醫查實作指引
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Resource Profile: ObservationPhysicalExamination IMRI

Official URL: https://hitstdio.ntunhs.edu.tw/imri/StructureDefinition/observation-physical-examination-imri Version: 0.1.0
Active as of 2024-08-12 Computable Name: ObservationPhysicalExaminationIMRI

此理學檢查發現(ObservationPhysicalExamination IMRI) Profile說明本IG如何進一步定義Observation Profile以呈現理學檢查發現資料；

因TWCoreIG尚無針對非實驗室檢驗檢查，故繼承原生Observation。

Usage:

Formal Views of Profile Content

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

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation Observation
... basedOn 0..* Reference(CarePlan IMRI | DeviceRequest | ImmunizationRecommendation | MedicationRequest IMRI | NutritionOrder | ServiceRequest) Fulfills plan, proposal or order
... partOf 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure IMRI | Immunization | ImagingStudy IMRI) Part of referenced event
... Slices for category 1..1 CodeableConcept Classification of type of observation
Slice: Unordered, Open by pattern:$this
.... category:ObservationCategoryCodes S 1..1 CodeableConcept Classification of type of observation
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: exam
.... Slices for coding S 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:loinc S 0..1 Coding Code defined by a terminology system
Binding: http://loinc.org/ (required)
..... coding:sct S 0..1 Coding Code defined by a terminology system
Binding: SNOMED CT Physical Examination值集 (required)
.... text S 0..1 string Plain text representation of the concept
... subject 0..1 Reference(Patient IMRI) Who and/or what the observation is about
... encounter 0..1 Reference(Encounter IMRI) Healthcare event during which this observation is made
... performer 0..* Reference(Practitioner IMRI | Organization Hospital Department IMRI | Patient IMRI | PractitionerRole IMRI | CareTeam) Who is responsible for the observation
... value[x] 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period 即為「理學檢查發現」，實際結果。
... hasMember 0..* Reference(ObservationLaboratory IMRI | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom 0..* Reference(DocumentReference | ImagingStudy IMRI | Media | QuestionnaireResponse | ObservationLaboratory IMRI | MolecularSequence) Related measurements the observation is made from

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.code.coding:loincrequiredhttp://loinc.org/
http://loinc.org/
Observation.code.coding:sctrequiredSCTPhysicalExamination
https://hitstdio.ntunhs.edu.tw/imri/ValueSet/physical-examination-sct
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... basedOn Σ 0..* Reference(CarePlan IMRI | DeviceRequest | ImmunizationRecommendation | MedicationRequest IMRI | NutritionOrder | ServiceRequest) Fulfills plan, proposal or order
... status ?!Σ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category 1..1 CodeableConcept Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:ObservationCategoryCodes S 1..1 CodeableConcept Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: exam
... code Σ 1..1 CodeableConcept 即為「理學檢查發現項目」，概念（concept）－參照一個專門術語或只是純文字。
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:loinc SΣ 0..1 Coding Code defined by a terminology system
Binding: http://loinc.org/ (required)
..... coding:sct SΣ 0..1 Coding Code defined by a terminology system
Binding: SNOMED CT Physical Examination值集 (required)
.... text SΣ 0..1 string Plain text representation of the concept
... subject Σ 0..1 Reference(Patient IMRI) Who and/or what the observation is about
... encounter Σ 0..1 Reference(Encounter IMRI) Healthcare event during which this observation is made
... performer Σ 0..* Reference(Practitioner IMRI | Organization Hospital Department IMRI | Patient IMRI | PractitionerRole IMRI | CareTeam) Who is responsible for the observation
... value[x] ΣC 0..1 即為「理學檢查發現」，實際結果。
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
... hasMember Σ 0..* Reference(ObservationLaboratory IMRI | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy IMRI | Media | QuestionnaireResponse | ObservationLaboratory IMRI | MolecularSequence) Related measurements the observation is made from

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:ObservationCategoryCodespreferredPattern: exam
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.code.coding:loincrequiredhttp://loinc.org/
http://loinc.org/
Observation.code.coding:sctrequiredSCTPhysicalExamination
https://hitstdio.ntunhs.edu.tw/imri/ValueSet/physical-examination-sct
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business Identifier for observation
... basedOn Σ 0..* Reference(CarePlan IMRI | DeviceRequest | ImmunizationRecommendation | MedicationRequest IMRI | NutritionOrder | ServiceRequest) Fulfills plan, proposal or order
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure IMRI | Immunization | ImagingStudy IMRI) Part of referenced event
... status ?!Σ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category 1..1 CodeableConcept Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:ObservationCategoryCodes S 1..1 CodeableConcept Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: exam
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code Σ 1..1 CodeableConcept 即為「理學檢查發現項目」，概念（concept）－參照一個專門術語或只是純文字。
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:loinc SΣ 0..1 Coding Code defined by a terminology system
Binding: http://loinc.org/ (required)
..... coding:sct SΣ 0..1 Coding Code defined by a terminology system
Binding: SNOMED CT Physical Examination值集 (required)
.... text SΣ 0..1 string Plain text representation of the concept
... subject Σ 0..1 Reference(Patient IMRI) Who and/or what the observation is about
... focus Σ 0..* Reference(Resource) What the observation is about, when it is not about the subject of record
... encounter Σ 0..1 Reference(Encounter IMRI) Healthcare event during which this observation is made
... effective[x] Σ 0..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... issued Σ 0..1 instant Date/Time this version was made available
... performer Σ 0..* Reference(Practitioner IMRI | Organization Hospital Department IMRI | Patient IMRI | PractitionerRole IMRI | CareTeam) Who is responsible for the observation
... value[x] ΣC 0..1 即為「理學檢查發現」，實際結果。
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

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


... note 0..* Annotation Comments about the observation
... bodySite 0..1 CodeableConcept Observed body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1 CodeableConcept How it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1 Reference(Specimen) Specimen used for this observation
... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... referenceRange C 0..* BackboneElement Provides guide for interpretation
obs-3: Must have at least a low or a high or text
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... low C 0..1 SimpleQuantity Low Range, if relevant
.... high C 0..1 SimpleQuantity High Range, if relevant
.... type 0..1 CodeableConcept Reference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

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


.... age 0..1 Range Applicable age range, if relevant
.... text 0..1 string Text based reference range in an observation
... hasMember Σ 0..* Reference(ObservationLaboratory IMRI | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy IMRI | Media | QuestionnaireResponse | ObservationLaboratory IMRI | MolecularSequence) Related measurements the observation is made from
... component Σ 0..* BackboneElement Component results
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 CodeableConcept Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ 0..1 Actual component result
..... valueQuantity Quantity
..... valueCodeableConcept CodeableConcept
..... valueString string
..... valueBoolean boolean
..... valueInteger integer
..... valueRange Range
..... valueRatio Ratio
..... valueSampledData SampledData
..... valueTime time
..... valueDateTime dateTime
..... valuePeriod Period
.... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..* CodeableConcept High, 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 / CodeURI
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:ObservationCategoryCodespreferredPattern: exam
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.code.coding:loincrequiredhttp://loinc.org/
http://loinc.org/
Observation.code.coding:sctrequiredSCTPhysicalExamination
https://hitstdio.ntunhs.edu.tw/imri/ValueSet/physical-examination-sct
from this IG
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Observation.methodexampleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
http://hl7.org/fhir/ValueSet/referencerange-meaning
from the FHIR Standard
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
http://hl7.org/fhir/ValueSet/referencerange-appliesto
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard

Differential View

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation Observation
... basedOn 0..* Reference(CarePlan IMRI | DeviceRequest | ImmunizationRecommendation | MedicationRequest IMRI | NutritionOrder | ServiceRequest) Fulfills plan, proposal or order
... partOf 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure IMRI | Immunization | ImagingStudy IMRI) Part of referenced event
... Slices for category 1..1 CodeableConcept Classification of type of observation
Slice: Unordered, Open by pattern:$this
.... category:ObservationCategoryCodes S 1..1 CodeableConcept Classification of type of observation
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: exam
.... Slices for coding S 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:loinc S 0..1 Coding Code defined by a terminology system
Binding: http://loinc.org/ (required)
..... coding:sct S 0..1 Coding Code defined by a terminology system
Binding: SNOMED CT Physical Examination值集 (required)
.... text S 0..1 string Plain text representation of the concept
... subject 0..1 Reference(Patient IMRI) Who and/or what the observation is about
... encounter 0..1 Reference(Encounter IMRI) Healthcare event during which this observation is made
... performer 0..* Reference(Practitioner IMRI | Organization Hospital Department IMRI | Patient IMRI | PractitionerRole IMRI | CareTeam) Who is responsible for the observation
... value[x] 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period 即為「理學檢查發現」，實際結果。
... hasMember 0..* Reference(ObservationLaboratory IMRI | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom 0..* Reference(DocumentReference | ImagingStudy IMRI | Media | QuestionnaireResponse | ObservationLaboratory IMRI | MolecularSequence) Related measurements the observation is made from

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.code.coding:loincrequiredhttp://loinc.org/
http://loinc.org/
Observation.code.coding:sctrequiredSCTPhysicalExamination
https://hitstdio.ntunhs.edu.tw/imri/ValueSet/physical-examination-sct
from this IG

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... basedOn Σ 0..* Reference(CarePlan IMRI | DeviceRequest | ImmunizationRecommendation | MedicationRequest IMRI | NutritionOrder | ServiceRequest) Fulfills plan, proposal or order
... status ?!Σ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category 1..1 CodeableConcept Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:ObservationCategoryCodes S 1..1 CodeableConcept Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: exam
... code Σ 1..1 CodeableConcept 即為「理學檢查發現項目」，概念（concept）－參照一個專門術語或只是純文字。
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:loinc SΣ 0..1 Coding Code defined by a terminology system
Binding: http://loinc.org/ (required)
..... coding:sct SΣ 0..1 Coding Code defined by a terminology system
Binding: SNOMED CT Physical Examination值集 (required)
.... text SΣ 0..1 string Plain text representation of the concept
... subject Σ 0..1 Reference(Patient IMRI) Who and/or what the observation is about
... encounter Σ 0..1 Reference(Encounter IMRI) Healthcare event during which this observation is made
... performer Σ 0..* Reference(Practitioner IMRI | Organization Hospital Department IMRI | Patient IMRI | PractitionerRole IMRI | CareTeam) Who is responsible for the observation
... value[x] ΣC 0..1 即為「理學檢查發現」，實際結果。
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
... hasMember Σ 0..* Reference(ObservationLaboratory IMRI | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy IMRI | Media | QuestionnaireResponse | ObservationLaboratory IMRI | MolecularSequence) Related measurements the observation is made from

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:ObservationCategoryCodespreferredPattern: exam
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.code.coding:loincrequiredhttp://loinc.org/
http://loinc.org/
Observation.code.coding:sctrequiredSCTPhysicalExamination
https://hitstdio.ntunhs.edu.tw/imri/ValueSet/physical-examination-sct
from this IG

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business Identifier for observation
... basedOn Σ 0..* Reference(CarePlan IMRI | DeviceRequest | ImmunizationRecommendation | MedicationRequest IMRI | NutritionOrder | ServiceRequest) Fulfills plan, proposal or order
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure IMRI | Immunization | ImagingStudy IMRI) Part of referenced event
... status ?!Σ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category 1..1 CodeableConcept Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:ObservationCategoryCodes S 1..1 CodeableConcept Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: exam
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code Σ 1..1 CodeableConcept 即為「理學檢查發現項目」，概念（concept）－參照一個專門術語或只是純文字。
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:loinc SΣ 0..1 Coding Code defined by a terminology system
Binding: http://loinc.org/ (required)
..... coding:sct SΣ 0..1 Coding Code defined by a terminology system
Binding: SNOMED CT Physical Examination值集 (required)
.... text SΣ 0..1 string Plain text representation of the concept
... subject Σ 0..1 Reference(Patient IMRI) Who and/or what the observation is about
... focus Σ 0..* Reference(Resource) What the observation is about, when it is not about the subject of record
... encounter Σ 0..1 Reference(Encounter IMRI) Healthcare event during which this observation is made
... effective[x] Σ 0..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... issued Σ 0..1 instant Date/Time this version was made available
... performer Σ 0..* Reference(Practitioner IMRI | Organization Hospital Department IMRI | Patient IMRI | PractitionerRole IMRI | CareTeam) Who is responsible for the observation
... value[x] ΣC 0..1 即為「理學檢查發現」，實際結果。
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

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


... note 0..* Annotation Comments about the observation
... bodySite 0..1 CodeableConcept Observed body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1 CodeableConcept How it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1 Reference(Specimen) Specimen used for this observation
... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... referenceRange C 0..* BackboneElement Provides guide for interpretation
obs-3: Must have at least a low or a high or text
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... low C 0..1 SimpleQuantity Low Range, if relevant
.... high C 0..1 SimpleQuantity High Range, if relevant
.... type 0..1 CodeableConcept Reference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

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


.... age 0..1 Range Applicable age range, if relevant
.... text 0..1 string Text based reference range in an observation
... hasMember Σ 0..* Reference(ObservationLaboratory IMRI | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy IMRI | Media | QuestionnaireResponse | ObservationLaboratory IMRI | MolecularSequence) Related measurements the observation is made from
... component Σ 0..* BackboneElement Component results
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 CodeableConcept Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ 0..1 Actual component result
..... valueQuantity Quantity
..... valueCodeableConcept CodeableConcept
..... valueString string
..... valueBoolean boolean
..... valueInteger integer
..... valueRange Range
..... valueRatio Ratio
..... valueSampledData SampledData
..... valueTime time
..... valueDateTime dateTime
..... valuePeriod Period
.... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..* CodeableConcept High, 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 / CodeURI
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:ObservationCategoryCodespreferredPattern: exam
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.code.coding:loincrequiredhttp://loinc.org/
http://loinc.org/
Observation.code.coding:sctrequiredSCTPhysicalExamination
https://hitstdio.ntunhs.edu.tw/imri/ValueSet/physical-examination-sct
from this IG
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Observation.methodexampleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
http://hl7.org/fhir/ValueSet/referencerange-meaning
from the FHIR Standard
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
http://hl7.org/fhir/ValueSet/referencerange-appliesto
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard

 

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