{ "resourceType": "StructureDefinition", "id": "Observation", "url": "http://StructureDefinition.hl7fhir.cn/Observation", "name": "Observation", "title": "临床观测", "status": "draft", "description": "对目标（患者、设备或其它对象）进行检测、观察后的观测结果。用于简单的观测，如设备测量、实验室细项结果、生命体征、身高、体重、吸烟状态等。检验报告类资源通过引用多个观测资源后才具有临床意义。", "fhirVersion": "4.0.0", "mapping": [ { "identity": "workflow", "uri": "http://hl7.org/fhir/workflow", "name": "Workflow Pattern" }, { "identity": "sct-concept", "uri": "http://snomed.info/conceptdomain", "name": "SNOMED CT Concept Domain Binding" }, { "identity": "v2", "uri": "http://hl7.org/v2", "name": "HL7 v2 Mapping" }, { "identity": "rim", "uri": "http://hl7.org/v3", "name": "RIM Mapping" }, { "identity": "w5", "uri": "http://hl7.org/fhir/fivews", "name": "FiveWs Pattern Mapping" }, { "identity": "sct-attr", "uri": "http://snomed.org/attributebinding", "name": "SNOMED CT Attribute Binding" } ], "kind": "resource", "abstract": false, "type": "Observation", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Observation", "derivation": "constraint", "snapshot": { "element": [ { "id": "Observation", "path": "Observation", "short": "观测结果", "definition": "对目标（患者、设备或其它对象）进行检测、观察后的观测结果。", "comment": "用于简单的观测，如设备测量、实验室细项结果、生命体征、身高、体重、吸烟状态等。检验报告类资源通过引用多个观测资源后才具有临床意义。", "alias": [ "Vital Signs", "Measurement", "Results", "Tests" ], "min": 0, "max": "*", "base": { "path": "Observation", "min": 0, "max": "*" }, "constraint": [ { "key": "dom-2", "severity": "error", "human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources", "expression": "contained.contained.empty()", "xpath": "not(parent::f:contained and f:contained)", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-4", "severity": "error", "human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated", "expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()", "xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-3", "severity": "error", "human": "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", "expression": "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()", "xpath": "not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice", "valueBoolean": true }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice-explanation", "valueMarkdown": "When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time." } ], "key": "dom-6", "severity": "warning", "human": "A resource should have narrative for robust management", "expression": "text.`div`.exists()", "xpath": "exists(f:text/h:div)", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-5", "severity": "error", "human": "If a resource is contained in another resource, it SHALL NOT have a security label", "expression": "contained.meta.security.empty()", "xpath": "not(exists(f:contained/*/f:meta/f:security))", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "obs-7", "severity": "error", "human": "If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present", "expression": "value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()", "xpath": "not(f:*[starts-with(local-name(.), 'value')] and (for $coding in f:code/f:coding return f:component/f:code/f:coding[f:code/@value=$coding/f:code/@value] [f:system/@value=$coding/f:system/@value]))", "source": "http://hl7.org/fhir/StructureDefinition/Observation" }, { "key": "obs-6", "severity": "error", "human": "dataAbsentReason SHALL only be present if Observation.value[x] is not present", "expression": "dataAbsentReason.empty() or value.empty()", "xpath": "not(exists(f:dataAbsentReason)) or (not(exists(*[starts-with(local-name(.), 'value')])))", "source": "http://hl7.org/fhir/StructureDefinition/Observation" } ], "mapping": [ { "identity": "rim", "map": "Entity. Role, or Act" }, { "identity": "workflow", "map": "Event" }, { "identity": "sct-concept", "map": "< 363787002 |Observable entity|" }, { "identity": "v2", "map": "OBX" }, { "identity": "rim", "map": "Observation[classCode=OBS, moodCode=EVN]" } ] }, { "id": "Observation.id", "path": "Observation.id", "short": "Logical id of this artifact", "definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.", "comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.", "min": 0, "max": "1", "base": { "path": "Resource.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "isSummary": true }, { "id": "Observation.meta", "path": "Observation.meta", "short": "Metadata about the resource", "definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.", "min": 0, "max": "1", "base": { "path": "Resource.meta", "min": 0, "max": "1" }, "type": [ { "code": "Meta" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.implicitRules", "path": "Observation.implicitRules", "short": "A set of rules under which this content was created", "definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.", "comment": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.", "min": 0, "max": "1", "base": { "path": "Resource.implicitRules", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": true, "isModifierReason": "This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "Observation.language", "path": "Observation.language", "short": "Language of the resource content", "definition": "The base language in which the resource is written.", "comment": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).", "min": 0, "max": "1", "base": { "path": "Resource.language", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet", "valueCanonical": "http://hl7.org/fhir/ValueSet/all-languages" }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Language" } ], "strength": "preferred", "description": "A human language.", "valueSet": "http://hl7.org/fhir/ValueSet/languages" }, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "Observation.text", "path": "Observation.text", "short": "Text summary of the resource, for human interpretation", "definition": "A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.", "comment": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded information is added later.", "alias": [ "narrative", "html", "xhtml", "display" ], "min": 0, "max": "1", "base": { "path": "DomainResource.text", "min": 0, "max": "1" }, "type": [ { "code": "Narrative" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" }, { "identity": "rim", "map": "Act.text?" } ] }, { "id": "Observation.contained", "path": "Observation.contained", "short": "Contained, inline Resources", "definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.", "comment": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.", "alias": [ "inline resources", "anonymous resources", "contained resources" ], "min": 0, "max": "*", "base": { "path": "DomainResource.contained", "min": 0, "max": "*" }, "type": [ { "code": "Resource" } ], "mapping": [ { "identity": "rim", "map": "Entity. Role, or Act" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.extension", "path": "Observation.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "DomainResource.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.modifierExtension", "path": "Observation.modifierExtension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Extensions that cannot be ignored", "definition": "May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "DomainResource.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them", "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.identifier", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status", "valueCode": "normative" }, { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-normative-version", "valueCode": "4.0.0" } ], "path": "Observation.identifier", "short": "业务标识符", "definition": "标识符，唯一且明确地标识某个域中的实体。常用作业务标识符，在不同业务域中的唯一标识ID。在很多场景下可作为交叉索引使用。", "comment": "业务ID不是资源服务器上的逻辑ID（非标识主键）", "requirements": "用于区分观测资源的实例，同时便于利用业务ID引用观测内容", "min": 0, "max": "*", "base": { "path": "Observation.identifier", "min": 0, "max": "*" }, "type": [ { "code": "Identifier", "profile": [ "http://StructureDefinition.hl7fhir.cn/Identifier" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "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]" }, { "identity": "servd", "map": "Identifier" }, { "identity": "workflow", "map": "Event.identifier" }, { "identity": "w5", "map": "FiveWs.identifier" }, { "identity": "v2", "map": "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." }, { "identity": "rim", "map": "id" } ] }, { "id": "Observation.basedOn", "path": "Observation.basedOn", "short": "产生原由事件", "definition": "为了满足此元素引用的事件（处方、医嘱、检验检查申请、照护计划等）才导致此观测资源的产生。例如，药品处方可能要求在发药之前对患者进行检验检查。", "comment": "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.", "requirements": "通过此元素可实现追溯与跟踪管理：一方面可以用于确认此观测事件是否已通过授权，另一方面还可以跟踪医嘱或申请单是否执行。", "alias": [ "Fulfills" ], "min": 0, "max": "*", "base": { "path": "Observation.basedOn", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/CarePlan", "http://StructureDefinition.hl7fhir.cn/MedicationRequest", "http://StructureDefinition.hl7fhir.cn/ServiceRequest", "http://StructureDefinition.hl7fhir.cn/NutritionOrder", "http://StructureDefinition.hl7fhir.cn/ImmunizationRecommendation", "http://StructureDefinition.hl7fhir.cn/DeviceRequest" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.basedOn" }, { "identity": "v2", "map": "ORC" }, { "identity": "rim", "map": ".inboundRelationship[typeCode=COMP].source[moodCode=EVN]" } ] }, { "id": "Observation.partOf", "path": "Observation.partOf", "short": "父事件", "definition": "包含此观测资源的一个更大的事件（如：治疗、用药记录、发药、免疫接种等），此观测资源仅作为其中的一个组成部分或步骤。", "comment": "若要将观测资源与医疗就诊资源相关联，应使用“Observation.encounter”元素。\r\n两个观测资源之间的关联请参阅Observation.hasMember和Observation.derivedFrom元素。", "alias": [ "Container" ], "min": 0, "max": "*", "base": { "path": "Observation.partOf", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/MedicationAdministration", "http://StructureDefinition.hl7fhir.cn/MedicationDispense", "http://StructureDefinition.hl7fhir.cn/MedicationStatement", "http://StructureDefinition.hl7fhir.cn/Procedure", "http://StructureDefinition.hl7fhir.cn/Immunization", "http://StructureDefinition.hl7fhir.cn/ImagingStudy" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.partOf" }, { "identity": "v2", "map": "Varies by domain" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=FLFS].target" } ] }, { "id": "Observation.status", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint", "valueString": "default: final" } ], "path": "Observation.status", "short": "状态", "definition": "观测结果值的状态\r\nregistered | preliminary | final | amended | corrected | entered-in-error | unknown", "comment": "此元素值的改变可能影响整个资源的意义。", "requirements": "需要对单个观测结果的状态进行跟踪。有些观测结果可能在整体报告审核之前就已通过审核。", "min": 1, "max": "1", "base": { "path": "Observation.status", "min": 1, "max": "1" }, "type": [ { "code": "code" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": true, "isModifierReason": "当此状态码为“entered-in-error”时，表示当前资源无效。", "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationStatus" } ], "strength": "required", "description": "Codes providing the status of an observation.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-status|4.0.1" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.status" }, { "identity": "w5", "map": "FiveWs.status" }, { "identity": "sct-concept", "map": "< 445584004 |Report by finality status|" }, { "identity": "v2", "map": "OBX-11" }, { "identity": "rim", "map": "status Amended & Final are differentiated by whether it is the subject of a ControlAct event with a type of \"revise\"" } ] }, { "id": "Observation.category", "path": "Observation.category", "short": "类别", "definition": "用来表示观观测分类的代码", "comment": "除了建议的类别值域集之外，还可以从其它维度自定义分类方案，并且可以同时使用多个类别。分类的粒度粗细由值域集中的概念定义。", "requirements": "用于对观测资源进行筛选检索和分类显示。", "min": 0, "max": "*", "base": { "path": "Observation.category", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationCategory" } ], "strength": "preferred", "description": "Codes for high level observation categories.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-category" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "w5", "map": "FiveWs.class" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=\"COMP].target[classCode=\"LIST\", moodCode=\"EVN\"].code" } ] }, { "id": "Observation.code", "path": "Observation.code", "short": "观测代码（名称)", "definition": "用编码表示观测到的内容。可以看作观测“项目名称”。", "comment": "如果Observation.component不为空，则需要将component元素中所有的值（编码-值对）结合此元素一起综合考虑，才能正确理解观测结果的含义。", "requirements": "精确的理解正在进行的是什么观测非常重要。", "alias": [ "Name" ], "min": 1, "max": "1", "base": { "path": "Observation.code", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationCode" } ], "strength": "example", "description": "Codes identifying names of simple observations.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-codes" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "workflow", "map": "Event.code" }, { "identity": "w5", "map": "FiveWs.what[x]" }, { "identity": "sct-concept", "map": "< 363787002 |Observable entity| OR < 386053000 |Evaluation procedure|" }, { "identity": "v2", "map": "OBX-3" }, { "identity": "rim", "map": "code" }, { "identity": "sct-attr", "map": "116680003 |Is a|" } ] }, { "id": "Observation.subject", "path": "Observation.subject", "short": "观测目标对象", "definition": "观测目标对象是一名患者或一组患者、位置或设备，观测结果记录在此对象的病历或报告中。 如果实际参与直接测量的观测对象与此目标对象（或对象的样本、部位）不同，应使用“Observation.focus”元素指定观测的实际测量对象， 并通过“Observation.code”来精确的表达观测的实际内容。", "comment": "除非由是某设备对某未知患者做的观测结果，否则此元素是必填项。 尽管如此，也必须在后期通过某种匹配技术将观测结果与患者关联，补充此元素并更新此观测结果。", "requirements": "如果不知道观测对象是谁或什么，那么此观测就没有意义。", "min": 0, "max": "1", "base": { "path": "Observation.subject", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Patient", "http://StructureDefinition.hl7fhir.cn/Group", "http://StructureDefinition.hl7fhir.cn/Device", "http://StructureDefinition.hl7fhir.cn/Location" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.subject" }, { "identity": "w5", "map": "FiveWs.subject[x]" }, { "identity": "v2", "map": "PID-3" }, { "identity": "rim", "map": "participation[typeCode=RTGT]" }, { "identity": "w5", "map": "FiveWs.subject" } ] }, { "id": "Observation.focus", "path": "Observation.focus", "short": "实际参与直接测量的观测对象", "definition": "当观测对象实际关注的并不是病历中的患者时，用于表示与患者相关的实际参与直接测量的观测对象，比如配偶、父母、胎儿或捐赠者。例如，母亲病历中对胎儿的观测。 观测的关注点也可以是当前病症、干预效果、目标的饮食、目标的另一个观测或体内物质（如肿瘤或植入装置）。 另一个例子是使用观测资源来表示母亲是否接受过更换其孩子气管套管的培训，在此场景下孩子是病历中的病人，母亲则是观测资源实际参与直接测量的观测对象。", "comment": "观测目标对象通常是一名患者或一组患者、位置或设备。 目标对象和实际参与直接测量的观测对象之间的区别不需要使用此元素单独表示，而是应该通过指定具体的观测代码（Observation.code）来区分。 如果需要引用观测使用的标本，应使用“Observation.specimen”元素。 如果想表示具体观测的身体部位，应使用“Observation.bodysite”元素。 如果需要用编码而不用资源来表示此元素，可以使用focusCode扩展（http://hl7.org/fhir/StructureDefinition/observation-focusCode）。", "min": 0, "max": "*", "base": { "path": "Observation.focus", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Patient", "http://StructureDefinition.hl7fhir.cn/Group", "http://StructureDefinition.hl7fhir.cn/Device", "http://StructureDefinition.hl7fhir.cn/Location" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "w5", "map": "FiveWs.subject[x]" }, { "identity": "v2", "map": "OBX-3" }, { "identity": "rim", "map": "participation[typeCode=SBJ]" }, { "identity": "w5", "map": "FiveWs.subject" } ] }, { "id": "Observation.encounter", "path": "Observation.encounter", "short": "医疗就诊活动", "definition": "在此医疗就诊活动（比如某次门诊、住院）期间产生的观测结果。", "comment": "这通常是发生在此医疗就诊活动期间的观测事件。虽然某些事件可能在医疗就诊活动之前或在完成之后发生，但仍在其相关（例如入院前检查）", "requirements": "对于某些观测项目来说，了解与其相关的具体医疗就诊活动很重要。", "alias": [ "Context" ], "min": 0, "max": "1", "base": { "path": "Observation.encounter", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Encounter" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.context" }, { "identity": "w5", "map": "FiveWs.context" }, { "identity": "v2", "map": "PV1" }, { "identity": "rim", "map": "inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]" } ] }, { "id": "Observation.effective[x]", "path": "Observation.effective[x]", "short": "发生时间", "definition": "观测发生的真实时间或时段。这通常是治疗或标本采集的时间，但此时间数据的来源可能未知。", "comment": "此元素至少应该提供一个日期，除非这是一个历史观测。 要记录不精确或“模糊”的时间（如，餐后血糖），请使用Timing数据类型，它用于测量与日常生活事件相关的时间。", "requirements": "观测发生的真实时间对其相关性以及趋势判定都很重要。", "alias": [ "Occurrence" ], "min": 0, "max": "1", "base": { "path": "Observation.effective[x]", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" }, { "code": "Period" }, { "code": "Timing" }, { "code": "instant" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.occurrence[x]" }, { "identity": "w5", "map": "FiveWs.done[x]" }, { "identity": "v2", "map": "OBX-14, and/or OBX-19 after v2.4 (depends on who observation made)" }, { "identity": "rim", "map": "effectiveTime" } ] }, { "id": "Observation.issued", "path": "Observation.issued", "short": "正式发布时间", "definition": "观测结果的发布日期和时间，通常是在审核和确认之后才发布。", "comment": "对于不需要审核和确认的观测，此元素的值可能与资源本身的“Meta.lastUpdated”时间相同。 有些观测则需要在其更新时进行审核和确认，这时此元素的时间可能早于资源本身的“Meta.lastUpdated”时间， 因为当更新的不是重要的临床信息时，不需要重新审核和发布，此时更新资源并不会更新此元素的值。", "min": 0, "max": "1", "base": { "path": "Observation.issued", "min": 0, "max": "1" }, "type": [ { "code": "instant" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "w5", "map": "FiveWs.recorded" }, { "identity": "v2", "map": "OBR.22 (or MSH.7), or perhaps OBX-19 (depends on who observation made)" }, { "identity": "rim", "map": "participation[typeCode=AUT].time" } ] }, { "id": "Observation.performer", "path": "Observation.performer", "short": "执行者", "definition": "对观测值的准备性负责的人", "comment": "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.", "requirements": "可增加观测结果的可信度，同时明确了后续问题的责任人。", "alias": [ "责任人" ], "min": 0, "max": "*", "base": { "path": "Observation.performer", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Practitioner", "http://StructureDefinition.hl7fhir.cn/PractitionerRole", "http://StructureDefinition.hl7fhir.cn/Organization", "http://StructureDefinition.hl7fhir.cn/CareTeam", "http://StructureDefinition.hl7fhir.cn/Patient", "http://StructureDefinition.hl7fhir.cn/RelatedPerson" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.performer.actor" }, { "identity": "w5", "map": "FiveWs.actor" }, { "identity": "v2", "map": "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'" }, { "identity": "rim", "map": "participation[typeCode=PRF]" } ] }, { "id": "Observation.value[x]", "path": "Observation.value[x]", "short": "实际的观测结果值", "definition": "若观测结果是一个简单值，则可以通过此元素来表示观测产生的结果信息。", "comment": "一个观测值可以是：1）此元素的单个值， 2）此单个值和observation.component元素中一组相关或明细指标的值，或者 3）仅使用observation.component元素中一组相关或明细指标的值。 如果此元素值不为空，则其数据类型应通过Observation.code确定。 如果此元素有固定的编码，或者由Observation.code定义了编码值，则对值的文本描述应该使用一个只有text元素的CodeableConcept数据类型来表示，而不用字符串类型。", "requirements": "观测资源都应该有值，除非有错误产生，或者它代表着一组观测。", "min": 0, "max": "1", "base": { "path": "Observation.value[x]", "min": 0, "max": "1" }, "type": [ { "code": "Quantity" }, { "code": "CodeableConcept" }, { "code": "string" }, { "code": "boolean" }, { "code": "integer" }, { "code": "Range" }, { "code": "Ratio" }, { "code": "SampledData" }, { "code": "time" }, { "code": "dateTime" }, { "code": "Period" } ], "condition": [ "ele-1", "obs-7" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "sct-concept", "map": "< 441742003 |Evaluation finding|" }, { "identity": "v2", "map": "OBX.2, OBX.5, OBX.6" }, { "identity": "rim", "map": "value" }, { "identity": "sct-attr", "map": "363714003 |Interprets|" } ] }, { "id": "Observation.dataAbsentReason", "path": "Observation.dataAbsentReason", "short": "无结果值或出错的原因", "definition": "如果Observation.value[x]缺少值，通过此元素说明缺失的原因。或者在检测过程中出现异常也可以用此元素来说明出错原因。", "comment": "在FHIR中，观测资源的空值（Null）或异常值有两种表示方法：一种方法是使用值域集，简单地将它们作为其中的概念来表示异常。 例如，血清检测的观测资源值可以是“检测”、“未检测”、“不确定”或“样本不合格”。 另一种方法是使用value元素记录实际观测结果，同时使用dataAbsentReason元素记录异常值。 例如，当检测未完成时，可以将“error”编码赋值给dataAbsentReason元素。 注意，只有当有观测值时才能报告。例如，只有细胞计数值当大于0时才能报告。 所以在实际用例中需要使用以上两种方法之一对观测的空值或异常值进行解释。", "requirements": "大部分在检测中出现的观测结果异常值都有必要处理。", "min": 0, "max": "1", "base": { "path": "Observation.dataAbsentReason", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1", "obs-6" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationValueAbsentReason" } ], "strength": "extensible", "description": "Codes specifying why the result (`Observation.value[x]`) is missing.", "valueSet": "http://hl7.org/fhir/ValueSet/data-absent-reason" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "value.nullFlavor" } ] }, { "id": "Observation.interpretation", "path": "Observation.interpretation", "short": "结果解释", "definition": "对观测值的分类评估。例如，高、低、正常。", "comment": "以前作为实验室结果的“异常标志”来使用，现在使用范围得到了扩展（扩展范围与其绑定的值域集中编码的含义相对应）。 此元素在报告中呈现方式通常是显示在观测结果值旁边的代码或符号，以表示结果的含义或正常状态。", "requirements": "为了充分理解观测结果的重要性，有必要对某些结果（特别是数值性结果或危急值）进行解释。", "alias": [ "Abnormal Flag", "异常标志" ], "min": 0, "max": "*", "base": { "path": "Observation.interpretation", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationInterpretation" } ], "strength": "extensible", "description": "Codes identifying interpretations of observations.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-interpretation" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "sct-concept", "map": "< 260245000 |Findings values|" }, { "identity": "v2", "map": "OBX-8" }, { "identity": "rim", "map": "interpretationCode" }, { "identity": "sct-attr", "map": "363713009 |Has interpretation|" } ] }, { "id": "Observation.note", "path": "Observation.note", "short": "备注", "definition": "对观测或结果的备注或评论。", "comment": "可能包括对观测结果的一般性陈述，或关于重大、意外或不可靠结果值的陈述，或与Observation.interpretation的相关信息。", "requirements": "提供自由文本附加信息很有必要。", "min": 0, "max": "*", "base": { "path": "Observation.note", "min": 0, "max": "*" }, "type": [ { "code": "Annotation" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "Act" }, { "identity": "v2", "map": "NTE.3 (partner NTE to OBX, or sometimes another (child?) OBX)" }, { "identity": "rim", "map": "subjectOf.observationEvent[code=\"annotation\"].value" } ] }, { "id": "Observation.bodySite", "path": "Observation.bodySite", "short": "观测部位", "definition": "在患者身体上进行观测的部位（即目标位置）。", "comment": "仅当Observation.code的概念中没有包含位置信息时才使用此元素。在有些系统中，可以用此元素来表示相关的观测，而不是作为此观测所包含的一部分。 在某些场景下可能需要使用单独的身体结构资源（BodyStructure），比如用于标识和跟踪不同的身体部位。 这种情况应该用一扩展元素来解决，参见BodyStructure引用扩展（http://hl7.org/fhir/extension-bodysite.html）。", "min": 0, "max": "1", "base": { "path": "Observation.bodySite", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "BodySite" } ], "strength": "example", "description": "Codes describing anatomical locations. May include laterality.", "valueSet": "http://hl7.org/fhir/ValueSet/body-site" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "sct-concept", "map": "< 123037004 |Body structure|" }, { "identity": "v2", "map": "OBX-20" }, { "identity": "rim", "map": "targetSiteCode" }, { "identity": "sct-attr", "map": "718497002 |Inherent location|" } ] }, { "id": "Observation.method", "path": "Observation.method", "short": "实验方法", "definition": "用于明确执行观测时所使用的方法和机制。", "comment": "仅当Observation.code的编码值的概念中没有暗含观测方法时才使用此元素。", "requirements": "在某些情况下，不同的观测（检验/实验）方法会产生不同的观测结果，所以仅当观测方法相同时所产生的结果才具有可比性，同理只有在明确了观测方法后才能确定结果值的意义。", "min": 0, "max": "1", "base": { "path": "Observation.method", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationMethod" } ], "strength": "example", "description": "Methods for simple observations.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-methods" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "OBX-17" }, { "identity": "rim", "map": "methodCode" } ] }, { "id": "Observation.specimen", "path": "Observation.specimen", "short": "观测使用的标本", "definition": "执行观测时所使用的样本或标本。", "comment": "仅当Observation.code的编码值的概念中没有暗含观测所使用的标本时才使用此元素。 虽然观测针是对目标（患者等）进行的，但在很多情况下需要通过标本作为载体才能完成具体的观测。 注意，观测资源中包含的标本信息并不一定会很精确。 另外，观测资源可用于对标本进行精确追踪时的场景（例如诊断报告）。", "min": 0, "max": "1", "base": { "path": "Observation.specimen", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Specimen" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "sct-concept", "map": "< 123038009 |Specimen|" }, { "identity": "v2", "map": "SPM segment" }, { "identity": "rim", "map": "participation[typeCode=SPC].specimen" }, { "identity": "sct-attr", "map": "704319004 |Inherent in|" } ] }, { "id": "Observation.device", "path": "Observation.device", "short": "测量仪器", "definition": "用来产生观测数据的仪器设备。", "comment": "注意，这里的设备不是指用于传输结果的相关设备，例如网关。与网络的相关设备应使用处出资源（Provenance）来记录。", "min": 0, "max": "1", "base": { "path": "Observation.device", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Device", "http://StructureDefinition.hl7fhir.cn/DeviceMetric" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "sct-concept", "map": "< 49062001 |Device|" }, { "identity": "v2", "map": "OBX-17 / PRT -10" }, { "identity": "rim", "map": "participation[typeCode=DEV]" }, { "identity": "sct-attr", "map": "424226004 |Using device|" } ] }, { "id": "Observation.referenceRange", "path": "Observation.referenceRange", "short": "参考范围", "definition": "观测结果的正常范围或推荐的参考范围，通此元素提供的范围值和实际结果值的比较，可以从量级上解释观测结果的意义。 若此元素有多个范围值，这些值之间是“或者”关系。 换句话说，可以使用两个“referenceRange”元素来表示两个范围的并集。", "comment": "多数观测值只有一个通用参考范围。 系统可能会根据对患者的相关信息（如年龄、性别、体重和其他信息）来提供更个性化的参考范围，但这可能是不可能或不适当的。 当提供多个参考范围时，应该通过“适用人群”（Observation.referenceRange.appliesTo）和”适用年龄段“（Observation.referenceRange.age） 来区分它们。", "requirements": "清楚哪些观测值是属于“正常”的，对评估观测结果的临床意义性很有帮助。不同的临床场景也需要使用不同的“参考范围”。", "min": 0, "max": "*", "base": { "path": "Observation.referenceRange", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "obs-3", "severity": "error", "human": "Must have at least a low or a high or text", "expression": "low.exists() or high.exists() or text.exists()", "xpath": "(exists(f:low) or exists(f:high)or exists(f:text))", "source": "http://hl7.org/fhir/StructureDefinition/Observation" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "OBX.7" }, { "identity": "rim", "map": "outboundRelationship[typeCode=REFV]/target[classCode=OBS, moodCode=EVN]" } ] }, { "id": "Observation.referenceRange.id", "path": "Observation.referenceRange.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "Observation.referenceRange.extension", "path": "Observation.referenceRange.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.referenceRange.modifierExtension", "path": "Observation.referenceRange.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.referenceRange.low", "path": "Observation.referenceRange.low", "short": "下限值", "definition": "参考范围下限的值。参考范围边界的下限包含该值（例如，参考范围>=5 - <=9）。如果下限值无临床意义，则可能不填（例如，参考范围<=2.3）。", "comment": "需要通过具体的场景来确定数量的类型和单位。", "alias": [ "最低值" ], "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.low", "min": 0, "max": "1" }, "type": [ { "code": "Quantity", "profile": [ "http://StructureDefinition.hl7fhir.cn/SimpleQuantity" ] } ], "condition": [ "ele-1", "obs-3" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "qty-3", "severity": "error", "human": "If a code for the unit is present, the system SHALL also be present", "expression": "code.empty() or system.exists()", "xpath": "not(exists(f:code)) or exists(f:system)", "source": "http://hl7.org/fhir/StructureDefinition/Quantity" }, { "key": "sqty-1", "severity": "error", "human": "The comparator is not used on a SimpleQuantity", "expression": "comparator.empty()", "xpath": "not(exists(f:comparator))", "source": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" } ], "isModifier": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "SN (see also Range) or CQ" }, { "identity": "rim", "map": "PQ, IVL, MO, CO, depending on the values" }, { "identity": "v2", "map": "OBX-7" }, { "identity": "rim", "map": "value:IVL_PQ.low" } ] }, { "id": "Observation.referenceRange.high", "path": "Observation.referenceRange.high", "short": "上限值", "definition": "参考范围上限的值。参考范围边界的上限包含该值，例如，参考范围为：（>=5 - <=9），此时上限值为9。如果上限值无临床意义，则可能不填（例如，参考范围>=2.3）。", "comment": "需要通过具体的场景来确定数量的类型和单位。", "alias": [ "最高值" ], "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.high", "min": 0, "max": "1" }, "type": [ { "code": "Quantity", "profile": [ "http://StructureDefinition.hl7fhir.cn/SimpleQuantity" ] } ], "condition": [ "ele-1", "obs-3" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "qty-3", "severity": "error", "human": "If a code for the unit is present, the system SHALL also be present", "expression": "code.empty() or system.exists()", "xpath": "not(exists(f:code)) or exists(f:system)", "source": "http://hl7.org/fhir/StructureDefinition/Quantity" }, { "key": "sqty-1", "severity": "error", "human": "The comparator is not used on a SimpleQuantity", "expression": "comparator.empty()", "xpath": "not(exists(f:comparator))", "source": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" } ], "isModifier": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "SN (see also Range) or CQ" }, { "identity": "rim", "map": "PQ, IVL, MO, CO, depending on the values" }, { "identity": "v2", "map": "OBX-7" }, { "identity": "rim", "map": "value:IVL_PQ.high" } ] }, { "id": "Observation.referenceRange.type", "path": "Observation.referenceRange.type", "short": "范围的类型", "definition": "用编码来表示参考范围的分类意义。例如，正常范围或治疗范围。", "comment": "当提供多个参考范围时，应该为此元素赋值，以区分不同范围的意义。", "requirements": "为正解的理解范围的意义，需要说明参考范围的类型，如：正常范围、推荐范围，治疗范围等等。", "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.type", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "meaningWhenMissing": "默认情况下，缺失此元素意味着：“正常范围”，", "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationRangeMeaning" } ], "strength": "preferred", "description": "Code for the meaning of a reference range.", "valueSet": "http://hl7.org/fhir/ValueSet/referencerange-meaning" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "sct-concept", "map": "< 260245000 |Findings values| OR \r< 365860008 |General clinical state finding| \rOR \r< 250171008 |Clinical history or observation findings| OR \r< 415229000 |Racial group| OR \r< 365400002 |Finding of puberty stage| OR\r< 443938003 |Procedure carried out on subject|" }, { "identity": "v2", "map": "OBX-10" }, { "identity": "rim", "map": "interpretationCode" } ] }, { "id": "Observation.referenceRange.appliesTo", "path": "Observation.referenceRange.appliesTo", "short": "适用人群", "definition": "用编码来表示此参考范围的适用目标人群。例如，正常人群、特定性别或种族对此参考范围适用。 若提供多个“appliesTo”元素提供值，则这些编码值之间是“并且”关系，即多个目标群体取交集。 例如，一个代表“女人”的编码加上一个代表“非裔美国人”的编码，意味着目标人群为“非裔美国女性”。", "comment": "如果有多个参考范围，则应该提供此元素。", "requirements": "为正确理解参考范围的意义，需要能够识别目标人群。", "min": 0, "max": "*", "base": { "path": "Observation.referenceRange.appliesTo", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "meaningWhenMissing": "如果没有提供此元素，则默认为“正常群体”。", "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationRangeType" } ], "strength": "example", "description": "Codes identifying the population the reference range applies to.", "valueSet": "http://hl7.org/fhir/ValueSet/referencerange-appliesto" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "sct-concept", "map": "< 260245000 |Findings values| OR \r< 365860008 |General clinical state finding| \rOR \r< 250171008 |Clinical history or observation findings| OR \r< 415229000 |Racial group| OR \r< 365400002 |Finding of puberty stage| OR\r< 443938003 |Procedure carried out on subject|" }, { "identity": "v2", "map": "OBX-10" }, { "identity": "rim", "map": "interpretationCode" } ] }, { "id": "Observation.referenceRange.age", "path": "Observation.referenceRange.age", "short": "适用年龄段", "definition": "此参考范围适用的年龄段，包括新生儿年龄（例如足月的周数）。", "comment": "年龄段应该是大于0并且小于观测目标的最大可能年龄", "requirements": "有些分析对年龄很敏感。", "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.age", "min": 0, "max": "1" }, "type": [ { "code": "Range" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "rng-2", "severity": "error", "human": "If present, low SHALL have a lower value than high", "expression": "low.empty() or high.empty() or (low <= high)", "xpath": "not(exists(f:low/f:value/@value)) or not(exists(f:high/f:value/@value)) or (number(f:low/f:value/@value) <= number(f:high/f:value/@value))", "source": "http://hl7.org/fhir/StructureDefinition/Range" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "NR and also possibly SN (but see also quantity)" }, { "identity": "rim", "map": "IVL [lowClosed=\"true\" and highClosed=\"true\"]or URG" }, { "identity": "rim", "map": "outboundRelationship[typeCode=PRCN].targetObservationCriterion[code=\"age\"].value" } ] }, { "id": "Observation.referenceRange.age.id", "path": "Observation.referenceRange.age.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "Observation.referenceRange.age.extension", "path": "Observation.referenceRange.age.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.referenceRange.age.low", "path": "Observation.referenceRange.age.low", "short": "最小年龄", "definition": "最小年龄不应小于0，并大于等于此值", "comment": "需要通过具体的场景来确定数量的类型和单位。", "min": 0, "max": "1", "base": { "path": "Range.low", "min": 0, "max": "1" }, "type": [ { "code": "Quantity", "profile": [ "http://StructureDefinition.hl7fhir.cn/SimpleQuantity" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "qty-3", "severity": "error", "human": "If a code for the unit is present, the system SHALL also be present", "expression": "code.empty() or system.exists()", "xpath": "not(exists(f:code)) or exists(f:system)", "source": "http://hl7.org/fhir/StructureDefinition/Quantity" }, { "key": "sqty-1", "severity": "error", "human": "The comparator is not used on a SimpleQuantity", "expression": "comparator.empty()", "xpath": "not(exists(f:comparator))", "source": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" } ], "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "SN (see also Range) or CQ" }, { "identity": "rim", "map": "PQ, IVL, MO, CO, depending on the values" }, { "identity": "v2", "map": "NR.1" }, { "identity": "rim", "map": "./low" } ] }, { "id": "Observation.referenceRange.age.high", "path": "Observation.referenceRange.age.high", "short": "最大年龄", "definition": "年龄小于等于此值", "comment": "需要通过具体的场景来确定数量的类型和单位。", "min": 0, "max": "1", "base": { "path": "Range.high", "min": 0, "max": "1" }, "type": [ { "code": "Quantity", "profile": [ "http://StructureDefinition.hl7fhir.cn/SimpleQuantity" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "qty-3", "severity": "error", "human": "If a code for the unit is present, the system SHALL also be present", "expression": "code.empty() or system.exists()", "xpath": "not(exists(f:code)) or exists(f:system)", "source": "http://hl7.org/fhir/StructureDefinition/Quantity" }, { "key": "sqty-1", "severity": "error", "human": "The comparator is not used on a SimpleQuantity", "expression": "comparator.empty()", "xpath": "not(exists(f:comparator))", "source": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" } ], "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "SN (see also Range) or CQ" }, { "identity": "rim", "map": "PQ, IVL, MO, CO, depending on the values" }, { "identity": "v2", "map": "NR.2" }, { "identity": "rim", "map": "./high" } ] }, { "id": "Observation.referenceRange.text", "path": "Observation.referenceRange.text", "short": "文本描述", "definition": "当定量的参考范围不适合时，用文本描述的观测参考范围。例如，参考值是“负数”或“正常值列表”。", "comment": "注意，FHIR中的字符串大小不能超过1MB。", "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.text", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "OBX-7" }, { "identity": "rim", "map": "value:ST" } ] }, { "id": "Observation.hasMember", "path": "Observation.hasMember", "short": "组成员", "definition": "当此观测是作为一组观测(（例如电池、一组检验、一组生命体征测量）)中的一个时，用此元素来引用该组中的其它组成员。", "comment": "使用此元素时，引用的观测资源通常都会有值，并且可能还会有一组相关资源。\r\n注意，系统可能会将“答卷资源”（QuestionnaireResponse）的结果计算为用观测值来表示的最终分数。\r\n组合使用观测的更多信息请参见 http://hl7.org/fhir/observation.html#obsgrouping", "min": 0, "max": "*", "base": { "path": "Observation.hasMember", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Observation", "http://StructureDefinition.hl7fhir.cn/QuestionnaireResponse", "http://StructureDefinition.hl7fhir.cn/MolecularSequence" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "v2", "map": "Relationships established by OBX-4 usage" }, { "identity": "rim", "map": "outBoundRelationship" } ] }, { "id": "Observation.derivedFrom", "path": "Observation.derivedFrom", "short": "作为依据的相关测量", "definition": "基于哪个资源得出此观测结果。例如，基于超声图像的胎儿大小测量。", "comment": "此元素中列出的资源可以是临床观测，也可以是其他测量，此观测的值来源于这些测量中。最常见的情况此元素会引用另一个观测资源。", "min": 0, "max": "*", "base": { "path": "Observation.derivedFrom", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Observation", "http://StructureDefinition.hl7fhir.cn/DocumentReference", "http://StructureDefinition.hl7fhir.cn/ImagingStudy", "http://StructureDefinition.hl7fhir.cn/Media", "http://StructureDefinition.hl7fhir.cn/QuestionnaireResponse", "http://StructureDefinition.hl7fhir.cn/MolecularSequence" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "v2", "map": "Relationships established by OBX-4 usage" }, { "identity": "rim", "map": ".targetObservation" } ] }, { "id": "Observation.component", "path": "Observation.component", "short": "明细项目", "definition": "有些观测是由多个明细观测项构成的。这些明细观测共享相同属性,但有各自不同的“编码-值”对。 例如：血压测量的明细观测分为收缩压和舒张压。", "comment": "关于观测资源的组成和组合使用，可参见 http://hl7.org/fhir/observation.html#notes", "requirements": "明细观测作为主观测资源的一部分（不可分开使用）共享主观测资源中的属性， 但主观测值的参考范围是不共享使用的，每个明细观测的参考范围可以独立设置。", "min": 0, "max": "*", "base": { "path": "Observation.component", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "containment by OBX-4?" }, { "identity": "rim", "map": "outBoundRelationship[typeCode=COMP]" } ] }, { "id": "Observation.component.id", "path": "Observation.component.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "Observation.component.extension", "path": "Observation.component.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.component.modifierExtension", "path": "Observation.component.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.component.code", "path": "Observation.component.code", "short": "观测明细项目代码", "definition": "以编码的形式描述观测到的内容。有时这被称为“观测代码”。", "comment": "如果Observation.component不为空，则需要将component元素中所有的值（编码-值对）结合此元素一起综合考虑，才能正确理解主观测结果的含义。", "requirements": "精确的理解正在进行的是什么观测非常重要。", "min": 1, "max": "1", "base": { "path": "Observation.component.code", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationCode" } ], "strength": "example", "description": "Codes identifying names of simple observations.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-codes" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "w5", "map": "FiveWs.what[x]" }, { "identity": "sct-concept", "map": "< 363787002 |Observable entity| OR \r< 386053000 |Evaluation procedure|" }, { "identity": "v2", "map": "OBX-3" }, { "identity": "rim", "map": "code" } ] }, { "id": "Observation.component.value[x]", "path": "Observation.component.value[x]", "short": "实际的明细结果值", "definition": "若观测结果是一个简单值，则可以通过此元素来表示观测产生的结果信息。", "comment": "当观测资源存在一组observation.component元素时，它可能同时具有一个结果值（例如Apgar评分）和明细观测项（Apgar评分中的每一个评分项）。 如果此元素值不为空，则其数据类型应通过Observation.code确定。 如果此元素有固定的编码，或者由Observation.code定义了编码值，则对值的文本描述应该使用一个只有text元素的CodeableConcept数据类型来表示，而不用字符串类型。", "requirements": "除非有错误产生，否则都应该有值", "min": 0, "max": "1", "base": { "path": "Observation.component.value[x]", "min": 0, "max": "1" }, "type": [ { "code": "Quantity" }, { "code": "CodeableConcept" }, { "code": "string" }, { "code": "boolean" }, { "code": "integer" }, { "code": "Range" }, { "code": "Ratio" }, { "code": "SampledData" }, { "code": "time" }, { "code": "dateTime" }, { "code": "Period" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "sct-concept", "map": "363714003 |Interprets| < 441742003 |Evaluation finding|" }, { "identity": "v2", "map": "OBX.2, OBX.5, OBX.6" }, { "identity": "rim", "map": "value" }, { "identity": "sct-attr", "map": "363714003 |Interprets|" } ] }, { "id": "Observation.component.dataAbsentReason", "path": "Observation.component.dataAbsentReason", "short": "无结果值或出错的原因", "definition": "如果Observation.value[x]缺少值，通过此元素说明缺失的原因。或者在检测过程中出现异常也可以用此元素来说明出错原因。", "comment": "在FHIR中，观测资源的空值（Null）或异常值有两种表示方法：一种方法是使用值域集，简单地将它们作为其中的概念来表示异常。 例如，血清检测的观测资源值可以是“检测”、“未检测”、“不确定”或“样本不合格”。 另一种方法是使用value元素记录实际观测结果，同时使用dataAbsentReason元素记录异常值。 例如，当检测未完成时，可以将“error”编码赋值给dataAbsentReason元素。 注意，只有当有观测值时才能报告。例如，只有细胞计数值当大于0时才能报告。 所以在实际用例中需要使用以上两种方法之一对观测的空值或异常值进行解释。", "requirements": "大部分在检测中出现的观测结果异常值都有必要处理。", "min": 0, "max": "1", "base": { "path": "Observation.component.dataAbsentReason", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1", "obs-6" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationValueAbsentReason" } ], "strength": "extensible", "description": "Codes specifying why the result (`Observation.value[x]`) is missing.", "valueSet": "http://hl7.org/fhir/ValueSet/data-absent-reason" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "value.nullFlavor" } ] }, { "id": "Observation.component.interpretation", "path": "Observation.component.interpretation", "short": "结果解释", "definition": "对明细观测值的分类评估。例如，高、低、正常。", "comment": "以前作为实验室结果的“异常标志”来使用，现在使用范围得到了扩展（扩展范围与其绑定的值域集中编码的含义相对应）。 此元素在报告中呈现方式通常是显示在观测结果值旁边的代码或符号，以表示结果的含义或正常状态。", "requirements": "为了充分理解观测结果的重要性，有必要对某些结果（特别是数值性结果或危急值）进行解释。", "alias": [ "Abnormal Flag", "异常标志" ], "min": 0, "max": "*", "base": { "path": "Observation.component.interpretation", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationInterpretation" } ], "strength": "extensible", "description": "Codes identifying interpretations of observations.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-interpretation" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "sct-concept", "map": "< 260245000 |Findings values|" }, { "identity": "v2", "map": "OBX-8" }, { "identity": "rim", "map": "interpretationCode" }, { "identity": "sct-attr", "map": "363713009 |Has interpretation|" } ] }, { "id": "Observation.component.referenceRange", "path": "Observation.component.referenceRange", "short": "参考范围", "definition": "观测结果的正常范围或推荐的参考范围，通此元素提供的范围值和实际结果值的比较，可以从量级上解释观测结果的意义。 若此元素有多个范围值，这些值之间是“或者”关系。 换句话说，可以使用两个“referenceRange”元素来表示两个范围的并集。", "comment": "多数观测值只有一个通用参考范围。 系统可能会根据对患者的相关信息（如年龄、性别、体重和其他信息）来提供更个性化的参考范围，但这可能是不可能或不适当的。 当提供多个参考范围时，应该通过“适用人群”（Observation.referenceRange.appliesTo）和”适用年龄段“（Observation.referenceRange.age） 来区分它们。", "requirements": "清楚哪些观测值是属于“正常”的，对评估观测结果的临床意义性很有帮助。不同的临床场景也需要使用不同的“参考范围”。", "min": 0, "max": "*", "base": { "path": "Observation.component.referenceRange", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "mapping": [ { "identity": "v2", "map": "OBX.7" }, { "identity": "rim", "map": "outboundRelationship[typeCode=REFV]/target[classCode=OBS, moodCode=EVN]" } ] }, { "id": "Observation.component.referenceRange.id", "path": "Observation.component.referenceRange.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "Observation.component.referenceRange.extension", "path": "Observation.component.referenceRange.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.component.referenceRange.modifierExtension", "path": "Observation.component.referenceRange.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.component.referenceRange.low", "path": "Observation.component.referenceRange.low", "short": "下限值", "definition": "参考范围下限的值。参考范围边界的下限包含该值（例如，参考范围>=5 - <=9）。如果下限值无临床意义，则可能不填（例如，参考范围<=2.3）。", "comment": "需要通过具体的场景来确定数量的类型和单位。", "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.low", "min": 0, "max": "1" }, "type": [ { "code": "Quantity", "profile": [ "http://StructureDefinition.hl7fhir.cn/SimpleQuantity" ] } ], "condition": [ "ele-1", "obs-3" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "qty-3", "severity": "error", "human": "If a code for the unit is present, the system SHALL also be present", "expression": "code.empty() or system.exists()", "xpath": "not(exists(f:code)) or exists(f:system)", "source": "http://hl7.org/fhir/StructureDefinition/Quantity" }, { "key": "sqty-1", "severity": "error", "human": "The comparator is not used on a SimpleQuantity", "expression": "comparator.empty()", "xpath": "not(exists(f:comparator))", "source": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" } ], "isModifier": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "SN (see also Range) or CQ" }, { "identity": "rim", "map": "PQ, IVL, MO, CO, depending on the values" }, { "identity": "v2", "map": "OBX-7" }, { "identity": "rim", "map": "value:IVL_PQ.low" } ] }, { "id": "Observation.component.referenceRange.high", "path": "Observation.component.referenceRange.high", "short": "上限值", "definition": "参考范围上限的值。参考范围边界的上限包含该值，例如，参考范围为：（>=5 - <=9），此时上限值为9。如果上限值无临床意义，则可能不填（例如，参考范围>=2.3）。", "comment": "需要通过具体的场景来确定数量的类型和单位。", "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.high", "min": 0, "max": "1" }, "type": [ { "code": "Quantity", "profile": [ "http://StructureDefinition.hl7fhir.cn/SimpleQuantity" ] } ], "condition": [ "ele-1", "obs-3" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "qty-3", "severity": "error", "human": "If a code for the unit is present, the system SHALL also be present", "expression": "code.empty() or system.exists()", "xpath": "not(exists(f:code)) or exists(f:system)", "source": "http://hl7.org/fhir/StructureDefinition/Quantity" }, { "key": "sqty-1", "severity": "error", "human": "The comparator is not used on a SimpleQuantity", "expression": "comparator.empty()", "xpath": "not(exists(f:comparator))", "source": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" } ], "isModifier": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "SN (see also Range) or CQ" }, { "identity": "rim", "map": "PQ, IVL, MO, CO, depending on the values" }, { "identity": "v2", "map": "OBX-7" }, { "identity": "rim", "map": "value:IVL_PQ.high" } ] }, { "id": "Observation.component.referenceRange.type", "path": "Observation.component.referenceRange.type", "short": "范围的类型", "definition": "用编码来表示参考范围的分类意义。例如，正常范围或治疗范围。", "comment": "当提供多个参考范围时，应该为此元素赋值，以区分不同范围的意义。", "requirements": "为正解的理解范围的意义，需要说明参考范围的类型，如：正常范围、推荐范围，治疗范围等等。", "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.type", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "meaningWhenMissing": "默认情况下，缺失此元素意味着：“正常范围”，", "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationRangeMeaning" } ], "strength": "preferred", "description": "Code for the meaning of a reference range.", "valueSet": "http://hl7.org/fhir/ValueSet/referencerange-meaning" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "sct-concept", "map": "< 260245000 |Findings values| OR \r< 365860008 |General clinical state finding| \rOR \r< 250171008 |Clinical history or observation findings| OR \r< 415229000 |Racial group| OR \r< 365400002 |Finding of puberty stage| OR\r< 443938003 |Procedure carried out on subject|" }, { "identity": "v2", "map": "OBX-10" }, { "identity": "rim", "map": "interpretationCode" } ] }, { "id": "Observation.component.referenceRange.appliesTo", "path": "Observation.component.referenceRange.appliesTo", "short": "适用人群", "definition": "用编码来表示此参考范围的适用目标人群。例如，正常人群、特定性别或种族对此参考范围适用。 若提供多个“appliesTo”元素提供值，则这些编码值之间是“并且”关系，即多个目标群体取交集。 例如，一个代表“女人”的编码加上一个代表“非裔美国人”的编码，意味着目标人群为“非裔美国女性”。", "comment": "如果有多个参考范围，则应该提供此元素。", "requirements": "为正确理解参考范围的意义，需要能够识别目标人群。", "min": 0, "max": "*", "base": { "path": "Observation.referenceRange.appliesTo", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationRangeType" } ], "strength": "example", "description": "Codes identifying the population the reference range applies to.", "valueSet": "http://hl7.org/fhir/ValueSet/referencerange-appliesto" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "sct-concept", "map": "< 260245000 |Findings values| OR \r< 365860008 |General clinical state finding| \rOR \r< 250171008 |Clinical history or observation findings| OR \r< 415229000 |Racial group| OR \r< 365400002 |Finding of puberty stage| OR\r< 443938003 |Procedure carried out on subject|" }, { "identity": "v2", "map": "OBX-10" }, { "identity": "rim", "map": "interpretationCode" } ] }, { "id": "Observation.component.referenceRange.age", "path": "Observation.component.referenceRange.age", "short": "适用年龄段", "definition": "此参考范围适用的年龄段，包括新生儿年龄（例如足月的周数）。", "comment": "年龄段应该是大于0并且小于观测目标的最大可能年龄", "requirements": "有些分析对年龄很敏感。", "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.age", "min": 0, "max": "1" }, "type": [ { "code": "Range" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "rng-2", "severity": "error", "human": "If present, low SHALL have a lower value than high", "expression": "low.empty() or high.empty() or (low <= high)", "xpath": "not(exists(f:low/f:value/@value)) or not(exists(f:high/f:value/@value)) or (number(f:low/f:value/@value) <= number(f:high/f:value/@value))", "source": "http://hl7.org/fhir/StructureDefinition/Range" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "NR and also possibly SN (but see also quantity)" }, { "identity": "rim", "map": "IVL [lowClosed=\"true\" and highClosed=\"true\"]or URG" }, { "identity": "rim", "map": "outboundRelationship[typeCode=PRCN].targetObservationCriterion[code=\"age\"].value" } ] }, { "id": "Observation.component.referenceRange.age.id", "path": "Observation.component.referenceRange.age.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "Observation.component.referenceRange.age.extension", "path": "Observation.component.referenceRange.age.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.component.referenceRange.age.low", "path": "Observation.component.referenceRange.age.low", "short": "最小年龄", "definition": "最小年龄不应小于0，大于等于此值", "comment": "需要通过具体的场景来确定数量的类型和单位。简单数量不能使用“值比较器”（comparetor）来对来实际值与声明的计量值之间的大小。", "min": 0, "max": "1", "base": { "path": "Range.low", "min": 0, "max": "1" }, "type": [ { "code": "Quantity", "profile": [ "http://StructureDefinition.hl7fhir.cn/SimpleQuantity" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "qty-3", "severity": "error", "human": "If a code for the unit is present, the system SHALL also be present", "expression": "code.empty() or system.exists()", "xpath": "not(exists(f:code)) or exists(f:system)", "source": "http://hl7.org/fhir/StructureDefinition/Quantity" }, { "key": "sqty-1", "severity": "error", "human": "The comparator is not used on a SimpleQuantity", "expression": "comparator.empty()", "xpath": "not(exists(f:comparator))", "source": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" } ], "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "SN (see also Range) or CQ" }, { "identity": "rim", "map": "PQ, IVL, MO, CO, depending on the values" }, { "identity": "v2", "map": "NR.1" }, { "identity": "rim", "map": "./low" } ] }, { "id": "Observation.component.referenceRange.age.high", "path": "Observation.component.referenceRange.age.high", "short": "最大年龄", "definition": "年龄小于等于此值", "comment": "需要通过具体的场景来确定数量的类型和单位。简单数量不能使用“值比较器”（comparetor）来对来实际值与声明的计量值之间的大小。", "min": 0, "max": "1", "base": { "path": "Range.high", "min": 0, "max": "1" }, "type": [ { "code": "Quantity", "profile": [ "http://StructureDefinition.hl7fhir.cn/SimpleQuantity" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "qty-3", "severity": "error", "human": "If a code for the unit is present, the system SHALL also be present", "expression": "code.empty() or system.exists()", "xpath": "not(exists(f:code)) or exists(f:system)", "source": "http://hl7.org/fhir/StructureDefinition/Quantity" }, { "key": "sqty-1", "severity": "error", "human": "The comparator is not used on a SimpleQuantity", "expression": "comparator.empty()", "xpath": "not(exists(f:comparator))", "source": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" } ], "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "SN (see also Range) or CQ" }, { "identity": "rim", "map": "PQ, IVL, MO, CO, depending on the values" }, { "identity": "v2", "map": "NR.2" }, { "identity": "rim", "map": "./high" } ] }, { "id": "Observation.component.referenceRange.text", "path": "Observation.component.referenceRange.text", "short": "文本描述", "definition": "当定量的参考范围不适合时，用文本描述的观测参考范围。例如，参考值是“负数”或“正常值列表”。", "comment": "注意，FHIR中的字符串大小不能超过1MB。", "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.text", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "OBX-7" }, { "identity": "rim", "map": "value:ST" } ] } ] }, "differential": { "element": [ { "id": "Observation", "path": "Observation", "short": "观测结果", "definition": "对目标（患者、设备或其它对象）进行检测、观察后的观测结果。", "comment": "用于简单的观测，如设备测量、实验室细项结果、生命体征、身高、体重、吸烟状态等。检验报告类资源通过引用多个观测资源后才具有临床意义。" }, { "id": "Observation.identifier", "path": "Observation.identifier", "requirements": "用于区分观测资源的实例，同时便于利用业务ID引用观测内容", "type": [ { "code": "Identifier", "profile": [ "http://StructureDefinition.hl7fhir.cn/Identifier" ] } ] }, { "id": "Observation.basedOn", "path": "Observation.basedOn", "short": "产生原由事件", "definition": "为了满足此元素引用的事件（处方、医嘱、检验检查申请、照护计划等）才导致此观测资源的产生。例如，药品处方可能要求在发药之前对患者进行检验检查。", "requirements": "通过此元素可实现追溯与跟踪管理：一方面可以用于确认此观测事件是否已通过授权，另一方面还可以跟踪医嘱或申请单是否执行。", "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/CarePlan", "http://StructureDefinition.hl7fhir.cn/MedicationRequest", "http://StructureDefinition.hl7fhir.cn/ServiceRequest", "http://StructureDefinition.hl7fhir.cn/NutritionOrder", "http://StructureDefinition.hl7fhir.cn/ImmunizationRecommendation", "http://StructureDefinition.hl7fhir.cn/DeviceRequest" ] } ] }, { "id": "Observation.partOf", "path": "Observation.partOf", "short": "父事件", "definition": "包含此观测资源的一个更大的事件（如：治疗、用药记录、发药、免疫接种等），此观测资源仅作为其中的一个组成部分或步骤。", "comment": "若要将观测资源与医疗就诊资源相关联，应使用“Observation.encounter”元素。\r\n两个观测资源之间的关联请参阅Observation.hasMember和Observation.derivedFrom元素。", "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/MedicationAdministration", "http://StructureDefinition.hl7fhir.cn/MedicationDispense", "http://StructureDefinition.hl7fhir.cn/MedicationStatement", "http://StructureDefinition.hl7fhir.cn/Procedure", "http://StructureDefinition.hl7fhir.cn/Immunization", "http://StructureDefinition.hl7fhir.cn/ImagingStudy" ] } ] }, { "id": "Observation.status", "path": "Observation.status", "short": "状态", "definition": "观测结果值的状态\r\nregistered | preliminary | final | amended | corrected | entered-in-error | unknown", "comment": "此元素值的改变可能影响整个资源的意义。", "requirements": "需要对单个观测结果的状态进行跟踪。有些观测结果可能在整体报告审核之前就已通过审核。", "isModifierReason": "当此状态码为“entered-in-error”时，表示当前资源无效。" }, { "id": "Observation.category", "path": "Observation.category", "short": "类别", "definition": "用来表示观观测分类的代码", "comment": "除了建议的类别值域集之外，还可以从其它维度自定义分类方案，并且可以同时使用多个类别。分类的粒度粗细由值域集中的概念定义。", "requirements": "用于对观测资源进行筛选检索和分类显示。" }, { "id": "Observation.code", "path": "Observation.code", "short": "观测代码（名称)", "definition": "用编码表示观测到的内容。可以看作观测“项目名称”。", "comment": "如果Observation.component不为空，则需要将component元素中所有的值（编码-值对）结合此元素一起综合考虑，才能正确理解观测结果的含义。", "requirements": "精确的理解正在进行的是什么观测非常重要。" }, { "id": "Observation.subject", "path": "Observation.subject", "short": "观测目标对象", "definition": "观测目标对象是一名患者或一组患者、位置或设备，观测结果记录在此对象的病历或报告中。 如果实际参与直接测量的观测对象与此目标对象（或对象的样本、部位）不同，应使用“Observation.focus”元素指定观测的实际测量对象， 并通过“Observation.code”来精确的表达观测的实际内容。", "comment": "除非由是某设备对某未知患者做的观测结果，否则此元素是必填项。 尽管如此，也必须在后期通过某种匹配技术将观测结果与患者关联，补充此元素并更新此观测结果。", "requirements": "如果不知道观测对象是谁或什么，那么此观测就没有意义。", "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Patient", "http://StructureDefinition.hl7fhir.cn/Group", "http://StructureDefinition.hl7fhir.cn/Device", "http://StructureDefinition.hl7fhir.cn/Location" ] } ] }, { "id": "Observation.focus", "path": "Observation.focus", "short": "实际参与直接测量的观测对象", "definition": "当观测对象实际关注的并不是病历中的患者时，用于表示与患者相关的实际参与直接测量的观测对象，比如配偶、父母、胎儿或捐赠者。例如，母亲病历中对胎儿的观测。 观测的关注点也可以是当前病症、干预效果、目标的饮食、目标的另一个观测或体内物质（如肿瘤或植入装置）。 另一个例子是使用观测资源来表示母亲是否接受过更换其孩子气管套管的培训，在此场景下孩子是病历中的病人，母亲则是观测资源实际参与直接测量的观测对象。", "comment": "观测目标对象通常是一名患者或一组患者、位置或设备。 目标对象和实际参与直接测量的观测对象之间的区别不需要使用此元素单独表示，而是应该通过指定具体的观测代码（Observation.code）来区分。 如果需要引用观测使用的标本，应使用“Observation.specimen”元素。 如果想表示具体观测的身体部位，应使用“Observation.bodysite”元素。 如果需要用编码而不用资源来表示此元素，可以使用focusCode扩展（http://hl7.org/fhir/StructureDefinition/observation-focusCode）。", "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Patient", "http://StructureDefinition.hl7fhir.cn/Group", "http://StructureDefinition.hl7fhir.cn/Device", "http://StructureDefinition.hl7fhir.cn/Location" ] } ] }, { "id": "Observation.encounter", "path": "Observation.encounter", "short": "医疗就诊活动", "definition": "在此医疗就诊活动（比如某次门诊、住院）期间产生的观测结果。", "comment": "这通常是发生在此医疗就诊活动期间的观测事件。虽然某些事件可能在医疗就诊活动之前或在完成之后发生，但仍在其相关（例如入院前检查）", "requirements": "对于某些观测项目来说，了解与其相关的具体医疗就诊活动很重要。", "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Encounter" ] } ] }, { "id": "Observation.effective[x]", "path": "Observation.effective[x]", "short": "发生时间", "definition": "观测发生的真实时间或时段。这通常是治疗或标本采集的时间，但此时间数据的来源可能未知。", "comment": "此元素至少应该提供一个日期，除非这是一个历史观测。 要记录不精确或“模糊”的时间（如，餐后血糖），请使用Timing数据类型，它用于测量与日常生活事件相关的时间。", "requirements": "观测发生的真实时间对其相关性以及趋势判定都很重要。" }, { "id": "Observation.issued", "path": "Observation.issued", "short": "正式发布时间", "definition": "观测结果的发布日期和时间，通常是在审核和确认之后才发布。", "comment": "对于不需要审核和确认的观测，此元素的值可能与资源本身的“Meta.lastUpdated”时间相同。 有些观测则需要在其更新时进行审核和确认，这时此元素的时间可能早于资源本身的“Meta.lastUpdated”时间， 因为当更新的不是重要的临床信息时，不需要重新审核和发布，此时更新资源并不会更新此元素的值。" }, { "id": "Observation.performer", "path": "Observation.performer", "short": "执行者", "definition": "对观测值的准备性负责的人", "requirements": "可增加观测结果的可信度，同时明确了后续问题的责任人。", "alias": [ "责任人" ], "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Practitioner", "http://StructureDefinition.hl7fhir.cn/PractitionerRole", "http://StructureDefinition.hl7fhir.cn/Organization", "http://StructureDefinition.hl7fhir.cn/CareTeam", "http://StructureDefinition.hl7fhir.cn/Patient", "http://StructureDefinition.hl7fhir.cn/RelatedPerson" ] } ] }, { "id": "Observation.value[x]", "path": "Observation.value[x]", "short": "实际的观测结果值", "definition": "若观测结果是一个简单值，则可以通过此元素来表示观测产生的结果信息。", "comment": "一个观测值可以是：1）此元素的单个值， 2）此单个值和observation.component元素中一组相关或明细指标的值，或者 3）仅使用observation.component元素中一组相关或明细指标的值。 如果此元素值不为空，则其数据类型应通过Observation.code确定。 如果此元素有固定的编码，或者由Observation.code定义了编码值，则对值的文本描述应该使用一个只有text元素的CodeableConcept数据类型来表示，而不用字符串类型。", "requirements": "观测资源都应该有值，除非有错误产生，或者它代表着一组观测。" }, { "id": "Observation.dataAbsentReason", "path": "Observation.dataAbsentReason", "short": "无结果值或出错的原因", "definition": "如果Observation.value[x]缺少值，通过此元素说明缺失的原因。或者在检测过程中出现异常也可以用此元素来说明出错原因。", "comment": "在FHIR中，观测资源的空值（Null）或异常值有两种表示方法：一种方法是使用值域集，简单地将它们作为其中的概念来表示异常。 例如，血清检测的观测资源值可以是“检测”、“未检测”、“不确定”或“样本不合格”。 另一种方法是使用value元素记录实际观测结果，同时使用dataAbsentReason元素记录异常值。 例如，当检测未完成时，可以将“error”编码赋值给dataAbsentReason元素。 注意，只有当有观测值时才能报告。例如，只有细胞计数值当大于0时才能报告。 所以在实际用例中需要使用以上两种方法之一对观测的空值或异常值进行解释。", "requirements": "大部分在检测中出现的观测结果异常值都有必要处理。" }, { "id": "Observation.interpretation", "path": "Observation.interpretation", "short": "结果解释", "definition": "对观测值的分类评估。例如，高、低、正常。", "comment": "以前作为实验室结果的“异常标志”来使用，现在使用范围得到了扩展（扩展范围与其绑定的值域集中编码的含义相对应）。 此元素在报告中呈现方式通常是显示在观测结果值旁边的代码或符号，以表示结果的含义或正常状态。", "requirements": "为了充分理解观测结果的重要性，有必要对某些结果（特别是数值性结果或危急值）进行解释。", "alias": [ "异常标志" ] }, { "id": "Observation.note", "path": "Observation.note", "short": "备注", "definition": "对观测或结果的备注或评论。", "comment": "可能包括对观测结果的一般性陈述，或关于重大、意外或不可靠结果值的陈述，或与Observation.interpretation的相关信息。", "requirements": "提供自由文本附加信息很有必要。" }, { "id": "Observation.bodySite", "path": "Observation.bodySite", "short": "观测部位", "definition": "在患者身体上进行观测的部位（即目标位置）。", "comment": "仅当Observation.code的概念中没有包含位置信息时才使用此元素。在有些系统中，可以用此元素来表示相关的观测，而不是作为此观测所包含的一部分。 在某些场景下可能需要使用单独的身体结构资源（BodyStructure），比如用于标识和跟踪不同的身体部位。 这种情况应该用一扩展元素来解决，参见BodyStructure引用扩展（http://hl7.org/fhir/extension-bodysite.html）。" }, { "id": "Observation.method", "path": "Observation.method", "short": "实验方法", "definition": "用于明确执行观测时所使用的方法和机制。", "comment": "仅当Observation.code的编码值的概念中没有暗含观测方法时才使用此元素。", "requirements": "在某些情况下，不同的观测（检验/实验）方法会产生不同的观测结果，所以仅当观测方法相同时所产生的结果才具有可比性，同理只有在明确了观测方法后才能确定结果值的意义。" }, { "id": "Observation.specimen", "path": "Observation.specimen", "short": "观测使用的标本", "definition": "执行观测时所使用的样本或标本。", "comment": "仅当Observation.code的编码值的概念中没有暗含观测所使用的标本时才使用此元素。 虽然观测针是对目标（患者等）进行的，但在很多情况下需要通过标本作为载体才能完成具体的观测。 注意，观测资源中包含的标本信息并不一定会很精确。 另外，观测资源可用于对标本进行精确追踪时的场景（例如诊断报告）。", "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Specimen" ] } ] }, { "id": "Observation.device", "path": "Observation.device", "short": "测量仪器", "definition": "用来产生观测数据的仪器设备。", "comment": "注意，这里的设备不是指用于传输结果的相关设备，例如网关。与网络的相关设备应使用处出资源（Provenance）来记录。", "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Device", "http://StructureDefinition.hl7fhir.cn/DeviceMetric" ] } ] }, { "id": "Observation.referenceRange", "path": "Observation.referenceRange", "short": "参考范围", "definition": "观测结果的正常范围或推荐的参考范围，通此元素提供的范围值和实际结果值的比较，可以从量级上解释观测结果的意义。 若此元素有多个范围值，这些值之间是“或者”关系。 换句话说，可以使用两个“referenceRange”元素来表示两个范围的并集。", "comment": "多数观测值只有一个通用参考范围。 系统可能会根据对患者的相关信息（如年龄、性别、体重和其他信息）来提供更个性化的参考范围，但这可能是不可能或不适当的。 当提供多个参考范围时，应该通过“适用人群”（Observation.referenceRange.appliesTo）和”适用年龄段“（Observation.referenceRange.age） 来区分它们。", "requirements": "清楚哪些观测值是属于“正常”的，对评估观测结果的临床意义性很有帮助。不同的临床场景也需要使用不同的“参考范围”。" }, { "id": "Observation.referenceRange.low", "path": "Observation.referenceRange.low", "short": "下限值", "definition": "参考范围下限的值。参考范围边界的下限包含该值（例如，参考范围>=5 - <=9）。如果下限值无临床意义，则可能不填（例如，参考范围<=2.3）。", "comment": "需要通过具体的场景来确定数量的类型和单位。", "alias": [ "最低值" ], "type": [ { "code": "Quantity", "profile": [ "http://StructureDefinition.hl7fhir.cn/SimpleQuantity" ] } ] }, { "id": "Observation.referenceRange.high", "path": "Observation.referenceRange.high", "short": "上限值", "definition": "参考范围上限的值。参考范围边界的上限包含该值，例如，参考范围为：（>=5 - <=9），此时上限值为9。如果上限值无临床意义，则可能不填（例如，参考范围>=2.3）。", "comment": "需要通过具体的场景来确定数量的类型和单位。", "alias": [ "最高值" ], "type": [ { "code": "Quantity", "profile": [ "http://StructureDefinition.hl7fhir.cn/SimpleQuantity" ] } ] }, { "id": "Observation.referenceRange.type", "path": "Observation.referenceRange.type", "short": "范围的类型", "definition": "用编码来表示参考范围的分类意义。例如，正常范围或治疗范围。", "comment": "当提供多个参考范围时，应该为此元素赋值，以区分不同范围的意义。", "requirements": "为正解的理解范围的意义，需要说明参考范围的类型，如：正常范围、推荐范围，治疗范围等等。", "meaningWhenMissing": "默认情况下，缺失此元素意味着：“正常范围”，" }, { "id": "Observation.referenceRange.appliesTo", "path": "Observation.referenceRange.appliesTo", "short": "适用人群", "definition": "用编码来表示此参考范围的适用目标人群。例如，正常人群、特定性别或种族对此参考范围适用。 若提供多个“appliesTo”元素提供值，则这些编码值之间是“并且”关系，即多个目标群体取交集。 例如，一个代表“女人”的编码加上一个代表“非裔美国人”的编码，意味着目标人群为“非裔美国女性”。", "comment": "如果有多个参考范围，则应该提供此元素。", "requirements": "为正确理解参考范围的意义，需要能够识别目标人群。", "meaningWhenMissing": "如果没有提供此元素，则默认为“正常群体”。" }, { "id": "Observation.referenceRange.age", "path": "Observation.referenceRange.age", "short": "适用年龄段", "definition": "此参考范围适用的年龄段，包括新生儿年龄（例如足月的周数）。", "comment": "年龄段应该是大于0并且小于观测目标的最大可能年龄", "requirements": "有些分析对年龄很敏感。" }, { "id": "Observation.referenceRange.age.low", "path": "Observation.referenceRange.age.low", "short": "最小年龄", "definition": "最小年龄不应小于0，并大于等于此值", "comment": "需要通过具体的场景来确定数量的类型和单位。", "type": [ { "code": "Quantity", "profile": [ "http://StructureDefinition.hl7fhir.cn/SimpleQuantity" ] } ] }, { "id": "Observation.referenceRange.age.high", "path": "Observation.referenceRange.age.high", "short": "最大年龄", "definition": "年龄小于等于此值", "comment": "需要通过具体的场景来确定数量的类型和单位。", "type": [ { "code": "Quantity", "profile": [ "http://StructureDefinition.hl7fhir.cn/SimpleQuantity" ] } ] }, { "id": "Observation.referenceRange.text", "path": "Observation.referenceRange.text", "short": "文本描述", "definition": "当定量的参考范围不适合时，用文本描述的观测参考范围。例如，参考值是“负数”或“正常值列表”。", "comment": "注意，FHIR中的字符串大小不能超过1MB。" }, { "id": "Observation.hasMember", "path": "Observation.hasMember", "short": "组成员", "definition": "当此观测是作为一组观测(（例如电池、一组检验、一组生命体征测量）)中的一个时，用此元素来引用该组中的其它组成员。", "comment": "使用此元素时，引用的观测资源通常都会有值，并且可能还会有一组相关资源。\r\n注意，系统可能会将“答卷资源”（QuestionnaireResponse）的结果计算为用观测值来表示的最终分数。\r\n组合使用观测的更多信息请参见 http://hl7.org/fhir/observation.html#obsgrouping", "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Observation", "http://StructureDefinition.hl7fhir.cn/QuestionnaireResponse", "http://StructureDefinition.hl7fhir.cn/MolecularSequence" ] } ] }, { "id": "Observation.derivedFrom", "path": "Observation.derivedFrom", "short": "作为依据的相关测量", "definition": "基于哪个资源得出此观测结果。例如，基于超声图像的胎儿大小测量。", "comment": "此元素中列出的资源可以是临床观测，也可以是其他测量，此观测的值来源于这些测量中。最常见的情况此元素会引用另一个观测资源。", "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Observation", "http://StructureDefinition.hl7fhir.cn/DocumentReference", "http://StructureDefinition.hl7fhir.cn/ImagingStudy", "http://StructureDefinition.hl7fhir.cn/Media", "http://StructureDefinition.hl7fhir.cn/QuestionnaireResponse", "http://StructureDefinition.hl7fhir.cn/MolecularSequence" ] } ] }, { "id": "Observation.component", "path": "Observation.component", "short": "明细项目", "definition": "有些观测是由多个明细观测项构成的。这些明细观测共享相同属性,但有各自不同的“编码-值”对。 例如：血压测量的明细观测分为收缩压和舒张压。", "comment": "关于观测资源的组成和组合使用，可参见 http://hl7.org/fhir/observation.html#notes", "requirements": "明细观测作为主观测资源的一部分（不可分开使用）共享主观测资源中的属性， 但主观测值的参考范围是不共享使用的，每个明细观测的参考范围可以独立设置。" }, { "id": "Observation.component.code", "path": "Observation.component.code", "short": "观测明细项目代码", "definition": "以编码的形式描述观测到的内容。有时这被称为“观测代码”。", "comment": "如果Observation.component不为空，则需要将component元素中所有的值（编码-值对）结合此元素一起综合考虑，才能正确理解主观测结果的含义。", "requirements": "精确的理解正在进行的是什么观测非常重要。" }, { "id": "Observation.component.value[x]", "path": "Observation.component.value[x]", "short": "实际的明细结果值", "definition": "若观测结果是一个简单值，则可以通过此元素来表示观测产生的结果信息。", "comment": "当观测资源存在一组observation.component元素时，它可能同时具有一个结果值（例如Apgar评分）和明细观测项（Apgar评分中的每一个评分项）。 如果此元素值不为空，则其数据类型应通过Observation.code确定。 如果此元素有固定的编码，或者由Observation.code定义了编码值，则对值的文本描述应该使用一个只有text元素的CodeableConcept数据类型来表示，而不用字符串类型。", "requirements": "除非有错误产生，否则都应该有值" }, { "id": "Observation.component.dataAbsentReason", "path": "Observation.component.dataAbsentReason", "short": "无结果值或出错的原因", "definition": "如果Observation.value[x]缺少值，通过此元素说明缺失的原因。或者在检测过程中出现异常也可以用此元素来说明出错原因。", "comment": "在FHIR中，观测资源的空值（Null）或异常值有两种表示方法：一种方法是使用值域集，简单地将它们作为其中的概念来表示异常。 例如，血清检测的观测资源值可以是“检测”、“未检测”、“不确定”或“样本不合格”。 另一种方法是使用value元素记录实际观测结果，同时使用dataAbsentReason元素记录异常值。 例如，当检测未完成时，可以将“error”编码赋值给dataAbsentReason元素。 注意，只有当有观测值时才能报告。例如，只有细胞计数值当大于0时才能报告。 所以在实际用例中需要使用以上两种方法之一对观测的空值或异常值进行解释。", "requirements": "大部分在检测中出现的观测结果异常值都有必要处理。" }, { "id": "Observation.component.interpretation", "path": "Observation.component.interpretation", "short": "结果解释", "definition": "对明细观测值的分类评估。例如，高、低、正常。", "comment": "以前作为实验室结果的“异常标志”来使用，现在使用范围得到了扩展（扩展范围与其绑定的值域集中编码的含义相对应）。 此元素在报告中呈现方式通常是显示在观测结果值旁边的代码或符号，以表示结果的含义或正常状态。", "requirements": "为了充分理解观测结果的重要性，有必要对某些结果（特别是数值性结果或危急值）进行解释。", "alias": [ "异常标志" ] }, { "id": "Observation.component.referenceRange", "path": "Observation.component.referenceRange", "short": "参考范围", "definition": "观测结果的正常范围或推荐的参考范围，通此元素提供的范围值和实际结果值的比较，可以从量级上解释观测结果的意义。 若此元素有多个范围值，这些值之间是“或者”关系。 换句话说，可以使用两个“referenceRange”元素来表示两个范围的并集。", "comment": "多数观测值只有一个通用参考范围。 系统可能会根据对患者的相关信息（如年龄、性别、体重和其他信息）来提供更个性化的参考范围，但这可能是不可能或不适当的。 当提供多个参考范围时，应该通过“适用人群”（Observation.referenceRange.appliesTo）和”适用年龄段“（Observation.referenceRange.age） 来区分它们。", "requirements": "清楚哪些观测值是属于“正常”的，对评估观测结果的临床意义性很有帮助。不同的临床场景也需要使用不同的“参考范围”。" }, { "id": "Observation.component.referenceRange.low", "path": "Observation.component.referenceRange.low", "short": "下限值", "definition": "参考范围下限的值。参考范围边界的下限包含该值（例如，参考范围>=5 - <=9）。如果下限值无临床意义，则可能不填（例如，参考范围<=2.3）。", "comment": "需要通过具体的场景来确定数量的类型和单位。", "type": [ { "code": "Quantity", "profile": [ "http://StructureDefinition.hl7fhir.cn/SimpleQuantity" ] } ] }, { "id": "Observation.component.referenceRange.high", "path": "Observation.component.referenceRange.high", "short": "上限值", "definition": "参考范围上限的值。参考范围边界的上限包含该值，例如，参考范围为：（>=5 - <=9），此时上限值为9。如果上限值无临床意义，则可能不填（例如，参考范围>=2.3）。", "comment": "需要通过具体的场景来确定数量的类型和单位。", "type": [ { "code": "Quantity", "profile": [ "http://StructureDefinition.hl7fhir.cn/SimpleQuantity" ] } ] }, { "id": "Observation.component.referenceRange.type", "path": "Observation.component.referenceRange.type", "short": "范围的类型", "definition": "用编码来表示参考范围的分类意义。例如，正常范围或治疗范围。", "comment": "当提供多个参考范围时，应该为此元素赋值，以区分不同范围的意义。", "requirements": "为正解的理解范围的意义，需要说明参考范围的类型，如：正常范围、推荐范围，治疗范围等等。", "meaningWhenMissing": "默认情况下，缺失此元素意味着：“正常范围”，" }, { "id": "Observation.component.referenceRange.appliesTo", "path": "Observation.component.referenceRange.appliesTo", "short": "适用人群", "definition": "用编码来表示此参考范围的适用目标人群。例如，正常人群、特定性别或种族对此参考范围适用。 若提供多个“appliesTo”元素提供值，则这些编码值之间是“并且”关系，即多个目标群体取交集。 例如，一个代表“女人”的编码加上一个代表“非裔美国人”的编码，意味着目标人群为“非裔美国女性”。", "comment": "如果有多个参考范围，则应该提供此元素。", "requirements": "为正确理解参考范围的意义，需要能够识别目标人群。" }, { "id": "Observation.component.referenceRange.age", "path": "Observation.component.referenceRange.age", "short": "适用年龄段", "definition": "此参考范围适用的年龄段，包括新生儿年龄（例如足月的周数）。", "comment": "年龄段应该是大于0并且小于观测目标的最大可能年龄", "requirements": "有些分析对年龄很敏感。" }, { "id": "Observation.component.referenceRange.age.low", "path": "Observation.component.referenceRange.age.low", "short": "最小年龄", "definition": "最小年龄不应小于0，大于等于此值", "type": [ { "code": "Quantity", "profile": [ "http://StructureDefinition.hl7fhir.cn/SimpleQuantity" ] } ] }, { "id": "Observation.component.referenceRange.age.high", "path": "Observation.component.referenceRange.age.high", "short": "最大年龄", "definition": "年龄小于等于此值", "type": [ { "code": "Quantity", "profile": [ "http://StructureDefinition.hl7fhir.cn/SimpleQuantity" ] } ] }, { "id": "Observation.component.referenceRange.text", "path": "Observation.component.referenceRange.text", "short": "文本描述", "definition": "当定量的参考范围不适合时，用文本描述的观测参考范围。例如，参考值是“负数”或“正常值列表”。", "comment": "注意，FHIR中的字符串大小不能超过1MB。" } ] } }