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Resource Observation - Content 3.9

Status: Not an approved resource: Exemplar - based on common patterns found in Consolidated CDA. Comments will be welcomeed by O & O workgroup

Simple assertions and measurements made about a patient, device or other subject.

The resource name as it appears in a RESTful URL is /observation/

This resource is a place-holder. It has not yet been vetted by the Orders & Observations Work Group.

Observations are a central element in healthcare. They are used to diagnose, monitor progress, determine baselines and patterns and even capture demographic characteristics. There are several resources such as LabReport to capture complex observations. However, most observations are simple name-value-pair assertions with little complexity. This is the resource to use for such use-cases. Possibilities include:

Personal characteristics: height, weight, eye-color
Vital signs: temperature, blood pressure, respiration rate
Diagnoses (Note: track-able conditions, allergies, adverse reactions and more complex structures are handled elsewhere)
Social history: tobacco use, family supports, cognitive status
Core characteristics: pregnancy status, death assertion
Simple scores: APGAR

Resource Content 3.9.1

UML Image

<Observation xmlns="http://hl7.org/fhir">
 <identifier><!-- 0..1 Identifier Observation id --></identifier>
 <type><!-- 1..1 CodeableConcept Kind of observation --></type>
 <bodySite><!-- 0..1 CodeableConcept Observed body part --></bodySite>
 <method><!-- 0..1 CodeableConcept How it was done --></method>
 <valid[x]><!-- 0..1 Period|dateTime|date Relevant time/time-period --></valid[x]>
 <subject><!-- 0..1 Resource(Patient|Group|Device|Animal) Who observation is about --></subject>
 <performer><!-- 0..1 Resource(Agent|Person|Device) Who did the observation --></performer>
 <value[x]><!-- 0..1 Quantity|CodeableConcept|Attachment|
              Ratio|Choice|Period|string Actual result --></value[x]>
 <interpretation><!-- 0..1 CodeableConcept High, low, normal, etc. --></interpretation>
 <normalValue[x]><!-- 0..1 Range|string Expected normal value range --></normalValue[x]>
 <component>  <!-- 0..* Component observation -->
  <type><!-- 1..1 CodeableConcept Kind of component observation --></type>
  <value[x]><!-- 1..1 Quantity|CodeableConcept|Attachment|
              Ratio|Choice|Period|string Actual componentresult --></value[x]>
 </component>
 <extension><!-- 0..* Extension  See Extensions  --></extension>
 <text><!-- 1..1 Narrative Text summary of resource (for human interpretation) --></text>
</Observation>

Alternate definitions: Schema/Schematron, RDF (to do), XML, XMI (to do), Resource Profile

Terminology Bindings

Path	Details	Strength
Observation.type	LOINC codes filtered to exclude lab, document,imaging and other complex codes	complete/suggested
Observation.bodySite	SNOMED-CT body sites	complete/suggested
Observation.method	Methods for simple observations (not bound to any particular codes)	complete/unstated
Observation.value[x]	SNOMED-CT observation value codes	complete/suggested
Observation.interpretation	Codes identifying interpretations of observations (see http://hl7.org/fhir/observation-interpretation for values)	complete/required
Observation.component.type	LOINC codes filtered to exclude lab, document,imaging and other complex codes	complete/suggested
Observation.component.value[x]	SNOMED-CT observation value codes	complete/suggested

Path

Details

Strength

Observation.type

LOINC codes filtered to exclude lab, document,imaging and other complex codes

complete/suggested

Observation.bodySite

SNOMED-CT body sites

complete/suggested

Observation.method

Methods for simple observations (not bound to any particular codes)

complete/unstated

Observation.value[x]

SNOMED-CT observation value codes

complete/suggested

Observation.interpretation

Codes identifying interpretations of observations (see http://hl7.org/fhir/observation-interpretation for values)

complete/required

Observation.component.type

LOINC codes filtered to exclude lab, document,imaging and other complex codes

complete/suggested

Observation.component.value[x]

SNOMED-CT observation value codes

complete/suggested

Constraints

Can only have normal range if value is a quantity (xpath: exists(f:valueQuantity) or not(exists(f:normalRange)))
Can have value or components but not both (xpath: exists(*[starts-with(local-name(.), 'value')])!=exists(f:component))

Notes: 3.9.2

At its simplest, these resource instances can consist of only a type and a value. The relevance of other properties will vary based on the type of observation. Normal range may be useful for systolic blood pressure, but has little relevance for something like "pregnancy status"
Profiles may be created to provide guidance on capturing certain types of simple observations. This resource focuses on the level of detail captured by most systems. However, any "simple" observation can easily be broken into numerous components and sub-components to provide additional information relevant in certain circumstances. As with other resources, extensions can be used to introduce this additional complexity.

Search Parameters 3.9.3

Search Parameters for RESTful searches. The standard parameters also apply. See Searching for more information.

$page : integer	Starting offset of the first record to return in the search set	single
$count : integer	Number of return records requested. The server is not bound to conform	single
$id : token	The logical resource id associated with the resource (must be supported by all servers)	single
test : qtoken	The name of the observation type or component type	union
result : qtoken	The name or code or value of a result	union
patient : qtoken	The identity of a patient	union
minDate : date	date equal to Results whose validity period covers this date or earlier	single
minDate-before : date	date before or equal to Results whose validity period covers this date or earlier	single
minDate-after : date	date after or equal to Results whose validity period covers this date or earlier	single
maxDate : date	date equal to Results whose validity period covers this date or sooner	single
maxDate-before : date	date before or equal to Results whose validity period covers this date or sooner	single
maxDate-after : date	date after or equal to Results whose validity period covers this date or sooner	single

(See Searching).

This is an old version of FHIR retained for archive purposes. Do not use for anything else
Implementers are welcome to experiment with the content defined here, but should note that the contents are subject to change without prior notice.
© HL7.org 2011 - 2012. FHIR v0.06 generated on Tue, Dec 4, 2012 00:04+1100. License