Observation

Measurements and simple assertions made about a patient, device or other subject.

= Must Support, = Is Modifier, = QiCore defined extension

Field	Card.	Type	Description
bodyPosition	0..1	Extension	An Extension Binding: SNOMED CT code system values descending from the following:'body position finding' 9851009 (preferred)
delta	0..1	Extension	An Extension Binding: Code system values for Observation Delta Value Set (example)
basedOn	0..*	List<CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ProcedureRequest | ReferralRequest>	A plan, proposal or order that is fulfilled in whole or in part by this event.
status	1..1	String	The status of the result value. Binding: Codes providing the status of an observation. (required)
category	1..*	List<Concept>	A code that classifies the general type of observation being made. Binding: Codes for high level observation categories. (preferred)
code	1..1	Concept	Describes what was observed. Sometimes this is called the observation "name". Binding: Codes identifying names of simple observations. (example)
subject	1..1	Patient | Group | Device | Location	The 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.
context	0..1	Encounter | Group	The healthcare event (e.g. a patient and healthcare provider interaction) during which this observation is made.
effective[x]	0..1	DateTime | 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.
issued	0..1	DateTime	The date and time this observation was made available to providers, typically after the results have been reviewed and verified.
performer	0..*	List<Practitioner | Organization | Patient | RelatedPerson>	Who was responsible for asserting the observed value as "true".
value[x]	0..1	Quantity | Concept | String | Boolean | 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 for coded results (preferred)
dataAbsentReason	0..1	Concept	Provides a reason why the expected value in the element Observation.value[x] is missing. Binding: Codes specifying why the result (Observation.value[x]) is missing. (extensible)
interpretation	0..1	Concept	The 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: Codes identifying interpretations of observations. (extensible)
bodySite	0..1	Concept	Indicates the site on the subject's body where the observation was made (i.e. the target site). Binding: Codes describing anatomical locations. May include laterality. (example)
method	0..1	Concept	Indicates the mechanism used to perform the observation. Binding: Methods for simple observations. (example)
specimen	0..1	Specimen	The specimen that was used when this observation was made.
device	0..1	Device | DeviceMetric	The device used to generate the observation data.
referenceRange	0..*	List<referenceRange>	Guidance on how to interpret the value by comparison to a normal or recommended range.
related	0..*	List<related>	A reference to another resource (usually another Observation) whose relationship is defined by the relationship type code.
component	0..*	List<component>	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.