Standard Health Record FHIR Implementation Guide

Profiles defined as part of this Guide

SHR Namespace Name Based On Definition
Actor EmergencyContact CareTeam A personal contact specifically designated to be used for emergencies.
Actor NoPrimaryCareProvider CareTeam The medical professional responsible for first-line care of an individual.
Actor Organization Organization A social or legal structure formed by human beings.
Actor Practitioner Practitioner A person who practices a healing art.
Actor PrimaryCareProvider CareTeam The medical professional responsible for first-line care of an individual.
Actor ProviderRelationship CareTeam A person or organization responsible for providing a service to the person of record. Such a relationship can exist without a specific encounter or services being rendered; for example, an emergency contact relationship can exist without ever calling upon that person. The entry can also be used to state that a provider relationship does not exist, e.g., patient does not have a primary care provider.
Actor RelatedPerson RelatedPerson A person, other than a practitioner or the patient (the person of record) who is relevant to the health or social situation of the subject.
Adverse AdverseEvent AdverseEvent Any unfavorable and unintended sign, symptom, disease, or other medical occurrence with a temporal association with the use of a medical product, procedure or other therapy, or in conjunction with a research study, regardless of causal relationship. EXAMPLE(S): death, back pain, headache, pulmonary embolism, heart attack.
Adverse AdverseReaction AdverseEvent Any noxious and unintended response to a medical product, procedure, or other intervention, for which a causal relationship to an intervention is at least a reasonable possibility i.e., the relationship cannot be ruled out. The AssessmentFocus is one or more observations, typically the symptoms of the adverse reaction, such as severe nausea or elevated liver enyzmes.
Allergy AllergyIntolerance AllergyIntolerance A statement pertaining to an individual's allergies and intolerances to substances or classes of substances. Can be used to record that a substance does not pose an elevated risk to the subject (AssertionNegationModifier = true).
Allergy DrugAllergy AllergyIntolerance An immune or biochemical adverse reaction to a medication.
Allergy FoodAllergy AllergyIntolerance An immune or biochemical adverse reaction to a food substance.
Allergy NoKnownAllergy AllergyIntolerance The subject has no known allergies to drugs, foods, biologics, or environmental factors.
Allergy NoKnownDrugAllergy AllergyIntolerance The subject has no known allergies to any medications.
Allergy NoKnownEnvironmentalAllergy AllergyIntolerance The subject has no known allergies to any environmental factors.
Allergy NoKnownFoodAllergy AllergyIntolerance The subject has no known allergies to any foods.
Assessment Assessment ClinicalImpression A conclusion (tentative or final) resulting from synthesis of evidence (one or more observations). An Assessment is a judgment rendered at a point in time. A diagnosis is a type of Assessment that can lead to creation of a Condition.
Base Entry DomainResource An item inserted in an electronic record.
Base Narrative Narrative A human-readable narrative, potentially including images, that contains a summary of the resource, and may be used to represent the content of the resource to a human.
Base Study ResearchStudy A clinical trial or other formal study.
Behavior AlcoholUse Observation The history of the subject's use of alcohol.
Behavior BehavioralObservation Observation A statement about observable responses, actions, or activities of the subject. Can be used to assert or deny behaviors.
Behavior DietAndNutrition Observation The usual food and drink consumed by an individual.
Behavior DietNutritionConcern Observation An anxiety or worry about the diet or nutritional intake of the subject.
Behavior ExerciseHoursPerWeek Observation Hours of moderate or vigorous activity per week.
Behavior HasSufficientFood Observation Frequency that the person of record unable to obtain food to stay hunger.
Behavior HoursSleepPerNight Observation Typical hours spent sleeping per night.
Behavior IntravenousDrugUse Observation Records whether the subject injects recreational drugs.
Behavior NicotineUse Observation Records the history of a subject's use of nicotine.
Behavior ONCSmokingStatus Observation Records the subject's use of tobacco.
Behavior PhysicalActivityLevel Observation The amount of exercise or other physical activity compared to others of the same age. See BMC Medical Research Methodology 2012 12:20 1471-2288.
Behavior PhysicalActivityLimitation Observation Anything that limits physical activity, including health factors, logistical, monetary, or social restrictions.
Behavior Religion Observation
Behavior ReligiousCongregation Observation A group of place of religious practice.
Behavior ReligiousPractice Observation The religion practiced by the focal subject.
Behavior ReligiousPracticeStatus Observation The extent to which the religious practice is actively followed.
Behavior ReligiousRestriction Observation Any restriction on that derives from religion and may impact medical treatment, other than dietary (handled elsewhere).
Behavior SleepQuality Observation Self-reported sleep quality.
Behavior SleepQualityReason Observation Reason for poor sleep quality.
Behavior SpecialDietFollowed Observation A type of nutritional plan followed by the subject.
Behavior SubstanceAbuseTreatment Procedure The treatment program used to address a substance abuse problem.
Behavior SubstanceUse Observation Assertion concerning the past or current use of a substance (alcohol, recreational drugs, illegal drugs, or abuse of prescription medication) that could negatively impact the subject's health.
Behavior TroubleFallingAsleep Observation How often the subject has trouble falling asleep.
Behavior TroubleStayingAsleep Observation How often the subject has trouble staying asleep.
Behavior ViolentBehaviorRisk Observation Risk or danger posed by the focal subject to others and/or his or herself due to violent behavior.
Behavior ViolentRiskToOthers Observation Risk or danger posed by the focal subject to others.
Behavior ViolentRiskToSelf Observation Risk or danger posed by the focal subject to his or herself.
Behavior WakeFeelingRested Observation How often the subject feels rested when they wake up.
Careplan CarePlan CarePlan Describes how one or more practitioners intend to deliver care for a particular patient, group or community for a period of time, possibly limited to care for a specific condition or set of conditions.
Careplan Goal Goal A broad statement about what should be accomplished and the progress towards that goal. It represents the intended long-term outcome toward which an individual or a group aspires, and toward which, effort is directed, in the form of activities.
Careplan Objective Goal Describes the of an expected or desired achievement that is well-defined, specific, measurable, and derived from one or more goals. There are similarities with Observation, since an objective can sometimes be interpreted as a yet-to-be-made, future observation with a certain target result.
Condition AcademicProblem Condition A problem with learning or behavior in a learning environment.
Condition Asplenia Condition Congenital absence of spleen.
Condition Condition Condition A representation of a disorder, abnormality, problem, injury, complaint, risk, functionality, concern, illness, disease, ailment, sickness, affliction, upset, difficulty, disorder, symptom, worry, or trouble. Condition can be used to track a problem or a risk over a period of time. By virtue of its continuity over time, Condition is different from an Observation or Assessment; Observations represents evidence, and an Assessment is a judgment based on evidence and rendered at a point in time. Diagnosis is a type of Assessment that can lead to creation of a Condition (as can an assessment of risk). The two relate because observations can lead to conclusion that a Condition exists. A statement that a certain condition does not exist should be an assessment. Not all conditions are problems, but all problems are (in some sense) conditions.
Condition Injury Condition Damage inflicted on the body by an external force.
Condition MentalHealthCondition Condition A condition relating to a person’s psychological and emotional well-being.
Core Address Address An address expressed using postal conventions (as opposed to GPS or other location definition formats). This data type may be used to convey addresses for use in delivering mail as well as for visiting locations and which might not be valid for mail delivery. There are a variety of postal address formats defined around the world. (Source: HL7 FHIR).
Core Age Age How long something has existed (quantitative).
Core AgeRange Range A quantitative range of ages. One of the two ages must be specified.
Core Annotation Annotation A text note which also contains information about who made the statement and when.
Core BodySite BodySite A location in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
Core CodeableConcept CodeableConcept A set of codes drawn from different coding systems, representing the same concept.
Core Coding Coding Coding of a concept, drawn from a controlled vocabulary. Includes the vocabulary and version, if applicable. May include a display text, and a descriptor expressing the intended interpretation of the code.
Core DollarAmount Quantity An amount of money expressed in US dollars.
Core Duration Duration The length of time that something continues.
Core EffectiveTimePeriod Period The date and time span for which something is active, valid, or in force.
Core GeopoliticalLocation Address The countries of the world and major geopolitical subregions, such as US states.
Core Geoposition Location The location on the surface of the Earth, described by a latitude and longitude (and optional altitude).
Core HumanName HumanName A name used by a human being, written as it would be typically expressed. May include a breakdown of the various elements of the name (family name, given name, etc.).
Core Identifier Identifier A unique string that identifies a specific person or thing.
Core LowerBound Quantity A measured or measurable amount with units that is known to be bounded from below by the quantity represented.
Core OrganizationalIdentifier Identifier Unique identifier of something or someone, assigned by an organization, and potentially effective for only a limited time period.
Core PeriodOfUse Period A period of time when a device, medication, or other therapy is used.
Core Quantity Quantity A quantity with units.
Core Range Range An interval defined by an upper and/or lower bound. One of the two bounds must be specified, and the lower bound must be less than the upper bound.
Core Ratio Ratio A unit of measurement for the quotient of the amount of one entity to another.
Core Statistic Quantity A quantity that represents a statistic, e.g. maximum, minimum, mean, median, etc.
Core TimePeriod Period A period of time defined by a start and end time, date, or year.
Core UnitedStatesAddress Address An address for a place in the USA, conforming to US mail postal conventions. (Source: HL7 FHIR).
Core UpperBound Quantity A measured or measurable amount with units that is known to be bounded from above by the quantity represented.
Demographics HealthInsurance Coverage Health insurance coverage available (even if not used for payment for a given encounter).
Demographics HomeTelephoneNumber ContactPoint A telephone number associated with a person's residence.
Demographics PersonOfRecord Patient Extended demographic information about the subject of this SHR.
Demographics Telecom ContactPoint An electronic means of contacting an organization or individual.
Demographics TelephoneNumber ContactPoint A sequence of decimal digits (0-9) that is used for identifying a destination telephone line or other device in a telephone network.
Demographics WorkTelephoneNumber ContactPoint A telephone number associated with a person's residence.
Device Device Device A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Device DeviceUse DeviceUseStatement A statement pertaining to the use of a device by a subject. May document the use of a device, or that the subject does not use a particular type of device.
Encounter Encounter Encounter A statement about a planned or actual interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.
Encounter Facility Location Services and space and equipment provided for a particular purpose; a building or place that provides a particular service or is used for a particular industry. Could be a clinical site, community site, or a mobile facility.
Environment AnimalExposure Observation The type of animals or pets the subject is exposed to.
Environment AnnualIncome Observation The amount of earnings made by a family unit in one year, estimated or self-reported.
Environment CanAffordChildCare Observation How often can the subject afford child care?
Environment CanAffordClothing Observation How often can the subject afford clothing?
Environment CanAffordDentalCare Observation How often can the subject afford dental care?
Environment CanAffordFood Observation How often can the subject afford food?
Environment CanAffordHousing Observation How often can the subject afford housing?
Environment CanAffordMedication Observation How often can the subject afford medications?
Environment CanAffordTransportation Observation How often can the subject afford transportation?
Environment CanAffordUtilities Observation How often can the subject afford utilities?
Environment Coinhabitant Observation A person living with the subject.
Environment DomesticViolence Observation Whether the subject experiences domestic violence.
Environment EmotionalSafety Observation Whether the subject feels physically safe in the subject's home environment.
Environment EnvironmentalExposures Observation
Environment ExposureToSubstance Observation A statement about exposure to a substance, type of substance, or disease vector potentially affecting health, including pollutants, blood products, pets, recreational drugs, sexual transmitted diseases, foods, toxins, pathogens, or prenatal exposures to teratogens. Can be used to assert or deny such exposures.
Environment FinancialSituation Observation Measures of the ability of the subject to obtain and pay for the necessities of life.
Environment HomeEnvironmentRisk Observation A risk experienced in the home environment.
Environment HouseholdSituation Observation Information about the makeup of the household of the subject.
Environment HouseholdSize Observation The number of people living together with mutual financial dependency. Besides the subject, the household size may include spouse or partner, dependent children including adopted and foster children, dependent parents, dependent siblings and other relatives, but not roommates, ex-spouses, non-dependent children, and unborn children. If the subject lives alone, the household size is 1.
Environment HousingSecurity Observation Whether the subject is at-risk of losing their housing or in a stable housing situation.
Environment IncomeSource Observation Where the household income comes from.
Environment IncomeStability Observation Whether the subject regards his or her source of income as dependable.
Environment NonCashBenefit Observation Government benefits received by the focal subject, other than cash benefits.
Environment NumberOfDependents Observation The number of dependents supported by the subject.
Environment PhysicalSafety Observation How often the subject feels physically safe in the subject's home environment.
Environment SocialEnvironment Observation Factors affecting the health of the subject in their daily living environment.
Environment TransportationAvailability Observation Whether the subject has reliable transportation to bring him or her to medical appointments and to get medications.
Immunization Immunization Immunization A statement relating to a vaccination that was or was not administered to the subject.
Immunization ImmunizationAdministered Immunization Represents an immunization that was administered to the subject.
Immunization ImmunizationNotGiven Immunization Represents an immunization that was not given.
Lab HIVScreeningTest Observation The result of an HIV Screening Test.
Lab HIVScreeningTestRequest ProcedureRequest A request for a rapid HIV screening test.
Lab HIVSupplementalTest Observation The result of a supplement HIV test, following up an initial screening.
Lab HIVSupplementalTestRequest ProcedureRequest A request for a confirmatory or additional test for HIV infection.
Lab Test Observation A laboratory, radiologic, or other clinical test or measurement used to determine the presence, absence, or degree of a condition, or assess the function or health of an individual. This includes patient-generated data, such as pedometer readings.
Lab TestRequest ProcedureRequest A record of a request (order) for a test to be performed.
Lifehistory CongenitalAbnormality Observation Any abnormality, genetic, anatomical, biochemical, evident at birth or during the neonatal period. Includes malformations, deformations, and chromosomal abnormalities.
Lifehistory EducationalAttainment Observation Educational attainment or level of education of individuals.
Lifehistory Employment Observation Engagement in an activity or service for profit, wages, salary, or as a service to others.
Lifehistory MilitaryService Observation History of service in the US military.
Lifehistory MilitaryStatus Observation The current connection to the US military.
Lifehistory Occupation Observation The principal activity that a person does to earn money, specifying the job performed by the subject, for example, accountant, programmer analyst, patient care associate, staff nurse, etc.
Lifehistory PrenatalExposure Observation Fetal contact with a dangerous substance via the mother.
Lifehistory Travel Observation Trip to a foreign country or an area, particularly when a health risk is involved.
Medication MaximumDosePerTimePeriod Ratio The maximum amount of a medication to be taken in a given period of time.
Medication Medication Medication A type of prescription drug or over-the-counter drug that is used to prevent, treat, or relieve symptoms of a disease or abnormal condition, but excluding vaccines.
Medication MedicationChange Basic Description of a modification or change of a medication or dosage.
Medication MedicationNotAdministered MedicationStatement A record of a medication NOT administered. Recorded when deviating from the care plan.
Medication MedicationNotPrescribed MedicationRequest A record of a medication NOT prescribed. Recorded only when deviating from the normal expectation, care plan, or standard of care.
Medication MedicationPrescription MedicationRequest Report of a medication prescription.
Medication MedicationRegimen Basic Use or application of over-the-counter and prescribed/recommended medications and infusions to meet guidelines for therapeutic action, safety, and schedule.
Medication MedicationUse MedicationStatement Report of a medication actually being used (or not used). Medication use is either reported, directly observed, or inferred from clinical events associated with orders, prescriptions written, pharmacy dispensings, procedural administrations, and other patient-reported information.
Observation BodyStructureObservation Observation Observation of the existence (or non-existence) distinct anatomical or pathological morphological feature or organizational pattern, acquired or innate. Examples include tissue types, tumors, and wounds. The observation has a body site that allows the the structure to be located in the body. The observation identifier allows other observations of the same body structure to be related to QualitativeValueScaleVSthis observation and tracked over time.
Observation Manifestation Observation A complaint or observed indication that a person has a condition or disease. Some examples of symptoms are headache, fever, fatigue, nausea, vomiting, and pain.
Observation Observation Observation An Observation represents evidence, both subjective and objective. Observation includes any information about a subject that results from an act of observing, measuring, or evaluation. The focus of an observation can include the subject's behavior, physiological state, health state, functional status, environment, exposures to substances, etc. An Observation contains information about the act of observing or measuring, and the result of the observation. The method of observing can vary widely, from questioning, physical examination, formal assessment vehicles, laboratory tests, imaging procedures, etc. Patient-reported information is also considered an observation, where subject and observer are the same individual.
Observation Panel Observation A grouped set of related observations, frequently captured at the same time. An example is a complete blood count (CBC), with separate observations for hemoglobin, hematocrit, etc. Could represent the content of a diagnostic report, such as a pathology report. Typically the Category and Reason are not given for individual observations that are part of the panel, but rather given at the level of the panel itself. The panel and all its sub-observations share the same metadata (provenance).
Observation SocialHistory Observation The external elements and conditions which surround, influence, and affect the life and development of the subject. Includes social conditions such as poverty, violence, bullying.
Oncology BRCA1Variant Observation Whether the patient has a mutation in the BRCA1 gene.
Oncology BRCA2Variant Observation Whether the patient has a mutation in the BRCA2 gene.
Oncology BreastCancer Condition A cancer originating in the tissues of the breast, and potentially spread to other organs of the body.
Oncology BreastCancerGeneticAnalysis Observation The status of genes known or suspected to play a role in breast cancer risk, for example, the tumor suppressor genes, BRCA1 and BRCA2.
Oncology BreastCancerReceptorStatus Observation Immunohistochemistry (IHC) assessment for estrogen receptor (ER) and progesterone receptor (PR) as well as IHC or in situ hybridization (ISH) determination of human epidermal growth factor receptor 2 (HER2) status
Oncology CancerGrowthPotential Observation Information relating to rate of cell growth or proportion of cancer cells within the tumor that are growing and dividing to form new cancer cells.
Oncology CancerLymphaticInvolvement Observation Whether or not lymph nodes contain cancer cells.
Oncology EstrogenReceptorStatus Observation Estrogen receptor alpha is the predominant estrogen receptor expressed in breast tissue and is overexpressed in around 50% of breast carcinomas. ER status (positive=present or overexpressed; negative=absent) is a factor in determining prognosis and treatment options.
Oncology GeneticVariant Observation Whether the patient carries a mutation in a particular gene.
Oncology HistologicGrade Observation The Elston Grade/Nottingham Score, representative of the aggressive potential of the tumor. Well differentiated (Grade 1) look similar to normal cells and are usually slow growing, while poorly differentiated cells (Grade 3) look very different than normal and are fast-growing.
Oncology HumanEpiduralGrowthFactorReceptor2Status Observation HER2 is a member of the human epidermal growth factor receptor family of proteins and is encoded by the ERBB2 oncogene. HER2 is overexpressed in 20-30% of breast tumors,10 and is associated with an aggressive clinical course and poor prognosis. HER2 status (positive=present or overexpressed; negative=absent) is a factor in determining prognosis and treatment options.
Oncology LymphaticSystemSubdivision BodySite A lymph node area or nodal group; a subdivision of the entire lymphatic system. For breast cancer, this includes 5 areas: internal mammary lymph nodes, axillary lymph nodes level I, II, and III, and the supraclavicular lymph nodes.
Oncology NeoplasmObservation Observation Observation of a unusual growth, for example, a tumor. The body site allows the abnormality to be located and identified. The abnormality identifier allows the tumor to be tracked over time.
Oncology PrimaryTumorSite BodySite The location of the primary tumor.
Oncology ProgesteroneReceptorStatus Observation Progesterone receptor is expressed in 65% of breast carcinomas. PR status (positive=present or overexpressed; negative=absent) is a factor in determining prognosis and treatment options.
Oncology Progression ClinicalImpression A finding related to the current trend of a disease. This concept is most often used for chronic and incurable diseases where the status and trendline of the disease is an important determinant of therapy and prognosis. The specific disorder being evaluated must be cited in the AssessmentFocus as a reference to a Condition.
Oncology ReceptorStatusObservation Observation Refers to the presence or absence of specific receptor molecules on the surface of a cells in a specimen.
Oncology TNMStage Observation The stage of a cancer, assessed according to the standard established by American Joint Committee on Cancer (AJCC). TNM Stage Grouping categorizes the progression of cancer using the Roman Numeral system. See Table 140 in HL7 CDA® R2 Implementation Guide: Clinical Oncology Treatment Plan and Summary, Release 1 - US Realm
Oncology ToxicReaction AdverseEvent An adverse reaction to medication, radiation treatment, or other therapy, that causes grade 3 or 4 adverse reaction.
Oncology TumorSize Observation Measurement of the longest diameter of a tumor, in situ or on a excised tumor. See CDISC Table 3.3.2
Procedure Procedure Procedure An action that is or was performed on a patient. This can be a physical intervention like an operation, or less invasive like counseling or hypnotherapy.
Sex ContraceptiveMethodRecommendation Basic The contraceptive method(s) recommended or prescribed by a provider, after counseling and assessment. More than one method can be selected, if applicable. .
Sex ContraceptiveMethodUsed Observation A contraceptive method used by the subject.
Sex ContraceptiveUse Observation Whether the subject uses contaceptives, and the method or methods of contraception used.
Sex CurrentPregnancyStatus Observation Whether or not the subject is currently pregnant.
Sex GenderIdentity Observation Subjective personal perception of one's own gender, which can be male, female, a blend of both, or neither.
Sex IntercourseDifficulty Observation Condition affecting sexual intercourse.
Sex NumberOfLivingChildren Observation Number of living children.
Sex NumberOfPreviousPregnancies Observation Number of previous pregnancies.
Sex NumberOfSexualPartnersPastYear Observation Number of sexual partners in past year.
Sex PregnancyHistory Observation Information about current and past pregnancies.
Sex PregnancyIntention Observation Whether the subject or his/her partner has a plan or desire to either become pregnant or have a child in the next year/near future.
Sex SexualActivity Observation Characterization of the sexual activity of the subject.
Sex SexualBehavior Observation Experience with sexual intercourse.
Sex SexualIdentity Observation Information on gender identity and sexual orientation.
Sex SexualOrientation Observation An inherent and enduring emotional, romantic or sexual attraction to other people.
Skin PressureUlcer Condition A single pressure ulcer, tracked over a period of time. Multiple PressureUlcerAssessments (at different times) may be associated with a single PressureUlcer.
Skin PressureUlcerManifestation Observation Observation regarding the properties and severity of a single pressure ulcer.
Skin SupportSurface Device A specific instance of a support surface used to distribute pressure and support a patient. The value is coding of the type of support surface.
Skin SupportSurfaceEmployed DeviceUseStatement A paricular instance of the use of a support surface in patient care.
Vital BloodPressure Observation The force of circulating blood on the walls of the arteries.
Vital BodyHeight Observation The distance from the sole to the crown of the head.
Vital BodyLength Observation The distance from the sole of the foot to the crown of the head, lying down (typically 0-2 years).
Vital BodyMassIndex Observation A general indicator of the body fat an individual is carrying based upon the ratio of weight to height.
Vital BodyTemperature Observation The measure of the level of heat in a human or animal.
Vital BodyWeight Observation The mass or quantity of heaviness of an individual. Does not include estimates of fetal bodyweight.
Vital HeadCircumference Observation Circumference of the head (typically 0-2 years).
Vital HeartRate Observation The number of times the heart ventricles contract per unit of time, usually per minute.
Vital OxygenSaturation Observation Oxygen saturation in Arterial blood by Pulse oximetry.
Vital RespiratoryRate Observation The rate of breathing (inhalation and exhalation) measured within in a unit time, expressed as breaths per minute.
Vital VitalSign Observation