- Measurements and simple assertions Profile of Observation for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.
-
-
Key: = Must support, = QICore-defined extension, = Is-Modifier
Field Card. Type and Description 
bodyPosition 0..1ConceptThe position of the body when the observation was done, e.g. standing, sitting. To be used only when the body position in not precoordinated in the observation code.Binding: Body Position (Preferred)
bodySite 0..1ConceptIndicates the site on the subject's body where the observation was made (i.e. the target site).Binding: SNOMED CT Body Structures (Example)
category 0..1ConceptA code that classifies the general type of observation being made. This is used for searching, sorting and display purposes.Binding: Observation Category Codes (Example)
code 1..1ConceptDescribes what was observed. Sometimes this is called the observation "name".Binding: US Laboratory Observation Profile Observation Name Codes (Preferred)
comments 0..1StringMay include statements about significant, unexpected or unreliable values, or information about the source of the value where this may be relevant to the interpretation of the result.component 0..*List<Component> (TBD)Some observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes. Examples include systolic and diastolic component observations for blood pressure measurement and multiple component observations for genetics observations.dataAbsentReason 0..1ConceptProvides a reason why the expected value in the element Observation.value[x] is missing.Binding: Observation Value Absent Reason (Extensible)
device 0..1Device | DeviceMetricThe device used to generate the observation data.effective[x] 0..1DateTime | interval<DateTime>The time or time-period the observed value is asserted as being true. For biological subjects - e.g. human patients - this is usually called the "physiologically relevant time". This is usually either the time of the procedure or of specimen collection, but very often the source of the date/time is not known, only the date/time itself.encounter 0..1EncounterThe healthcare event (e.g. a patient and healthcare provider interaction) during which this observation is made.identifier 0..*List<Identifier>A unique identifier for the simple observation instance.interpretation 0..1ConceptThe assessment made based on the result of the observation. Intended as a simple compact code often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result. Otherwise known as abnormal flag.Binding: Observation Interpretation Codes (Extensible)
issued 0..1DateTimeThe date and time this observation was made available to providers, typically after the results have been reviewed and verified.method 0..1ConceptIndicates the mechanism used to perform the observation.Binding: Observation Methods (Example)
performer 0..*List<Practitioner | Organization | Patient | RelatedPerson>Who was responsible for asserting the observed value as "true".referenceRange 0..*List<ReferenceRange> (TBD)Guidance on how to interpret the value by comparison to a normal or recommended range.related 0..*List<Related> (TBD)A reference to another resource (usually another Observation but could also be a QuestionnaireAnswer) whose relationship is defined by the relationship type code.specimen 0..1SpecimenThe specimen that was used when this observation was made.status 1..1codeThe status of the result value.Binding: ObservationStatus (Required)
subject 0..1Patient | Group | Device | LocationThe patient, or group of patients, location, or device whose characteristics (direct or indirect) are described by the observation and into whose record the observation is placed. Comments: Indirect characteristics may be those of a specimen, fetus, donor, other observer (for example a relative or EMT), or any observation made about the subject.value[x] 0..1Quantity | Concept | String | interval<Quantity> | Ratio | SampledData | Attachment | Time | DateTime | interval<DateTime>The information determined as a result of making the observation, if the information has a simple value.Binding: SNOMED CT Codes (Preferred)
Key: = Must support, = QICore-defined extension, = Is-Modifier
-