Release 4B Ballot #1

This page is part of the FHIR Specification (v4.1.0: Release 4B Ballot #1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R4B R4 R3

Codesystem-observation-category.json

Orders and Observations Work GroupMaturity Level: N/AStandards Status: Informative

Raw JSON (canonical form + also see JSON Format Specification)

Definition for Code System ObservationCategoryCodes

{
  "resourceType" : "CodeSystem",
  "id" : "observation-category",
  "meta" : {
    "lastUpdated" : "2021-03-11T17:06:20.662+11:00",
    "profile" : ["http://hl7.org/fhir/StructureDefinition/shareablecodesystem"]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div>!-- Snipped for Brevity --></div>"
  },
  "extension" : [{
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
    "valueCode" : "oo"
  }],
  "url" : "http://terminology.hl7.org/CodeSystem/observation-category",
  "identifier" : [{
    "system" : "urn:ietf:rfc:3986",
    "value" : "urn:oid:2.16.840.1.113883.4.642.1.1125"
  }],
  "version" : "4.1.0",
  "name" : "ObservationCategoryCodes",
  "title" : "Observation Category Codes",
  "status" : "draft",
  "experimental" : false,
  "description" : "Observation Category codes.",
  "caseSensitive" : true,
  "valueSet" : "http://hl7.org/fhir/ValueSet/observation-category",
  "content" : "complete",
  "concept" : [{
    "code" : "social-history",
    "display" : "Social History",
    "definition" : "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."
  },
  {
    "code" : "vital-signs",
    "display" : "Vital Signs",
    "definition" : " 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."
  },
  {
    "code" : "imaging",
    "display" : "Imaging",
    "definition" : "Observations generated by imaging. The scope includes observations regarding plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, and nuclear medicine."
  },
  {
    "code" : "laboratory",
    "display" : "Laboratory",
    "definition" : "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."
  },
  {
    "code" : "procedure",
    "display" : "Procedure",
    "definition" : "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."
  },
  {
    "code" : "survey",
    "display" : "Survey",
    "definition" : "Assessment tool/survey instrument observations (e.g., Apgar Scores, Montreal Cognitive Assessment (MoCA))."
  },
  {
    "code" : "exam",
    "display" : "Exam",
    "definition" : "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."
  },
  {
    "code" : "therapy",
    "display" : "Therapy",
    "definition" : "Observations generated by non-interventional treatment protocols (e.g. occupational, physical, radiation, nutritional and medication therapy)"
  },
  {
    "code" : "activity",
    "display" : "Activity",
    "definition" : "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)"
  }]
}

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.