HL7 FHIR JP Core ImplementationGuide
1.1.1 - release Japan flag

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

Resource Profile: JP Core Observation SocialHistory Profile

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

JP_Observation_SocialHistory

Title

JP Core Observation SocialHistory 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、生活背景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バイタルサイン情報について、情報の登録や検索、取得のために、JP_Observation_SocialHistory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。 JP_Observation_SocialHistory 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、期間での患者生活背景情報の参照
  • Patientリソースから指定された患者生活背景情報項目に対する、指定された期間での患者生活背景情報の参照
  • 指定された期間や患者生活背景情報項目に対し、条件に合致する患者生活背景情報、または関連する他のリソース(Observationリソースや、Patientリソース等)の参照。

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患者バイタルサインに該当する情報項目の1つを取り扱う際に、必要な要件を定義している。

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:$this
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*JP_Observation_Common生活背景の情報
... Slices for category 1..*CodeableConceptClassification of type of observation Observationの種類(タイプ)の分類
Slice: Unordered, Open by pattern:$this
.... category:socialHistory 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: social-history
... code 1..1CodeableConceptType of observation (code / type) observation のタイプ(コードまたはタイプ)
Binding: JP Core Observation SocialHistory Code ValueSet (preferred)
... subject 1..1Reference(JP Core Patient Profile)Who and/or what the observation is about 観察対象者
... 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
... value[x] 0..1Actual result 実際の結果値
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
... derivedFrom 0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | JP Core Observation Common Profile | MolecularSequence | JP Core Observation SocialHistory Profile)Related measurements the observation is made from observation が作られる元の関連する測定

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*JP_Observation_Common生活背景の情報
... 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:socialHistory 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..1idUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1idUnique 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: social-history
...... 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 Observation SocialHistory Code ValueSet (preferred)
... 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
... value[x] ΣC0..1Actual result 実際の結果値
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
... 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: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... 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: ObservationMethods (example): Methods for simple observations.

... 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)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 SocialHistory Profile)Related measurements the observation is made from observation が作られる元の関連する測定
... component Σ0..*BackboneElementComponent results  コンポーネント結果
.... 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: LOINCCodes (example): Codes identifying names of simple observations.

.... 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:socialHistorypreferredPattern: social-history
Observation.codepreferredJP_ObservationSocialHistoryCode_VS (a valid code from http://jpfhir.jp/fhir/core/CodeSystem/JP_ObservationSocialHistoryCode_CS)
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySiteexampleSNOMEDCTBodyStructures
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
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

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*JP_Observation_Common生活背景の情報
... 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:socialHistory 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: social-history
... code 1..1CodeableConceptType of observation (code / type) observation のタイプ(コードまたはタイプ)
Binding: JP Core Observation SocialHistory Code ValueSet (preferred)
... subject 1..1Reference(JP Core Patient Profile)Who and/or what the observation is about 観察対象者
... 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
... value[x] 0..1Actual result 実際の結果値
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
... derivedFrom 0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | JP Core Observation Common Profile | MolecularSequence | JP Core Observation SocialHistory Profile)Related measurements the observation is made from observation が作られる元の関連する測定

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*JP_Observation_Common生活背景の情報
... 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:socialHistory 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..1idUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1idUnique 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: social-history
...... 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 Observation SocialHistory Code ValueSet (preferred)
... 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
... value[x] ΣC0..1Actual result 実際の結果値
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
... 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: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... 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: ObservationMethods (example): Methods for simple observations.

... 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)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 SocialHistory Profile)Related measurements the observation is made from observation が作られる元の関連する測定
... component Σ0..*BackboneElementComponent results  コンポーネント結果
.... 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: LOINCCodes (example): Codes identifying names of simple observations.

.... 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:socialHistorypreferredPattern: social-history
Observation.codepreferredJP_ObservationSocialHistoryCode_VS (a valid code from http://jpfhir.jp/fhir/core/CodeSystem/JP_ObservationSocialHistoryCode_CS)
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySiteexampleSNOMEDCTBodyStructures
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
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︓生活背景情報項目の状態は必須である
  • category︓このリソースが示す生活背景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生活背景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生活背景情報項目が、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

Extension定義

このプロファイルでは拡張定義は行っていない。

利用方法

OperationおよびSearch Parameter 一覧

Search Parameter一覧

生活背景情報ユースケースのSearch Parameter一覧は共通情報プロファイルに記載されている。

検索時のcategoryパラメータは”vital-sign”となる。

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

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