Observation

The SHR Observation domain contains basic definitions used to capture information about measurements, lab tests, and assessments.

BooleanObservation [Entry]

An observation whose value is a quantity

Based On Observation

Value:  boolean
ObservationCode required A term from a controlled vocabulary that defines the data element (the question, not the answer) as specifically as possible. The specific code should always align with the concept of the element, but may be more specific. For example, the concept associated with medications is code for 'medication used', but the ObservationCode is the code for the particular medication used. For tests, ObservationCode identifies the specific test being performed, and for observations, the specific question being asked.
ObservationCategory 0 or more A categorization of the observation according to how the observation was collected or its clinical area.
ObservationReason optional The reason for making the observation.
ObservationNonOccurrenceModifier optional True if the observation did not occcur, e.g., if a test was not performed or the assessment was not done, when it might otherwise be expected.
ObservationStatus required A qualifier describing the stage or administrative state of the observation. If not given, it is assumed the status is final.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
ObservationMethod optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
ClinicallyRelevantTime optional The time or time period that the observation addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
Participant 0 or more A statement about an actor who did (or did not) participate in a certain task or activity. Unlike a HealthcareInvolvement which continues over period of time, the participant is associated with doing or not doing a specific task, such admitting a patient, performing a procedure, or taking a measurement.
Setting 0 or more Description of the place or type of surroundings where something is positioned or where an event takes place.
Location 0 or more A position, site, or point in space where something can be found.

ClinicallyRelevantTime

The time or time period that the observation addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).

Value:  GeneralizedTemporalContext A generalized indicator of a dateTime or an age when an event happened.

CodeableConceptObservation [Entry]

An observation whose value is a codeable concept

Based On Observation

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.
ObservationCode required A term from a controlled vocabulary that defines the data element (the question, not the answer) as specifically as possible. The specific code should always align with the concept of the element, but may be more specific. For example, the concept associated with medications is code for 'medication used', but the ObservationCode is the code for the particular medication used. For tests, ObservationCode identifies the specific test being performed, and for observations, the specific question being asked.
ObservationCategory 0 or more A categorization of the observation according to how the observation was collected or its clinical area.
ObservationReason optional The reason for making the observation.
ObservationNonOccurrenceModifier optional True if the observation did not occcur, e.g., if a test was not performed or the assessment was not done, when it might otherwise be expected.
ObservationStatus required A qualifier describing the stage or administrative state of the observation. If not given, it is assumed the status is final.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
ObservationMethod optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
ClinicallyRelevantTime optional The time or time period that the observation addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
Participant 0 or more A statement about an actor who did (or did not) participate in a certain task or activity. Unlike a HealthcareInvolvement which continues over period of time, the participant is associated with doing or not doing a specific task, such admitting a patient, performing a procedure, or taking a measurement.
Setting 0 or more Description of the place or type of surroundings where something is positioned or where an event takes place.
Location 0 or more A position, site, or point in space where something can be found.

HistoryObservation

Captures some aspect of the life, health, or medical history of a subject. History of previous events (C2004062)

Based On Observation

ObservationCategory includes History of previous events (C2004062) 1 or more A categorization of the observation according to how the observation was collected or its clinical area.
ObservationStatus from NonLabObservationStatusVS required A qualifier describing the stage or administrative state of the observation. If not given, it is assumed the status is final.
ObservationCode required A term from a controlled vocabulary that defines the data element (the question, not the answer) as specifically as possible. The specific code should always align with the concept of the element, but may be more specific. For example, the concept associated with medications is code for 'medication used', but the ObservationCode is the code for the particular medication used. For tests, ObservationCode identifies the specific test being performed, and for observations, the specific question being asked.
ObservationReason optional The reason for making the observation.
ObservationNonOccurrenceModifier optional True if the observation did not occcur, e.g., if a test was not performed or the assessment was not done, when it might otherwise be expected.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
ObservationMethod optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
ClinicallyRelevantTime optional The time or time period that the observation addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
Participant 0 or more A statement about an actor who did (or did not) participate in a certain task or activity. Unlike a HealthcareInvolvement which continues over period of time, the participant is associated with doing or not doing a specific task, such admitting a patient, performing a procedure, or taking a measurement.
Setting 0 or more Description of the place or type of surroundings where something is positioned or where an event takes place.
Location 0 or more A position, site, or point in space where something can be found.

Observation [Entry]

An act that is intended to result in new information about a subject. The focus of an observation can include the subject's behavior, physiological state, functional status, environment, exposures to substances, etc. The method of observing can be via direct questions, formal assessment vehicle, laboratory test, or imaging procedure. C1554188

ObservationCode required A term from a controlled vocabulary that defines the data element (the question, not the answer) as specifically as possible. The specific code should always align with the concept of the element, but may be more specific. For example, the concept associated with medications is code for 'medication used', but the ObservationCode is the code for the particular medication used. For tests, ObservationCode identifies the specific test being performed, and for observations, the specific question being asked.
ObservationCategory 0 or more A categorization of the observation according to how the observation was collected or its clinical area.
ObservationReason optional The reason for making the observation.
ObservationNonOccurrenceModifier optional True if the observation did not occcur, e.g., if a test was not performed or the assessment was not done, when it might otherwise be expected.
ObservationStatus required A qualifier describing the stage or administrative state of the observation. If not given, it is assumed the status is final.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
ObservationMethod optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
ClinicallyRelevantTime optional The time or time period that the observation addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
Participant 0 or more A statement about an actor who did (or did not) participate in a certain task or activity. Unlike a HealthcareInvolvement which continues over period of time, the participant is associated with doing or not doing a specific task, such admitting a patient, performing a procedure, or taking a measurement.
Setting 0 or more Description of the place or type of surroundings where something is positioned or where an event takes place.
Location 0 or more A position, site, or point in space where something can be found.

ObservationCategory

A categorization of the observation according to how the observation was collected or its clinical area.

Value:  Choice
         |  CodeableConcept from http://hl7.org/fhir/ValueSet/observation-category required A set of codes drawn from different coding systems, representing the same concept.
         |  CodeableConcept required A set of codes drawn from different coding systems, representing the same concept.

ObservationCode

A term from a controlled vocabulary that defines the data element (the question, not the answer) as specifically as possible. The specific code should always align with the concept of the element, but may be more specific. For example, the concept associated with medications is code for 'medication used', but the ObservationCode is the code for the particular medication used. For tests, ObservationCode identifies the specific test being performed, and for observations, the specific question being asked.

Based On ActionCode

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.

ObservationMethod

The method of the observation, for example, the specific imaging technical or assessment vehicle.

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.

ObservationNonOccurrenceModifier

True if the observation did not occcur, e.g., if a test was not performed or the assessment was not done, when it might otherwise be expected.

Based On NonOccurrenceModifier

Value:  boolean
Reason from ObservationNotMadeReasonVS optional The justification for an action or non-action, conclusion, opinion, etc.

ObservationQualifier

A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar. C1443279

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.

ObservationReason

The reason for making the observation.

Based On Reason

Value:  Choice
         |  string required
         |  CodeableConcept required A set of codes drawn from different coding systems, representing the same concept.

ObservationStatus

A qualifier describing the stage or administrative state of the observation. If not given, it is assumed the status is final.

Value:  code from http://hl7.org/fhir/ValueSet/observation-status

Panel [Entry]

A group of related observations, usually (but not always) taken together, whose result is captured in a report. Typically the ObservationCategory and ObservationReason are not given for individual observations that are part of the panel, but rather given at the level of the panel itself. Typically, the panel and all its sub-observations share the same metadata (provenance).

PanelCode required A term from a controlled vocabulary that defines the data element (the question, not the answer) as specifically as possible. The panel code provides the identity of the type of panel.
ServiceCategory optional A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.
ObservationReason optional The reason for making the observation.
ObservationNonOccurrenceModifier optional True if the observation did not occcur, e.g., if a test was not performed or the assessment was not done, when it might otherwise be expected.
ReportStatus required The status of the report associated with this panel.
ObservationMethod optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
ClinicallyRelevantTime optional The time or time period that the observation addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
Participant 0 or more A statement about an actor who did (or did not) participate in a certain task or activity. Unlike a HealthcareInvolvement which continues over period of time, the participant is associated with doing or not doing a specific task, such admitting a patient, performing a procedure, or taking a measurement.
Specimen (TBD) 0 or more Description TBD
Interpretation 0 or more A clinical interpretation of a measurement.
Comment optional A critical or explanatory note written to discuss, support, explain changes to, or dispute information.
Setting 0 or more Description of the place or type of surroundings where something is positioned or where an event takes place.
Location 0 or more A position, site, or point in space where something can be found.

PanelCode

A term from a controlled vocabulary that defines the data element (the question, not the answer) as specifically as possible. The panel code provides the identity of the type of panel.

Based On ActionCode

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.

QuantitativeObservation [Entry]

An observation whose value is a quantity

Based On Observation

Value:  Quantity A quantity with units.
ObservationCode required A term from a controlled vocabulary that defines the data element (the question, not the answer) as specifically as possible. The specific code should always align with the concept of the element, but may be more specific. For example, the concept associated with medications is code for 'medication used', but the ObservationCode is the code for the particular medication used. For tests, ObservationCode identifies the specific test being performed, and for observations, the specific question being asked.
ObservationCategory 0 or more A categorization of the observation according to how the observation was collected or its clinical area.
ObservationReason optional The reason for making the observation.
ObservationNonOccurrenceModifier optional True if the observation did not occcur, e.g., if a test was not performed or the assessment was not done, when it might otherwise be expected.
ObservationStatus required A qualifier describing the stage or administrative state of the observation. If not given, it is assumed the status is final.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
ObservationMethod optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
ClinicallyRelevantTime optional The time or time period that the observation addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
Participant 0 or more A statement about an actor who did (or did not) participate in a certain task or activity. Unlike a HealthcareInvolvement which continues over period of time, the participant is associated with doing or not doing a specific task, such admitting a patient, performing a procedure, or taking a measurement.
Setting 0 or more Description of the place or type of surroundings where something is positioned or where an event takes place.
Location 0 or more A position, site, or point in space where something can be found.

ReportStatus

The status of the report associated with this panel.

Value:  code from http://hl7.org/fhir/ValueSet/diagnostic-report-status

ServiceCategory

A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.

SocialHistory

The external elements and conditions which surround, influence, and affect the life and development of the subject. Includes social conditions such as poverty, violence, bullying. C3714536

Based On HistoryObservation

ObservationStatus from NonLabObservationStatusVS required A qualifier describing the stage or administrative state of the observation. If not given, it is assumed the status is final.
ObservationCategory includes social history (social-history) 1 or more A categorization of the observation according to how the observation was collected or its clinical area.
ObservationCode required A term from a controlled vocabulary that defines the data element (the question, not the answer) as specifically as possible. The specific code should always align with the concept of the element, but may be more specific. For example, the concept associated with medications is code for 'medication used', but the ObservationCode is the code for the particular medication used. For tests, ObservationCode identifies the specific test being performed, and for observations, the specific question being asked.
ObservationReason optional The reason for making the observation.
ObservationNonOccurrenceModifier optional True if the observation did not occcur, e.g., if a test was not performed or the assessment was not done, when it might otherwise be expected.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
ObservationMethod optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
ClinicallyRelevantTime optional The time or time period that the observation addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
Participant 0 or more A statement about an actor who did (or did not) participate in a certain task or activity. Unlike a HealthcareInvolvement which continues over period of time, the participant is associated with doing or not doing a specific task, such admitting a patient, performing a procedure, or taking a measurement.
Setting 0 or more Description of the place or type of surroundings where something is positioned or where an event takes place.
Location 0 or more A position, site, or point in space where something can be found.