This Section describes the expected capabilities of the US Core Server actor which is responsible for providing responses to the queries submitted by the US Core Requestors. The complete list of FHIR profiles, RESTful operations, and search parameters supported by US Core Servers are defined. Systems implementing this capability statement should meet the ONC 2015 Common Clinical Data Set (CCDS) access requirement for Patient Selection 170.315(g)(7) and Application Access - Data Category Request 170.315(g)(8) and the ONC U.S. Core Data for Interoperability (USCDI) Version 4 July 2023.

The US Core ADI DocumentReference Profile inherits from the FHIR DocumentReference resource; refer to it for scope and usage definitions. This profile and the US Core Observation ADI Documentation Profile meet the U.S. Core Data for Interoperability (USCDI) Advance Directive Observation Data Element requirements. It sets minimum expectations for searching and fetching patient ADI documents using the DocumentReference resource. Examples of advance healthcare directive documents include physician order for life sustaining treatment (POLST), do not resuscitate order (DNR), and medical power of attorney. In addition to the document contents, it communicates the type of advance directive document, the author, the verifier, and other properties. To represent whether advance directive documents exist for a patient, see the US Core Observation ADI Documentation Profile. This profile sets minimum expectations for searching and fetching patient ADI documents using the DocumentReference resource. It specifies which core elements, extensions, vocabularies, and value sets SHALL be present and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption.

The US Core Encounter Profile inherits from the FHIR Encounter resource; refer to it for scope and usage definitions. This profile sets minimum expectations for the Encounter resource to record, search, and fetch basic encounter information for an individual patient. It specifies which core elements, extensions, vocabularies, and value sets SHALL be present and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption.

The US Core Immunization Profile inherits from the FHIR Immunization resource; refer to it for scope and usage definitions. This profile sets minimum expectations for the Immunization resource to record, search, and fetch immunization history associated with a patient. It specifies which core elements, extensions, vocabularies, and value sets SHALL be present and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption.

The US Core MedicationDispense Profile inherits from the FHIR MedicationDispense resource; refer to it for scope and usage definitions. This profile sets minimum expectations for the MedicationDispense resource to record, search, and fetch the state of a patients medication with regards to dispensing or other activity. (e.g., dispensed, partially dispensed, not dispensed) It specifies which core elements, extensions, vocabularies, and value sets SHALL be present and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption.

The US Core MedicationRequest Profile inherits from the FHIR MedicationRequest resource; refer to it for scope and usage definitions. This profile meets the requirements of the U.S. Core Data for Interoperability (USCDI) Medications Data Class. This profile sets minimum expectations for the MedicationRequest resource to record, search, and fetch a patient's medication prescriptions or orders. It specifies which core elements, extensions, vocabularies, and value sets SHALL be present in the resource and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption.

The US Core Observation ADI Documentation Profile inherits from the FHIR Observation resource; refer to it for scope and usage definitions. This profile and the US Core Observation ADI DocumentationReference Profile meet the U.S. Core Data for Interoperability (USCDI) Advance Directive Observation Data Element requirements. It is used to communicate the presence and location of advance directive documents for a patient. Examples of advance healthcare directive documents include physician order for life sustaining treatment (POLST), do not resuscitate order (DNR), and medical power of attorney. To communicate the type of advance directive document, the author, the verifier, and other properties, see the US Core Observation ADI Documentation Profile. This profile sets minimum expectations for the Observation resource to record, search, and fetch findings about the presence of a patient's advance directives. It specifies which core elements, extensions, vocabularies, and value sets SHALL be present in the resource and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption.

The US Core Patient Profile inherits from the FHIR Patient resource; refer to it for scope and usage definitions. This profile meets the requirements of the U.S. Core Data for Interoperability (USCDI) Patient Demographics/Information Data Class. It sets minimum expectations for the Patient resource to record, search, and fetch basic demographics and other administrative information about an individual patient. It specifies which core elements, extensions, vocabularies, and value sets SHALL be present and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption.

The US Core Provenance Profile inherits from the FHIR Provenance resource; refer to it for scope and usage definitions. This profile sets minimum expectations for the Provenance resource to record, search, and fetch provenance information associated with a record. It covers the minimal (basic) information to support lineage of information. It specifies which core elements, extensions, vocabularies, and value sets SHALL be present and constrains how the elements are used. Before reviewing this profile, implementers are encouraged to read the Basic Provenance guidance page, which documents several key use cases, specifically, the organization responsible for the most recent action on the resource.

The US Core ServiceRequest Profile inherits from the FHIR ServiceRequest resource; refer to it for scope and usage definitions. This profile sets minimum expectations for recording, searching, and fetching the ServiceRequest information. It specifies which core elements, extensions, vocabularies, and value sets SHALL be present and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption.

The US Core Specimen Profile inherits from the FHIR Specimen resource; refer to it for scope and usage definitions. This profile sets minimum expectations for the Specimen resource to record, search, and fetch information about substances associated with a patient being sampled or tested (such as nasopharyngeal swab, whole blood, or serum). It specifies which core elements, extensions, vocabularies, and value sets SHALL be present and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption.

This extension is a modified from the FHIR Standard Patient Sex Parameter For Clinical Use Extension to show how the .code element which is defined as a "code that has the same meaning as the element in a particular terminology" can be used to fulfil USCDI's Applicable Vocabulary Standard(s) = LOINC 99501-9 (Sex parameter for clinical use). It also displays the element in the slice and uses the loinc in the URL so it can be seen in the instance.

This extension indicates when the information in the document was verified.

This extension indicates the individual's need for an interpreter to communicate healthcare information in a language other than the default language of the organization.

The US Core ADI Finding Value Set is a 'starter set' of findings used for fetching and storing advanced directives.

The US Core Clinical Note Type Value Set is a 'starter set' of types supported for fetching and storing clinical notes.

Concepts representing locations and settings where healthcare services are provided.

This value set contains concepts the provide information regarding a specimen, including the container, that does not meet a laboratory’s criteria for acceptability.

This is a Observation example for the USCDI5 ADI Observation Data Element to show whether and location of a patient has an advance directive using a new code = "45473-6" - (Advance directive/living will completed) and and value of "Yes"/"No"/"Unknown" (TODO: pick a convenient value set LOINC answer list ll50-6, Snomed, hl7 (https://terminology.hl7.org/ValueSet-yes-no-unknown-not-asked.html))

This is a Observation example for the USCDI5 ADI Observation Data Element to show whether a patient has an advance directive using a new code = "45473-6" - (Advance directive/living will completed) and and value of "Yes"/"No"/"Unknown" (TODO: pick a convenient value set LOINC answer list ll50-6, Snomed, hl7 (https://terminology.hl7.org/ValueSet-yes-no-unknown-not-asked.html))

​This is a discharge summary example for the US Core DocumentReference. It is used in the Write Note Example.

This is a an example of ADI-DNI (PDF) for the US Core ADI DocumentReference Profile

This is a an example of Living Will (PDF) for the US Core ADI DocumentReference Profile

This is a an example of POLST (PDF) for the US Core ADI DocumentReference Profile

​This bundle is a the response to a $docref operation and contains an example US Core DocumentReference. It is used in Example 1: Request the latest CCD.

​This bundle is a the response to a $docref operation and contains an examples of US Core DocumentReference. It is used in Example 2: Request Procedure Notes and Discharge Summaries for 2019.

This is a encounter 1 example for the US Core Encounter Profile.

This is an example for the US Core Immunization Profile.

This is a serum specimen example for the US Core Specimen Profile. It demonstrates the use of the USCDI requirements for specimen condition using SNOMED CT codes

This is a dispense example for the US Core MedicationDispense Profile.

This is an prescribed oral solution example for the US Core MedicationRequest Profile. It represents the medication and reason using codes.

This is a patient example for the US Core Patient Profile.