INTEROPen CareConnect Base STU3 Implementation Guide
3.0.0 - CI Build
INTEROPen CareConnect Base STU3 Implementation Guide - Local Development build (v3.0.0). See the Directory of published versions
Definitions for the CareConnect-RiskAssessment-1 Profile.
1. RiskAssessment | |
Definition | An assessment of the likely outcome(s) for a patient or other subject as well as the likelihood of each outcome. |
Control | 0..* |
Alternate Names | Prognosis |
Invariants | Defined on this element dom-1: If the resource is contained in another resource, it SHALL NOT contain any narrative (: contained.text.empty()) dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (: contained.contained.empty()) dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource (: contained.where(('#'+id in %resource.descendants().reference).not()).empty()) dom-4: 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()) |
2. RiskAssessment.id | |
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. |
Control | 0..1 |
Type | id |
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
3. RiskAssessment.meta | |
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource. |
Control | 0..1 |
Type | Meta |
4. RiskAssessment.implicitRules | |
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. |
Control | 0..1 |
Type | uri |
Is Modifier | true |
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation. |
5. RiskAssessment.language | |
Definition | The base language in which the resource is written. |
Control | 0..1 |
Binding | A human language. The codes SHALL be taken from Common Languages; other codes may be used where these codes are not suitable Max Binding: All Languages |
Type | code |
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). |
6. RiskAssessment.text | |
Definition | A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. |
Control | 0..1 This element is affected by the following invariants: dom-1 |
Type | Narrative |
Alternate Names | narrative, html, xhtml, display |
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later. |
7. RiskAssessment.contained | |
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. |
Control | 0..* |
Type | Resource |
Alternate Names | inline resources, anonymous resources, contained resources |
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. |
8. RiskAssessment.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
9. RiskAssessment.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
10. RiskAssessment.identifier | |
Definition | Business identifier assigned to the risk assessment. |
Note | This is a business identifier, not a resource identifier (see discussion) |
Control | 0..1 |
Type | Identifier |
11. RiskAssessment.identifier.id | |
Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
Control | 0..1 |
Type | string |
12. RiskAssessment.identifier.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Slicing | This element introduces a set of slices on RiskAssessment.identifier.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
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13. RiskAssessment.identifier.use | |
Definition | The purpose of this identifier. |
Control | 0..1 |
Binding | Identifies the purpose for this identifier, if known . The codes SHALL be taken from IdentifierUse |
Type | code |
Is Modifier | true |
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. |
Comments | This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. |
14. RiskAssessment.identifier.type | |
Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose. |
Control | 0..1 |
Binding | A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. The codes SHALL be taken from Identifier Type Codes; other codes may be used where these codes are not suitable |
Type | CodeableConcept |
Requirements | Allows users to make use of identifiers when the identifier system is not known. |
Comments | This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. |
15. RiskAssessment.identifier.system | |
Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique. |
Control | 0..1 |
Type | uri |
Requirements | There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. |
Example | General:http://www.acme.com/identifiers/patient |
16. RiskAssessment.identifier.value | |
Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system. |
Control | 0..1 |
Type | string |
Comments | If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. |
Example | General:123456 |
17. RiskAssessment.identifier.period | |
Definition | Time period during which identifier is/was valid for use. |
Control | 0..1 |
Type | Period |
18. RiskAssessment.identifier.assigner | |
Definition | Organization that issued/manages the identifier. |
Control | 0..1 |
Type | Reference(CareConnect-Organization-1) |
Comments | The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization. |
19. RiskAssessment.basedOn | |
Definition | A reference to the request that is fulfilled by this risk assessment. |
Control | 0..1 |
Type | Reference(Resource) |
20. RiskAssessment.parent | |
Definition | A reference to a resource that this risk assessment is part of, such as a Procedure. |
Control | 0..1 |
Type | Reference(Resource) |
21. RiskAssessment.status | |
Definition | The status of the RiskAssessment, using the same statuses as an Observation. |
Control | 1..1 |
Binding | The status of the risk assessment; e.g. preliminary, final, amended, etc. The codes SHALL be taken from ObservationStatus |
Type | code |
22. RiskAssessment.method | |
Definition | The algorithm, process or mechanism used to evaluate the risk. |
Control | 0..1 |
Binding | The mechanism or algorithm used to make the assessment; e.g. TIMI, PRISM, Cardiff Type 2 diabetes, etc. |
Type | CodeableConcept |
Requirements | The method can influence the results of the assessment. |
23. RiskAssessment.code | |
Definition | The type of the risk assessment performed. |
Control | 0..1 |
Type | CodeableConcept |
24. RiskAssessment.subject | |
Definition | The patient or group the risk assessment applies to. |
Control | 0..1 |
Type | Reference(Group | CareConnect-Patient-1) |
25. RiskAssessment.context | |
Definition | The encounter where the assessment was performed. |
Control | 0..1 |
Type | Reference(CareConnect-EpisodeOfCare-1 | CareConnect-Encounter-1) |
26. RiskAssessment.occurrence[x] | |
Definition | The date (and possibly time) the risk assessment was performed. |
Control | 0..1 |
Type | Choice of: dateTime, Period |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Requirements | The assessment results lose validity the more time elapses from when they are first made. |
27. RiskAssessment.condition | |
Definition | For assessments or prognosis specific to a particular condition, indicates the condition being assessed. |
Control | 0..1 |
Type | Reference(CareConnect-Condition-1) |
28. RiskAssessment.performer | |
Definition | The provider or software application that performed the assessment. |
Control | 0..1 |
Type | Reference(Device | CareConnect-Practitioner-1) |
29. RiskAssessment.reason[x] | |
Definition | The reason the risk assessment was performed. |
Control | 0..1 |
Type | Choice of: CodeableConcept, Reference(Resource) |
[x] Note | See Choice of Data Types for further information about how to use [x] |
30. RiskAssessment.basis | |
Definition | Indicates the source data considered as part of the assessment (FamilyHistory, Observations, Procedures, Conditions, etc.). |
Control | 0..* |
Type | Reference(Resource) |
31. RiskAssessment.prediction | |
Definition | Describes the expected outcome for the subject. |
Control | 0..* |
Type | BackboneElement |
Comments | Multiple repetitions can be used to identify the same type of outcome in different timeframes as well as different types of outcomes. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count())) ras-2: Must be <= 100 (: probability is decimal implies probability.as(decimal) <= 100) |
32. RiskAssessment.prediction.id | |
Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
Control | 0..1 |
Type | string |
33. RiskAssessment.prediction.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
34. RiskAssessment.prediction.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Alternate Names | extensions, user content, modifiers |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
35. RiskAssessment.prediction.outcome | |
Definition | One of the potential outcomes for the patient (e.g. remission, death, a particular condition). |
Control | 1..1 |
Binding | The condition or other outcome; e.g. death, remission, amputation, infection, etc. |
Type | CodeableConcept |
36. RiskAssessment.prediction.probability[x] | |
Definition | How likely is the outcome (in the specified timeframe). |
Control | 0..1 |
Type | Choice of: decimal, Range |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Comments | If range is used, it represents the lower and upper bounds of certainty; e.g. 40-60% Decimal values are expressed as percentages as well (max = 100). |
Invariants | Defined on this element ras-1: low and high must be percentages, if present (: (low.empty() or ((low.code = '%') and (low.system = %ucum))) and (high.empty() or ((high.code = '%') and (high.system = %ucum)))) |
37. RiskAssessment.prediction.qualitativeRisk | |
Definition | How likely is the outcome (in the specified timeframe), expressed as a qualitative value (e.g. low, medium, high). |
Control | 0..1 |
Binding | The likelihood of the occurrence of a specified outcome For example codes, see Risk Probability |
Type | CodeableConcept |
38. RiskAssessment.prediction.relativeRisk | |
Definition | Indicates the risk for this particular subject (with their specific characteristics) divided by the risk of the population in general. (Numbers greater than 1 = higher risk than the population, numbers less than 1 = lower risk.). |
Control | 0..1 |
Type | decimal |
Requirements | Absolute risk is less meaningful than relative risk. |
39. RiskAssessment.prediction.when[x] | |
Definition | Indicates the period of time or age range of the subject to which the specified probability applies. |
Control | 0..1 |
Type | Choice of: Period, Range |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Comments | If not specified, the risk applies "over the subject's lifespan". |
40. RiskAssessment.prediction.rationale | |
Definition | Additional information explaining the basis for the prediction. |
Control | 0..1 |
Type | string |
41. RiskAssessment.mitigation | |
Definition | A description of the steps that might be taken to reduce the identified risk(s). |
Control | 0..1 |
Type | string |
Requirements | One of the main reasons for assessing risks is to identify whether interventional steps are needed to reduce risk. |
42. RiskAssessment.comment | |
Definition | Additional comments about the risk assessment. |
Control | 0..1 |
Type | string |