HL7 FHIR JP Core ImplementationGuide
1.1.1 - ci-build Japan flag

HL7 FHIR JP Core ImplementationGuide - Local Development build (v1.1.1). See the Directory of published versions

Resource Profile: JP_Observation_PhysicalExam - Detailed Descriptions

Active as of 2022-10-24

Definitions for the jp-observation-physicalexam resource profile.

1. Observation
Definition

身体所見に関する測定や簡単な観察事実

患者、デバイス、またはその他の対象について行われた測定と簡単な観察事実(assertion)。

Comments

身体所見に関するObservation(検査測定や観察事実)の制約プロフィール

すべてのObservation(検査測定や観察事実)の共通部分のプロファイル

2. Observation.category
Control10..*
Comments

In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set.

【JP Core仕様】基底仕様のカテゴリ「exam」固定とする

In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set. 必要なカテゴリ値セットに加えて、この要素を使用すると、所有者のカテゴリの定義に基づいたさまざまなカテゴリ化スキームが可能になり、複数のカテゴリを一度に効果的に使用できる。粒度のレベルは、値セットのカテゴリの概念によって定義される。

SlicingThis element introduces a set of slices on Observation.category. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ $this
3. Observation.category:exam
SliceNameexam
Control1..1
Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://terminology.hl7.org/CodeSystem/observation-category"/>
    <code value="exam"/>
  </coding>
</valueCodeableConcept>
4. Observation.code
BindingThe codes SHOULD be taken from JP Core Physical Exam Code ValueSetFor example codes, see LOINCCodes
Comments

All code-value and, if present, component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.

【JP Core仕様】所見の有無を表すコード(固定値)

All code-value and, if present, component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation. observationの意味を正しく理解するには、すべてのcode-valueペアと、さらに存在する場合にはcomponent.code-component.valueのペアが、考慮される必要がある。

5. Observation.code.coding
Control0..?
SlicingThis element introduces a set of slices on Observation.code.coding. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ $this
6. Observation.code.coding:physicalExamCode
SliceNamephysicalExamCode
Definition

身体所見項目コード。本ユースケースにおける項目コード推奨値をスライスにて示している。

Control0..1
Comments

推奨項目コードは必須ではない、派生先によるコード体系を作成し割り振ることを否定しない

Pattern Value<valueCoding xmlns="http://hl7.org/fhir">
  <system value="http://jpfhir.jp/fhir/core/CodeSystem/JP_PhysicalExamCode_CS"/>
  <code value="physical-findings"/>
  <display value="Physical Findings"/>
</valueCoding>
7. Observation.subject
Control10..1
TypeReference(JP_Patient|Group|Device|JP_Location))
Comments

One would expect this element to be a cardinality of 1..1. The only circumstance in which the subject can be missing is when the observation is made by a device that does not know the patient. In this case, the observation SHALL be matched to a patient through some context/channel matching technique, and at this point, the observation should be updated.

【JP Core仕様】患者

One would expect this element to be a cardinality of 1..1. The only circumstance in which the subject can be missing is when the observation is made by a device that does not know the patient. In this case, the observation SHALL be matched to a patient through some context/channel matching technique, and at this point, the observation should be updated. この要素は1..1のcardinalityになるはずと考えられる。この要素が欠損値になる唯一の状況は、対象患者が不明なデバイスによって観察が行われるケースである。この場合、観察は何らかのコンテキスト/チャネルマッチング技術を介して患者にマッチングされる必要があり、患者にマッチングされれば、その時点で本要素を更新する必要がある。

8. Observation.encounter
Comments

This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).

【JP Core仕様】診察

This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests). 通常、イベントが発生したEncounterであるが、一部のイベントは、エンEncounterの正式な完了の前または後に開始される場合があり、その場合でもEncounterのコンテキストに関連付けられている(例:入院前の臨床検査)。

9. Observation.effective[x]
TypeChoice of: , , Timing, instant
[x] NoteSee Choice of Data Types for further information about how to use [x]
Comments

At least a date should be present unless this observation is a historical report. For recording imprecise or "fuzzy" times (For example, a blood glucose measurement taken "after breakfast") use the Timing datatype which allow the measurement to be tied to regular life events.

【JP Core仕様】effectiveDateTime:医療者が確認した日時

effectivePeriod:医療者が確認した期間

At least a date should be present unless this observation is a historical report. For recording imprecise or "fuzzy" times (For example, a blood glucose measurement taken "after breakfast") use the Timing datatype which allow the measurement to be tied to regular life events. この観察結果が過去の報告でない限り、少なくとも日付が存在する必要がある。不正確または「あいまいな」時間を記録するには(たとえば、「朝食後」に行われた血糖測定)、[Timing](datatypes.html#timing)データ型を使用して、測定を通常のライフイベントに関連付けることができる。

10. Observation.valueCodeableConcept
Control0..1
BindingThe codes SHOULD be taken from hl7VS-yes-no-Indicator
TypeCodeableConcept
11. Observation.bodySite
BindingThe codes SHOULD be taken from JP Core Observation PhysicalExam BodySite ValueSetFor example codes, see SNOMEDCTBodyStructures
Comments

ICD-11

Only used if not implicit in code found in Observation.code. In many systems, this may be represented as a related observation instead of an inline component.

If the use case requires BodySite to be handled as a separate resource (e.g. to identify and track separately) then use the standard extension bodySite.

12. Observation.method
BindingThe codes SHOULD be taken from JP Core Observation PhysicalExam Method ValueSetFor example codes, see ObservationMethods
Comments

MEDIS症状・所見マスターの「診察方法」

Only used if not implicit in code for Observation.code.

13. Observation.hasMember
TypeReference(JP_Observation_Common|QuestionnaireResponse|MolecularSequence|JP_Observation_PhysicalExam))
Comments

When using this element, an observation will typically have either a value or a set of related resources, although both may be present in some cases. For a discussion on the ways Observations can assembled in groups together, see Notes below. Note that a system may calculate results from QuestionnaireResponse into a final score and represent the score as an Observation.

【JP Core仕様】関連する参照リソースにJP_Observation_PhysicalExamを追加

When using this element, an observation will typically have either a value or a set of related resources, although both may be present in some cases. For a discussion on the ways Observations can assembled in groups together, see Notes below. Note that a system may calculate results from QuestionnaireResponse into a final score and represent the score as an Observation. この要素を使用する場合、observationには通常、値または関連するリソースのセットのいじれかを含む。その両方を含む場合もある。複数のobservationをグループに一緒にまとめる方法については、以下の[メモ](observation.html#obsgrouping)を参照せよ。システムは、[QuestionnaireResponse](questionnaireresponse.html)からの結果を計算して最終スコアにし、そのスコアをobservationとして表す場合があることに注意。

14. Observation.derivedFrom
TypeReference(DocumentReference|ImagingStudy|Media|QuestionnaireResponse|JP_Observation_Common|MolecularSequence|JP_Observation_PhysicalExam))
Comments

All the reference choices that are listed in this element can represent clinical observations and other measurements that may be the source for a derived value. The most common reference will be another Observation. For a discussion on the ways Observations can assembled in groups together, see Notes below.

【JP Core仕様】導出元の参照リソースにJP_Observation_PhysicalExamを追加

All the reference choices that are listed in this element can represent clinical observations and other measurements that may be the source for a derived value. The most common reference will be another Observation. For a discussion on the ways Observations can assembled in groups together, see Notes below. この要素にリストされているすべての参照の選択肢は、派生値の元のデータなる可能性のある臨床観察やその他の測定値を表すことができる。最も一般的な参照先は、別のobservationである。observationをグループに一緒にまとめる方法については、以下の[メモ](observation.html#obsgrouping)を参照すること。

15. Observation.component
Comments

For a discussion on the ways Observations can be assembled in groups together see Notes below.

【JP Core仕様】具体的な所見を記載する

For a discussion on the ways Observations can be assembled in groups together see Notes below. 複数のObservation をグループに一緒にまとめる方法については、以下の[Notes](observation.html#notes)を参照すること。

16. Observation.component.code
BindingThe codes SHOULD be taken from JP Core Physical Exam Code ValueSetFor example codes, see LOINCCodes
Comments

All code-value and component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.

【JP Core仕様】具体的な所見を表すコード(固定値)

17. Observation.component.code.coding
Control0..?
SlicingThis element introduces a set of slices on Observation.component.code.coding. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ $this
18. Observation.component.code.coding:physicalExamCode
SliceNamephysicalExamCode
Definition

身体所見項目コード。本ユースケースにおける項目コード推奨値をスライスにて示している。

Control0..1
Comments

推奨項目コードは必須ではない、派生先によるコード体系を作成し割り振ることを否定しない

Pattern Value<valueCoding xmlns="http://hl7.org/fhir">
  <system value="http://jpfhir.jp/fhir/core/CodeSystem/JP_PhysicalExamCode_CS"/>
  <code value="detailed-physical-findings"/>
  <display value="Detailed Physical Findings"/>
</valueCoding>
1. Observation
Definition

身体所見に関する測定や簡単な観察事実

Measurements and simple assertions made about a patient, device or other subject.

Control0..*
Alternate NamesVital Signs, Measurement, Results, Tests
Comments

身体所見に関するObservation(検査測定や観察事実)の制約プロフィール

Used for simple observations such as device measurements, laboratory atomic results, vital signs, height, weight, smoking status, comments, etc. Other resources are used to provide context for observations such as laboratory reports, etc.

InvariantsDefined on this element
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (: contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (: contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (: text.`div`.exists())
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present (: dataAbsentReason.empty() or value.empty())
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present (: value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty())
2. Observation.implicitRules
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.

Control0..1
Typeuri
Is Modifiertrue
Comments

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.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
3. Observation.modifierExtension
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.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
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.

Alternate Namesextensions, user content
Comments

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.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
4. Observation.status
Definition

The status of the result value. 結果値のステータス。

The status of the result value.

Control1..1
BindingThe codes SHALL be taken from ObservationStatus

Codes providing the status of an observation.

Typecode
Is Modifiertrue
Requirements

Need to track the status of individual results. Some results are finalized before the whole report is finalized.

Comments

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. このリソースは現在有効でないというマークをするコードを含んでいるため、この要素はモディファイアー(修飾的要素)として位置づけられている。

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
5. Observation.category
Definition

A code that classifies the general type of observation being made. 実施されているobservationの一般的なタイプを分類するコード

A code that classifies the general type of observation being made.

Control10..*
BindingThe codes SHOULD be taken from ObservationCategoryCodes

Codes for high level observation categories.

TypeCodeableConcept
Requirements

Used for filtering what observations are retrieved and displayed.

Comments

In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set.

【JP Core仕様】基底仕様のカテゴリ「exam」固定とする

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Observation.category. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ $this
6. Observation.category:exam
SliceNameexam
Definition

A code that classifies the general type of observation being made. 実施されているobservationの一般的なタイプを分類するコード

A code that classifies the general type of observation being made.

Control10..1*
BindingThe codes SHOULD be taken from ObservationCategoryCodes

Codes for high level observation categories.

TypeCodeableConcept
Requirements

Used for filtering what observations are retrieved and displayed.

Comments

In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set. 必要なカテゴリ値セットに加えて、この要素を使用すると、所有者のカテゴリの定義に基づいたさまざまなカテゴリ化スキームが可能になり、複数のカテゴリを一度に効果的に使用できる。粒度のレベルは、値セットのカテゴリの概念によって定義される。

In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://terminology.hl7.org/CodeSystem/observation-category"/>
    <code value="exam"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
7. Observation.code
Definition

Describes what was observed. Sometimes this is called the observation "name".

observationの対象物を記述する。 observation の名前で呼ばれることもある。

Control1..1
BindingThe codes SHOULD be taken from JP Core Physical Exam Code ValueSetFor example codes, see LOINCCodes
TypeCodeableConcept
Requirements

Knowing what kind of observation is being made is essential to understanding the observation.

Alternate NamesName
Comments

All code-value and, if present, component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.

【JP Core仕様】所見の有無を表すコード(固定値)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
8. Observation.code.coding
Definition

A reference to a code defined by a terminology system.

Control0..*
TypeCoding
Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Observation.code.coding. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ $this
9. Observation.code.coding:physicalExamCode
SliceNamephysicalExamCode
Definition

身体所見項目コード。本ユースケースにおける項目コード推奨値をスライスにて示している。

A reference to a code defined by a terminology system.

Control0..1*
TypeCoding
Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

推奨項目コードは必須ではない、派生先によるコード体系を作成し割り振ることを否定しない

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Pattern Value<valueCoding xmlns="http://hl7.org/fhir">
  <system value="http://jpfhir.jp/fhir/core/CodeSystem/JP_PhysicalExamCode_CS"/>
  <code value="physical-findings"/>
  <display value="Physical Findings"/>
</valueCoding>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
10. Observation.subject
Definition

The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the focus element or the code itself specifies the actual focus of the observation. この観察が行われた対象となる患者、または患者のグループ、場所、またはデバイス、あるいはそれらの記録。 もし観察の実際の焦点が対象(または対象のサンプル、一部、または領域)と異なる場合、 focus要素または code自体が観察の実際の焦点を指し示す。

The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the focus element or the code itself specifies the actual focus of the observation.

Control10..1
TypeReference(JP_Patient|Patient|Group|Device|Location))
Requirements

Observations have no value if you don't know who or what they're about.

Comments

One would expect this element to be a cardinality of 1..1. The only circumstance in which the subject can be missing is when the observation is made by a device that does not know the patient. In this case, the observation SHALL be matched to a patient through some context/channel matching technique, and at this point, the observation should be updated.

【JP Core仕様】患者

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
11. Observation.encounter
Definition

The healthcare event (e.g. a patient and healthcare provider interaction) during which this observation is made. このobservationが行われるヘルスケアイベント(患者とヘルスケアプロバイダの相互作用など)(受診、入院など)。

The healthcare event (e.g. a patient and healthcare provider interaction) during which this observation is made.

Control0..1
TypeReference(JP_Encounter|Encounter))
Requirements

For some observations it may be important to know the link between an observation and a particular encounter.

Alternate NamesContext
Comments

This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).

【JP Core仕様】診察

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
12. Observation.effective[x]
Definition

The time or time-period the observed value is asserted as being true. For biological subjects - e.g. human patients - this is usually called the "physiologically relevant time". This is usually either the time of the procedure or of specimen collection, but very often the source of the date/time is not known, only the date/time itself. 観測値が関連する時間または期間。レポートの対象が患者である場合、これは通常、処置や検体採取の時刻のいずれかであるが、日付/時刻の出処は不明であり、日付/時刻自体のみのことがある。

The time or time-period the observed value is asserted as being true. For biological subjects - e.g. human patients - this is usually called the "physiologically relevant time". This is usually either the time of the procedure or of specimen collection, but very often the source of the date/time is not known, only the date/time itself.

Control0..1
TypeChoice of: dateTime, Period, Timing, instant
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Knowing when an observation was deemed true is important to its relevance as well as determining trends.

Alternate NamesOccurrence
Comments

At least a date should be present unless this observation is a historical report. For recording imprecise or "fuzzy" times (For example, a blood glucose measurement taken "after breakfast") use the Timing datatype which allow the measurement to be tied to regular life events.

【JP Core仕様】effectiveDateTime:医療者が確認した日時

effectivePeriod:医療者が確認した期間

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
13. Observation.value[x]
Definition

The information determined as a result of making the observation, if the information has a simple value. 結果情報が単純な値である場合、observationを行った結果として決定された情報。

The information determined as a result of making the observation, if the information has a simple value.

Control0..1 This element is affected by the following invariants: obs-7
TypeChoice of: Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations.

Comments

An observation may have; 1) a single value here, 2) both a value and a set of related or component values, or 3) only a set of related or component values. If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the Notes section below.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Observation.value[x]. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • type @ $this
14. Observation.value[x]:valueCodeableConcept
SliceNamevalueCodeableConcept
Definition

The information determined as a result of making the observation, if the information has a simple value. 結果情報が単純な値である場合、observationを行った結果として決定された情報。

The information determined as a result of making the observation, if the information has a simple value.

Control0..1 This element is affected by the following invariants: obs-7
BindingThe codes SHOULD be taken from hl7VS-yes-no-IndicatorFor codes, see (unbound)
TypeChoice of: CodeableConcept, dateTime, boolean, string, SampledData, Quantity, Period, Ratio, integer, time, Range
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations.

Comments

An observation may have; 1) a single value here, 2) both a value and a set of related or component values, or 3) only a set of related or component values. If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the Notes section below.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
15. Observation.bodySite
Definition

Indicates the site on the subject's body where the observation was made (i.e. the target site).

Control0..1
BindingThe codes SHOULD be taken from JP Core Observation PhysicalExam BodySite ValueSetFor example codes, see SNOMEDCTBodyStructures
TypeCodeableConcept
Comments

ICD-11

Only used if not implicit in code found in Observation.code. In many systems, this may be represented as a related observation instead of an inline component.

If the use case requires BodySite to be handled as a separate resource (e.g. to identify and track separately) then use the standard extension bodySite.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
16. Observation.method
Definition

Indicates the mechanism used to perform the observation.

Control0..1
BindingThe codes SHOULD be taken from JP Core Observation PhysicalExam Method ValueSetFor example codes, see ObservationMethods
TypeCodeableConcept
Requirements

In some cases, method can impact results and is thus used for determining whether results can be compared or determining significance of results.

Comments

MEDIS症状・所見マスターの「診察方法」

Only used if not implicit in code for Observation.code.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
17. Observation.hasMember
Definition

This observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group. このobservationは、グループのメンバーとしてターゲットを含むグループobservation(たとえば、一連検査セット、パネル検査、バイタルサイン測定値のセット)である。

This observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group.

Control0..*
TypeReference(JP_Observation_Common|QuestionnaireResponse|MolecularSequence|JP_Observation_PhysicalExam|Observation))
Comments

When using this element, an observation will typically have either a value or a set of related resources, although both may be present in some cases. For a discussion on the ways Observations can assembled in groups together, see Notes below. Note that a system may calculate results from QuestionnaireResponse into a final score and represent the score as an Observation.

【JP Core仕様】関連する参照リソースにJP_Observation_PhysicalExamを追加

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
18. Observation.derivedFrom
Definition

The target resource that represents a measurement from which this observation value is derived. For example, a calculated anion gap or a fetal measurement based on an ultrasound image. このobservation が導出される元の測定値を表すターゲットリソース。たとえば、超音波画像に基づいて計算されたアニオンギャップまたは胎児の測定値の場合、この要素には、元となった超音波画像検査結果への参照を設定する。

The target resource that represents a measurement from which this observation value is derived. For example, a calculated anion gap or a fetal measurement based on an ultrasound image.

Control0..*
TypeReference(DocumentReference|ImagingStudy|Media|QuestionnaireResponse|JP_Observation_Common|MolecularSequence|JP_Observation_PhysicalExam|Observation))
Comments

All the reference choices that are listed in this element can represent clinical observations and other measurements that may be the source for a derived value. The most common reference will be another Observation. For a discussion on the ways Observations can assembled in groups together, see Notes below.

【JP Core仕様】導出元の参照リソースにJP_Observation_PhysicalExamを追加

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
19. Observation.component
Definition

Some observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes. Examples include systolic and diastolic component observations for blood pressure measurement and multiple component observations for genetics observations. 一部の観測には、複数のコンポーネントの観測がある。これらのコンポーネントの観察結果は、同じ属性を共有する個別のコード値のペアとして表される。例としては、血圧測定のための収縮期および拡張期のコンポーネントの観察や、遺伝学の観察のための複数のコンポーネントの観察がある。

Some observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes. Examples include systolic and diastolic component observations for blood pressure measurement and multiple component observations for genetics observations.

Control0..*
TypeBackboneElement
Requirements

Component observations share the same attributes in the Observation resource as the primary observation and are always treated a part of a single observation (they are not separable). However, the reference range for the primary observation value is not inherited by the component values and is required when appropriate for each component observation. コンポーネントobservation は プライマリobservation としてのobservation リソースの中で同じ属性を共有し、常に単一のobservation の一部として扱われる(つまりそれらは分離可能ではないん)。ただし、プライマリobservationのreference rangeはコンポーネント値に継承されないため、reference rangeは各コンポーネントobservation に適切であれば必要である。

Component observations share the same attributes in the Observation resource as the primary observation and are always treated a part of a single observation (they are not separable). However, the reference range for the primary observation value is not inherited by the component values and is required when appropriate for each component observation.

Comments

For a discussion on the ways Observations can be assembled in groups together see Notes below.

【JP Core仕様】具体的な所見を記載する

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
20. Observation.component.modifierExtension
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.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
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.

Alternate Namesextensions, user content, modifiers
Comments

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.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
21. Observation.component.code
Definition

Describes what was observed. Sometimes this is called the observation "code".

Control1..1
BindingThe codes SHOULD be taken from JP Core Physical Exam Code ValueSetFor example codes, see LOINCCodes
TypeCodeableConcept
Requirements

Knowing what kind of observation is being made is essential to understanding the observation.

Comments

All code-value and component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.

【JP Core仕様】具体的な所見を表すコード(固定値)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
22. Observation.component.code.coding
Definition

A reference to a code defined by a terminology system.

Control0..*
TypeCoding
Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Observation.component.code.coding. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ $this
23. Observation.component.code.coding:physicalExamCode
SliceNamephysicalExamCode
Definition

身体所見項目コード。本ユースケースにおける項目コード推奨値をスライスにて示している。

A reference to a code defined by a terminology system.

Control0..1*
TypeCoding
Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

推奨項目コードは必須ではない、派生先によるコード体系を作成し割り振ることを否定しない

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Pattern Value<valueCoding xmlns="http://hl7.org/fhir">
  <system value="http://jpfhir.jp/fhir/core/CodeSystem/JP_PhysicalExamCode_CS"/>
  <code value="detailed-physical-findings"/>
  <display value="Detailed Physical Findings"/>
</valueCoding>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
1. Observation
Definition

身体所見に関する測定や簡単な観察事実

Control0..*
Alternate NamesVital SignsMeasurementResultsTests
Comments

身体所見に関するObservation(検査測定や観察事実)の制約プロフィール

2. Observation.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Control0..1
Typeid
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

3. Observation.meta
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.

Control0..1
TypeMeta
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
4. Observation.implicitRules
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.

Control0..1
Typeuri
Is Modifiertrue
Comments

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.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
5. Observation.language
Definition

The base language in which the resource is written.

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages A human language
Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Comments

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).

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
6. Observation.text
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.

Control0..1
TypeNarrative
Alternate Namesnarrativehtmlxhtmldisplay
Comments

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.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
7. Observation.contained
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.

Control0..*
TypeResource
Alternate Namesinline resourcesanonymous resourcescontained resources
Comments

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.

8. Observation.extension
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.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

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.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
9. Observation.modifierExtension
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.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
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.

Alternate Namesextensionsuser content
Comments

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.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
10. Observation.identifier
Definition

A unique identifier assigned to this observation. Observationに割り当てられたユニーク(一意)の識別ID

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

Allows observations to be distinguished and referenced.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
11. Observation.basedOn
Definition

A plan, proposal or order that is fulfilled in whole or in part by this event. For example, a MedicationRequest may require a patient to have laboratory test performed before it is dispensed. このイベントによって全体または部分的に実施されるプラン、提案、依頼。たとえばMedicationRequest は調剤される前に臨床検査を患者に行う必要があるかもしれない。

Control0..*
TypeReference(CarePlanDeviceRequestImmunizationRecommendationJP_MedicationRequestJP_MedicationRequest_InjectionNutritionOrderServiceRequest))
Requirements

Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon.

Alternate NamesFulfills
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
12. Observation.partOf
Definition

A larger event of which this particular Observation is a component or step. For example, an observation as part of a procedure. この特定のObservationが別のより大きなイベントの要素あるいは一段階であるような親イベント。たとえば、一連の処置手順の一部としてのObservation。

Control0..*
TypeReference(JP_MedicationAdministrationJP_MedicationAdministration_InjectionJP_MedicationDispenseBaseMedicationStatementJP_ProcedureJP_ImmunizationImagingStudy))
Alternate NamesContainer
Comments

To link an Observation to an Encounter use encounter. See the Notes below for guidance on referencing another Observation. ObservationをEncounterにencounter要素を使ってリンクする。もうひとつ別のObservationを参照することについては、以降にあるt Notes をガイダンスとして参照のこと。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
13. Observation.status
Definition

The status of the result value. 結果値のステータス。

Control1..1
BindingThe codes SHALL be taken from ObservationStatus Codes providing the status of an observation
Typecode
Is Modifiertrue
Requirements

Need to track the status of individual results. Some results are finalized before the whole report is finalized.

Comments

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. このリソースは現在有効でないというマークをするコードを含んでいるため、この要素はモディファイアー(修飾的要素)として位置づけられている。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
14. Observation.category
Definition

A code that classifies the general type of observation being made. 実施されているobservationの一般的なタイプを分類するコード

Control1..*
BindingThe codes SHOULD be taken from ObservationCategoryCodes Codes for high level observation categories
TypeCodeableConcept
Requirements

Used for filtering what observations are retrieved and displayed.

Comments

In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set.

【JP Core仕様】基底仕様のカテゴリ「exam」固定とする

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Observation.category. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ $this
15. Observation.category:exam
SliceNameexam
Definition

A code that classifies the general type of observation being made. 実施されているobservationの一般的なタイプを分類するコード

Control1..1
BindingThe codes SHOULD be taken from ObservationCategoryCodes Codes for high level observation categories
TypeCodeableConcept
Requirements

Used for filtering what observations are retrieved and displayed.

Comments

In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set. 必要なカテゴリ値セットに加えて、この要素を使用すると、所有者のカテゴリの定義に基づいたさまざまなカテゴリ化スキームが可能になり、複数のカテゴリを一度に効果的に使用できる。粒度のレベルは、値セットのカテゴリの概念によって定義される。

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://terminology.hl7.org/CodeSystem/observation-category"/>
    <code value="exam"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
16. Observation.code
Definition

Describes what was observed. Sometimes this is called the observation "name".

observationの対象物を記述する。 observation の名前で呼ばれることもある。

Control1..1
BindingThe codes SHOULD be taken from JP Core Physical Exam Code ValueSet
TypeCodeableConcept
Requirements

Knowing what kind of observation is being made is essential to understanding the observation.

Alternate NamesName
Comments

All code-value and, if present, component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.

【JP Core仕様】所見の有無を表すコード(固定値)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
17. Observation.code.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
18. Observation.code.extension
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.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

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.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
SlicingThis element introduces a set of slices on Observation.code.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
19. Observation.code.coding
Definition

A reference to a code defined by a terminology system.

Control0..*
TypeCoding
Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Observation.code.coding. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ $this
20. Observation.code.coding:physicalExamCode
SliceNamephysicalExamCode
Definition

身体所見項目コード。本ユースケースにおける項目コード推奨値をスライスにて示している。

Control0..1
TypeCoding
Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

推奨項目コードは必須ではない、派生先によるコード体系を作成し割り振ることを否定しない

Pattern Value<valueCoding xmlns="http://hl7.org/fhir">
  <system value="http://jpfhir.jp/fhir/core/CodeSystem/JP_PhysicalExamCode_CS"/>
  <code value="physical-findings"/>
  <display value="Physical Findings"/>
</valueCoding>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
21. Observation.code.text
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Control0..1
Typestring
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
22. Observation.subject
Definition

The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the focus element or the code itself specifies the actual focus of the observation. この観察が行われた対象となる患者、または患者のグループ、場所、またはデバイス、あるいはそれらの記録。 もし観察の実際の焦点が対象(または対象のサンプル、一部、または領域)と異なる場合、 focus要素または code自体が観察の実際の焦点を指し示す。

Control1..1
TypeReference(JP_Patient))
Requirements

Observations have no value if you don't know who or what they're about.

Comments

One would expect this element to be a cardinality of 1..1. The only circumstance in which the subject can be missing is when the observation is made by a device that does not know the patient. In this case, the observation SHALL be matched to a patient through some context/channel matching technique, and at this point, the observation should be updated.

【JP Core仕様】患者

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
23. Observation.focus
Definition

The actual focus of an observation when it is not the patient of record representing something or someone associated with the patient such as a spouse, parent, fetus, or donor. For example, fetus observations in a mother's record. The focus of an observation could also be an existing condition, an intervention, the subject's diet, another observation of the subject, or a body structure such as tumor or implanted device. An example use case would be using the Observation resource to capture whether the mother is trained to change her child's tracheostomy tube. In this example, the child is the patient of record and the mother is the focus. 配偶者、親、胎児、ドナーなど、患者に関連する何かまたは誰かを表す記録の患者ではない場合の、観察の実際の焦点。たとえば、母親の記録にある胎児の観察。観察の焦点はまた、既存の状態、介入、対象の食事、対象の別の観察、または腫瘍または埋め込まれた装置などの体の構造であり得る。使用例はobservationリソースを使用して、母親が子供の気管切開チューブを交換するように訓練されているかどうかをキャプチャすることである。この例では、子供が記録の患者であり、母親が焦点(focus)となる。

Control0..*
TypeReference(Resource))
Comments

Typically, an observation is made about the subject - a patient, or group of patients, location, or device - and the distinction between the subject and what is directly measured for an observation is specified in the observation code itself ( e.g., "Blood Glucose") and does not need to be represented separately using this element. Use specimen if a reference to a specimen is required. If a code is required instead of a resource use either bodysite for bodysites or the standard extension focusCode. 通常、observationは対象(患者、または患者のグループ、場所、またはデバイス)について行われ、対象とobservationのために直接測定されるものとの区別は、observationコード自体(例:「血糖値」 )で記述され、この要素を使用して個別に表す必要はない。検体(標本)への参照が必要な場合は、 specimen要素を使用する。リソースの代わりにコードが必要な場合は、人体部位にはbodysite要素を使用するか、標準の拡張機能[focusCode](extension-observation-focuscode.html)を使用する。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
24. Observation.encounter
Definition

The healthcare event (e.g. a patient and healthcare provider interaction) during which this observation is made. このobservationが行われるヘルスケアイベント(患者とヘルスケアプロバイダの相互作用など)(受診、入院など)。

Control0..1
TypeReference(JP_Encounter))
Requirements

For some observations it may be important to know the link between an observation and a particular encounter.

Alternate NamesContext
Comments

This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).

【JP Core仕様】診察

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
25. Observation.effective[x]
Definition

The time or time-period the observed value is asserted as being true. For biological subjects - e.g. human patients - this is usually called the "physiologically relevant time". This is usually either the time of the procedure or of specimen collection, but very often the source of the date/time is not known, only the date/time itself. 観測値が関連する時間または期間。レポートの対象が患者である場合、これは通常、処置や検体採取の時刻のいずれかであるが、日付/時刻の出処は不明であり、日付/時刻自体のみのことがある。

Control0..1
TypeChoice of: dateTime, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Knowing when an observation was deemed true is important to its relevance as well as determining trends.

Alternate NamesOccurrence
Comments

At least a date should be present unless this observation is a historical report. For recording imprecise or "fuzzy" times (For example, a blood glucose measurement taken "after breakfast") use the Timing datatype which allow the measurement to be tied to regular life events.

【JP Core仕様】effectiveDateTime:医療者が確認した日時

effectivePeriod:医療者が確認した期間

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
26. Observation.issued
Definition

The date and time this version of the observation was made available to providers, typically after the results have been reviewed and verified. このバージョンのレポートが医療者に提供された日時。通常、レポートがレビューおよび検証された後となる。

Control0..1
Typeinstant
Comments

For Observations that don’t require review and verification, it may be the same as the lastUpdated time of the resource itself. For Observations that do require review and verification for certain updates, it might not be the same as the lastUpdated time of the resource itself due to a non-clinically significant update that doesn’t require the new version to be reviewed and verified again. レビューと検証を必要としないobservationの場合、リソース自体の[lastUpdated](resource-definitions.html#Meta.lastUpdated)日時と同じになる場合がある。特定の更新のレビューと検証が必要なobservationの場合、新しいバージョンを再度レビューして検証する必要がないような臨床的に重要でない更新がなされたために、リソース自体の「lastUpdated」時間はこれと異なる場合がある。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
27. Observation.performer
Definition

Who was responsible for asserting the observed value as "true". そのobservationは真だと言える責任者

Control0..*
TypeReference(JP_PractitionerJP_PractitionerRoleJP_OrganizationCareTeamJP_PatientRelatedPerson))
Requirements

May give a degree of confidence in the observation and also indicates where follow-up questions should be directed.

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. 参照は、実際のFHIRリソースへの参照である必要があり、解決可能(内容に到達可能)である必要がある(アクセス制御、一時的な使用不可などを考慮に入れる)。解決は、URLから取得するか、リソースタイプによって該当する場合は、絶対参照を正規URLとして扱い、ローカルレジストリ/リポジトリで検索することによって行うことができる。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
28. Observation.value[x]
Definition

The information determined as a result of making the observation, if the information has a simple value. 結果情報が単純な値である場合、observationを行った結果として決定された情報。

Control0..1 This element is affected by the following invariants: obs-7
TypeChoice of: Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations.

Comments

An observation may have; 1) a single value here, 2) both a value and a set of related or component values, or 3) only a set of related or component values. If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the Notes section below.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Observation.value[x]. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • type @ $this
29. Observation.value[x]:valueCodeableConcept
SliceNamevalueCodeableConcept
Definition

The information determined as a result of making the observation, if the information has a simple value. 結果情報が単純な値である場合、observationを行った結果として決定された情報。

Control0..1 This element is affected by the following invariants: obs-7
BindingThe codes SHOULD be taken from hl7VS-yes-no-Indicator
TypeCodeableConcept
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations.

Comments

An observation may have; 1) a single value here, 2) both a value and a set of related or component values, or 3) only a set of related or component values. If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the Notes section below.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
30. Observation.dataAbsentReason
Definition

Provides a reason why the expected value in the element Observation.value[x] is missing. Observation.value[x] 要素に期待される結果が存在しない理由を設定する。

Control0..1 This element is affected by the following invariants: obs-6
BindingThe codes SHALL be taken from DataAbsentReason; other codes may be used where these codes are not suitable Codes specifying why the result (Observation.value[x]) is missing
TypeCodeableConcept
Requirements

For many results it is necessary to handle exceptional values in measurements.

Comments

Null or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. For example, measurement values for a serology test could be "detected", "not detected", "inconclusive", or "specimen unsatisfactory".

The alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For example, the dataAbsentReason code "error" could be used when the measurement was not completed. Note that an observation may only be reported if there are values to report. For example differential cell counts values may be reported only when > 0. Because of these options, use-case agreements are required to interpret general observations for null or exceptional values.

ヌル値または例外値は、FHIRオブザベーションで2つの方法で表すことができる。 1つの方法は、それらを値セットに含めて、値の例外を表す方法である。たとえば、血清学的検査の測定値は、「検出された」、「検出されなかった」、「決定的でない」、または「検体が不十分」である可能性がある。別の方法は、実際の観測にvalue要素を使用し、明示的なdataAbsentReason要素を使用して例外的な値を記録することである。たとえば、測定が完了しなかった場合、dataAbsentReasonコード「error」を使用できる。この場合には、観測値は、報告する値がある場合にのみ報告される可能性があることに注意する必要がある。たとえば、差分セルカウント値は> 0の場合にのみ報告される場合がある。これらのオプションのため、nullまたは例外値の一般的な観測値を解釈するにはユースケースの合意が必要である。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
31. Observation.interpretation
Definition

A categorical assessment of an observation value. For example, high, low, normal. 観測値のカテゴリ別評価。たとえば、高、低、通常。

Control0..*
BindingThe codes SHALL be taken from ObservationInterpretationCodes; other codes may be used where these codes are not suitable Codes identifying interpretations of observations
TypeCodeableConcept
Requirements

For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. 一部の結果、特に数値結果については、結果の意義を完全に理解するためには解釈コードが必要である。

Alternate NamesAbnormal Flag
Comments

Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result.

「異常フラグ」として呼ばれる検査結果解釈コードが従来から使用されており、その使用はコード化された解釈が関連するような他の場合でも拡大して使われている。多くの場合、1つ以上の単純でコンパクトなコードとして報告され、この要素は、結果の意味や正常かどうかを示すために、レポートや時系列表で結果値の隣に配置されることがよくある。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
32. Observation.note
Definition

Comments about the observation or the results. 観測値、結果に対するコメント

Control0..*
TypeAnnotation
Requirements

Need to be able to provide free text additional information. フリーテキストの追加情報を提供できる必要がある。

Comments

May include general statements about the observation, or statements about significant, unexpected or unreliable results values, or information about its source when relevant to its interpretation.

観察(結果)に関する一般的な記述、重要な、予期しない、または信頼できない結果値に関する記述、またはその解釈に関連する場合はそのソースに関する情報が含まれる場合がある。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
33. Observation.bodySite
Definition

Indicates the site on the subject's body where the observation was made (i.e. the target site).

Control0..1
BindingThe codes SHOULD be taken from JP Core Observation PhysicalExam BodySite ValueSet
TypeCodeableConcept
Comments

ICD-11

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
34. Observation.method
Definition

Indicates the mechanism used to perform the observation.

Control0..1
BindingThe codes SHOULD be taken from JP Core Observation PhysicalExam Method ValueSet
TypeCodeableConcept
Requirements

In some cases, method can impact results and is thus used for determining whether results can be compared or determining significance of results.

Comments

MEDIS症状・所見マスターの「診察方法」

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
35. Observation.specimen
Definition

The specimen that was used when this observation was made. この観察(観測、検査)が実施されたときに使われた検体材料

Control0..1
TypeReference(Specimen))
Comments

Should only be used if not implicit in code found in Observation.code. Observations are not made on specimens themselves; they are made on a subject, but in many cases by the means of a specimen. Note that although specimens are often involved, they are not always tracked and reported explicitly. Also note that observation resources may be used in contexts that track the specimen explicitly (e.g. Diagnostic Report). Observation.codeにあるコードで暗黙的に示されない場合にのみ使用する必要がある。検体自体の観察は行われない。観察(観測、検査)対象者に対して実施されるが、多くの場合には対象者から得られた検体に対して実施される。検体が奥の場合に関わるが、それらは常に追跡され、明示的に報告されるとは限らないことに注意すること。またobservationリソースは、検体を明示的に記述するような状況下(診断レポートなど)で使用される場合があることに注意。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
36. Observation.device
Definition

The device used to generate the observation data. 観察データを生成するために使われた機器

Control0..1
TypeReference(DeviceDeviceMetric))
Comments

Note that this is not meant to represent a device involved in the transmission of the result, e.g., a gateway. Such devices may be documented using the Provenance resource where relevant. これは、結果の送信に関与するデバイス(ゲートウェイなど)を表すことを意図したものではない。そのようなデバイスは、必要に応じてProvenanceリソースを使用して文書化する。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
37. Observation.referenceRange
Definition

Guidance on how to interpret the value by comparison to a normal or recommended range. Multiple reference ranges are interpreted as an "OR". In other words, to represent two distinct target populations, two referenceRange elements would be used.

Control0..*
TypeBackboneElement
Requirements

Knowing what values are considered "normal" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts. どの値が「正常」と見なされるかを知ることは、特定の結果の意義を評価するのに役立つ。さまざまなコンテキストに対応するため複数の参照範囲を提供できる必要がある。

Comments

Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this might not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties. 通常の範囲または推奨範囲と比較して値を解釈する方法に関するガイダンス。複数の参照範囲は「OR」として解釈される。つまり、2つの異なるターゲット母集団を表すために、2つの referenceRange要素が使用される。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
obs-3: Must have at least a low or a high or text (: low.exists() or high.exists() or text.exists())
38. Observation.referenceRange.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
39. Observation.referenceRange.extension
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.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

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.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
40. Observation.referenceRange.modifierExtension
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.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
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.

Alternate Namesextensionsuser contentmodifiers
Comments

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.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
41. Observation.referenceRange.low
Definition

The value of the low bound of the reference range. The low bound of the reference range endpoint is inclusive of the value (e.g. reference range is >=5 - <=9). If the low bound is omitted, it is assumed to be meaningless (e.g. reference range is <=2.3).

Control0..1 This element is affected by the following invariants: obs-3
TypeQuantity(SimpleQuantity)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
42. Observation.referenceRange.high
Definition

The value of the high bound of the reference range. The high bound of the reference range endpoint is inclusive of the value (e.g. reference range is >=5 - <=9). If the high bound is omitted, it is assumed to be meaningless (e.g. reference range is >= 2.3).

Control0..1 This element is affected by the following invariants: obs-3
TypeQuantity(SimpleQuantity)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
43. Observation.referenceRange.type
Definition

Codes to indicate the what part of the targeted reference population it applies to. For example, the normal or therapeutic range.

Control0..1
BindingThe codes SHOULD be taken from ObservationReferenceRangeMeaningCodes Code for the meaning of a reference range
TypeCodeableConcept
Requirements

Need to be able to say what kind of reference range this is - normal, recommended, therapeutic, etc., - for proper interpretation.

Comments

This SHOULD be populated if there is more than one range. If this element is not present then the normal range is assumed.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
44. Observation.referenceRange.appliesTo
Definition

Codes to indicate the target population this reference range applies to. For example, a reference range may be based on the normal population or a particular sex or race. Multiple appliesTo are interpreted as an "AND" of the target populations. For example, to represent a target population of African American females, both a code of female and a code for African American would be used.

Control0..*
BindingFor example codes, see ObservationReferenceRangeAppliesToCodes Codes identifying the population the reference range applies to
TypeCodeableConcept
Requirements

Need to be able to identify the target population for proper interpretation.

Comments

This SHOULD be populated if there is more than one range. If this element is not present then the normal population is assumed.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
45. Observation.referenceRange.age
Definition

The age at which this reference range is applicable. This is a neonatal age (e.g. number of weeks at term) if the meaning says so.

Control0..1
TypeRange
Requirements

Some analytes vary greatly over age.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
46. Observation.referenceRange.text
Definition

Text based reference range in an observation which may be used when a quantitative range is not appropriate for an observation. An example would be a reference value of "Negative" or a list or table of "normals".

Control0..1
Typestring
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
47. Observation.hasMember
Definition

This observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group. このobservationは、グループのメンバーとしてターゲットを含むグループobservation(たとえば、一連検査セット、パネル検査、バイタルサイン測定値のセット)である。

Control0..*
TypeReference(JP_Observation_CommonQuestionnaireResponseMolecularSequenceJP_Observation_PhysicalExam))
Comments

When using this element, an observation will typically have either a value or a set of related resources, although both may be present in some cases. For a discussion on the ways Observations can assembled in groups together, see Notes below. Note that a system may calculate results from QuestionnaireResponse into a final score and represent the score as an Observation.

【JP Core仕様】関連する参照リソースにJP_Observation_PhysicalExamを追加

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
48. Observation.derivedFrom
Definition

The target resource that represents a measurement from which this observation value is derived. For example, a calculated anion gap or a fetal measurement based on an ultrasound image. このobservation が導出される元の測定値を表すターゲットリソース。たとえば、超音波画像に基づいて計算されたアニオンギャップまたは胎児の測定値の場合、この要素には、元となった超音波画像検査結果への参照を設定する。

Control0..*
TypeReference(DocumentReferenceImagingStudyMediaQuestionnaireResponseJP_Observation_CommonMolecularSequenceJP_Observation_PhysicalExam))
Comments

All the reference choices that are listed in this element can represent clinical observations and other measurements that may be the source for a derived value. The most common reference will be another Observation. For a discussion on the ways Observations can assembled in groups together, see Notes below.

【JP Core仕様】導出元の参照リソースにJP_Observation_PhysicalExamを追加

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
49. Observation.component
Definition

Some observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes. Examples include systolic and diastolic component observations for blood pressure measurement and multiple component observations for genetics observations. 一部の観測には、複数のコンポーネントの観測がある。これらのコンポーネントの観察結果は、同じ属性を共有する個別のコード値のペアとして表される。例としては、血圧測定のための収縮期および拡張期のコンポーネントの観察や、遺伝学の観察のための複数のコンポーネントの観察がある。

Control0..*
TypeBackboneElement
Requirements

Component observations share the same attributes in the Observation resource as the primary observation and are always treated a part of a single observation (they are not separable). However, the reference range for the primary observation value is not inherited by the component values and is required when appropriate for each component observation. コンポーネントobservation は プライマリobservation としてのobservation リソースの中で同じ属性を共有し、常に単一のobservation の一部として扱われる(つまりそれらは分離可能ではないん)。ただし、プライマリobservationのreference rangeはコンポーネント値に継承されないため、reference rangeは各コンポーネントobservation に適切であれば必要である。

Comments

For a discussion on the ways Observations can be assembled in groups together see Notes below.

【JP Core仕様】具体的な所見を記載する

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
50. Observation.component.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
51. Observation.component.extension
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.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

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.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
52. Observation.component.modifierExtension
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.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
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.

Alternate Namesextensionsuser contentmodifiers
Comments

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.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
53. Observation.component.code
Definition

Describes what was observed. Sometimes this is called the observation "code".

Control1..1
BindingThe codes SHOULD be taken from JP Core Physical Exam Code ValueSet
TypeCodeableConcept
Requirements

Knowing what kind of observation is being made is essential to understanding the observation.

Comments

All code-value and component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.

【JP Core仕様】具体的な所見を表すコード(固定値)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
54. Observation.component.code.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
55. Observation.component.code.extension
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.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

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.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
SlicingThis element introduces a set of slices on Observation.component.code.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
56. Observation.component.code.coding
Definition

A reference to a code defined by a terminology system.

Control0..*
TypeCoding
Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Observation.component.code.coding. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ $this
57. Observation.component.code.coding:physicalExamCode
SliceNamephysicalExamCode
Definition

身体所見項目コード。本ユースケースにおける項目コード推奨値をスライスにて示している。

Control0..1
TypeCoding
Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

推奨項目コードは必須ではない、派生先によるコード体系を作成し割り振ることを否定しない

Pattern Value<valueCoding xmlns="http://hl7.org/fhir">
  <system value="http://jpfhir.jp/fhir/core/CodeSystem/JP_PhysicalExamCode_CS"/>
  <code value="detailed-physical-findings"/>
  <display value="Detailed Physical Findings"/>
</valueCoding>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
58. Observation.component.code.text
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Control0..1
Typestring
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
59. Observation.component.value[x]
Definition

The information determined as a result of making the observation, if the information has a simple value.

Control0..1
TypeChoice of: Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations.

Comments

Used when observation has a set of component observations. An observation may have both a value (e.g. an Apgar score) and component observations (the observations from which the Apgar score was derived). If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the Notes section below.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
60. Observation.component.dataAbsentReason
Definition

Provides a reason why the expected value in the element Observation.component.value[x] is missing.

Control0..1 This element is affected by the following invariants: obs-6
BindingThe codes SHALL be taken from DataAbsentReason; other codes may be used where these codes are not suitable Codes specifying why the result (Observation.value[x]) is missing
TypeCodeableConcept
Requirements

For many results it is necessary to handle exceptional values in measurements.

Comments

"Null" or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. For example, measurement values for a serology test could be "detected", "not detected", "inconclusive", or "test not done".

The alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For example, the dataAbsentReason code "error" could be used when the measurement was not completed. Because of these options, use-case agreements are required to interpret general observations for exceptional values.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
61. Observation.component.interpretation
Definition

A categorical assessment of an observation value. For example, high, low, normal.

Control0..*
BindingThe codes SHALL be taken from ObservationInterpretationCodes; other codes may be used where these codes are not suitable Codes identifying interpretations of observations
TypeCodeableConcept
Requirements

For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result.

Alternate NamesAbnormal Flag
Comments

Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
62. Observation.component.referenceRange
Definition

Guidance on how to interpret the value by comparison to a normal or recommended range.

Control0..*
TypeSee ttp://hl7.org/fhir/StructureDefinition/Observation#Observation.referenceRange
Requirements

Knowing what values are considered "normal" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts.

Comments

Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this might not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))