US Core Implementation Guide
4.1.0 - STU4 Ballot

This page is part of the US Core (v4.1.0: STU5 Ballot 1) based on FHIR R4. The current version which supercedes this version is 5.0.1. For a full list of available versions, see the Directory of published versions

ValueSet: US Core Observation Category Codes

Summary

Defining URL:http://hl7.org/fhir/us/core/ValueSet/us-core-observation-category
Version:4.1.0
Name:USCoreObservationCategory
Title:US Core Observation Category Codes
Status:Active as of 11/11/21
Definition:

HL7 FHIR concepts to classify an observation

Publisher:HL7 International - Cross-Group Projects
Copyright:
  • LOINC (http://loinc.org). LOINC is copyright © 1995-2020, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license at http://loinc.org/license. LOINC® is a registered United States trademark of Regenstrief Institute, Inc"/>
Source Resource:XML / JSON / Turtle

References

This value set is not used here; it may be used elsewhere (e.g. specifications and/or implementations that use this content)

The publication tooling does not currently support generation of this Value Set expansion. We anticipate updates to enable this feature before this guide is published. For this ballot, we have provided the manual expansion below for your review.

Code System Display Definition
social-history http://terminology.hl7.org/CodeSystem/observation-category Social History Social History Observations define the patient’s occupational, personal (e.g., lifestyle), social, familial, and environmental history and health risk factors that may impact the patient’s health.
vital-signs http://terminology.hl7.org/CodeSystem/observation-category Vital Signs Clinical observations measure the body’s basic functions such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area.
imaging http://terminology.hl7.org/CodeSystem/observation-category Imaging Observations generated by imaging. The scope includes observations regarding plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, and nuclear medicine.
laboratory http://terminology.hl7.org/CodeSystem/observation-category 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 (including digital pathology), microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory.
procedure http://terminology.hl7.org/CodeSystem/observation-category Procedure Observations generated by other procedures. This category includes observations resulting from interventional and non-interventional procedures excluding laboratory 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. An example would be when a gastroenterologist reports the size of a polyp observed during a colonoscopy.
survey http://terminology.hl7.org/CodeSystem/observation-category Survey Assessment tool/survey instrument observations (e.g., Apgar Scores, Montreal Cognitive Assessment (MoCA)).
exam http://terminology.hl7.org/CodeSystem/observation-category 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.
therapy http://terminology.hl7.org/CodeSystem/observation-category Therapy Observations generated by non-interventional treatment protocols (e.g. occupational, physical, radiation, nutritional and medication therapy)
activity http://terminology.hl7.org/CodeSystem/observation-category Activity Observations that measure or record any bodily activity that enhances or maintains physical fitness and overall health and wellness. Not under direct supervision of practitioner such as a physical therapist. (e.g., laps swum, steps, sleep data)
LG41762-2 http://loinc.org SocialDeterminantsOfHealth -

Logical Definition (CLD)

This value set includes codes based on the following rules:

 

Expansion

This value set contains 9 concepts

Expansion based on Observation Category Codes v0.1.0 (CodeSystem)

All codes in this table are from the system http://terminology.hl7.org/CodeSystem/observation-category

CodeDisplayDefinition
social-historySocial HistorySocial History Observations define the patient's occupational, personal (e.g., lifestyle), social, familial, and environmental history and health risk factors that may impact the patient's health.
vital-signsVital SignsClinical observations measure the body's basic functions such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area.
imagingImagingObservations generated by imaging. The scope includes observations regarding plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, and nuclear medicine.
laboratoryLaboratoryThe 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 (including digital pathology), microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory.
procedureProcedureObservations generated by other procedures. This category includes observations resulting from interventional and non-interventional procedures excluding laboratory 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. An example would be when a gastroenterologist reports the size of a polyp observed during a colonoscopy.
surveySurveyAssessment tool/survey instrument observations (e.g., Apgar Scores, Montreal Cognitive Assessment (MoCA)).
examExamObservations 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.
therapyTherapyObservations generated by non-interventional treatment protocols (e.g. occupational, physical, radiation, nutritional and medication therapy)
activityActivityObservations that measure or record any bodily activity that enhances or maintains physical fitness and overall health and wellness. Not under direct supervision of practitioner such as a physical therapist. (e.g., laps swum, steps, sleep data)

Explanation of the columns that may appear on this page:

Level A few code lists that FHIR defines are hierarchical - each code is assigned a level. In this scheme, some codes are under other codes, and imply that the code they are under also applies
Source The source of the definition of the code (when the value set draws in codes defined elsewhere)
Code The code (used as the code in the resource instance)
Display The display (used in the display element of a Coding). If there is no display, implementers should not simply display the code, but map the concept into their application
Definition An explanation of the meaning of the concept
Comments Additional notes about how to use the code