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 Core Observation PhysicalExam Profile

項目内容
定義URL http://jpfhir.jp/fhir/core/StructureDefinition/JP_Observation_PhysicalExam
Version 1.1.1
Name

JP_Observation_PhysicalExam

Title

JP Core Observation PhysicalExam Profile

Status Active ( 2022-10-24 )
Copyright

Copyright FHIR Japanese implementation research working group in Japan Association of Medical Informatics (JAMI) 一般社団法人日本医療情報学会NeXEHRS課題研究会FHIR日本実装検討WG

このプロファイルはObservationリソースに対して、身体所見のデータを送受信するための制約と拡張を定めたものである。


本プロファイル説明は、患者に付属する一項目分の身体所見情報について、情報の登録や検索、取得のために、FHIR Observationリソースを使用するにあたっての、最低限の制約を記述したものである。

Observationリソースに対して本プロファイルに準拠する場合に必須となる要素や、サポートすべき拡張、用語、検索パラメータを定義する。

背景および想定シナリオ

本プロファイルは、以下のようなユースケースを想定している。

  • Patientリソースから指定された日時、期間での身体所見情報の参照
  • Patientリソースから指定された診察方法に対する指定された期間での身体所見情報の参照

スコープ

Observationはヘルスケアの中心的な要素であり、診断の支援、進捗状況の監視、ベースラインやパターンの決定、さらには人口統計学的特性の把握に使用される。ほとんどのObservationは、いくつかのメタデータを持つ単純な名前/値のペアのアサーションであるが、いくつかのObservationは、他のObservationを論理的にグループ化したり、あるいはマルチコンポーネントのObservationであったりする。

本プロファイルでは上記想定シナリオにて用いられるObservationの用途がスコープであり、患者基本情報の中でも特に身体所見に該当する情報項目の1つを取り扱う際に、必要な要件を定義している。

プロファイル定義

Usage:

プロファイル詳細

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from JP_Observation_Common

Summary

Mandatory: 3 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Observation.category is sliced based on the value of pattern:$this
  • The element Observation.code.coding is sliced based on the value of pattern:$this
  • The element Observation.component.code.coding is sliced based on the value of pattern:$this
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*JP_Observation_Common身体所見に関する測定や簡単な観察事実(assertion)
... Slices for category 1..*CodeableConceptClassification of type of observation Observationの種類(タイプ)の分類
Slice: Unordered, Open by pattern:$this
.... category:exam 1..1CodeableConceptClassification of type of observation Observationの種類(タイプ)の分類
Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: exam
... code 1..1CodeableConceptType of observation (code / type) observation のタイプ(コードまたはタイプ)
Binding: JP Core Physical Exam Code ValueSet (preferred)
.... Slices for coding 0..*CodingCode defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:physicalExamCode 0..1Coding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。【詳細参照】
Required Pattern: At least the following
...... system1..1uriIdentity of the terminology system
Fixed Value: http://jpfhir.jp/fhir/core/CodeSystem/JP_PhysicalExamCode_CS
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: physical-findings
...... display1..1stringRepresentation defined by the system
Fixed Value: Physical Findings
... subject 1..1Reference(JP Core Patient Profile)Who and/or what the observation is about 観察対象者
... encounter 0..1Reference(JP Core Encounter Profile)Healthcare event during which this observation is made このobservationが行われるヘルスケアイベント
... effective[x] 0..1Clinically relevant time/time-period for observation 臨床的に関連する時刻または時間
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... valueCodeableConcept 0..1CodeableConcept所見の有無(Y or N)を指定する
Binding: hl7VS-yes-no-Indicator (preferred)
... bodySite 0..1CodeableConceptBindingについてはユースケースに応じて各プロファイルで定義すること
Binding: JP Core Observation PhysicalExam BodySite ValueSet (preferred)
... method 0..1CodeableConceptBindingについてはユースケースに応じて各プロファイルで定義すること
Binding: JP Core Observation PhysicalExam Method ValueSet (preferred)
... hasMember 0..*Reference(JP Core Observation Common Profile | QuestionnaireResponse | MolecularSequence | JP Core Observation PhysicalExam Profile)Related resource that belongs to the Observation group observationグループに属する関連リソース
... derivedFrom 0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | JP Core Observation Common Profile | MolecularSequence | JP Core Observation PhysicalExam Profile)Related measurements the observation is made from observation が作られる元の関連する測定
... component 0..*BackboneElement所見有り(valueCodeableConceptがY)の場合に、具体的な所見をコード、または文字列で記載する
.... code 1..1CodeableConceptType of component observation (code / type)
Binding: JP Core Physical Exam Code ValueSet (preferred)
..... Slices for coding 0..*CodingCode defined by a terminology system
Slice: Unordered, Open by pattern:$this
...... coding:physicalExamCode 0..1Coding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。【詳細参照】
Required Pattern: At least the following
....... system1..1uriIdentity of the terminology system
Fixed Value: http://jpfhir.jp/fhir/core/CodeSystem/JP_PhysicalExamCode_CS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: detailed-physical-findings
....... display1..1stringRepresentation defined by the system
Fixed Value: Detailed Physical Findings

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*JP_Observation_Common身体所見に関する測定や簡単な観察事実(assertion)
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation Observationのためのビジネス識別子
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | JP Core MedicationRequest Profile | JP Core MedicationRequest Injection Profile | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order 実施されるプラン、提案、依頼
... partOf Σ0..*Reference(JP Core MedicationAdministration Profile | JP Core MedicationAdministration Injection Profile | JP Core MedicationDispenseBase Profile | MedicationStatement | JP Core Procedure Profile | JP Core Immunization Profile | ImagingStudy)Part of referenced event 参照されるイベントの一部分
... status ?!Σ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category 1..*CodeableConceptClassification of type of observation Observationの種類(タイプ)の分類
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:exam 1..1CodeableConceptClassification of type of observation Observationの種類(タイプ)の分類
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: exam
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... code Σ1..1CodeableConceptType of observation (code / type) observation のタイプ(コードまたはタイプ)
Binding: JP Core Physical Exam Code ValueSet (preferred)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ0..*CodingCode defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:physicalExamCode Σ0..1Coding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。【詳細参照】

Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://jpfhir.jp/fhir/core/CodeSystem/JP_PhysicalExamCode_CS
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: physical-findings
...... display1..1stringRepresentation defined by the system
Fixed Value: Physical Findings
...... userSelected0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... subject Σ1..1Reference(JP Core Patient Profile)Who and/or what the observation is about 観察対象者
... focus Σ0..*Reference(Resource)What the observation is about, when it is not about the subject of record subject 要素が実際のobservationの対象でない場合に、observation の対象物
... encounter Σ0..1Reference(JP Core Encounter Profile)Healthcare event during which this observation is made このobservationが行われるヘルスケアイベント
... effective[x] Σ0..1Clinically relevant time/time-period for observation 臨床的に関連する時刻または時間
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDate/Time this version was made available このバージョンが利用可能となった日時
... performer Σ0..*Reference(JP Core Practitioner Profile | JP Core PractitionerRole Profile | JP Core Organization Profile | CareTeam | JP Core Patient Profile | RelatedPerson)Who is responsible for the observation observationに責任をもつ者
... Slices for value[x] ΣC0..1Actual result 実際の結果値
Slice: Unordered, Open by type:$this
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
.... value[x]:valueCodeableConcept ΣC0..1CodeableConcept所見の有無(Y or N)を指定する
Binding: hl7VS-yes-no-Indicator (preferred)
... dataAbsentReason C0..1CodeableConceptWhy the result is missing 結果が欠損値である理由
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..*AnnotationComments about the observation 結果に対するコメント
... bodySite 0..1CodeableConceptBindingについてはユースケースに応じて各プロファイルで定義すること
Binding: JP Core Observation PhysicalExam BodySite ValueSet (preferred)
... method 0..1CodeableConceptBindingについてはユースケースに応じて各プロファイルで定義すること
Binding: JP Core Observation PhysicalExam Method ValueSet (preferred)
... specimen 0..1Reference(Specimen)Specimen used for this observation 観察(観測、検査)に使われた検体材料
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device 測定機器
... referenceRange C0..*BackboneElementProvides guide for interpretation 解釈のためのガイドを与える
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low C0..1SimpleQuantityLow Range, if relevant
.... high C0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember Σ0..*Reference(JP Core Observation Common Profile | QuestionnaireResponse | MolecularSequence | JP Core Observation PhysicalExam Profile)Related resource that belongs to the Observation group observationグループに属する関連リソース
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | JP Core Observation Common Profile | MolecularSequence | JP Core Observation PhysicalExam Profile)Related measurements the observation is made from observation が作られる元の関連する測定
... component Σ0..*BackboneElement所見有り(valueCodeableConceptがY)の場合に、具体的な所見をコード、または文字列で記載する
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: JP Core Physical Exam Code ValueSet (preferred)
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... Slices for coding Σ0..*CodingCode defined by a terminology system
Slice: Unordered, Open by pattern:$this
...... coding:physicalExamCode Σ0..1Coding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。【詳細参照】

Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://jpfhir.jp/fhir/core/CodeSystem/JP_PhysicalExamCode_CS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: detailed-physical-findings
....... display1..1stringRepresentation defined by the system
Fixed Value: Detailed Physical Findings
....... userSelected0..1booleanIf this coding was chosen directly by the user
..... text Σ0..1stringPlain text representation of the concept
.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason C0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


.... referenceRange 0..*See referenceRange (Observation)Provides guide for interpretation of component result

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Observation.statusrequiredObservationStatus
Observation.categorypreferredObservationCategoryCodes
Observation.category:exampreferredPattern: exam
Observation.codepreferredJP_PhysicalExamCode_VS (a valid code from JP Core Physical Exam Code CodeSystem)
Observation.value[x]:valueCodeableConceptpreferredHl7VSYesNoIndicator
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySitepreferredJP_ObservationPhysicalExamBodySite_VS (a valid code from http://jpfhir.jp/fhir/core/CodeSystem/JP_ObservationPhysicalExamBodySite_CS)
Observation.methodpreferredJP_ObservationPhysicalExamMethod_VS (a valid code from JP Core Observation PhysicalExam Method CodeSystem)
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codepreferredJP_PhysicalExamCode_VS (a valid code from JP Core Physical Exam Code CodeSystem)
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
obs-3errorObservation.referenceRangeMust have at least a low or a high or text
: low.exists() or high.exists() or text.exists()

This structure is derived from JP_Observation_Common

Summary

Mandatory: 3 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Observation.category is sliced based on the value of pattern:$this
  • The element Observation.code.coding is sliced based on the value of pattern:$this
  • The element Observation.component.code.coding is sliced based on the value of pattern:$this

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*JP_Observation_Common身体所見に関する測定や簡単な観察事実(assertion)
... Slices for category 1..*CodeableConceptClassification of type of observation Observationの種類(タイプ)の分類
Slice: Unordered, Open by pattern:$this
.... category:exam 1..1CodeableConceptClassification of type of observation Observationの種類(タイプ)の分類
Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: exam
... code 1..1CodeableConceptType of observation (code / type) observation のタイプ(コードまたはタイプ)
Binding: JP Core Physical Exam Code ValueSet (preferred)
.... Slices for coding 0..*CodingCode defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:physicalExamCode 0..1Coding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。【詳細参照】
Required Pattern: At least the following
...... system1..1uriIdentity of the terminology system
Fixed Value: http://jpfhir.jp/fhir/core/CodeSystem/JP_PhysicalExamCode_CS
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: physical-findings
...... display1..1stringRepresentation defined by the system
Fixed Value: Physical Findings
... subject 1..1Reference(JP Core Patient Profile)Who and/or what the observation is about 観察対象者
... encounter 0..1Reference(JP Core Encounter Profile)Healthcare event during which this observation is made このobservationが行われるヘルスケアイベント
... effective[x] 0..1Clinically relevant time/time-period for observation 臨床的に関連する時刻または時間
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... valueCodeableConcept 0..1CodeableConcept所見の有無(Y or N)を指定する
Binding: hl7VS-yes-no-Indicator (preferred)
... bodySite 0..1CodeableConceptBindingについてはユースケースに応じて各プロファイルで定義すること
Binding: JP Core Observation PhysicalExam BodySite ValueSet (preferred)
... method 0..1CodeableConceptBindingについてはユースケースに応じて各プロファイルで定義すること
Binding: JP Core Observation PhysicalExam Method ValueSet (preferred)
... hasMember 0..*Reference(JP Core Observation Common Profile | QuestionnaireResponse | MolecularSequence | JP Core Observation PhysicalExam Profile)Related resource that belongs to the Observation group observationグループに属する関連リソース
... derivedFrom 0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | JP Core Observation Common Profile | MolecularSequence | JP Core Observation PhysicalExam Profile)Related measurements the observation is made from observation が作られる元の関連する測定
... component 0..*BackboneElement所見有り(valueCodeableConceptがY)の場合に、具体的な所見をコード、または文字列で記載する
.... code 1..1CodeableConceptType of component observation (code / type)
Binding: JP Core Physical Exam Code ValueSet (preferred)
..... Slices for coding 0..*CodingCode defined by a terminology system
Slice: Unordered, Open by pattern:$this
...... coding:physicalExamCode 0..1Coding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。【詳細参照】
Required Pattern: At least the following
....... system1..1uriIdentity of the terminology system
Fixed Value: http://jpfhir.jp/fhir/core/CodeSystem/JP_PhysicalExamCode_CS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: detailed-physical-findings
....... display1..1stringRepresentation defined by the system
Fixed Value: Detailed Physical Findings

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*JP_Observation_Common身体所見に関する測定や簡単な観察事実(assertion)
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation Observationのためのビジネス識別子
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | JP Core MedicationRequest Profile | JP Core MedicationRequest Injection Profile | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order 実施されるプラン、提案、依頼
... partOf Σ0..*Reference(JP Core MedicationAdministration Profile | JP Core MedicationAdministration Injection Profile | JP Core MedicationDispenseBase Profile | MedicationStatement | JP Core Procedure Profile | JP Core Immunization Profile | ImagingStudy)Part of referenced event 参照されるイベントの一部分
... status ?!Σ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category 1..*CodeableConceptClassification of type of observation Observationの種類(タイプ)の分類
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:exam 1..1CodeableConceptClassification of type of observation Observationの種類(タイプ)の分類
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: exam
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... code Σ1..1CodeableConceptType of observation (code / type) observation のタイプ(コードまたはタイプ)
Binding: JP Core Physical Exam Code ValueSet (preferred)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ0..*CodingCode defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:physicalExamCode Σ0..1Coding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。【詳細参照】

Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://jpfhir.jp/fhir/core/CodeSystem/JP_PhysicalExamCode_CS
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: physical-findings
...... display1..1stringRepresentation defined by the system
Fixed Value: Physical Findings
...... userSelected0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... subject Σ1..1Reference(JP Core Patient Profile)Who and/or what the observation is about 観察対象者
... focus Σ0..*Reference(Resource)What the observation is about, when it is not about the subject of record subject 要素が実際のobservationの対象でない場合に、observation の対象物
... encounter Σ0..1Reference(JP Core Encounter Profile)Healthcare event during which this observation is made このobservationが行われるヘルスケアイベント
... effective[x] Σ0..1Clinically relevant time/time-period for observation 臨床的に関連する時刻または時間
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDate/Time this version was made available このバージョンが利用可能となった日時
... performer Σ0..*Reference(JP Core Practitioner Profile | JP Core PractitionerRole Profile | JP Core Organization Profile | CareTeam | JP Core Patient Profile | RelatedPerson)Who is responsible for the observation observationに責任をもつ者
... Slices for value[x] ΣC0..1Actual result 実際の結果値
Slice: Unordered, Open by type:$this
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
.... value[x]:valueCodeableConcept ΣC0..1CodeableConcept所見の有無(Y or N)を指定する
Binding: hl7VS-yes-no-Indicator (preferred)
... dataAbsentReason C0..1CodeableConceptWhy the result is missing 結果が欠損値である理由
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..*AnnotationComments about the observation 結果に対するコメント
... bodySite 0..1CodeableConceptBindingについてはユースケースに応じて各プロファイルで定義すること
Binding: JP Core Observation PhysicalExam BodySite ValueSet (preferred)
... method 0..1CodeableConceptBindingについてはユースケースに応じて各プロファイルで定義すること
Binding: JP Core Observation PhysicalExam Method ValueSet (preferred)
... specimen 0..1Reference(Specimen)Specimen used for this observation 観察(観測、検査)に使われた検体材料
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device 測定機器
... referenceRange C0..*BackboneElementProvides guide for interpretation 解釈のためのガイドを与える
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low C0..1SimpleQuantityLow Range, if relevant
.... high C0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember Σ0..*Reference(JP Core Observation Common Profile | QuestionnaireResponse | MolecularSequence | JP Core Observation PhysicalExam Profile)Related resource that belongs to the Observation group observationグループに属する関連リソース
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | JP Core Observation Common Profile | MolecularSequence | JP Core Observation PhysicalExam Profile)Related measurements the observation is made from observation が作られる元の関連する測定
... component Σ0..*BackboneElement所見有り(valueCodeableConceptがY)の場合に、具体的な所見をコード、または文字列で記載する
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: JP Core Physical Exam Code ValueSet (preferred)
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... Slices for coding Σ0..*CodingCode defined by a terminology system
Slice: Unordered, Open by pattern:$this
...... coding:physicalExamCode Σ0..1Coding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。【詳細参照】

Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://jpfhir.jp/fhir/core/CodeSystem/JP_PhysicalExamCode_CS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: detailed-physical-findings
....... display1..1stringRepresentation defined by the system
Fixed Value: Detailed Physical Findings
....... userSelected0..1booleanIf this coding was chosen directly by the user
..... text Σ0..1stringPlain text representation of the concept
.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason C0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


.... referenceRange 0..*See referenceRange (Observation)Provides guide for interpretation of component result

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Observation.statusrequiredObservationStatus
Observation.categorypreferredObservationCategoryCodes
Observation.category:exampreferredPattern: exam
Observation.codepreferredJP_PhysicalExamCode_VS (a valid code from JP Core Physical Exam Code CodeSystem)
Observation.value[x]:valueCodeableConceptpreferredHl7VSYesNoIndicator
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySitepreferredJP_ObservationPhysicalExamBodySite_VS (a valid code from http://jpfhir.jp/fhir/core/CodeSystem/JP_ObservationPhysicalExamBodySite_CS)
Observation.methodpreferredJP_ObservationPhysicalExamMethod_VS (a valid code from JP Core Observation PhysicalExam Method CodeSystem)
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codepreferredJP_PhysicalExamCode_VS (a valid code from JP Core Physical Exam Code CodeSystem)
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
obs-3errorObservation.referenceRangeMust have at least a low or a high or text
: low.exists() or high.exists() or text.exists()

 

Other representations of profile: CSV, Excel, Schematron

必須要素

本プロファイルでは、次の要素を持たなければならない。

  • status︓身体所見情報項目の状態は必須である
  • category︓このリソースが示す身体所見情報項目を分類するための区分であり、このプロファイルでは必須とする
  • code︓このリソースは何の身体所見情報項目であるかを示すため必須である
  • subject︓このリソースが示す身体所見情報項目が、どの患者のものかを示すため、このプロファイルでは参照するpatientリソースの定義を必須とする

Extensions定義

本プロファイルで追加定義された拡張はない。

利用方法

OperationおよびSearch Parameter 一覧

Search Parameter一覧

身体所見ユースケースのSearch Parameter一覧は共通情報プロファイルに記載されている。

検索時のcategoryパラメータは”exam”となる。

Observation共通情報プロファイル#Search Parameter一覧

Operation一覧

ObservationリソースのOperation一覧の定義はユースケースに依存せず共通であるため、共通情報プロファイルに記載されている。

Observation共通情報プロファイル#Operation一覧

サンプル