MII-Initiative

MII IG Symptom DE v2024

Observation

Beschreibung

Messungen oder Zuweisungen zu einem Patienten. Die meisten Beobachtungen sind einfache Entity/Value Paare, sie können aber auch komplex hierarchisch aufgebaut sein.

NameStatusVersionCanonicalBasis
MII_PR_Symptom_Observationactive2024.0.0-ballothttps://www.medizininformatik-initiative.de/fhir/ext/modul-symptom/StructureDefinition/finding-observationhttp://hl7.org/fhir/StructureDefinition/Observation

Inhalt

identifierS Σ0..*Identifier
basedOnΣ I0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)
partOfΣ I0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)
statusS Σ ?!1..1codeBinding
categoryS0..*CodeableConceptBinding
codeS Σ1..1CodeableConcept
subjectS Σ I0..1MII-Reference(Patient | Group)
focusΣ I0..*Reference(Resource)
encounterΣ I0..1Reference(Encounter)
effectiveDateTimedateTime
effectivePeriodPeriod
effectiveTimingTiming
effectiveInstantinstant
issuedS Σ0..1instant
performerΣ I0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)
valueQuantityQuantity
valueCodeableConceptCodeableConcept
valueStringstring
valueBooleanboolean
valueIntegerinteger
valueRangeRange
valueRatioRatio
valueSampledDataSampledData
valueTimetime
valueDateTimedateTime
valuePeriodPeriod
dataAbsentReasonS I0..1CodeableConceptBinding
interpretationS0..*CodeableConceptBinding
note0..*Annotation
bodySite0..1CodeableConcept
methodS0..1CodeableConcept
specimenS I0..1Reference(Specimen)
deviceS I0..1Reference(Device | DeviceMetric)
lowI0..1SimpleQuantity
highI0..1SimpleQuantity
type0..1CodeableConceptBinding
appliesTo0..*CodeableConcept
ageI0..1Range
text0..1string
hasMemberS Σ I0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)
derivedFromS Σ I0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)
codeΣ1..1CodeableConcept
valueQuantityQuantity
valueCodeableConceptCodeableConcept
valueStringstring
valueBooleanboolean
valueIntegerinteger
valueRangeRange
valueRatioRatio
valueSampledDataSampledData
valueTimetime
valueDateTimedateTime
valuePeriodPeriod
dataAbsentReasonI0..1CodeableConceptBinding
interpretation0..*CodeableConceptBinding
referenceRange0..*see (referenceRange)

Messungen oder Zuweisungen zu einem Patienten. Die meisten Beobachtungen sind einfache Entity/Value Paare, sie können aber auch komplex hierarchisch aufgebaut sein.

Feldname
Observation.identifier
Observation.status
Observation.category
Observation.code
Observation.subject
Observation.effective[x]
Observation.issued
Observation.value[x]
Observation.dataAbsentReason
Observation.interpretation
Observation.method
Observation.specimen
Observation.device
Observation.referenceRange
Observation.hasMember
Observation.derivedFrom
Observation.component
<StructureDefinition xmlns="http://hl7.org/fhir">
    <id value="mii-pr-symptom-observation" />
    <url value="https://www.medizininformatik-initiative.de/fhir/ext/modul-symptom/StructureDefinition/finding-observation" />
    <version value="2024.0.0-ballot" />
    <name value="MII_PR_Symptom_Observation" />
    <status value="active" />
    <publisher value="Medizininformatik Initiative" />
    <contact>
        <telecom>
            <system value="url" />
            <value value="https://www.medizininformatik-initiative.de" />
        </telecom>
    </contact>
    <description value="Messungen oder Zuweisungen zu einem Patienten. Die meisten Beobachtungen sind einfache Entity/Value Paare, sie k&#246;nnen aber auch komplex hierarchisch aufgebaut sein." />
    <fhirVersion value="4.0.1" />
    <mapping>
        <identity value="workflow" />
        <uri value="http://hl7.org/fhir/workflow" />
        <name value="Workflow Pattern" />
    </mapping>
    <mapping>
        <identity value="sct-concept" />
        <uri value="http://snomed.info/conceptdomain" />
        <name value="SNOMED CT Concept Domain Binding" />
    </mapping>
    <mapping>
        <identity value="v2" />
        <uri value="http://hl7.org/v2" />
        <name value="HL7 v2 Mapping" />
    </mapping>
    <mapping>
        <identity value="rim" />
        <uri value="http://hl7.org/v3" />
        <name value="RIM Mapping" />
    </mapping>
    <mapping>
        <identity value="w5" />
        <uri value="http://hl7.org/fhir/fivews" />
        <name value="FiveWs Pattern Mapping" />
    </mapping>
    <mapping>
        <identity value="sct-attr" />
        <uri value="http://snomed.org/attributebinding" />
        <name value="SNOMED CT Attribute Binding" />
    </mapping>
    <kind value="resource" />
    <abstract value="false" />
    <type value="Observation" />
    <baseDefinition value="http://hl7.org/fhir/StructureDefinition/Observation" />
    <derivation value="constraint" />
    <differential>
        <element id="Observation.identifier">
            <path value="Observation.identifier" />
            <mustSupport value="true" />
        </element>
        <element id="Observation.status">
            <path value="Observation.status" />
            <mustSupport value="true" />
        </element>
        <element id="Observation.category">
            <path value="Observation.category" />
            <mustSupport value="true" />
        </element>
        <element id="Observation.code">
            <path value="Observation.code" />
            <mustSupport value="true" />
        </element>
        <element id="Observation.subject">
            <path value="Observation.subject" />
            <type>
                <code value="Reference" />
                <profile value="https://www.medizininformatik-initiative.de/fhir/core/StructureDefinition/MII-Reference" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/Patient" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/Group" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="Observation.effective[x]">
            <path value="Observation.effective[x]" />
            <mustSupport value="true" />
        </element>
        <element id="Observation.issued">
            <path value="Observation.issued" />
            <mustSupport value="true" />
        </element>
        <element id="Observation.value[x]">
            <path value="Observation.value[x]" />
            <mustSupport value="true" />
        </element>
        <element id="Observation.dataAbsentReason">
            <path value="Observation.dataAbsentReason" />
            <mustSupport value="true" />
        </element>
        <element id="Observation.interpretation">
            <path value="Observation.interpretation" />
            <mustSupport value="true" />
        </element>
        <element id="Observation.method">
            <path value="Observation.method" />
            <mustSupport value="true" />
        </element>
        <element id="Observation.specimen">
            <path value="Observation.specimen" />
            <mustSupport value="true" />
        </element>
        <element id="Observation.device">
            <path value="Observation.device" />
            <mustSupport value="true" />
        </element>
        <element id="Observation.referenceRange">
            <path value="Observation.referenceRange" />
            <mustSupport value="true" />
        </element>
        <element id="Observation.hasMember">
            <path value="Observation.hasMember" />
            <mustSupport value="true" />
        </element>
        <element id="Observation.derivedFrom">
            <path value="Observation.derivedFrom" />
            <mustSupport value="true" />
        </element>
        <element id="Observation.component">
            <path value="Observation.component" />
            <mustSupport value="true" />
        </element>
    </differential>
</StructureDefinition>
{
    "resourceType": "StructureDefinition",
    "id": "mii-pr-symptom-observation",
    "url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-symptom/StructureDefinition/finding-observation",
    "version": "2024.0.0-ballot",
    "name": "MII_PR_Symptom_Observation",
    "status": "active",
    "publisher": "Medizininformatik Initiative",
    "contact":  [
        {
            "telecom":  [
                {
                    "system": "url",
                    "value": "https://www.medizininformatik-initiative.de"
                }
            ]
        }
    ],
    "description": "Messungen oder Zuweisungen zu einem Patienten. Die meisten Beobachtungen sind einfache Entity/Value Paare, sie können aber auch komplex hierarchisch aufgebaut sein.",
    "fhirVersion": "4.0.1",
    "mapping":  [
        {
            "identity": "workflow",
            "uri": "http://hl7.org/fhir/workflow",
            "name": "Workflow Pattern"
        },
        {
            "identity": "sct-concept",
            "uri": "http://snomed.info/conceptdomain",
            "name": "SNOMED CT Concept Domain Binding"
        },
        {
            "identity": "v2",
            "uri": "http://hl7.org/v2",
            "name": "HL7 v2 Mapping"
        },
        {
            "identity": "rim",
            "uri": "http://hl7.org/v3",
            "name": "RIM Mapping"
        },
        {
            "identity": "w5",
            "uri": "http://hl7.org/fhir/fivews",
            "name": "FiveWs Pattern Mapping"
        },
        {
            "identity": "sct-attr",
            "uri": "http://snomed.org/attributebinding",
            "name": "SNOMED CT Attribute Binding"
        }
    ],
    "kind": "resource",
    "abstract": false,
    "type": "Observation",
    "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Observation",
    "derivation": "constraint",
    "differential": {
        "element":  [
            {
                "id": "Observation.identifier",
                "path": "Observation.identifier",
                "mustSupport": true
            },
            {
                "id": "Observation.status",
                "path": "Observation.status",
                "mustSupport": true
            },
            {
                "id": "Observation.category",
                "path": "Observation.category",
                "mustSupport": true
            },
            {
                "id": "Observation.code",
                "path": "Observation.code",
                "mustSupport": true
            },
            {
                "id": "Observation.subject",
                "path": "Observation.subject",
                "type":  [
                    {
                        "code": "Reference",
                        "profile":  [
                            "https://www.medizininformatik-initiative.de/fhir/core/StructureDefinition/MII-Reference"
                        ],
                        "targetProfile":  [
                            "http://hl7.org/fhir/StructureDefinition/Patient",
                            "http://hl7.org/fhir/StructureDefinition/Group"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "Observation.effective[x]",
                "path": "Observation.effective[x]",
                "mustSupport": true
            },
            {
                "id": "Observation.issued",
                "path": "Observation.issued",
                "mustSupport": true
            },
            {
                "id": "Observation.value[x]",
                "path": "Observation.value[x]",
                "mustSupport": true
            },
            {
                "id": "Observation.dataAbsentReason",
                "path": "Observation.dataAbsentReason",
                "mustSupport": true
            },
            {
                "id": "Observation.interpretation",
                "path": "Observation.interpretation",
                "mustSupport": true
            },
            {
                "id": "Observation.method",
                "path": "Observation.method",
                "mustSupport": true
            },
            {
                "id": "Observation.specimen",
                "path": "Observation.specimen",
                "mustSupport": true
            },
            {
                "id": "Observation.device",
                "path": "Observation.device",
                "mustSupport": true
            },
            {
                "id": "Observation.referenceRange",
                "path": "Observation.referenceRange",
                "mustSupport": true
            },
            {
                "id": "Observation.hasMember",
                "path": "Observation.hasMember",
                "mustSupport": true
            },
            {
                "id": "Observation.derivedFrom",
                "path": "Observation.derivedFrom",
                "mustSupport": true
            },
            {
                "id": "Observation.component",
                "path": "Observation.component",
                "mustSupport": true
            }
        ]
    }
}

FHIRDatensatzErklaerung
ObservationSymptom.Observation

Observation i. S. einer FHIR Observation: Messungen oder Zuweisungen zu einem Patienten. Die meisten Beobachtungen sind einfache Entity/Value Paare, sie können aber auch komplex hierarchisch aufgebaut sein.

Observation.identifierSymptom.Observation.Identifikator

Eindeutiger Identifier der Observation

Observation.code.coding.displaySymptom.Observation.Bezeichnung

Natürlichsprachige Bezeichnung der Observation

Observation.code.textSymptom.Observation.Beschreibung

Natürlichsprachige Beschreibung der Beobachtung

Observation.categorySymptom.Observation.Kategorie

Kategorie der Observation

Observation.statusSymptom.Observation.Status

Status der Observation

Observation.codeSymptom.Observation.Code

Code der Observation: z. B. LOINC, SNOMED CT, HPO

Observation.effectiveDateTimeSymptom.Observation.Zeitspanne

Klinisch relevante Zeitpunkte/Zeitspanne

Observation.effectivePeriod.startSymptom.Observation.Zeitspanne.Startzeitpunkt

Klinisch relevanter (Start-)Zeitpunkt einer Observation

Observation.effectivePeriod.endSymptom.Observation.Zeitspanne.Endzeitpunkt

Klinisch relevanter Endzeitpunkt einer Observation

Observation.issuedSymptom.Observation.Dokumentationsdatum

Zeitpunkt der Dokumentation der Observation.

Observation.value[x]Symptom.Observation.Wert[x]

Wert der Observation

Observation.referenceRangeSymptom.Observation.ReferenzIntervall

Referenz-Intervall entsprechend des eingebetteten komplexen Typs (Observation.referenceRange)

Observation.dataAbesentReasonSymptom.Observation.GrundNichtVorhandenerDaten

Grund für nicht vorhandene Daten der Observation

Observation.interpretationSymptom.Observation.Interpretation

Interpretation einer Observation

Observation.noteSymptom.Observation.Kommentar

Natürlichsprachiger Kommentar zur Observation.

Observation.bodySiteSymptom.Observation.Lokalisation

Lokalisation der Observation als SNOMED CT Body Structure codiert.

Observation.subjectSymptom.Observation.Patient

Link auf Patient

Observation.encounterSymptom.Observation.Fall

Fall der Observation

Observation.specimenSymptom.Observation.Probe

Referenz auf die Probe, auf der die Observation basiert

Observation.deviceSymptom.Observation.Messgeraet

Referenz auf das verwendete Mess-/Untersuchungsgerät

Observation.methodSymptom.Observation.Methode

Methode der Untersuchung

Observation.hasMemberSymptom.Observation.BezugZuHatTeil

Bezug zu Ressourcen, die zu dieser Observation gehören (Observation, QuestionnaireResponse, MolecularSequence)

Observation.derivedFromSymptom.Observation.BezugVonIstTeilVon

Referenz auf Messunger/Beobachtungen, aus denen diese Observation hervorgeht.

Observation.componentSymptom.Observation.Komponente

Komponente einer Observation mit mehreren Komponenten (z. B. Blutdruck) entsprechend des komplexen Typs (Observation.component) mit .code, .value, .dataAbsentReason, .interpretation, .referenceRange (alle wie oben beschrieben)


Beispiele

Beispiel einer Observation-Ressource:

{
    "resourceType": "Observation",
    "id": "mii-exa-symptom-arachnodactyly",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/ext/modul-symptom/StructureDefinition/finding-observation"
        ]
    },
    "status": "final",
    "subject": {
        "reference": "Patient/example"
    },
    "code": {
        "coding":  [
            {
                "code": "HP:0001166",
                "system": "http://github.com/phenopackets/core-ig/CodeSystem/hpo",
                "display": "Arachnodactyly"
            }
        ]
    },
    "valueCodeableConcept": {
        "coding":  [
            {
                "code": "LA9633-4",
                "system": "http://loinc.org",
                "display": "Present"
            }
        ]
    }
}