Current Build

Переводит команда Health Samurai . Приглашаем поучаствовать в русификации стандарта FHIR: GitHub , Email.

Orders and Observations Work Group Maturity Level: 5Trial Use Use Context: Any

Определения для профиля bodyheight.

Observation
Element IdObservation
Definition

This profile defines how to represent Body Height observations in FHIR using a standard LOINC code and UCUM units of measure.

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

Используется для таких простых наблюдений, как измерения устройств, лабораторные атомарные результаты, основные показатели состояния организма, рост, вес, статус курильщика, комментарии и т. п. Для обеспечения контекста наблюдений используются другие ресурсы, например лабораторные отчеты и др.

Invariants
Inherited by this element
dom-2RuleЕсли ресурс встроен в другой ресурс, он НЕ ДОЛЖЕН содержать описательной частиcontained.contained.empty()
vs-2RuleIf there is no component or hasMember element then either a value[x] or a data absent reason must be present.(component.empty() and hasMember.empty()) implies (dataAbsentReason or value)
dom-3RuleЕсли ресурс встроен в другой ресурс, где-то в родительском ресурсе на него ДОЛЖНА БЫТЬ дана ссылка or SHALL refer to the containing resourcecontained.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-4RuleЕсли ресурс встроен в другой ресурс, он НЕ ДОЛЖЕН иметь meta.versionId или meta.lastUpdatedcontained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5RuleIf a resource is contained in another resource, it SHALL NOT have a security labelcontained.meta.security.empty()
dom-6GuidelineA resource should have narrative for robust managementtext.div.exists()
This is (only) a best practice guideline because:

When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.

obs-6RuleЭлемент dataAbsentReason должен присутствовать только в том случае, если Observation.value[x] отсутствуетdataAbsentReason.empty() or value.empty()
obs-7RuleIf Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be presentvalue.empty() or component.code.where( (coding.code = %resource.code.coding.code) and (coding.system = %resource.code.coding.system)).empty()
Observation.id
Element IdObservation.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.

Observation.meta
Element IdObservation.meta
Definition

Метаданные ресурса. Это такая информация, которая поддерживается инфраструктурой. Изменения этой информации не всегда можно ассоциировать с версионными изменениями ресурса.

Control0..1
TypeMeta
Observation.implicitRules
Element IdObservation.implicitRules
Definition

Ссылка на свод правил, которым следовали при создании этого ресурса и которые необходимо понимать при обработке этого содержимого. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Control0..1
Typeuri
Is Modifiertrue (Reason: This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation)
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.

Observation.language
Element IdObservation.language
Definition

Основной язык, на котором написан ресурс.

Control0..1
Terminology BindingЕстественный язык.
The codes SHOULD be taken from Language
Typecode
Comments

Язык указывается для поддержки предварительной обработки текстов и доступности для понимания (например при преобразовании текста в речь используется языковой тег). HTML-тег language в описательной части применяется к этой описательной части. Языковой тег ресурса может использоваться для указания языков других представлений, генерируемых из данных ресурса

Не все содержание ресурса должно быть на указанном основном языке. Resource.language нельзя автоматически принимать за язык описательной части. Если язык указан, его также следует указать в элементе div в HTML (информацию о связи между xml:lang и HTML-атрибутом lang см. в правилах HTML5).

Observation.text
Element IdObservation.text
Definition

Человекочитаемая описательная часть, содержащая краткое изложение ресурса, которая может использоваться для представления содержимого ресурса человеку. От описательной части не требуется кодировать все структурированные данные, но она должна содержать достаточно сведений, чтобы простое её прочтение человеком было "клинически безопасным". Определения ресурсов могут описывать, какое содержимое должно быть представлено в описательной части для обеспечения клинической безопасной.

Control0..1
TypeNarrative
Alternate Namesnarrative, html, xhtml, display
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.

Observation.contained
Element IdObservation.contained
Definition

Эти ресурсы не обладают независимым существованием вне ресурса, который их содержит - их нельзя идентифицировать независимо, и они не могут иметь своей собственной независимой транзакционной области действия.

Control0..*
TypeResource
Alternate Namesinline resources, anonymous resources, contained resources
Comments

Этого не следует делать, когда содержимое может быть идентифицировано должным образом, поскольку, потеряв идентификацию, будет чрезвычайно сложно (и контекстно-зависимо) снова восстановить её. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Observation.extension
Element IdObservation.extension
Definition

Может использоваться для представления дополнительной информации, не являющейся частью базового определения ресурса. Чтобы сделать использование расширений надежным и управляемым, существует строгий набор управления применительно к определению и использованию расширений. Хотя каждому реализатору разрешается определять расширения, имеется набор требований, которые должны выполняться в рамках определения расширения.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

Не должно быть никаких предрассудков по использованию расширений любыми приложениями, проектами или стандартами - вне зависимости от учреждения или юрисдикции, которые используют или задают расширение. Именно использование расширений позволяет спецификации FHIR сохранять простоту для всех.

Observation.modifierExtension
Element IdObservation.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. 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 (Reason: Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them)
Alternate Namesextensions, user content
Comments

Не должно быть никаких предрассудков по использованию расширений любыми приложениями, проектами или стандартами - вне зависимости от учреждения или юрисдикции, которые используют или задают расширение. Именно использование расширений позволяет спецификации FHIR сохранять простоту для всех.

Observation.identifier
Element IdObservation.identifier
Definition

A unique identifier assigned to this observation.

Control0..*
TypeIdentifier
Requirements

Позволяет различать наблюдения и ссылаться на них.

Observation.basedOn
Element IdObservation.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.

Control0..*
TypeReference(CarePlan)
Requirements

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

Alternate NamesFulfills
Observation.partOf
Element IdObservation.partOf
Definition

A larger event of which this particular Observation is a component or step. For example, an observation as part of a procedure.

Control0..*
TypeReference(MedicationAdministration)
Alternate NamesContainer
Comments

To link an Observation to an Encounter use encounter. See the Notes below for guidance on referencing another Observation.

Observation.status
Element IdObservation.status
Definition

Статус значения результата.

Control1..1
Terminology Bindingnull
The codes SHALL be taken from ObservationStatus
Typecode
Is Modifiertrue (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Must Supporttrue
Requirements

Необходимо отслеживать статус отдельных результатов - некоторые результаты становятся окончательными до того, как весь отчет целиком становится окончательным.

Comments

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

Observation.category
Element IdObservation.category
Definition

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

Control1..*
Terminology BindingКоды высокоуровневой классификации наблюдений.
The codes SHOULD be taken from Observation Category Codes
TypeCodeableConcept
Must Supporttrue
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.

SlicingThis element introduces a set of slices. The slicing rules are:
  • unordered
  • Open
  • discriminators: value:coding.code, value:coding.system
Observation.category(VSCat)
Element IdObservation.category:VSCat
Definition

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

Control1..1
Terminology BindingКоды высокоуровневой классификации наблюдений.
The codes SHOULD be taken from Observation Category Codes
TypeCodeableConcept
Must Supporttrue
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.

Observation.category.id
Element IdObservation.category:VSCat.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
Observation.category.extension
Element IdObservation.category:VSCat.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 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.

SlicingThis element introduces a set of slices. The slicing rules are:
  • unordered
  • Open
  • discriminators: value:url
Observation.category.coding
Element IdObservation.category:VSCat.coding
Definition

A reference to a code defined by a terminology system.

Control1..*
TypeCoding
Must Supporttrue
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.

Observation.category.coding.id
Element IdObservation.category:VSCat.coding.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
Observation.category.coding.extension
Element IdObservation.category:VSCat.coding.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 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.

SlicingThis element introduces a set of slices. The slicing rules are:
  • unordered
  • Open
  • discriminators: value:url
Observation.category.coding.system
Element IdObservation.category:VSCat.coding.system
Definition

Идентификация кодовой системы, которая определяет смысл обозначения в коде.

Control1..1
Typeuri
Must Supporttrue
Requirements

Нужна однозначная информация об источнике определения обозначения.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Fixed Valuehttp://terminology.hl7.org/CodeSystem/observation-category
Observation.category.coding.version
Element IdObservation.category:VSCat.coding.version
Definition

Версия кодовой системы, которая была использована при выборе этого кода. Обратите внимание, что поддерживаемая в хорошем состоянии кодовая система не нуждается в указании версии из-за непротиворечивости смысла кодов в разных версиях. Однако в этом нельзя быть постоянно уверенным, и когда непротиворечивость значений не гарантируется, НЕОБХОДИМО указывать версию.

Control0..1
Typestring
Comments

Где справочник не четко определяет, какую строку следует использовать для идентификации версий кодовой системы, рекомендуется использовать дату (выраженную в FHIR-формате даты) официальной публикации этой версии в качестве даты версии.

Observation.category.coding.code
Element IdObservation.category:VSCat.coding.code
Definition

Обозначение в синтаксисе, определенном системой. Обозначение может быть стандартным кодом или выражением в синтаксисе, определенном кодовой системой (например посткоординация).

Control1..1
Typecode
Must Supporttrue
Requirements

Необходимо ссылаться на конкретный код в системе.

Fixed Valuevital-signs
Observation.category.coding.display
Element IdObservation.category:VSCat.coding.display
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Control0..1
Typestring
Requirements

Нужна возможность передавать человекочитаемое значение кода для читателей, которые не знакомы с системой.

Observation.category.coding.userSelected
Element IdObservation.category:VSCat.coding.userSelected
Definition

Указывает, что этот кодинг был выбран непосредственно пользователем - то есть из списка выбора доступных элементов (кодов или значений для отображения).

Control0..1
Typeboolean
Requirements

Определено в качестве критерия клинической безопасности - что именно эта пара system/code была выбрана явным образом, а не подразумевается системой на основе каких-то правил или языковой обработки.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

Observation.category.text
Element IdObservation.category:VSCat.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.

Observation.code
Element IdObservation.code
Definition

Body Height.

Control1..1
Terminology BindingThis identifies the vital sign result type.
The codes SHALL be taken from Vital Signs; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Requirements
  1. SHALL contain exactly one [1..1] code, where the @code SHOULD be selected from ValueSet HITSP Vital Sign Result Type 2.16.840.1.113883.3.88.12.80.62 DYNAMIC (CONF:7301).
Alternate NamesName, Test
Comments

additional codes that translate or map to this code are allowed. For example a more granular LOINC code or code that is used locally in a system.

Observation.code.id
Element IdObservation.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
Observation.code.extension
Element IdObservation.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 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.

SlicingThis element introduces a set of slices. The slicing rules are:
  • unordered
  • Open
  • discriminators: value:url
Observation.code.coding
Element IdObservation.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.

SlicingThis element introduces a set of slices. The slicing rules are:
  • unordered
  • Open
  • discriminators: value:code, value:system
Observation.code.coding(BodyHeightCode)
Element IdObservation.code.coding:BodyHeightCode
Definition

A reference to a code defined by a terminology system.

Control1..1
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.

Observation.code.coding.id
Element IdObservation.code.coding:BodyHeightCode.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
Observation.code.coding.extension
Element IdObservation.code.coding:BodyHeightCode.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 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.

SlicingThis element introduces a set of slices. The slicing rules are:
  • unordered
  • Open
  • discriminators: value:url
Observation.code.coding.system
Element IdObservation.code.coding:BodyHeightCode.system
Definition

Идентификация кодовой системы, которая определяет смысл обозначения в коде.

Control1..1
Typeuri
Requirements

Нужна однозначная информация об источнике определения обозначения.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Fixed Valuehttp://loinc.org
Observation.code.coding.version
Element IdObservation.code.coding:BodyHeightCode.version
Definition

Версия кодовой системы, которая была использована при выборе этого кода. Обратите внимание, что поддерживаемая в хорошем состоянии кодовая система не нуждается в указании версии из-за непротиворечивости смысла кодов в разных версиях. Однако в этом нельзя быть постоянно уверенным, и когда непротиворечивость значений не гарантируется, НЕОБХОДИМО указывать версию.

Control0..1
Typestring
Comments

Где справочник не четко определяет, какую строку следует использовать для идентификации версий кодовой системы, рекомендуется использовать дату (выраженную в FHIR-формате даты) официальной публикации этой версии в качестве даты версии.

Observation.code.coding.code
Element IdObservation.code.coding:BodyHeightCode.code
Definition

Обозначение в синтаксисе, определенном системой. Обозначение может быть стандартным кодом или выражением в синтаксисе, определенном кодовой системой (например посткоординация).

Control1..1
Typecode
Requirements

Необходимо ссылаться на конкретный код в системе.

Fixed Value8302-2
Observation.code.coding.display
Element IdObservation.code.coding:BodyHeightCode.display
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Control0..1
Typestring
Requirements

Нужна возможность передавать человекочитаемое значение кода для читателей, которые не знакомы с системой.

Observation.code.coding.userSelected
Element IdObservation.code.coding:BodyHeightCode.userSelected
Definition

Указывает, что этот кодинг был выбран непосредственно пользователем - то есть из списка выбора доступных элементов (кодов или значений для отображения).

Control0..1
Typeboolean
Requirements

Определено в качестве критерия клинической безопасности - что именно эта пара system/code была выбрана явным образом, а не подразумевается системой на основе каких-то правил или языковой обработки.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

Observation.code.text
Element IdObservation.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.

Observation.subject
Element IdObservation.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.

Control1..1
TypeReference(Patient)
Must Supporttrue
Requirements

Наблюдения не имеют смысла, если вы не знаете, над кем или чем они проводились.

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.

Observation.focus
Element IdObservation.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.

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.

Observation.encounter
Element IdObservation.encounter
Definition

Событие здравоохранения (например взаимодействие пациента и поставщика медицинских услуг), во время которого было сделано это наблюдение.

Control0..1
TypeReference(Encounter)
Requirements

Для некоторых наблюдений может быть важно знать связь между наблюдением и конкретным 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).

Observation.effective[x]
Element IdObservation.effective[x]
Definition

Often just a dateTime for Vital Signs.

Control1..1
TypeChoice of: dateTime, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
Requirements

Знание о том, когда наблюдение считалось верным, важно для понимания его актуальности, а также определения тенденций.

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.

Invariants
Inherited by this element
vs-1Ruleif Observation.effective[x] is dateTime and has a value then that value shall be precise to the day($this as dateTime).toString().length() >= 8
Observation.issued
Element IdObservation.issued
Definition

Дата и время, когда это наблюдение стало доступно поставщикам, обычно после проверки и верификации результатов.

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.

Observation.performer
Element IdObservation.performer
Definition

Who was responsible for asserting the observed value as "true".

Control0..*
TypeReference(Practitioner)
Requirements

Может дать степень уверенность в наблюдении и также указать, куда следует направлять последующие вопросы.

Observation.value[x]
Element IdObservation.value[x]
Definition

Vital Signs value are recorded using the Quantity data type. For supporting observations such as Cuff size could use other datatypes such as CodeableConcept.

Control0..1 This element is affected by the following invariants: obs-7
TypeQuantity
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
Requirements
  1. SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:7305).
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.

Observation.value[x].id
Element IdObservation.value[x].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
Observation.value[x].extension
Element IdObservation.value[x].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 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.

SlicingThis element introduces a set of slices. The slicing rules are:
  • unordered
  • Open
  • discriminators: value:url
Observation.value[x].value
Element IdObservation.value[x].value
Definition

Значение измеренной величины. Значение включает в себя неявное указание точности в представлении значения.

Control1..1
Typedecimal
Must Supporttrue
Requirements

Точность обрабатывается неявно почти во всех случаях измерения.

Comments

Неявная точность значения всегда должна учитываться. Денежные значения имеют свои собственные правила для обработки точности (см. стандартные учебники по бухгалтерскому учету).

Observation.value[x].comparator
Element IdObservation.value[x].comparator
Definition

How the value should be understood and represented - whether the actual value is greater or less than the stated value due to measurement issues; e.g. if the comparator is "<" , then the real value is < stated value.

Control0..1
Terminology BindingHow the Quantity should be understood and represented.
The codes SHALL be taken from QuantityComparator
Typecode
Is Modifiertrue (Reason: Помечено как "Is Modifier", поскольку компаратор существенно модифицирует интерпретацию значения. Если компаратор не указан, значит модификации значения нет)
Requirements

Нужна система обработки измерений, где значением будет <5ug/L или >400mg/L из-за ограничений методологии измерения.

Meaning if MissingIf there is no comparator, then there is no modification of the value
Observation.value[x].unit
Element IdObservation.value[x].unit
Definition

A human-readable form of the unit.

Control1..1
Typestring
Must Supporttrue
Requirements

There are many representations for units of measure and in many contexts, particular representations are fixed and required. I.e. mcg for micrograms.

Observation.value[x].system
Element IdObservation.value[x].system
Definition

Идентификация системы, которая обеспечивает кодированную форму единиц измерения.

Control1..1 This element is affected by the following invariants: qty-3
Typeuri
Must Supporttrue
Requirements

Нужно знать систему, которая определяет кодированную форму единиц измерения.

Fixed Valuehttp://unitsofmeasure.org
Observation.value[x].code
Element IdObservation.value[x].code
Definition

Coded responses from the common UCUM units for vital signs value set.

Control1..1
Terminology BindingCommon UCUM units for body length measures such as Body Height and Head Circumference.
The codes SHALL be taken from Body Length Units
Typecode
Must Supporttrue
Requirements

Need a computable form of the unit that is fixed across all forms. UCUM provides this for quantities, but SNOMED CT provides many units of interest.

Comments

The preferred system is UCUM, but SNOMED CT can also be used (for customary units) or ISO 4217 for currency. The context of use may additionally require a code from a particular system.

Observation.dataAbsentReason
Element IdObservation.dataAbsentReason
Definition

Указывает причину, почему ожидаемое значение в элементе Observation.value[x] отсутствует.

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

Исключительные значения в измерениях необходимо обрабатывать по многим причинам.

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.

Observation.interpretation
Element IdObservation.interpretation
Definition

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

Control0..*
Terminology BindingКоды интерпретаций наблюдений.
The codes SHALL be taken from Observation Interpretation Codes; other codes may be used where these codes are not suitable
TypeCodeableConcept
Requirements

Для некоторых результатов, особенно числовых, для полного понимания смысла результата необходима интерпретация.

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.

Observation.note
Element IdObservation.note
Definition

Comments about the observation or the results.

Control0..*
TypeAnnotation
Requirements

Нужна возможность указать дополнительную информацию в виде произвольного текста.

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.

Observation.bodySite
Element IdObservation.bodySite
Definition

Указывает место на теле субъекта, где проводится наблюдение (т. е. целевое место).

Control0..1
Terminology BindingКоды для описания анатомического расположения. Могут включать указание латеральности.
For example codes, see SNOMED CT Body Structures
TypeCodeableConcept
Comments

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

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

Observation.method
Element IdObservation.method
Definition

Указывает механизм проведения наблюдения.

Control0..1
Terminology BindingМетоды простых наблюдений.
For example codes, see Observation Methods
TypeCodeableConcept
Requirements

В некоторых случаях метод может влиять на результаты и, таким образом, для определения, могут ли результаты быть сравнимыми, или определения смысла результатов.

Comments

Используется только в случае, если это не явно из кода в Observation.code.

Observation.specimen
Element IdObservation.specimen
Definition

Образец для анализа, над которым проводилось наблюдение.

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.device
Element IdObservation.device
Definition

Устройство, используемое для генерации данных наблюдения.

Control0..1
TypeReference(Device)
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.

Observation.referenceRange
Element IdObservation.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

Знание того, какие значения считаются "нормальными", может помочь определить значимость конкретного результата. Нужна возможность указывать несколько диапазонов нормальных значений для различных контекстов.

Comments

Большинство наблюдений имеют только один общий диапазон нормальных значений. Системы МОГУТ ограничиться указанием только актуального диапазона нормальных значений на основе знаний о пациенте (например специфичный для пациента возраст, пол, вес и другие факторы), однако это может быть невозможно или не допустимо. При предоставлении более одного диапазона нормальных значений, различия между ними ДОЛЖНЫ указываться в свойствах reference range и/или age.

Invariants
Inherited by this element
ele-1RuleAll FHIR elements must have a @value or childrenhasValue() or (children().count() > id.count())
obs-3RuleДолжен быть указан хотя бы один элемент из low, high или textlow.exists() or high.exists() or text.exists()
Observation.referenceRange.id
Element IdObservation.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
Observation.referenceRange.extension
Element IdObservation.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 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.

Observation.referenceRange.modifierExtension
Element IdObservation.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. 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 (Reason: Modifier extensions are expected to modify the meaning or interpretation of the element that contains them)
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.

Observation.referenceRange.low
Element IdObservation.referenceRange.low
Definition

Значение нижней границы диапазона нормальных значений. Конечная точка нижней границы диапазона нормальных значений используется включительно (например диапазон нормальных значений >=5 - <=9). Если нижняя граница опущена, то предполагается, что она не имеет смысла (например диапазон нормальных значений <=2.3).

Control0..1 This element is affected by the following invariants: obs-3
TypeQuantity(SimpleQuantity)
Observation.referenceRange.high
Element IdObservation.referenceRange.high
Definition

Значение верхней границы диапазона нормальных значений. Конечная точка верхней границы диапазона нормальных значений используется включительно (например диапазон нормальных значений >=5 - <=9). Если верхняя граница опущена, то предполагается, что она не имеет смысла (например диапазон нормальных значений >= 2.3).

Control0..1 This element is affected by the following invariants: obs-3
TypeQuantity(SimpleQuantity)
Observation.referenceRange.type
Element IdObservation.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
Terminology BindingCode for the meaning of a reference range.
The codes SHOULD be taken from Observation Reference Range Meaning Codes
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.

Observation.referenceRange.appliesTo
Element IdObservation.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..*
Terminology BindingCodes identifying the population the reference range applies to.
For example codes, see Observation Reference Range Applies To Codes
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.

Observation.referenceRange.age
Element IdObservation.referenceRange.age
Definition

Возраст, в котором этот диапазон нормальных значений применяется. Это неонатальный возраст (например число недель в сроке), если указано такое значение.

Control0..1
TypeRange
Requirements

Некоторые вещества, определяемые при анализе, сильно различаются для разного возраста.

Observation.referenceRange.text
Element IdObservation.referenceRange.text
Definition

Текстовое описание диапазона нормальных значений в наблюдении, которое может использоваться, когда количественный диапазон не подходит для этого наблюдения. Примером будет эталонное значение "Negative" или список или таблица 'нормальных' значений.

Control0..1
Typestring
Observation.hasMember
Element IdObservation.hasMember
Definition

Used when reporting vital signs panel components.

Control0..*
TypeReference(QuestionnaireResponse)
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.

Observation.derivedFrom
Element IdObservation.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.

Control0..*
TypeReference(DocumentReference)
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.

Observation.component
Element IdObservation.component
Definition

Used when reporting systolic and diastolic blood pressure.

Control0..*
TypeBackboneElement
Must Supporttrue
Requirements

Составные наблюдения разделяют одинаковые атрибуты в ресурсе Observation в качестве первичного наблюдения и всегда обрабатываются как единое наблюдение (они неразделимы). Однако диапазон нормальных значений для значения первичного наблюдения не наследуется значениями компонентов и требуется, когда это целесообразно, для каждого компонента наблюдения.

Comments

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

Invariants
Inherited by this element
ele-1RuleAll FHIR elements must have a @value or childrenhasValue() or (children().count() > id.count())
vs-3RuleIf there is no a value a data absent reason must be presentvalue.exists() or dataAbsentReason.exists()
Observation.component.id
Element IdObservation.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
Observation.component.extension
Element IdObservation.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 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.

Observation.component.modifierExtension
Element IdObservation.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. 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 (Reason: Modifier extensions are expected to modify the meaning or interpretation of the element that contains them)
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.

Observation.component.code
Element IdObservation.component.code
Definition

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

Control1..1
Terminology BindingThis identifies the vital sign result type.
The codes SHALL be taken from Vital Signs; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Requirements

Знание вида проводимого наблюдения очень важно для понимания значения этого наблюдения.

Comments

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

Observation.component.value[x]
Element IdObservation.component.value[x]
Definition

Vital Sign Value recorded with UCUM.

Control0..1
Terminology BindingCommon UCUM units for recording Vital Signs.
The codes SHALL be taken from Vital Signs Units
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]
Must Supporttrue
Requirements
  1. SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:7305).
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.

Observation.component.dataAbsentReason
Element IdObservation.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
Terminology BindingCodes specifying why the result (`Observation.value[x]`) is missing.
The codes SHALL be taken from DataAbsentReason; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Requirements

Исключительные значения в измерениях необходимо обрабатывать по многим причинам.

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.

Observation.component.interpretation
Element IdObservation.component.interpretation
Definition

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

Control0..*
Terminology BindingКоды интерпретаций наблюдений.
The codes SHALL be taken from Observation Interpretation Codes; other codes may be used where these codes are not suitable
TypeCodeableConcept
Requirements

Для некоторых результатов, особенно числовых, для полного понимания смысла результата необходима интерпретация.

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.

Observation.component.referenceRange
Element IdObservation.component.referenceRange
Definition

Руководство о том, как интерпретировать значение по сравнению с нормальным или рекомендованным диапазоном.

Control0..*
TypeSee Observation.referenceRange
Requirements

Знание того, какие значения считаются "нормальными", может помочь определить значимость конкретного результата. Нужна возможность указывать несколько диапазонов нормальных значений для различных контекстов.

Comments

Большинство наблюдений имеют только один общий диапазон нормальных значений. Системы МОГУТ ограничиться указанием только актуального диапазона нормальных значений на основе знаний о пациенте (например специфичный для пациента возраст, пол, вес и другие факторы), однако это может быть невозможно или не допустимо. При предоставлении более одного диапазона нормальных значений, различия между ними ДОЛЖНЫ указываться в свойствах reference range и/или age.