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Vocabulary Work Group | Maturity Level: N/A | Standards Status: Informative |
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High level observation categories for the general type of observation being made. URL: http://hl7-fhir.github.io/valueset-observation-category.html This is an inline code system http://hl7.org/fhir/observation-category.
<?xml version="1.0" encoding="UTF-8"?> <CodeSystem xmlns="http://hl7.org/fhir"> <id value="v3-ObservationCategory"/> <meta> <lastUpdated value="2018-08-12T00:00:00.000+10:00"/> </meta> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p> Release Date: 2018-08-12</p> <table class="grid"> <tr> <td> <b> Level</b> </td> <td> <b> Code</b> </td> <td> <b> Display</b> </td> <td> <b> Definition</b> </td> </tr> <tr> <td> 1</td> <td> exam <a name="v3-ObservationCategory-exam"> </a> </td> <td> Exam</td> <td> 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. <br/> </td> </tr> <tr> <td> 1</td> <td> imaging <a name="v3-ObservationCategory-imaging"> </a> </td> <td> Imaging</td> <td> Observations generated by imaging. The scope includes observations, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine. <br/> </td> </tr> <tr> <td> 1</td> <td> laboratory <a name="v3-ObservationCategory-laboratory"> </a> </td> <td> Laboratory</td> <td> 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. <br/> </td> </tr> <tr> <td> 1</td> <td> procedure <a name="v3-ObservationCategory-procedure"> </a> </td> <td> Procedure</td> <td> 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. <br/> </td> </tr> <tr> <td> 1</td> <td> social-history <a name="v3-ObservationCategory-social-history"> </a> </td> <td> Social History</td> <td> 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. <br/> </td> </tr> <tr> <td> 1</td> <td> survey <a name="v3-ObservationCategory-survey"> </a> </td> <td> Survey</td> <td> Assessment tool/survey instrument observations (e.g. Apgar Scores, Montreal Cognitive Assessment (MoCA)) <br/> </td> </tr> <tr> <td> 1</td> <td> therapy <a name="v3-ObservationCategory-therapy"> </a> </td> <td> Therapy</td> <td> Observations generated by non-interventional treatment protocols (e.g. occupational, physical, radiation, nutritional and medication therapy) <br/> </td> </tr> <tr> <td> 1</td> <td> vital-signs <a name="v3-ObservationCategory-vital-signs"> </a> </td> <td> Vital Signs</td> <td> 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. <br/> </td> </tr> </table> </div> </text> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status"> <valueCode value="external"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm"> <valueInteger value="0"/> </extension> <url value="http://terminology.hl7.org/CodeSystem/v3-ObservationCategory"/> <identifier> <system value="urn:ietf:rfc:3986"/> <value value="urn:oid:2.16.840.1.113883.4.642.1.222"/> </identifier> <version value="2018-08-12"/> <name value="v3.ObservationCategory"/> <title value="v3 Code System ObservationCategory"/> <status value="active"/> <experimental value="false"/> <date value="2018-08-12T00:00:00+10:00"/> <publisher value="HL7, Inc"/> <contact> <telecom> <system value="url"/> <value value="http://hl7.org"/> </telecom> </contact> <description value=" High level observation categories for the general type of observation being made. URL: http://hl7-fhir.github.io/valueset-observation-category.html This is an inline code system http://hl7.org/fhir/observation-category."/> <caseSensitive value="true"/> <valueSet value="http://terminology.hl7.org/ValueSet/v3-ObservationCategory"/> <hierarchyMeaning value="is-a"/> <content value="complete"/> <concept> <code value="exam"/> <display value="Exam"/> <definition value="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."/> </concept> <concept> <code value="imaging"/> <display value="Imaging"/> <definition value="Observations generated by imaging. The scope includes observations, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine."/> </concept> <concept> <code value="laboratory"/> <display value="Laboratory"/> <definition value="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."/> </concept> <concept> <code value="procedure"/> <display value="Procedure"/> <definition value="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."/> </concept> <concept> <code value="social-history"/> <display value="Social History"/> <definition value="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."/> </concept> <concept> <code value="survey"/> <display value="Survey"/> <definition value="Assessment tool/survey instrument observations (e.g. Apgar Scores, Montreal Cognitive Assessment (MoCA))"/> </concept> <concept> <code value="therapy"/> <display value="Therapy"/> <definition value="Observations generated by non-interventional treatment protocols (e.g. occupational, physical, radiation, nutritional and medication therapy)"/> </concept> <concept> <code value="vital-signs"/> <display value="Vital Signs"/> <definition value="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."/> </concept> </CodeSystem>
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.