Soziale Informationen

Soziale Informationen sind Freitext-Angaben (valueString), die in einer Observation transportiert werden. Da sie sich auf die gesamte pflegebedürftige Person beziehen, entfallen die Punkte bodySite, method, specimen, device und referenceRange. Die category wird festgelegt auf social-history.

GeNSSocial

identifierΣ0..*Identifier
basedOnΣ I0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)
partOfΣ I0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)
statusΣ ?!1..1codeBinding
systemΣ0..1uriFixed Value
versionΣ0..1string
codeΣ0..1codeFixed Value
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
codingΣ0..*CodingFixed Value
textΣ0..1string
subjectΣ I1..1Reference(Patient | GeNSPatient)
focusΣ I0..*Reference(Resource)
encounterΣ I0..1Reference(Encounter)
effectiveDateTimedateTime
effectivePeriodPeriod
effectiveTimingTiming
effectiveInstantinstant
issuedΣ0..1instant
performerΣ I0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)
valueStringstring
dataAbsentReasonI0..1CodeableConceptBinding
interpretation0..*CodeableConceptBinding
note0..*Annotation
bodySite0..0CodeableConcept
method0..0CodeableConcept
specimenI0..0Reference(Specimen)
deviceI0..0Reference(Device | DeviceMetric)
hasMemberΣ I0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)
derivedFromΣ I0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)
codeΣ1..1CodeableConcept
valueQuantityQuantity
valueCodeableConceptCodeableConcept
valueStringstring
valueBooleanboolean
valueIntegerinteger
valueRangeRange
valueRatioRatio
valueSampledDataSampledData
valueTimetime
valueDateTimedateTime
valuePeriodPeriod
dataAbsentReasonI0..1CodeableConceptBinding
interpretation0..*CodeableConceptBinding
referenceRange0..*see (referenceRange)

Beispiel: Familie

<Observation xmlns="http://hl7.org/fhir">
    <id value="GeNS_EX_Familie" />
    <meta>
        <profile value="http://hs-osnabrueck.de/fhir/ePflegebericht/StructureDefinition/Social" />
    </meta>
    <status value="final" />
    <category>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/observation-category" />
            <code value="social-history" />
        </coding>
    </category>
    <code>
        <coding>
            <system value="http://loinc.org" />
            <code value="29762-2" />
            <display value="Social History" />
        </coding>
    </code>
    <subject>
        <reference value="Patient/example" />
    </subject>
    <valueString value="zwei erwachsene Kinder: 1 Tochter mit Familie in Berlin, 1 Tochter mit Familie in Kiel" />
</Observation>

Beispiel: Soziales Engagement

<Observation xmlns="http://hl7.org/fhir">
    <id value="GeNS_EX_Soziales" />
    <meta>
        <profile value="http://hs-osnabrueck.de/fhir/ePflegebericht/StructureDefinition/Social" />
    </meta>
    <status value="final" />
    <category>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/observation-category" />
            <code value="social-history" />
        </coding>
    </category>
    <code>
        <coding>
            <system value="http://loinc.org" />
            <code value="29762-2" />
            <display value="Social History" />
        </coding>
    </code>
    <subject>
        <reference value="Patient/example" />
    </subject>
    <valueString value="Mitglied des Kirchenvorstandes seiner Heimatgemeinde St. Matthias in Halle" />
</Observation>