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Finding

The SHR Finding domain contains basic definitions used to capture subjective and objective information about the subject. Things observed about the subject can include demographic facts, history, subjective and objective observations, assessments, and judgments, excluding actual or potential interventions, and range from simple answered questions to vital signs and laboratory results.

ApplicableAgeRange

The age at which this reference range is applicable. This is a neonatal age (e.g. number of weeks at term) if the meaning says so.

Value:  Range An interval defined by a quantitative upper and/or lower bound. One of the two bounds must be specified, and the lower bound must be less than the upper bound. When Quantities are specified, the units of measure must be the same.

ApplicableSubpopulation

Codes to indicate the target population this reference range applies to. For example, a reference range may be based on the normal population or a particular sex or race. Target Population (C0039309)

Value:  CodeableConcept from http://hl7.org/fhir/ValueSet/referencerange-appliesto (if covered) A set of codes drawn from different coding systems, representing the same concept.

Assertion [Entry]

A unary observation, also known as an assertion, is an observation that takes the form of a single code, without an explicit question or property. Examples include reported symptoms such as 'chest pain' and simple reports such as 'bed in low position'. Assertions may be negated using the NegationFlag; if true, the assertion is taken as false. The question code is defaulted to 'assertion' since an assertion has no explicit question. Assertions may include a body site.

Based On Observation

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.
ObservationCode is Not applicable (385432009) required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason not used Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
Specimen not used Sample for analysis
Device not used 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.
ReferenceRange not used The usual or acceptable range for a test result.
NegationFlag optional A flag that indicates the meaning to be conveyed is the logical opposite of the current assertion. The assertion is negated only when the NegationIndicator is true. If absent or false, the assertion is not negated.
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category (if covered) 0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Components optional Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

ChangeFlag

Indicator of significant change (delta) from the last or previous measurement. C1705241

Value:  CodeableConcept must be from ChangeFlagVS A set of codes drawn from different coding systems, representing the same concept.

ClinicallyRelevantTime

The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).

Value:  Choice
         |  dateTime required
         |  TimePeriod required A period of time defined by a start and end time, date, or year. If the start element is missing, the start of the period is not known. If the end element is missing, it means that the period is ongoing, or the start may be in the past, and the end date in the future, which means that period is expected/planned to end at the specified time. The end value includes any matching date/time. For example, the period 2011-05-23 to 2011-05-27 includes all the times from the start of the 23rd May through to the end of the 27th of May.
         |  Timing required A timing schedule that specifies an event that may occur multiple times. Timing offers a choice of multiple OccurrenceTime (used is used to specify specific times), or recurrence patterns.

Components

Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.

Value:  ObservationComponent A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.

Evidence

A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.

Value:  Choice
         |  CodeableConcept required A set of codes drawn from different coding systems, representing the same concept.
         |  Content required A item that can constitute the payload of an Entry, aka an EntryElement.

Finding [Abstract]

Base class for assertions and observations. The subject of a finding can be the entire patient, or an entity such as a location body structure, intervention, or condition. Things observed about the subject can include social and behavioral factors, subjective and objective observations, and assessments.

Based On Content

Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical or assessment vehicle.
FindingStatus optional Indicates whether the finding is preliminary, amended, final, etc..
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

FindingMethod

The technique used to create the finding, for example, the specific imaging technical or assessment vehicle.

Value:  Choice
         |  string required
         |  CodeableConcept required A set of codes drawn from different coding systems, representing the same concept.
         |  ProcedurePerformed required

FindingStatus

Indicates whether the finding is preliminary, amended, final, etc..

Value:  CodeableConcept must be from http://hl7.org/fhir/ValueSet/observation-status A set of codes drawn from different coding systems, representing the same concept.

Interpretation

A clinical interpretation of a finding. C0420833

Value:  CodeableConcept must be from http://hl7.org/fhir/ValueSet/observation-interpretation A set of codes drawn from different coding systems, representing the same concept.

Members

Members represent the elements of a group of a related observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author.

Value:  Observation Parent class for subjective or objective findings about a subject. An observation includes direct results of seeing, measuring, or evaluating. The method of observing can vary widely, and include measurement, direct questioning, physical examination, laboratory tests, and imaging procedures. Patient-generated data are also considered observations.

NegationFlag

A flag that indicates the meaning to be conveyed is the logical opposite of the current assertion. The assertion is negated only when the NegationIndicator is true. If absent or false, the assertion is not negated. C1518422

Value:  boolean

Observation [Entry]

Parent class for subjective or objective findings about a subject. An observation includes direct results of seeing, measuring, or evaluating. The method of observing can vary widely, and include measurement, direct questioning, physical examination, laboratory tests, and imaging procedures. Patient-generated data are also considered observations. C1554188

Based On Finding

Value:  Choice
         |  Quantity required A quantity with units, whose value may be bounded from above or below, as defined in FHIR
         |  CodeableConcept required A set of codes drawn from different coding systems, representing the same concept.
         |  string required
         |  boolean required
         |  Range required An interval defined by a quantitative upper and/or lower bound. One of the two bounds must be specified, and the lower bound must be less than the upper bound. When Quantities are specified, the units of measure must be the same.
         |  Ratio required A unit of measurement for the quotient of the amount of one entity to another.
         |  Attachment required A file that contains audio, video, image, or similar content.
         |  time required
         |  dateTime required
         |  TimePeriod required A period of time defined by a start and end time, date, or year. If the start element is missing, the start of the period is not known. If the end element is missing, it means that the period is ongoing, or the start may be in the past, and the end date in the future, which means that period is expected/planned to end at the specified time. The end value includes any matching date/time. For example, the period 2011-05-23 to 2011-05-27 includes all the times from the start of the 23rd May through to the end of the 27th of May.
         |  IntegerQuantity required A Quantity that is an integer.
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category (if covered) 0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
Specimen optional Sample for analysis
Device optional 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.
ReferenceRange 0 or more The usual or acceptable range for a test result.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Components optional Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

ObservationCode

A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'. C1706203

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.

ObservationComponent

A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.

Value:  Choice
         |  Quantity required A quantity with units, whose value may be bounded from above or below, as defined in FHIR
         |  CodeableConcept required A set of codes drawn from different coding systems, representing the same concept.
         |  string required
         |  Range required An interval defined by a quantitative upper and/or lower bound. One of the two bounds must be specified, and the lower bound must be less than the upper bound. When Quantities are specified, the units of measure must be the same.
         |  Ratio required A unit of measurement for the quotient of the amount of one entity to another.
         |  Attachment required A file that contains audio, video, image, or similar content.
         |  time required
         |  dateTime required
         |  TimePeriod required A period of time defined by a start and end time, date, or year. If the start element is missing, the start of the period is not known. If the end element is missing, it means that the period is ongoing, or the start may be in the past, and the end date in the future, which means that period is expected/planned to end at the specified time. The end value includes any matching date/time. For example, the period 2011-05-23 to 2011-05-27 includes all the times from the start of the 23rd May through to the end of the 27th of May.
         |  IntegerQuantity required A Quantity that is an integer.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Components optional Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.

ObservationQualifier

A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar. C1443279

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.

Panel [Entry]

A grouped set of related findings, frequently captured at the same time. An example is a complete blood count (CBC), with separate observations for hemoglobin, hematocrit, etc. Typically the Category and Reason are not given for individual findings 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).

Based On Observation

Value:  Choice
         |  Quantity required A quantity with units, whose value may be bounded from above or below, as defined in FHIR
         |  CodeableConcept required A set of codes drawn from different coding systems, representing the same concept.
         |  string required
         |  boolean required
         |  Range required An interval defined by a quantitative upper and/or lower bound. One of the two bounds must be specified, and the lower bound must be less than the upper bound. When Quantities are specified, the units of measure must be the same.
         |  Ratio required A unit of measurement for the quotient of the amount of one entity to another.
         |  Attachment required A file that contains audio, video, image, or similar content.
         |  time required
         |  dateTime required
         |  TimePeriod required A period of time defined by a start and end time, date, or year. If the start element is missing, the start of the period is not known. If the end element is missing, it means that the period is ongoing, or the start may be in the past, and the end date in the future, which means that period is expected/planned to end at the specified time. The end value includes any matching date/time. For example, the period 2011-05-23 to 2011-05-27 includes all the times from the start of the 23rd May through to the end of the 27th of May.
         |  IntegerQuantity required A Quantity that is an integer.
Components not used Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.
Members required Members represent the elements of a group of a related observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author.
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category (if covered) 0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
Specimen optional Sample for analysis
Device optional 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.
ReferenceRange 0 or more The usual or acceptable range for a test result.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

QuestionAnswer [Entry]

A question-answer or property-value pair, regarding a subject (aka an object-attribute-value triple). A QuestionAnswer is a simplified observation that does not involve a specimen, device, or reference range.

Based On Observation

Value:  Choice
         |  Quantity required A quantity with units, whose value may be bounded from above or below, as defined in FHIR
         |  CodeableConcept required A set of codes drawn from different coding systems, representing the same concept.
         |  string required
         |  boolean required
         |  Range required An interval defined by a quantitative upper and/or lower bound. One of the two bounds must be specified, and the lower bound must be less than the upper bound. When Quantities are specified, the units of measure must be the same.
         |  Ratio required A unit of measurement for the quotient of the amount of one entity to another.
         |  Attachment required A file that contains audio, video, image, or similar content.
         |  time required
         |  dateTime required
         |  TimePeriod required A period of time defined by a start and end time, date, or year. If the start element is missing, the start of the period is not known. If the end element is missing, it means that the period is ongoing, or the start may be in the past, and the end date in the future, which means that period is expected/planned to end at the specified time. The end value includes any matching date/time. For example, the period 2011-05-23 to 2011-05-27 includes all the times from the start of the 23rd May through to the end of the 27th of May.
         |  IntegerQuantity required A Quantity that is an integer.
Specimen not used Sample for analysis
Device not used 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.
ReferenceRange not used The usual or acceptable range for a test result.
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category (if covered) 0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Components optional Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

QuestionAnswerPanel [Entry]

A panel whose members are QuestionAnswer.

Based On Panel

Value:  Choice
         |  Quantity required A quantity with units, whose value may be bounded from above or below, as defined in FHIR
         |  CodeableConcept required A set of codes drawn from different coding systems, representing the same concept.
         |  string required
         |  boolean required
         |  Range required An interval defined by a quantitative upper and/or lower bound. One of the two bounds must be specified, and the lower bound must be less than the upper bound. When Quantities are specified, the units of measure must be the same.
         |  Ratio required A unit of measurement for the quotient of the amount of one entity to another.
         |  Attachment required A file that contains audio, video, image, or similar content.
         |  time required
         |  dateTime required
         |  TimePeriod required A period of time defined by a start and end time, date, or year. If the start element is missing, the start of the period is not known. If the end element is missing, it means that the period is ongoing, or the start may be in the past, and the end date in the future, which means that period is expected/planned to end at the specified time. The end value includes any matching date/time. For example, the period 2011-05-23 to 2011-05-27 includes all the times from the start of the 23rd May through to the end of the 27th of May.
         |  IntegerQuantity required A Quantity that is an integer.
Specimen not used Sample for analysis
Device not used 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.
ReferenceRange not used The usual or acceptable range for a test result.
Members must be a QuestionAnswer required Members represent the elements of a group of a related observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author.
Components not used Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category (if covered) 0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

ReferenceRange

The usual or acceptable range for a test result. C0883335

Value:  Range An interval defined by a quantitative upper and/or lower bound. One of the two bounds must be specified, and the lower bound must be less than the upper bound. When Quantities are specified, the units of measure must be the same.
Type from http://hl7.org/fhir/ValueSet/referencerange-meaning (if covered) optional The most specific code (lowest level term) describing the kind or sort of thing being represented.
ApplicableSubpopulation optional Codes to indicate the target population this reference range applies to. For example, a reference range may be based on the normal population or a particular sex or race.
ApplicableAgeRange optional The age at which this reference range is applicable. This is a neonatal age (e.g. number of weeks at term) if the meaning says so.

RelatedFinding

Findings associated with this item.

Value:  Finding Base class for assertions and observations. The subject of a finding can be the entire patient, or an entity such as a location body structure, intervention, or condition. Things observed about the subject can include social and behavioral factors, subjective and objective observations, and assessments.

ValueAbsentReason

Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value). C1709044]

Value:  CodeableConcept must be from ValueAbsentReasonVS A set of codes drawn from different coding systems, representing the same concept.