Release Date: 2018-08-12

LevelCodeDisplayDefinition
1exam Exam Observations generated by physical exam findings including direct observations made by a clinician and use of simple instruments and the result of simple maneuvers performed directly on the patient's body.
1imaging Imaging Observations generated by imaging. The scope includes observations, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine.
1laboratory Laboratory The results of observations generated by laboratories. Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory.
1procedure Procedure Observations generated by other procedures. This category includes observations resulting from interventional and non-interventional procedures excluding lab and imaging (e.g. cardiology catheterization, endoscopy, electrodiagnostics, etc.). Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy.
1social-history Social History The Social History Observations define the patient's occupational, personal (e.g. lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity and religious affiliation.
1survey Survey Assessment tool/survey instrument observations (e.g. Apgar Scores, Montreal Cognitive Assessment (MoCA))
1therapy Therapy Observations generated by non-interventional treatment protocols (e.g. occupational, physical, radiation, nutritional and medication therapy)
1vital-signs Vital Signs Clinical observations measure the body's basic functions such as such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area.
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