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Observation Profile

Справочник и наборы значений для Code, Interpretation, Quantity.unit Ссылка hasMember, identifier.Assigner, note.AuthorReference, performer – на наш профиль. TODO: нечетко указана привязка справочника единиц измерения в referenceRange - к value или unit, не все ссылки профилированы. QUESTION - как указать, в каком случае применяются справочник групп крови, микробов и т.п.

Результат наблюдения

TODO

НазваниеФлагиКол-воТипОписание
LabObservation
0..*Observation
Observation
code
MS0..1
Binding: CoreVsLabTests (required) Федеральный справочник лабораторных исследований. Справочник лабораторных тестов
device
MS0..1Reference(LabDevice | DeviceMetric)
effective
MS0..1
dateTime
MS0..1dateTime
Period
MS0..1Period
hasMember
MS0..1Reference(LabObservation | MolecularSequence | QuestionnaireResponse)
subject
0..1Reference(CorePatient)
encounter
0..1Reference(CoreEncounter)
performer
MS0..1Reference(CorePractitioner | CorePractitionerRole)
[ ]
interpretation
MS0..*vector
Binding: CoreVsResultInterpretation (required) Справочник кодов интерпретации результатов
note
MS0..1
referenceRange
0..*BackboneElement
low
MS0..1Quantity
Binding: CoreVsUnits (required) Единицы измерения
value
MS0..1decimal
unit
MS0..1string
system
MS0..1uri
code
MS0..1code
high
MS0..1Quantity
type
MS0..1CodeableConcept
appliesTo
MS0..1CodeableConcept
age
MS0..1Range
text
MS0..1string
specimen
MS0..1Reference(LabSpecimen)
НазваниеФлагиКол-воТипОписание
LabObservation
0..*Observation
Observation
resourceType
0..1string
id
SU0..1string
Logical id of this artifact
meta
SU0..1Meta
Metadata about the resource
text
0..1Narrative
Text summary of the resource, for human interpretation
contained
0..*Resource
extension
0..*Extension
implicitRules
SU?!0..1uri
A set of rules under which this content was created
modifierExtension
0..*Extension
language
0..1code
Language of the resource content
Binding: languages (preferred) This value set includes common codes from BCP-47 (http://tools.ietf.org/html/bcp47)
category
0..*CodeableConcept
referenceRange
0..*BackboneElement
low
MS0..1Quantity
Low Range, if relevant
Binding: CoreVsUnits (required) Единицы измерения
value
MS0..1decimal
unit
MS0..1string
system
MS0..1uri
code
MS0..1code
high
MS0..1Quantity
High Range, if relevant
type
MS0..1CodeableConcept
Reference range qualifier
Binding: referencerange-meaning (preferred) This value set defines a set of codes that can be used to indicate the meaning/use of a reference range for a particular target population.
appliesTo
MS0..1CodeableConcept
age
MS0..1Range
Applicable age range, if relevant
text
MS0..1string
Text based reference range in an observation
hasMember
MS0..*Reference(LabObservation | MolecularSequence | QuestionnaireResponse)
derivedFrom
0..*Reference(Media | QuestionnaireResponse | ImagingStudy | Observation | DocumentReference | MolecularSequence)
interpretation
MS0..*CodeableConcept
Binding: CoreVsResultInterpretation (required) Справочник кодов интерпретации результатов
encounter
SU0..1Reference(CoreEncounter)
Healthcare event during which this observation is made
method
0..1CodeableConcept
How it was done
specimen
MS0..1Reference(LabSpecimen)
Specimen used for this observation
value
SU0..1
Actual result
time
0..1time
SampledData
0..1SampledData
string
0..1string
dateTime
0..1dateTime
Range
0..1Range
1
integer
0..1integer
Ratio
0..1Ratio
Period
0..1Period
CodeableConcept
0..1CodeableConcept
Quantity
0..1Quantity
boolean
0..1boolean
component
0..*BackboneElement
code
SU1..1CodeableConcept
Type of component observation (code / type)
value
SU0..1
Actual component result
time
0..1time
SampledData
0..1SampledData
string
0..1string
dateTime
0..1dateTime
Range
0..1Range
1
integer
0..1integer
Ratio
0..1Ratio
Period
0..1Period
CodeableConcept
0..1CodeableConcept
Quantity
0..1Quantity
boolean
0..1boolean
dataAbsentReason
0..1CodeableConcept
Why the component result is missing
interpretation
0..*CodeableConcept
[ ]
referenceRange
0..*vector
note
MS0..*Annotation
status
SU?!1..1code
registered | preliminary | final | amended +
Binding: observation-status (required) Codes providing the status of an observation.
effective
MS0..1
Clinically relevant time/time-period for observation
dateTime
MS0..1dateTime
Period
MS0..1Period
Timing
0..1Timing
instant
0..1instant
code
MS1..1CodeableConcept
Type of observation (code / type)
Binding: CoreVsLabTests (required) Федеральный справочник лабораторных исследований. Справочник лабораторных тестов
identifier
0..*Identifier
bodySite
0..1CodeableConcept
Observed body part
focus
0..*Reference()
issued
SU0..1instant
Date/Time this version was made available
device
MS0..1Reference(LabDevice | DeviceMetric)
(Measurement) Device
basedOn
0..*Reference(NutritionOrder | ServiceRequest | CarePlan | ImmunizationRecommendation | DeviceRequest | MedicationRequest)
partOf
0..*Reference(MedicationDispense | MedicationAdministration | ImagingStudy | Procedure | Immunization | MedicationStatement)
subject
SU0..1Reference(CorePatient)
Who and/or what the observation is about
performer
MS0..*Reference(CorePractitioner | CorePractitionerRole)
dataAbsentReason
0..1CodeableConcept
Why the result is missing
  • Схема валидна

referenceRange:
- text: 120 - 150 г/л
  low: {system: 1.2.643.5.1.13.13.11.1358, code: '60', value: 120, unit: г/л}
  high: {system: 1.2.643.5.1.13.13.11.1358, code: '60', value: 150, unit: г/л}
  type:
    coding:
    - {system: 'http://terminology.hl7.org/CodeSystem/referencerange-meaning', code: normal}
interpretation:
- coding:
  - {system: 1.2.643.5.1.13.13.99.2.257, code: H}
specimen: {reference: 'urn:uuid:62EABEF7-BE84-6122-B3B3-A6A0542F73A5'}
value:
  Quantity: {system: 1.2.643.5.1.13.13.11.1358, code: '60', value: 166, unit: г/л}
resourceType: Observation
status: final
effective: {dateTime: '2018-12-20T08:55:00+3:00'}
code:
  coding:
  - {system: 1.2.643.5.1.13.13.11.1080, code: '1017128', version: '3.28', display: 'Гемоглобин общий, массовая концентрация в крови'}
device: {reference: 'urn:uuid:64239DC1-EE5A-D938-B969-2B982C8DB9A5'}
performer:
- {reference: 'urn:uuid:0226CC34-5362-561D-B97A-1DAD5D3DE859'}
- {reference: ''}

referenceRange:
- text: не обнаруживаются
  type:
    coding:
    - {system: 'http://terminology.hl7.org/CodeSystem/referencerange-meaning', code: normal}
interpretation:
  coding:
  - {system: 1.2.643.5.1.13.13.99.2.257, code: A}
specimen: {reference: 'urn:uuid:62EABEF7-BE84-6122-B3B3-A6A0542F73A5'}
valueString: ++
resourceType: Observation
note:
- text: 'Количество шизоцитов: 8,35% от общего количества эритроцитов'
  authorReference: {reference: 'urn:uuid:0226CC34-5362-561D-B97A-1DAD5D3DE859'}
  time: '2018-12-20T16:13:00+3:00'
effectiveDateTime: '2018-12-20T08:55:00+3:00'
status: final
code:
  coding:
  - {system: 1.2.643.5.1.13.13.11.1080, code: '1017482', version: '3.28', display: 'Шизоциты, обнаружение в крови методом автоматизированного подсчёта'}
device: {reference: 'urn:uuid:64239DC1-EE5A-D938-B969-2B982C8DB9A5'}
performer:
- {reference: 'urn:uuid:0226CC34-5362-561D-B97A-1DAD5D3DE859'}
- {reference: ''}

referenceRange:
- text: 1 - 3 в поле зрения
  low: {system: 1.2.643.5.1.13.13.11.1358, code: '334', value: '1', unit: 1/поле зр.}
  high: {system: 1.2.643.5.1.13.13.11.1358, code: '334', value: '3', unit: 1/поле зр.}
  type:
    coding:
    - {system: 'http://terminology.hl7.org/CodeSystem/referencerange-meaning', code: normal}
interpretation:
  coding:
  - {system: 1.2.643.5.1.13.13.99.2.257, code: HU}
specimen: {reference: 'urn:uuid:F3CC67D9-6023-5E8B-ABA3-2EC9C33EB4C2'}
valueString: 10-25-30 в поле зрения
resourceType: Observation
effectiveDateTime: '2018-12-20T10:42:00+3:00'
status: final
code:
  coding:
  - {system: 1.2.643.5.1.13.13.11.1080, code: '1017508', version: '3.28', display: 'Шизоциты, количество в поле зрения в крови методом световой микроскопии'}
performer:
- {reference: 'urn:uuid:0226CC34-5362-561D-B97A-1DAD5D3DE859'}

resourceType: Observation
status: final
code:
  coding:
  - {system: 1.2.643.5.1.13.13.11.1080, code: '1018738', version: '3.28', display: 'Гиперхромия, обнаружение в крови методом световой микроскопии'}
effectiveDateTime: '2018-12-20T10:42:00+3:00'
specimen: {reference: 'urn:uuid:F3CC67D9-6023-5E8B-ABA3-2EC9C33EB4C2'}
performer:
- {reference: 'urn:uuid:0226CC34-5362-561D-B97A-1DAD5D3DE859'}
valueString: умеренная

resourceType: Observation
status: final
code:
  coding:
  - {system: 1.2.643.5.1.13.13.11.1080, code: '1038629', version: '3.28', display: Группа крови AB0 подтверждающим методом}
specimen: {reference: 'urn:uuid:45E0AC8C-0132-BD37-95D5-3FE815B974EA'}
performer:
- {reference: 'urn:uuid:0226CC34-5362-561D-B97A-1DAD5D3DE859'}
valueCodeableConcept:
  coding:
  - {system: 1.2.643.5.1.13.13.11.1061, code: '103', version: '2.1'}
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