Observation | I | | Observation | Element IdShort description 生活背景の情報 Alternate names Vital Signs, Measurement, Results, Tests Definition Comments 生活背景に関するObservation(収集したり観察した事実など)の制約プロフィール
Data Type Observation Constraints- dom-2:If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.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() - dom-3:If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() - dom-6:A resource should have narrative for robust management
text.`div`.exists() - dom-5:If a resource is contained in another resource, it SHALL NOT have a security label
contained.meta.security.empty() - obs-7:If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() - obs-6:dataAbsentReason SHALL only be present if Observation.value[x] is not present
dataAbsentReason.empty() or value.empty()
Mappings- rim:Entity. Role, or Act
- workflow:Event
- sct-concept:< 363787002 |Observable entity|
- v2:OBX
- rim:Observation[classCode=OBS, moodCode=EVN]
|
identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdShort description Business Identifier for observation Observationのためのビジネス識別子 Definition A unique identifier assigned to this observation.
Observationに割り当てられたユニーク(一意)の識別ID
Requirements Allows observations to be distinguished and referenced.
Data Type Identifier Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim:n/a
- v2:CX / EI (occasionally, more often EI maps to a resource id or a URL)
- rim:II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
- servd:Identifier
- workflow:Event.identifier
- w5:FiveWs.identifier
- v2:OBX.21 For OBX segments from systems without OBX-21 support a combination of ORC/OBR and OBX must be negotiated between trading partners to uniquely identify the OBX segment. Depending on how V2 has been implemented each of these may be an option: 1) OBR-3 + OBX-3 + OBX-4 or 2) OBR-3 + OBR-4 + OBX-3 + OBX-4 or 2) some other way to uniquely ID the OBR/ORC + OBX-3 + OBX-4.
- rim:id
|
basedOn | Σ I | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | There are no (further) constraints on this element Element IdShort description Fulfills plan, proposal or order 実施されるプラン、提案、依頼 Alternate names Fulfills Definition A plan, proposal or order that is fulfilled in whole or in part by this event. For example, a MedicationRequest may require a patient to have laboratory test performed before it is dispensed.
このイベントによって全体または部分的に実施されるプラン、提案、依頼。たとえばMedicationRequest は調剤される前に臨床検査を患者に行う必要があるかもしれない。
Requirements Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon.
Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Data Type Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1:SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings- rim:n/a
- rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow:Event.basedOn
- v2:ORC
- rim:.inboundRelationship[typeCode=COMP].source[moodCode=EVN]
|
partOf | Σ I | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | There are no (further) constraints on this element Element IdShort description Part of referenced event 参照されるイベントの一部分 Alternate names Container Definition A larger event of which this particular Observation is a component or step. For example, an observation as part of a procedure.
この特定のObservationが別のより大きなイベントの要素あるいは一段階であるような親イベント。たとえば、一連の処置手順の一部としてのObservation.
Comments To link an Observation to an Encounter use encounter . See the Notes below for guidance on referencing another Observation.
ObservationをEncounterにencounter要素を使ってリンクする。もうひとつ別のObservationを参照することについては、以降にあるt Notes をガイダンスとして参照のこと。
Data Type Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1:SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings- rim:n/a
- rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow:Event.partOf
- v2:Varies by domain
- rim:.outboundRelationship[typeCode=FLFS].target
|
status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element IdShort description registered | preliminary | final | amended + Definition The status of the result value. 結果値のステータス。
Requirements Need to track the status of individual results. Some results are finalized before the whole report is finalized.
Comments This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
このリソースは現在有効でないというマークをするコードを含んでいるため、この要素はモディファイアー(修飾的要素)として位置づけられている。
Data Type code Binding Codes providing the status of an observation. ObservationStatus (required)Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim:n/a
- workflow:Event.status
- w5:FiveWs.status
- sct-concept:< 445584004 |Report by finality status|
- v2:OBX-11
- rim:status Amended & Final are differentiated by whether it is the subject of a ControlAct event with a type of "revise"
|
category | | 1..1 | CodeableConceptBindingFixed Value | Element IdShort description Classification of type of observation Obserbationの種類(タイプ)の分類 Definition A code that classifies the general type of observation being made.
実施されているobservationの一般的なタイプを分類するコード
Requirements Used for filtering what observations are retrieved and displayed.
Comments In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set.
【JP仕様】
基底仕様のカテゴリ「social-history」固定とする
Data Type CodeableConcept Binding Codes for high level observation categories. ObservationCategoryCodes (preferred)Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Fixed Value
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/observation-category",
"code": "social-history"
}
]
} Mappings- rim:n/a
- v2:CE/CNE/CWE
- rim:CD
- orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
- w5:FiveWs.class
- rim:.outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
|
code | Σ | 1..1 | CodeableConceptBinding | Element IdShort description Type of observation (code / type) observation のタイプ(コードまたはタイプ) Alternate names Name Definition Describes what was observed. Sometimes this is called the observation "name".
observationの対象物を記述する。 observation の名前で呼ばれることもある。
Requirements Knowing what kind of observation is being made is essential to understanding the observation.
Comments All code-value and, if present, component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.
【JP仕様】
項目についてはMEDISのJ-MIXの「生活背景情報」を基にバリューセットを定義する
具体的なコードについてはSWG6と連携して決定する必要がある(TBD)
Data Type CodeableConcept Binding Codes identifying names of simple observations. http://jpfhir.jp/fhir/Common/ValueSet/socialHistory-code (preferred)Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim:n/a
- v2:CE/CNE/CWE
- rim:CD
- orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
- workflow:Event.code
- w5:FiveWs.what[x]
- sct-concept:< 363787002 |Observable entity| OR < 386053000 |Evaluation procedure|
- v2:OBX-3
- rim:code
- sct-attr:116680003 |Is a|
|
subject | Σ I | 1..1 | Reference(Patient) | Element IdShort description Who and/or what the observation is about 観察対象者 Definition The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the focus element or the code itself specifies the actual focus of the observation.
この観察が行われた対象となる患者、または患者のグループ、場所、またはデバイス、あるいはそれらの記録。
もし観察の実際の焦点が対象(または対象のサンプル、一部、または領域)と異なる場合、 focus 要素または code 自体が観察の実際の焦点を指し示す。
Requirements Observations have no value if you don't know who or what they're about.
Comments One would expect this element to be a cardinality of 1..1. The only circumstance in which the subject can be missing is when the observation is made by a device that does not know the patient. In this case, the observation SHALL be matched to a patient through some context/channel matching technique, and at this point, the observation should be updated.
【JP仕様】
患者
Data Type Reference(Patient) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1:SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings- rim:n/a
- rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow:Event.subject
- w5:FiveWs.subject[x]
- v2:PID-3
- rim:participation[typeCode=RTGT]
- w5:FiveWs.subject
|
focus | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdShort description What the observation is about, when it is not about the subject of record subject 要素が実際のobservationの対象でない場合に、observation の対象物。 Definition The actual focus of an observation when it is not the patient of record representing something or someone associated with the patient such as a spouse, parent, fetus, or donor. For example, fetus observations in a mother's record. The focus of an observation could also be an existing condition, an intervention, the subject's diet, another observation of the subject, or a body structure such as tumor or implanted device. An example use case would be using the Observation resource to capture whether the mother is trained to change her child's tracheostomy tube. In this example, the child is the patient of record and the mother is the focus.
配偶者、親、胎児、ドナーなど、患者に関連する何かまたは誰かを表す記録の患者ではない場合の、観察の実際の焦点。たとえば、母親の記録にある胎児の観察。観察の焦点はまた、既存の状態、介入、対象の食事、対象の別の観察、または腫瘍または埋め込まれた装置などの体の構造であり得る。使用例はobservationリソースを使用して、母親が子供の気管切開チューブを交換するように訓練されているかどうかをキャプチャすることです。この例では、子供が記録の患者であり、母親が焦点(focus)となる。
Comments Typically, an observation is made about the subject - a patient, or group of patients, location, or device - and the distinction between the subject and what is directly measured for an observation is specified in the observation code itself ( e.g., "Blood Glucose") and does not need to be represented separately using this element. Use specimen if a reference to a specimen is required. If a code is required instead of a resource use either bodysite for bodysites or the standard extension focusCode.
通常、observationは対象(患者、または患者のグループ、場所、またはデバイス)について行われ、対象とobservationのために直接測定されるものとの区別は、observationコード自体(例:「血糖値」 )で記述され、この要素を使用して個別に表す必要はない。検体(標本)への参照が必要な場合は、 specimin 要素を使用する。リソースの代わりにコードが必要な場合は、人体部位にはbodysite 要素を使用するか、標準の拡張機能[focusCode](extension-observation-focuscode.html)を使用する。
Data Type Reference(Resource) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1:SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings- rim:n/a
- rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- w5:FiveWs.subject[x]
- v2:OBX-3
- rim:participation[typeCode=SBJ]
- w5:FiveWs.subject
|
encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdShort description Healthcare event during which this observation is made このobservationが行われるヘルスケアイベント Alternate names Context Definition The healthcare event (e.g. a patient and healthcare provider interaction) during which this observation is made.
このobservationが行われるヘルスケアイベント(患者とヘルスケアプロバイダーの相互作用など)(受診、入院など)。
Requirements For some observations it may be important to know the link between an observation and a particular encounter.
Comments This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
通常、イベントが発生したEncounterですが、一部のイベントは、エンEncounterの正式な完了の前または後に開始される場合があり、その場合でもEncounterのコンテキストに関連付けられている(例:入院前の臨床検査)。
Data Type Reference(Encounter) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1:SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings- rim:n/a
- rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow:Event.context
- w5:FiveWs.context
- v2:PV1
- rim:inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
|
effective[x] | Σ | 0..1 | | Element IdShort description Clinically relevant time/time-period for observation 臨床的に関連する時刻または時間 Alternate names Occurrence Definition The time or time-period the observed value is asserted as being true. For biological subjects - e.g. human patients - this is usually called the "physiologically relevant time". This is usually either the time of the procedure or of specimen collection, but very often the source of the date/time is not known, only the date/time itself.
観測値が関連する時間または期間。レポートの対象が患者である場合、これは通常、処置や検体採取の時刻のいずれかですが、日付/時刻の出処は不明であり、日付/時刻自体のみのことがある。
Requirements Knowing when an observation was deemed true is important to its relevance as well as determining trends.
Comments At least a date should be present unless this observation is a historical report. For recording imprecise or "fuzzy" times (For example, a blood glucose measurement taken "after breakfast") use the Timing datatype which allow the measurement to be tied to regular life events.
【JP仕様】
effectiveDateTime:医療者が確認した日時
effectivePeriod:医療者が確認した期間
Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim:n/a
- workflow:Event.occurrence[x]
- w5:FiveWs.done[x]
- v2:OBX-14, and/or OBX-19 after v2.4 (depends on who observation made)
- rim:effectiveTime
|
effectiveDateTime | | | dateTime | Data Type dateTime |
effectivePeriod | | | Period | Data Type Period |
issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element IdShort description Date/Time this version was made available このバージョンが利用可能となった日時 Definition The date and time this version of the observation was made available to providers, typically after the results have been reviewed and verified.
このバージョンのレポートが医療者に提供された日時。通常、レポートがレビューおよび検証された後となる。
Comments For Observations that don’t require review and verification, it may be the same as the lastUpdated time of the resource itself. For Observations that do require review and verification for certain updates, it might not be the same as the lastUpdated time of the resource itself due to a non-clinically significant update that doesn’t require the new version to be reviewed and verified again.
レビューと検証を必要としないobservationの場合、リソース自体の[lastUpdated ](resource-definitions.html#Meta.lastUpdated)日時と同じになる場合があります。特定の更新のレビューと検証が必要なobservationの場合、新しいバージョンを再度レビューして検証する必要がないような臨床的に重要でない更新がなされたために、リソース自体の「lastUpdated」時間はこれと異なる場合がある。
Data Type instant Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim:n/a
- w5:FiveWs.recorded
- v2:OBR.22 (or MSH.7), or perhaps OBX-19 (depends on who observation made)
- rim:participation[typeCode=AUT].time
|
performer | Σ I | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | There are no (further) constraints on this element Element IdShort description Who is responsible for the observation observationに責任をもつ者 Definition Who was responsible for asserting the observed value as "true".
そのobservationは真だと言える責任者
Requirements May give a degree of confidence in the observation and also indicates where follow-up questions should be directed.
Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
参照は、実際のFHIRリソースへの参照である必要があり、解決可能(内容に到達可能)である必要がある(アクセス制御、一時的な使用不可などを考慮に入れる)。解決は、URLから取得するか、リソースタイプによって該当する場合は、絶対参照を正規URLとして扱い、ローカルレジストリ/リポジトリで検索することによって行うことができる。
Data Type Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1:SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings- rim:n/a
- rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow:Event.performer.actor
- w5:FiveWs.actor
- v2:OBX.15 / (Practitioner) OBX-16, PRT-5:PRT-4='RO' / (Device) OBX-18 , PRT-10:PRT-4='EQUIP' / (Organization) OBX-23, PRT-8:PRT-4='PO'
- rim:participation[typeCode=PRF]
|
value[x] | Σ I | 0..1 | | Element IdShort description Actual result 実際の結果値 Definition The information determined as a result of making the observation, if the information has a simple value.
結果情報が単純な値である場合、observationを行った結果として決定された情報。
Requirements An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations.
Comments An observation may have; 1) a single value here, 2) both a value and a set of related or component values, or 3) only a set of related or component values. If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the Notes section below.
【JP仕様】
文字列、コード、数値に限定する
Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim:n/a
- sct-concept:< 441742003 |Evaluation finding|
- v2:OBX.2, OBX.5, OBX.6
- rim:value
- sct-attr:363714003 |Interprets|
|
valueQuantity | | | Quantity | Data Type Quantity |
valueCodeableConcept | | | CodeableConcept | Data Type CodeableConcept |
valueString | | | string | Data Type string |
dataAbsentReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdObservation.dataAbsentReason Short description Why the result is missing 結果が欠損値である理由 Definition Provides a reason why the expected value in the element Observation.value[x] is missing.
Observation.value[x] 要素に期待される結果が存在しない理由を設定する。
Requirements For many results it is necessary to handle exceptional values in measurements.
Comments Null or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. For example, measurement values for a serology test could be "detected", "not detected", "inconclusive", or "specimen unsatisfactory".
The alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For example, the dataAbsentReason code "error" could be used when the measurement was not completed. Note that an observation may only be reported if there are values to report. For example differential cell counts values may be reported only when > 0. Because of these options, use-case agreements are required to interpret general observations for null or exceptional values.
ヌル値または例外値は、FHIRオブザベーションで2つの方法で表すことができる。 1つの方法は、それらを値セットに含めて、値の例外を表す方法である。たとえば、血清学的検査の測定値は、「検出された」、「検出されなかった」、「決定的でない」、または「検体が不十分」である可能性がある。別の方法は、実際の観測にvalue要素を使用し、明示的なdataAbsentReason要素を使用して例外的な値を記録することである。たとえば、測定が完了しなかった場合、dataAbsentReasonコード「error」を使用できる。この場合には、観測値は、報告する値がある場合にのみ報告される可能性があることに注意する必要がある。たとえば、差分セルカウント値は> 0の場合にのみ報告される場合がある。これらのオプションのため、nullまたは例外値の一般的な観測値を解釈するにはユースケースの合意が必要である。
Data Type CodeableConcept Binding Codes specifying why the result (`Observation.value[x]`) is missing. DataAbsentReason (extensible)Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim:n/a
- v2:CE/CNE/CWE
- rim:CD
- orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
- v2:N/A
- rim:value.nullFlavor
|
interpretation | | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdObservation.interpretation Short description High, low, normal, etc. Alternate names Abnormal Flag Definition A categorical assessment of an observation value. For example, high, low, normal.
観測値のカテゴリ別評価。たとえば、高、低、通常。
Requirements For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result.
一部の結果、特に数値結果については、結果の意義を完全に理解するためには解釈コードが必要である。
Comments Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result.
「異常フラグ」として呼ばれる検査結果解釈コードが従来から使用されており、その使用はコード化された解釈が関連するような他の場合でも拡大して使われている。多くの場合、1つ以上の単純でコンパクトなコードとして報告され、この要素は、結果の意味や正常かどうかを示すために、レポートや時系列表で結果値の隣に配置されることがよくあります。
Data Type CodeableConcept Binding Codes identifying interpretations of observations. ObservationInterpretationCodes (extensible)Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim:n/a
- v2:CE/CNE/CWE
- rim:CD
- orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
- sct-concept:< 260245000 |Findings values|
- v2:OBX-8
- rim:interpretationCode
- sct-attr:363713009 |Has interpretation|
|
note | | 0..* | Annotation | There are no (further) constraints on this element Element IdShort description Comments about the observation 結果に対するコメント Definition Comments about the observation or the results.
観測値、結果に対するコメント
Requirements Need to be able to provide free text additional information.
フリーテキストの追加情報を提供できる必要がある。
Comments May include general statements about the observation, or statements about significant, unexpected or unreliable results values, or information about its source when relevant to its interpretation.
観察(結果)に関する一般的な記述、重要な、予期しない、または信頼できない結果値に関する記述、またはその解釈に関連する場合はそのソースに関する情報が含まれる場合がある。
Data Type Annotation Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim:n/a
- v2:N/A
- rim:Act
- v2:NTE.3 (partner NTE to OBX, or sometimes another (child?) OBX)
- rim:subjectOf.observationEvent[code="annotation"].value
|
bodySite | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdShort description Observed body part 観察された身体部位 Definition Indicates the site on the subject's body where the observation was made (i.e. the target site).
観察が行われた被験者の体の部位(すなわち、標的部位)を示します。
Comments Only used if not implicit in code found in Observation.code. In many systems, this may be represented as a related observation instead of an inline component.
If the use case requires BodySite to be handled as a separate resource (e.g. to identify and track separately) then use the standard extension bodySite.
Observation.codeにあるコードだけでは暗黙的に部位はわからない場合にだけ使用される。多くのシステムでは、これはデータ中の部分情報ではなく関連する観察(観測)として記述さえる場合がある。
もしBodySiteを個別のリソースとして処理する必要があるような使用例(たとえば、個別に識別して追跡するなど)においては、標準の拡張機能[bodySite](extension-bodysite.html)を使用する。
Data Type CodeableConcept Binding Codes describing anatomical locations. May include laterality. SNOMEDCTBodyStructures (example)Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim:n/a
- v2:CE/CNE/CWE
- rim:CD
- orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
- sct-concept:< 123037004 |Body structure|
- v2:OBX-20
- rim:targetSiteCode
- sct-attr:718497002 |Inherent location|
|
method | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdShort description How it was done どのように実施されたか。 Definition Indicates the mechanism used to perform the observation.
観測を実行するために使用されるメカニズムを示す。
Requirements In some cases, method can impact results and is thus used for determining whether results can be compared or determining significance of results.
場合によっては、観察(観測・検査)方法によっては結果に影響を与える可能性があるため、結果を比較できるかどうかを判断したり、結果の重要性を判断したりするために使用される。
Comments Only used if not implicit in code for Observation.code.
Observation.codeのコードでは暗黙的に示されない場合にだけ使用する。
Data Type CodeableConcept Binding Methods for simple observations. ObservationMethods (example)Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim:n/a
- v2:CE/CNE/CWE
- rim:CD
- orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
- v2:OBX-17
- rim:methodCode
|
specimen | I | 0..1 | Reference(Specimen) | There are no (further) constraints on this element Element IdShort description Specimen used for this observation 観察(観測、検査)に使われた検体材料 Definition The specimen that was used when this observation was made.
この観察(観測、検査)が実施されたときに使われた検体材料
Comments Should only be used if not implicit in code found in Observation.code . Observations are not made on specimens themselves; they are made on a subject, but in many cases by the means of a specimen. Note that although specimens are often involved, they are not always tracked and reported explicitly. Also note that observation resources may be used in contexts that track the specimen explicitly (e.g. Diagnostic Report).
Observation.code にあるコードで暗黙的に示されない場合にのみ使用する必要がある。検体自体の観察は行われない。観察(観測、検査)対象者に対して実施されるが、多くの場合には対象者から得られた検体に対して実施される。検体が奥の場合に関わるが、それらは常に追跡され、明示的に報告されるとは限らないことに注意すること。またobservationリソースは、検体を明示的に記述するような状況下(診断レポートなど)で使用される場合があることに注意。
Data Type Reference(Specimen) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1:SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings- rim:n/a
- rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- sct-concept:< 123038009 |Specimen|
- v2:SPM segment
- rim:participation[typeCode=SPC].specimen
- sct-attr:704319004 |Inherent in|
|
device | I | 0..1 | Reference(Device | DeviceMetric) | There are no (further) constraints on this element Element IdShort description (Measurement) Device 測定機器 Definition The device used to generate the observation data.
観察データを生成するために使われた機器
Comments Note that this is not meant to represent a device involved in the transmission of the result, e.g., a gateway. Such devices may be documented using the Provenance resource where relevant.
これは、結果の送信に関与するデバイス(ゲートウェイなど)を表すことを意図したものではない。そのようなデバイスは、必要に応じてProvenanceリソースを使用して文書化する。
Data Type Reference(Device | DeviceMetric) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1:SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings- rim:n/a
- rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- sct-concept:< 49062001 |Device|
- v2:OBX-17 / PRT -10
- rim:participation[typeCode=DEV]
- sct-attr:424226004 |Using device|
|
referenceRange | I | 0..* | BackboneElement | There are no (further) constraints on this element Element IdObservation.referenceRange Short description Provides guide for interpretation 解釈のためのガイドを与える Definition Guidance on how to interpret the value by comparison to a normal or recommended range. Multiple reference ranges are interpreted as an "OR". In other words, to represent two distinct target populations, two referenceRange elements would be used.
Requirements Knowing what values are considered "normal" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts.
どの値が「正常」と見なされるかを知ることは、特定の結果の意義を評価するのに役立つ。さまざまなコンテキストに対応するため複数の参照範囲を提供できる必要がある。
Comments Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this might not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.
通常の範囲または推奨範囲と比較して値を解釈する方法に関するガイダンス。複数の参照範囲は「OR」として解釈されます。つまり、2つの異なるターゲット母集団を表すために、2つの referenceRange 要素が使用される。
Data Type BackboneElement Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - obs-3:Must have at least a low or a high or text
low.exists() or high.exists() or text.exists()
Mappings- rim:n/a
- v2:OBX.7
- rim:outboundRelationship[typeCode=REFV]/target[classCode=OBS, moodCode=EVN]
|
low | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element IdObservation.referenceRange.low Short description Low Range, if relevant Definition The value of the low bound of the reference range. The low bound of the reference range endpoint is inclusive of the value (e.g. reference range is >=5 - <=9). If the low bound is omitted, it is assumed to be meaningless (e.g. reference range is <=2.3).
Comments The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.
Data Type SimpleQuantity Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - qty-3:If a code for the unit is present, the system SHALL also be present
code.empty() or system.exists() - sqty-1:The comparator is not used on a SimpleQuantity
comparator.empty()
Mappings- rim:n/a
- v2:SN (see also Range) or CQ
- rim:PQ, IVL<PQ>, MO, CO, depending on the values
- v2:OBX-7
- rim:value:IVL_PQ.low
|
high | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element IdObservation.referenceRange.high Short description High Range, if relevant Definition The value of the high bound of the reference range. The high bound of the reference range endpoint is inclusive of the value (e.g. reference range is >=5 - <=9). If the high bound is omitted, it is assumed to be meaningless (e.g. reference range is >= 2.3).
Comments The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.
Data Type SimpleQuantity Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - qty-3:If a code for the unit is present, the system SHALL also be present
code.empty() or system.exists() - sqty-1:The comparator is not used on a SimpleQuantity
comparator.empty()
Mappings- rim:n/a
- v2:SN (see also Range) or CQ
- rim:PQ, IVL<PQ>, MO, CO, depending on the values
- v2:OBX-7
- rim:value:IVL_PQ.high
|
type | | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdObservation.referenceRange.type Short description Reference range qualifier Definition Codes to indicate the what part of the targeted reference population it applies to. For example, the normal or therapeutic range.
Requirements Need to be able to say what kind of reference range this is - normal, recommended, therapeutic, etc., - for proper interpretation.
Comments This SHOULD be populated if there is more than one range. If this element is not present then the normal range is assumed.
Data Type CodeableConcept Binding Code for the meaning of a reference range. ObservationReferenceRangeMeaningCodes (preferred)Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim:n/a
- v2:CE/CNE/CWE
- rim:CD
- orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
- sct-concept:< 260245000 |Findings values| OR
< 365860008 |General clinical state finding|
OR
< 250171008 |Clinical history or observation findings| OR
< 415229000 |Racial group| OR
< 365400002 |Finding of puberty stage| OR
< 443938003 |Procedure carried out on subject|
- v2:OBX-10
- rim:interpretationCode
|
appliesTo | | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdObservation.referenceRange.appliesTo Short description Reference range population Definition 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. Multiple appliesTo are interpreted as an "AND" of the target populations. For example, to represent a target population of African American females, both a code of female and a code for African American would be used.
Requirements Need to be able to identify the target population for proper interpretation.
Comments This SHOULD be populated if there is more than one range. If this element is not present then the normal population is assumed.
Data Type CodeableConcept Binding Codes identifying the population the reference range applies to. ObservationReferenceRangeAppliesToCodes (example)Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim:n/a
- v2:CE/CNE/CWE
- rim:CD
- orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
- sct-concept:< 260245000 |Findings values| OR
< 365860008 |General clinical state finding|
OR
< 250171008 |Clinical history or observation findings| OR
< 415229000 |Racial group| OR
< 365400002 |Finding of puberty stage| OR
< 443938003 |Procedure carried out on subject|
- v2:OBX-10
- rim:interpretationCode
|
age | I | 0..1 | Range | There are no (further) constraints on this element Element IdObservation.referenceRange.age Short description Applicable age range, if relevant Definition 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.
Requirements Some analytes vary greatly over age.
Comments The stated low and high value are assumed to have arbitrarily high precision when it comes to determining which values are in the range. I.e. 1.99 is not in the range 2 -> 3.
Data Type Range Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - rng-2:If present, low SHALL have a lower value than high
low.empty() or high.empty() or (low <= high)
Mappings- rim:n/a
- v2:NR and also possibly SN (but see also quantity)
- rim:IVL<QTY[not(type="TS")]> [lowClosed="true" and highClosed="true"]or URG<QTY[not(type="TS")]>
- rim:outboundRelationship[typeCode=PRCN].targetObservationCriterion[code="age"].value
|
text | | 0..1 | string | There are no (further) constraints on this element Element IdObservation.referenceRange.text Short description Text based reference range in an observation Definition Text based reference range in an observation which may be used when a quantitative range is not appropriate for an observation. An example would be a reference value of "Negative" or a list or table of "normals".
Comments Note that FHIR strings SHALL NOT exceed 1MB in size
Data Type string Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim:n/a
- v2:OBX-7
- rim:value:ST
|
hasMember | Σ I | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | There are no (further) constraints on this element Element IdShort description Related resource that belongs to the Observation group observationグループに属する関連リソース Definition This observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group.
このobserbationは、グループのメンバーとしてターゲットを含むグループobserbation(たとえば、一連検査セット、パネル検査、バイタルサイン測定値のセット)です。
Comments When using this element, an observation will typically have either a value or a set of related resources, although both may be present in some cases. For a discussion on the ways Observations can assembled in groups together, see Notes below. Note that a system may calculate results from QuestionnaireResponse into a final score and represent the score as an Observation.
この要素を使用する場合、observationには通常、値または関連するリソースのセットのいじれかを含む。その両方を含む場合もある。複数のobservationをグループに一緒にまとめる方法については、以下の[メモ](observation.html#obsgrouping)を参照せよ。システムは、[QuestionnaireResponse](questionnaireresponse.html)からの結果を計算して最終スコアにし、そのスコアをobservationとして表す場合があることに注意。
Data Type Reference(Observation | QuestionnaireResponse | MolecularSequence) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1:SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings- rim:n/a
- rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- v2:Relationships established by OBX-4 usage
- rim:outBoundRelationship
|
derivedFrom | Σ I | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence | JP_Observation_SocialHistory) | Element IdShort description Related measurements the observation is made from observation がつくりゃれる元の関連する測定 Definition The target resource that represents a measurement from which this observation value is derived. For example, a calculated anion gap or a fetal measurement based on an ultrasound image.
このobservation が導出される元の測定値を表すターゲットリソース。たとえば、超音波画像に基づいて計算されたアニオンギャップまたは胎児の測定値の場合、この要素には、元となった超音波画像検査結果への参照を設定する。
Comments All the reference choices that are listed in this element can represent clinical observations and other measurements that may be the source for a derived value. The most common reference will be another Observation. For a discussion on the ways Observations can assembled in groups together, see Notes below.
【JP仕様】
導出元の参照リソースにJP_Observation_SocialHistoryを追加
Data Type Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence | JP_Observation_SocialHistory) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1:SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings- rim:n/a
- rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- v2:Relationships established by OBX-4 usage
- rim:.targetObservation
|
component | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdShort description Component results コンポーネント結果 Definition Some observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes. Examples include systolic and diastolic component observations for blood pressure measurement and multiple component observations for genetics observations.
一部の観測には、複数のコンポーネントの観測がある。これらのコンポーネントの観察結果は、同じ属性を共有する個別のコード値のペアとして表される。例としては、血圧測定のための収縮期および拡張期のコンポーネントの観察や、遺伝学の観察のための複数のコンポーネントの観察がある。
Requirements Component observations share the same attributes in the Observation resource as the primary observation and are always treated a part of a single observation (they are not separable). However, the reference range for the primary observation value is not inherited by the component values and is required when appropriate for each component observation.
コンポーネントobservation は プライマリobservation としてのobservation リソースの中で同じ属性を共有し、常に単一のobservation の一部として扱われる(つまりそれらは分離可能ではないん)。ただし、プライマリobservationのreference rangeはコンポーネント値に継承されないため、reference rangeは各コンポーネントobservation に適切であれば必要である。
Comments For a discussion on the ways Observations can be assembled in groups together see Notes below.
複数のObservation をグループに一緒にまとめる方法については、以下の[Notes](observation.html#notes)を参照してください。
Data Type BackboneElement Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim:n/a
- v2:containment by OBX-4?
- rim:outBoundRelationship[typeCode=COMP]
|
code | Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element IdObservation.component.code Short description Type of component observation (code / type) Definition Describes what was observed. Sometimes this is called the observation "code".
Requirements Knowing what kind of observation is being made is essential to understanding the observation.
Comments All code-value and component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.
Data Type CodeableConcept Binding Codes identifying names of simple observations. LOINCCodes (example)Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim:n/a
- v2:CE/CNE/CWE
- rim:CD
- orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
- w5:FiveWs.what[x]
- sct-concept:< 363787002 |Observable entity| OR
< 386053000 |Evaluation procedure|
- v2:OBX-3
- rim:code
|
value[x] | Σ | 0..1 | | There are no (further) constraints on this element Element IdObservation.component.value[x] Short description Actual component result Definition The information determined as a result of making the observation, if the information has a simple value.
Requirements An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations.
Comments Used when observation has a set of component observations. An observation may have both a value (e.g. an Apgar score) and component observations (the observations from which the Apgar score was derived). If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the Notes section below.
Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim:n/a
- sct-concept:363714003 |Interprets| < 441742003 |Evaluation finding|
- v2:OBX.2, OBX.5, OBX.6
- rim:value
- sct-attr:363714003 |Interprets|
|
valueQuantity | | | Quantity | There are no (further) constraints on this element Data Type Quantity |
valueCodeableConcept | | | CodeableConcept | There are no (further) constraints on this element Data Type CodeableConcept |
valueString | | | string | There are no (further) constraints on this element Data Type string |
valueBoolean | | | boolean | There are no (further) constraints on this element Data Type boolean |
valueInteger | | | integer | There are no (further) constraints on this element Data Type integer |
valueRange | | | Range | There are no (further) constraints on this element Data Type Range |
valueRatio | | | Ratio | There are no (further) constraints on this element Data Type Ratio |
valueSampledData | | | SampledData | There are no (further) constraints on this element Data Type SampledData |
valueTime | | | time | There are no (further) constraints on this element Data Type time |
valueDateTime | | | dateTime | There are no (further) constraints on this element Data Type dateTime |
valuePeriod | | | Period | There are no (further) constraints on this element Data Type Period |
dataAbsentReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdObservation.component.dataAbsentReason Short description Why the component result is missing Definition Provides a reason why the expected value in the element Observation.component.value[x] is missing.
Requirements For many results it is necessary to handle exceptional values in measurements.
Comments "Null" or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. For example, measurement values for a serology test could be "detected", "not detected", "inconclusive", or "test not done".
The alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For example, the dataAbsentReason code "error" could be used when the measurement was not completed. Because of these options, use-case agreements are required to interpret general observations for exceptional values.
Data Type CodeableConcept Binding Codes specifying why the result (`Observation.value[x]`) is missing. DataAbsentReason (extensible)Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim:n/a
- v2:CE/CNE/CWE
- rim:CD
- orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
- v2:N/A
- rim:value.nullFlavor
|
interpretation | | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdObservation.component.interpretation Short description High, low, normal, etc. Alternate names Abnormal Flag Definition A categorical assessment of an observation value. For example, high, low, normal.
Requirements For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result.
Comments Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result.
Data Type CodeableConcept Binding Codes identifying interpretations of observations. ObservationInterpretationCodes (extensible)Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim:n/a
- v2:CE/CNE/CWE
- rim:CD
- orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
- sct-concept:< 260245000 |Findings values|
- v2:OBX-8
- rim:interpretationCode
- sct-attr:363713009 |Has interpretation|
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referenceRange | | 0..* | see (referenceRange) | There are no (further) constraints on this element Element IdObservation.component.referenceRange Short description Provides guide for interpretation of component result Definition Guidance on how to interpret the value by comparison to a normal or recommended range.
Requirements Knowing what values are considered "normal" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts.
Comments Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this might not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.
Mappings- v2:OBX.7
- rim:outboundRelationship[typeCode=REFV]/target[classCode=OBS, moodCode=EVN]
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