The formal definitions for the elements in the observation resource. Also available as an XML file.
| Observation |
| Definition | Simple assertions and measurements made about a patient, device or other subject |
| Control | 1..1 |
| Requirements | Observations are a key aspect of healthcare. This resource is used to capture those that do not require more sophisticated mechanisms. |
| Aliases | Vital Signs |
| Comments | Used for "simple" observations such as vital signs, height, weight, smoking status, comments, etc. *Not* used for lab results, diagnostic images or other more complex observations. |
| RIM Mapping | Observation[isNormalAct() and subsumesCode("ActClass#OBS", classCode) and moodCode="EVN" and domainMember("SimpleObservationType", code)] |
| Observation.identifier |
| Definition | A unique identifier for the simple observation |
| Control | 0..1 |
| Type | Identifier |
| Requirements | Allows observations to be distinguished and referenced |
| RIM Mapping | unique(./id[displayable="true" and scope="OBJ"]) |
| v2 Mapping | OBX.21 |
| Observation.type |
| Definition | Identifies what type of observation was performed |
| Control | 1..1 |
| Type | CodeableConcept from SimpleObservationType |
| Must Understand | true |
| Requirements | Knowing what kind of observation is being made is essential to understanding the observation. |
| RIM Mapping | ./code |
| v2 Mapping | OBX.3 |
| Observation.bodySite |
| Definition | Indicates where on the subject's body the observation was made. |
| Control | 0..1 |
| Type | CodeableConcept from ObservationBodySite |
| Requirements | Knowing where observation is made is important for tracking if multiple sites are possible. |
| Comments | Only used if not implicit in code for SimpleObservation.result.type |
| RIM Mapping | unique(./targetSiteCode) |
| v2 Mapping | OBX.20 |
| Observation.method |
| Definition | Indicates the mechanism used to perform the observation |
| Control | 0..1 |
| Type | CodeableConcept from SimpleObservationMethod |
| Requirements | In some cases, method can impact results and is thus for determing whether results can be compared or determining significance of results |
| Comments | Only used if not implicit in code for SimpleObservation.result.type |
| RIM Mapping | unique(./methodCode) |
| v2 Mapping | OBX.17 |
| Observation.valid[x] |
| Definition | The time or time-period the observed value is asserted as being true |
| Control | 0..1 |
| Type | Period|dateTime|date |
| Requirements | Knowing when an observation was deemed true is important to its relevance as well as determining trends |
| RIM Mapping | ./effectiveTime[type='IVL_TS' or type='TS'] |
| v2 Mapping | OBX.14 |
| Observation.subject |
| Definition | The thing the observation is being made about |
| Control | 0..1 |
| Type | Resource(Patient|Group|Device|Animal) |
| Must Understand | true |
| Requirements | Observations have no value if you don't know who or what they're about. |
| RIM Mapping | unique(./participation[isHighest(priorityCode) and typeCode="SBJ" and isNormalParticipation()]/role
or ./participation[isHighest(priorityCode) and typeCode="SBJ" and isNormalParticipation()]/role/entity) |
| v2 Mapping | PID |
| Observation.performer |
| Definition | Who was responsible for asserting the observed value as "true" |
| Control | 0..1 |
| Type | Resource(Agent|Person|Device) |
| Requirements | May give a degree of confidence in the observation and also indicates where follow-up questions should be directed. |
| Comments | This would only be "Device" if the device takes responsibility for the measurement, not to capture the device used by a human to make the measurement. (The latter could be captured as an extension.) |
| RIM Mapping | unique(./participation[isHighest(priorityCode) and typeCode="PRF" and isNormalParticipation()]/role
or
./participation[isHighest(priorityCode) and typeCode="PRF" and isNormalParticipation()]/role/entity] |
| v2 Mapping | OBX.15 |
| Observation.value[x] |
| Definition | The information determined as a result of making the observation |
| Control | 0..1 |
| Type | Quantity|CodeableConcept|Attachment|Ratio|Choice|Period|string from SimpleObservationResult |
| Must Understand | true |
| Requirements | A result with no value isn't much use. (Though an exceptional value such as 'unknown' may still be useful.) |
| Comments | Result value set should allow for Unkown and other exceptional values. The datatype for this element should be determined by SimpleObservation.result.type |
| RIM Mapping | ./value |
| v2 Mapping | OBX.5, OBX.6 |
| Observation.interpretation |
| Definition | The assessment made based on the result of the observation. |
| Control | 0..1 |
| Type | CodeableConcept from SimpleObservationInterpretation |
| Requirements | For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. |
| RIM Mapping | unique(./interpretationCode) |
| v2 Mapping | OBX.8 |
| Observation.normalValue[x] |
| Definition | For numeric results, indicates the boundaries within which "normal" values should occur |
| Control | 0..1 |
| Type | Range|string |
| Requirements | Knowing what values are considered "normal" can help evaluate the significance of a particular result. |
| Comments | This might be generic or be specific to the patient's age, gender, weight and other factors. |
| RIM Mapping | ./outboundRelationship[typeCode="REFV" and isNormalActRelationship()]/target[subsumesCode("ActClass#OBS", classCode) and moodCode="EVN" and isCriterionInd="true" and isNormalAct() and interpretationCode="ObservationInterpretationNormality#N"]
|
| v2 Mapping | OBX.7 |
| Observation.component |
| Definition | Component observation |
| Control | 0..* |
| Must Understand | true |
| Requirements | Some observations such as blood pressure have multiple components. |
| Comments | In most cases, this is only expected to recurse to a maximum of one level |
| RIM Mapping | ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[isNormalAct() and subsumesCode("ActClass#OBS", classCode) and moodCode="EVN" and fromDomain(code, "SimpleObservationSubType")] |
| Observation.component.type |
| Definition | Identifies what type of sub-observation was performed |
| Control | 1..1 |
| Type | CodeableConcept from SimpleSubObservationType |
| Must Understand | true |
| Requirements | Knowing what kind of observation is being made is essential to understanding the observation. |
| RIM Mapping | ./code |
| v2 Mapping | OBX.3 |
| Observation.component.value[x] |
| Definition | The information determined as a result of making the sub-observation |
| Control | 1..1 |
| Type | Quantity|CodeableConcept|Attachment|Ratio|Choice|Period|string from SimpleSubObservationResult |
| Must Understand | true |
| Requirements | A result with no value isn't much use. (Though an exceptional value such as 'unknown' may still be useful.) |
| Comments | Result value set should allow for Unkown and other exceptional values. The datatype for this element should be determined by SimpleObservation.result.type |
| RIM Mapping | ./value |
| v2 Mapping | OBX.5, OBX.6 |
| Observation.extension |
| Definition | See Extensions |
| Control | 0..* |
| Type | Extension |
| Observation.text |
| Definition | Text summary of resource (for human interpretation) |
| Control | 1..1 |
| Type | Narrative |
. Page versions: R5 R4B R4 R3 R2
This is an old version of FHIR retained for archive purposes. Do not use for anything else