QICoreObservation

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	The 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.
delta	0..1	Extension	The qualitative change in the value relative to the previous measurement. Usually only recorded if the change is clinically significant.
identifier	0..*	List<Identifier>	A unique identifier assigned to this observation.
basedOn	0..*	List<QICoreCarePlan | QICoreDeviceNotRequested | QICoreImmunizationRecommendation | QICoreMedicationNotRequested | QICoreNutritionOrder | QICoreServiceNotRequested>	A plan, proposal or order that is fulfilled in whole or in part by this event. For example, a MedicationRequest may require a patient to have laboratory test performed before it is dispensed.
partOf	0..*	List<QICoreMedicationAdministration | QICoreMedicationDispense | QICoreMedicationStatement | QICoreProcedure | QICoreImmunization | QICoreImagingStudy>	A larger event of which this particular Observation is a component or step. For example, an observation as part of a procedure.
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	QICorePatient | QICoreDevice | QICoreLocation	The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the `focus` element or the `code` itself specifies the actual focus of the observation.
focus	0..*	List<Resource>	The actual focus of an observation when it is not the patient of record representing something or someone associated with the patient such as a spouse, parent, fetus, or donor. For example, fetus observations in a mother's record. The focus of an observation could also be an existing condition, an intervention, the subject's diet, another observation of the subject, or a body structure such as tumor or implanted device. An example use case would be using the Observation resource to capture whether the mother is trained to change her child's tracheostomy tube. In this example, the child is the patient of record and the mother is the focus.
encounter	0..1	QICoreEncounter	The healthcare event (e.g. a patient and healthcare provider interaction) during which this observation is made.
effective[x]	0..1	DateTime | Interval<DateTime> | Timing | 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 version of the observation was made available to providers, typically after the results have been reviewed and verified.
performer	0..*	List<QICorePractitioner | QICoreOrganization | QICorePatient | QICoreRelatedPerson>	Who was responsible for asserting the observed value as "true".
value[x]	0..1	Quantity | Concept | String | Boolean | Integer | Interval<Quantity> | Ratio | SampledData | 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..*	List<Concept>	A categorical assessment of an observation value. For example, high, low, normal. Binding: Codes identifying interpretations of observations. (extensible)
note	0..*	List<Annotation>	Comments about the observation or the results.
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	QICoreSpecimen	The specimen that was used when this observation was made.
device	0..1	QICoreDevice | 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. Multiple reference ranges are interpreted as an "OR". In other words, to represent two distinct target populations, two `referenceRange` elements would be used.
hasMember	0..*	List<QICoreObservation | QuestionnaireResponse | MolecularSequence>	This observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group.
derivedFrom	0..*	List<QICoreObservation | QuestionnaireResponse>	The target resource that represents a measurement from which this observation value is derived. For example, a calculated anion gap or a fetal measurement based on an ultrasound image.
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.