2.1.3.1.2. JP Core Observation(バイタルサイン)プロファイル
2.1.3.1.2.1. 概要
項目 | 内容 |
---|---|
定義URL | http://jpfhir.jp/fhir/core/StructureDefinition/JP_Observation_VitalSigns |
バージョン | 1.0.0 |
名前 | JPCoreObservationVitalSignsProfile |
タイトル | JP Core Observation Vital Signs Profile |
ステータス | アクティブ(2021-11-03) |
定義 | このプロファイルはObservation リソースにて、患者バイタルサインの1項目を対象として表現するための制約と拡張を定めたものである。 |
公開者 | FHIR® Japanese implementation research working group in Japan Association of Medical Informatics (JAMI) |
Copyright | FHIR® Japanese implementation research working group in Japan Association of Medical Informatics (JAMI) |
ソースリソース | https://simplifier.net/jp-core-draftv1/jpobservationvitalsigns |
本プロファイル説明は、患者に付属する一項目分のバイタルサイン情報について、情報の登録や検索、取得のために、FHIR Observation
リソースを使用するにあたっての、最低限の制約を記述したものである。
Observation
リソースに対して本プロファイルに準拠する場合に必須となる要素や、サポートすべき拡張、用語、検索パラメータを定義する。
2.1.3.1.2.1.1. 背景および想定シナリオ
本プロファイルは、以下のようなユースケースを想定している。
Patient
リソースからの指定された日時、期間での患者バイタルサイン情報の参照Patient
リソースからの指定された患者バイタルサイン項目に対する指定された期間でのバイタルサイン情報の参照Patient
リソースからの標準値を外れた患者バイタルサイン情報の参照- 指定された期間や患者バイタルサイン項目に対し、条件に合致するバイタルサイン情報、または関連する他のリソース(
Observation
リソースや、Patient
リソース等)の参照。
2.1.3.1.2.1.2. スコープ
Observtion
はヘルスケアの中心的な要素であり、診断の支援、進捗状況の監視、ベースラインやパターンの決定、さらには人口統計学的特性の把握に使用されます。ほとんどのObservation
は、いくつかのメタデータを持つ単純な名前/値のペアのアサーションであるが、いくつかのObservation
は、他の Observation
を論理的にグループ化したり、あるいはマルチコンポーネントのObservation
であったりする。
このプロファイルでは上記想定シナリオにて用いられるObservation
の用途がスコープであり、患者基本情報の中でも特に患者バイタルサインに該当する情報項目の1つを取り扱う際に、必要な要件を定義している。
2.1.3.1.2.2. 関連するプロファイル
このプロファイルは、以下のリソースに対して定義された各プロファイルから直接参照される可能性がある。
AdverseEvent
Appointment
CarePlan
ChargeItem
ClinicalImpression
Communication
CommunicationRequest
Condition
Contract
DeviceRequest
DeviceUseStatement
DiagnosticReport
Encounter
FamilyMemberHistory
Goal
GuidanceResponse
ImagingStudy
Immunization
MedicationAdministration
MedicationRequest
MedicationStatement
MolecularSequence
Observation
Procedure
QuestionnaireResponse
RequestGroup
RiskAssessment
ServiceRequest
SupplyRequest
2.1.3.1.2.3. リソース定義
Observation | I | Observation | Element IdObservation バイタルサインに関する測定や簡単な観察事実(assertion) Alternate namesVital Signs, Measurement, Results, Tests Definitionバイタルサインに関する測定と簡単な観察事実(assertion)。 バイタルサインに関するObservation(検査測定や観察事実)の制約プロフィール
| |
identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdObservation.identifier Business Identifier for observation Observationのためのビジネス識別子 DefinitionA 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 Allows observations to be distinguished and referenced.
|
basedOn | Σ I | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | There are no (further) constraints on this element Element IdObservation.basedOn Fulfills plan, proposal or order 実施されるプラン、提案、依頼 Alternate namesFulfills DefinitionA 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。 Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon. 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. Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Constraints
|
partOf | Σ I | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | There are no (further) constraints on this element Element IdObservation.partOf Part of referenced event 参照されるイベントの一部分 Alternate namesContainer DefinitionA 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. To link an Observation to an Encounter use Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Constraints
|
status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element IdObservation.status registered | preliminary | final | amended + DefinitionThe status of the result value. 結果値のステータス。 Need to track the status of individual results. Some results are finalized before the whole report is finalized. 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。 Codes providing the status of an observation. ObservationStatus (required)Constraints
|
category | 1..* | CodeableConceptBinding | Element IdObservation.category Classification of type of observation Obserbationの種類(タイプ)の分類 DefinitionA 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 Used for filtering what observations are retrieved and displayed. 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】 Codes for high level observation categories. http://jpfhir.jp/fhir/Common/ValueSet/vitalSigns-category (preferred)Constraints
| |
code | Σ | 1..1 | CodeableConceptBinding | Element IdObservation.code Type of observation (code / type) observation のタイプ(コードまたはタイプ) Alternate namesName DefinitionDescribes 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。 Knowing what kind of observation is being made is essential to understanding the observation. 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】 Codes identifying names of simple observations. http://jpfhir.jp/fhir/Common/ValueSet/vitalSigns-code (preferred)Constraints
|
subject | Σ I | 1..1 | Reference(Patient) | Element IdObservation.subject Who and/or what the observation is about 観察対象者 DefinitionThe 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 Observations have no value if you don't know who or what they're about. 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】
|
focus | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdObservation.focus 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。 DefinitionThe 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。 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
|
encounter | Σ I | 1..1 | Reference(Encounter) | Element IdObservation.encounter 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 namesContext DefinitionThe 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)。 For some observations it may be important to know the link between an observation and a particular encounter. 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). 【JP仕様】
|
effective[x] | Σ | 0..1 | Element IdObservation.effective[x] Clinically relevant time/time-period for observation 臨床的に関連する時刻または時間 Alternate namesOccurrence DefinitionThe 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。 Knowing when an observation was deemed true is important to its relevance as well as determining trends. 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 | dateTime | Data Type | ||
effectivePeriod | Period | Data Type | ||
issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element IdObservation.issued 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 DefinitionThe 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。 For Observations that don’t require review and verification, it may be the same as the
|
performer | Σ I | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | There are no (further) constraints on this element Element IdObservation.performer Who is responsible for the observation observationに責任をもつ者 DefinitionWho was responsible for asserting the observed value as "true". そのobservationは真だと言える責任者 May give a degree of confidence in the observation and also indicates where follow-up questions should be directed. 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。 Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Constraints
|
value[x] | Σ I | 0..1 | There are no (further) constraints on this element Element IdObservation.value[x] Actual result 実際の結果値 DefinitionThe 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。 An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations. 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.
| |
valueQuantity | Quantity | There are no (further) constraints on this element Data Type | ||
valueCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data Type | ||
valueString | string | There are no (further) constraints on this element Data Type | ||
valueBoolean | boolean | There are no (further) constraints on this element Data Type | ||
valueInteger | integer | There are no (further) constraints on this element Data Type | ||
valueRange | Range | There are no (further) constraints on this element Data Type | ||
valueRatio | Ratio | There are no (further) constraints on this element Data Type | ||
valueSampledData | SampledData | There are no (further) constraints on this element Data Type | ||
valueTime | time | There are no (further) constraints on this element Data Type | ||
valueDateTime | dateTime | There are no (further) constraints on this element Data Type | ||
valuePeriod | Period | There are no (further) constraints on this element Data Type | ||
dataAbsentReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdObservation.dataAbsentReason Why the result is missing 結果が欠損値である理由 DefinitionProvides 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。 For many results it is necessary to handle exceptional values in measurements. 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。 Codes specifying why the result (`Observation.value[x]`) is missing. DataAbsentReason (extensible)Constraints
|
interpretation | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdObservation.interpretation High, low, normal, etc. Alternate namesAbnormal Flag DefinitionA 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。 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。 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。 Codes identifying interpretations of observations. ObservationInterpretationCodes (extensible)Constraints
| |
note | 0..* | Annotation | There are no (further) constraints on this element Element IdObservation.note Comments about the observation 結果に対するコメント DefinitionComments about the observation or the results. 観測値、結果に対するコメント 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。 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。
| |
bodySite | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdObservation.bodySite Observed body part 観察された身体部位 DefinitionIndicates 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。 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。 Codes describing anatomical locations. May include laterality. SNOMEDCTBodyStructures (example)Constraints
| |
method | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdObservation.method How it was done どのように実施されたか。 DefinitionIndicates 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。 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。 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。 Methods for simple observations. ObservationMethods (example)Constraints
| |
specimen | I | 0..1 | Reference(Specimen) | There are no (further) constraints on this element Element IdObservation.specimen Specimen used for this observation 観察(観測、検査)に使われた検体材料 DefinitionThe 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 Should only be used if not implicit in code found in
|
device | I | 0..1 | Reference(Device | DeviceMetric) | There are no (further) constraints on this element Element IdObservation.device (Measurement) Device 測定機器 DefinitionThe 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 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。 Reference(Device | DeviceMetric) Constraints
|
referenceRange | I | 0..* | BackboneElement | There are no (further) constraints on this element Element IdObservation.referenceRange Provides guide for interpretation 解釈のためのガイドを与える DefinitionGuidance 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 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。 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
|
low | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element IdObservation.referenceRange.low Low Range, if relevant DefinitionThe 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). 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.
|
high | I | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element IdObservation.referenceRange.high High Range, if relevant DefinitionThe 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). 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.
|
type | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdObservation.referenceRange.type Reference range qualifier DefinitionCodes to indicate the what part of the targeted reference population it applies to. For example, the normal or therapeutic range. Need to be able to say what kind of reference range this is - normal, recommended, therapeutic, etc., - for proper interpretation. This SHOULD be populated if there is more than one range. If this element is not present then the normal range is assumed. Code for the meaning of a reference range. ObservationReferenceRangeMeaningCodes (preferred)Constraints
| |
appliesTo | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdObservation.referenceRange.appliesTo Reference range population DefinitionCodes 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 Need to be able to identify the target population for proper interpretation. This SHOULD be populated if there is more than one range. If this element is not present then the normal population is assumed. Codes identifying the population the reference range applies to. ObservationReferenceRangeAppliesToCodes (example)Constraints
| |
age | I | 0..1 | Range | There are no (further) constraints on this element Element IdObservation.referenceRange.age Applicable age range, if relevant DefinitionThe 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. Some analytes vary greatly over age. 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.
|
text | 0..1 | string | There are no (further) constraints on this element Element IdObservation.referenceRange.text Text based reference range in an observation DefinitionText 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". Note that FHIR strings SHALL NOT exceed 1MB in size
| |
hasMember | Σ I | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence | JP_Observation_VitalSigns) | Element IdObservation.hasMember Related resource that belongs to the Observation group observationグループに属する関連リソース DefinitionThis 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。 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. 【JP仕様】 Reference(Observation | QuestionnaireResponse | MolecularSequence | JP_Observation_VitalSigns) Constraints
|
derivedFrom | Σ I | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence | JP_Observation_VitalSigns) | Element IdObservation.derivedFrom Related measurements the observation is made from observation がつくりゃれる元の関連する測定 DefinitionThe 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。 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】 Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence | JP_Observation_VitalSigns) Constraints
|
component | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdObservation.component Component results コンポーネント結果 DefinitionSome 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。 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。 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。
|
code | Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element IdObservation.component.code Type of component observation (code / type) DefinitionDescribes what was observed. Sometimes this is called the observation "code". Knowing what kind of observation is being made is essential to understanding the observation. All code-value and component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation. Codes identifying names of simple observations. LOINCCodes (example)Constraints
|
value[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdObservation.component.value[x] Actual component result DefinitionThe information determined as a result of making the observation, if the information has a simple value. An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations. 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.
| |
valueQuantity | Quantity | There are no (further) constraints on this element Data Type | ||
valueCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data Type | ||
valueString | string | There are no (further) constraints on this element Data Type | ||
valueBoolean | boolean | There are no (further) constraints on this element Data Type | ||
valueInteger | integer | There are no (further) constraints on this element Data Type | ||
valueRange | Range | There are no (further) constraints on this element Data Type | ||
valueRatio | Ratio | There are no (further) constraints on this element Data Type | ||
valueSampledData | SampledData | There are no (further) constraints on this element Data Type | ||
valueTime | time | There are no (further) constraints on this element Data Type | ||
valueDateTime | dateTime | There are no (further) constraints on this element Data Type | ||
valuePeriod | Period | There are no (further) constraints on this element Data Type | ||
dataAbsentReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdObservation.component.dataAbsentReason Why the component result is missing DefinitionProvides a reason why the expected value in the element Observation.component.value[x] is missing. For many results it is necessary to handle exceptional values in measurements. "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. Codes specifying why the result (`Observation.value[x]`) is missing. DataAbsentReason (extensible)Constraints
|
interpretation | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdObservation.component.interpretation High, low, normal, etc. Alternate namesAbnormal Flag DefinitionA categorical assessment of an observation value. For example, high, low, normal. For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. 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. Codes identifying interpretations of observations. ObservationInterpretationCodes (extensible)Constraints
| |
referenceRange | 0..* | see (referenceRange) | There are no (further) constraints on this element Element IdObservation.component.referenceRange Provides guide for interpretation of component result DefinitionGuidance on how to interpret the value by comparison to a normal or recommended range. 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. 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.
|
2.1.3.1.2.3.1. 必須要素
次のデータ項目は必須(データが存在しなければならない)、あるいは、データが送信システムに存在する場合はサポートされなければならないことを意味する(Must Support)。
2.1.3.1.2.3.1.1. 必須
本プロファイルは、次の要素を持たなければならない。
status
︓患者バイタルサイン情報項目の状態は必須である。category
︓このリソースが示す患者バイタルサイン情報項目を分類するための区分であり、このプロファイルでは必須とする。code
︓このリソースは何の患者バイタルサイン情報項目であるかを示すため必須である。subject
︓このリソースが示す患者バイタルサイン情報項目が、どの患者のものかを示すため、このプロファイルでは参照するpatient
リソースの定義を必須とする。encouter
:このリソースが示す患者バイタルサイン情報項目が、どの診療イベントにより発生したものかを示すため、このプロファイルでは必須とする。
2.1.3.1.2.3.1.2. Must Support
このプロファイルでは MustSupport要素定義は行っていない。
2.1.3.1.2.3.2. Extension定義
このプロファイルでは拡張定義は行っていない。
2.1.3.1.2.3.3. 用語定義
Path | 定義 | バインディング強度 | バリューセット |
---|---|---|---|
Observation.category |
MEDISの看護実践用語標準マスター<看護観察編>の大分類1.バイタルサイン・基本情報、中分類1.バイタルサインの「焦点」を基にバリューセットを定義する | Preferred | VitalSignsCategory |
Observation.code |
MEDISの看護実践用語標準マスター<看護観察編>の大分類1.バイタルサイン・基本情報、中分類1.バイタルサインを対象とする | Preferred | VitalSignsCode |
2.1.3.1.2.3.4. 制約一覧
このプロファイルでは制約定義は行っていない。
2.1.3.1.2.4. 利用方法
2.1.3.1.2.4.1. インタラクション一覧
Observation
リソースのインタラクション一覧の定義はユースケースに依存せず共通であるため、共通情報プロファイルに記載されている。
Observation共通情報プロファイル#インタラクション一覧
2.1.3.1.2.4.2. OperationおよびSearch Parameter 一覧
2.1.3.1.2.4.2.1. Search Parameter一覧
バイタルサインユースケースのSearch Parameter一覧は共通情報プロファイルに記載されている。
検索時のcategory
パラメータは"vital-sign"となる。
Observation共通情報プロファイル#Search Parameter一覧
2.1.3.1.2.4.2.2. Operation一覧
Observation
リソースのOperation一覧の定義はユースケースに依存せず共通であるため、共通情報プロファイルに記載されている。