aufnahmezeitpunkt
... performer Σ 0..* Reference(KBV_PR_WEST_Practitioner(1.0.0-kommentierung) | KBV_PR_WEST_PractitionerRole(1.0.0-kommentierung)) Who is responsible for the observation
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... Slices for value[x] SΣC 1..1 string Actual result
Slice: Unordered, Closed by type:$this
.... value[x]:valueString SΣC 1..1 string Beschreibung

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.code Base example LOINC Codes 📍4.0.1 FHIR Std.
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-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(4 nested mandatory elements)
Must-Support: 21 elements
Fixed: 6 elements
Prohibited: 33 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Observation.meta.profile
  • The element 1 is sliced based on the value of Observation.code.coding (Closed)
  • The element 1 is sliced based on the value of Observation.effective[x] (Closed)
  • The element 1 is sliced based on the value of Observation.value[x] (Closed)

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* Observation(4.0.1) Anamnese
Constraints: obs-6, obs-7
... id Σ 1..1 id Logical id of this artifact
... meta SΣ 1..1 Meta Metadata about the resource
.... Slices for profile SΣ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
Slice: Unordered, Open by value:$this
..... profile:mioProfile SΣ 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to

Fixed Value: https://fhir.kbv.de/StructureDefinition/KBV_PR_WEST_Observation_Anamnese|1.0.0-kommentierung
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... status ?!SΣ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.
Fixed Value: final
... code SΣ 1..1 CodeableConcept Observation Anamnese
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... Slices for coding SΣ 1..2 Coding Code defined by a terminology system
Slice: Unordered, Closed by value:system
..... coding:snomed SΣ 1..1 Coding Code defined by a terminology system
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: 365854008
...... display SΣ 0..1 string Representation defined by the system
Required Pattern: History finding
..... coding:loinc SΣ 0..1 Coding Code defined by a terminology system
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: 10164-2
...... display SΣ 0..1 string Representation defined by the system
Required Pattern: History of Present illness Narrative
... subject SΣ 1..1 Reference(KBV_PR_WEST_Patient(1.0.0-kommentierung)) Patientenbezug
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
... encounter SΣ 0..1 Reference(KBV_PR_WEST_Encounter(1.0.0-kommentierung)) Begegnung
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
... Slices for effective[x] SΣ 0..1 dateTime Clinically relevant time/time-period for observation
Slice: Unordered, Closed by type:$this
.... effective[x]:effectiveDateTime Σ 0..1 dateTime Aufnahmezeitpunkt
... performer Σ 0..* Reference(KBV_PR_WEST_Practitioner(1.0.0-kommentierung) | KBV_PR_WEST_PractitionerRole(1.0.0-kommentierung)) Who is responsible for the observation
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... Slices for value[x] SΣC 1..1 string Actual result
Slice: Unordered, Closed by type:$this
.... value[x]:valueString SΣC 1..1 string Beschreibung

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Observation.status Base required ObservationStatus 📍4.0.1 FHIR Std.
Observation.code Base example LOINC Codes 📍4.0.1 FHIR Std.
Observation.component.​code Base example LOINC 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-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(4.0.1) Anamnese
... id 1..1 id Logical id of this artifact
... meta S 1..1 Meta Metadata about the resource
.... versionId 0..0 Version specific identifier
.... lastUpdated 0..0 When the resource version last changed
.... source 0..0 Identifies where the resource comes from
.... Slices for profile S 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
Slice: Unordered, Open by value:$this
..... profile:mioProfile S 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to
Fixed Value: https://fhir.kbv.de/StructureDefinition/KBV_PR_WEST_Observation_Anamnese|1.0.0-kommentierung
... text 0..0 Text summary of the resource, for human interpretation
... identifier 0..0 Business Identifier for observation
... basedOn 0..0 Fulfills plan, proposal or order
... partOf 0..0 Part of referenced event
... status S 1..1 code registered | preliminary | final | amended +
Fixed Value: final
... category 0..0 Classification of type of observation
... code S 1..1 CodeableConcept Observation Anamnese
.... Slices for coding S 1..2 Coding Code defined by a terminology system
Slice: Unordered, Closed by value:system
..... coding:snomed S 1..1 Coding Code defined by a terminology system
...... system S 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... code S 1..1 code Symbol in syntax defined by the system
Fixed Value: 365854008
...... display S 0..1 string Representation defined by the system
Required Pattern: History finding
...... userSelected 0..0 If this coding was chosen directly by the user
..... coding:loinc S 0..1 Coding Code defined by a terminology system
...... system S 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... code S 1..1 code Symbol in syntax defined by the system
Fixed Value: 10164-2
...... display S 0..1 string Representation defined by the system
Required Pattern: History of Present illness Narrative
...... userSelected 0..0 If this coding was chosen directly by the user
.... text 0..0 Plain text representation of the concept
... subject S 1..1 Reference(KBV_PR_WEST_Patient(1.0.0-kommentierung)) Patientenbezug
.... reference S 1..1 string Literal reference, Relative, internal or absolute URL
.... type 0..0 Type the reference refers to (e.g. "Patient")
.... identifier 0..0 Logical reference, when literal reference is not known
.... display 0..0 Text alternative for the resource
... focus 0..0 What the observation is about, when it is not about the subject of record
... encounter S 0..1 Reference(KBV_PR_WEST_Encounter(1.0.0-kommentierung)) Begegnung
.... reference S 1..1 string Literal reference, Relative, internal or absolute URL
.... type 0..0 Type the reference refers to (e.g. "Patient")
.... identifier 0..0 Logical reference, when literal reference is not known
.... display 0..0 Text alternative for the resource
... Slices for effective[x] S 0..1 dateTime Clinically relevant time/time-period for observation
Slice: Unordered, Closed by type:$this
.... effective[x]:effectiveDateTime 0..1 dateTime Aufnahmezeitpunkt
... issued 0..0 Date/Time this version was made available
... performer 0..* Reference(KBV_PR_WEST_Practitioner(1.0.0-kommentierung) | KBV_PR_WEST_PractitionerRole(1.0.0-kommentierung)) Who is responsible for the observation
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... type 0..0 Type the reference refers to (e.g. "Patient")
.... identifier 0..0 Logical reference, when literal reference is not known
.... display 0..0 Text alternative for the resource
... Slices for value[x] S 1..1 string Actual result
Slice: Unordered, Closed by type:$this
.... value[x]:valueString S 1..1 string Beschreibung
... dataAbsentReason 0..0 Why the result is missing
... interpretation 0..0 High, low, normal, etc.
... note 0..0 Comments about the observation
... bodySite 0..0 Observed body part
... method 0..0 How it was done
... specimen 0..0 Specimen used for this observation
... device 0..0 (Measurement) Device
... referenceRange 0..0 Provides guide for interpretation
... hasMember 0..0 Related resource that belongs to the Observation group
... derivedFrom 0..0 Related measurements the observation is made from
... component 0..0 Component results

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* Observation(4.0.1) Anamnese
Constraints: obs-6, obs-7
... id Σ 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
.... Slices for profile SΣ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
Slice: Unordered, Open by value:$this
..... profile:mioProfile SΣ 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to

Fixed Value: https://fhir.kbv.de/StructureDefinition/KBV_PR_WEST_Observation_Anamnese|1.0.0-kommentierung
.... 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
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.
Fixed Value: final
... code SΣ 1..1 CodeableConcept Observation Anamnese
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 1..2 Coding Code defined by a terminology system
Slice: Unordered, Closed by value:system
..... coding:snomed SΣ 1..1 Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: 365854008
...... display SΣ 0..1 string Representation defined by the system
Required Pattern: History finding
..... coding:loinc SΣ 0..1 Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: 10164-2
...... display SΣ 0..1 string Representation defined by the system
Required Pattern: History of Present illness Narrative
... subject SΣ 1..1 Reference(KBV_PR_WEST_Patient(1.0.0-kommentierung)) Patientenbezug
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
... encounter SΣ 0..1 Reference(KBV_PR_WEST_Encounter(1.0.0-kommentierung)) Begegnung
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
... Slices for effective[x] SΣ 0..1 dateTime Clinically relevant time/time-period for observation
Slice: Unordered, Closed by type:$this
.... effective[x]:effectiveDateTime Σ 0..1 dateTime Aufnahmezeitpunkt
... performer Σ 0..* Reference(KBV_PR_WEST_Practitioner(1.0.0-kommentierung) | KBV_PR_WEST_PractitionerRole(1.0.0-kommentierung)) Who is responsible for the observation
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... Slices for value[x] SΣC 1..1 string Actual result
Slice: Unordered, Closed by type:$this
.... value[x]:valueString SΣC 1..1 string Beschreibung

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.code Base example LOINC Codes 📍4.0.1 FHIR Std.
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-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(4 nested mandatory elements)
Must-Support: 21 elements
Fixed: 6 elements
Prohibited: 33 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Observation.meta.profile
  • The element 1 is sliced based on the value of Observation.code.coding (Closed)
  • The element 1 is sliced based on the value of Observation.effective[x] (Closed)
  • The element 1 is sliced based on the value of Observation.value[x] (Closed)

 

Other representations of profile: CSV, Excel, Schematron