Vital

The SHR Vital domain contains definitions for basic physiological measurements categorized as vital signs.

BloodPressure [Entry]

The force of circulating blood on the walls of the arteries. 55284-4

Based On VitalSign

Value:  Quantity A quantity with units.
SystolicPressure required The blood pressure during the contraction of the left ventricle of the heart, when blood pressure is at its highest.
DiastolicPressure required The blood pressure after the contraction of the heart while the chambers of the heart refill with blood, when the pressure is lowest.
BodySite from BloodPressureBodySiteVS optional Location on or in the body.
ObservationQualifier from BloodPressureQualifierVS 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.
HeadTiltAngle optional The angle at which the head is tilted relative to a level position while physiologic tests are taken.
ObservationCategory includes vital-signs 1 or more A categorization of the observation according to how the observation was collected or its clinical area.
Specimen (TBD) not used Description TBD
ObservationCode must be a TestCode 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.
         where  TestCode is 55284-4 The code for a laboratory, radiologic, and other clinical test or measurement that helps to determine the presence, absence, or degree of a condition, or assess the health of an individual.
ObservationMethod must be a TestMethod optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
         where  TestMethod from BloodPressureMethodVS The technique used to carry out a procedure, if not implicit in the test code.
BodyPosition optional The position or physical attitude of the body.
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Interpretation optional A clinical interpretation of a measurement.
ReferenceRange optional The usual or acceptable range for a test result.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
TestRequest optional A record of a request (order) for a test to be performed.
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.
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.

BodyHeight [Entry]

The distance from the sole to the crown of the head. 8302-2

Based On VitalSign

Value:  Quantity Units is cm (cm) A quantity with units.
ObservationQualifier from BodyHeightQualifierVS 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.
ObservationCategory includes vital-signs 1 or more A categorization of the observation according to how the observation was collected or its clinical area.
Specimen (TBD) not used Description TBD
ObservationCode must be a TestCode 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.
         where  TestCode is 8302-2 The code for a laboratory, radiologic, and other clinical test or measurement that helps to determine the presence, absence, or degree of a condition, or assess the health of an individual.
ObservationMethod must be a TestMethod optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
BodySite optional Location on or in the body.
BodyPosition optional The position or physical attitude of the body.
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Interpretation optional A clinical interpretation of a measurement.
ReferenceRange optional The usual or acceptable range for a test result.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
TestRequest optional A record of a request (order) for a test to be performed.
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.
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.

BodyLength [Entry]

The distance from the sole of the foot to the crown of the head, lying down (typically 0-2 years). 8306-3

Based On BodyHeight

Value:  Quantity Units is cm (cm) A quantity with units.
ObservationQualifier from BodyHeightQualifierVS 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.
ObservationCategory includes vital-signs 1 or more A categorization of the observation according to how the observation was collected or its clinical area.
Specimen (TBD) not used Description TBD
ObservationCode must be a TestCode 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.
         where  TestCode is 8306-3 The code for a laboratory, radiologic, and other clinical test or measurement that helps to determine the presence, absence, or degree of a condition, or assess the health of an individual.
ObservationMethod must be a TestMethod optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
BodySite optional Location on or in the body.
BodyPosition optional The position or physical attitude of the body.
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Interpretation optional A clinical interpretation of a measurement.
ReferenceRange optional The usual or acceptable range for a test result.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
TestRequest optional A record of a request (order) for a test to be performed.
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.
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.

BodyMassIndex [Entry]

A general indicator of the body fat an individual is carrying based upon the ratio of weight to height. 39156-5

Based On VitalSign

Value:  Quantity A quantity with units.
BodyWeight optional The mass or quantity of heaviness of an individual. Does not include estimates of fetal bodyweight.
BodyHeight optional The distance from the sole to the crown of the head.
ObservationCategory includes vital-signs 1 or more A categorization of the observation according to how the observation was collected or its clinical area.
Specimen (TBD) not used Description TBD
ObservationCode must be a TestCode 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.
         where  TestCode is 39156-5 The code for a laboratory, radiologic, and other clinical test or measurement that helps to determine the presence, absence, or degree of a condition, or assess the health of an individual.
ObservationMethod must be a TestMethod optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
BodySite optional Location on or in the body.
BodyPosition optional The position or physical attitude of the body.
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Interpretation optional A clinical interpretation of a measurement.
ReferenceRange optional The usual or acceptable range for a test result.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
TestRequest optional A record of a request (order) for a test to be performed.
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.
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.

BodyTemperature [Entry]

The measure of the level of heat in a human or animal. 8310-5

Based On VitalSign

Value:  Quantity Units is C (Cel) A quantity with units.
BodySite from BodyTemperatureBodySiteVS optional Location on or in the body.
ObservationQualifier from BodyTemperatureQualifierVS 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.
ObservationCategory includes vital-signs 1 or more A categorization of the observation according to how the observation was collected or its clinical area.
Specimen (TBD) not used Description TBD
ObservationCode must be a TestCode 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.
         where  TestCode is 8310-5 The code for a laboratory, radiologic, and other clinical test or measurement that helps to determine the presence, absence, or degree of a condition, or assess the health of an individual.
ObservationMethod must be a TestMethod optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
BodyPosition optional The position or physical attitude of the body.
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Interpretation optional A clinical interpretation of a measurement.
ReferenceRange optional The usual or acceptable range for a test result.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
TestRequest optional A record of a request (order) for a test to be performed.
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.
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.

BodyWeight [Entry]

The mass or quantity of heaviness of an individual. Does not include estimates of fetal bodyweight. 29463-7

Based On VitalSign

Value:  Quantity Units is kg (kg) A quantity with units.
ObservationQualifier from BodyWeightQualifierVS 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.
ObservationCategory includes vital-signs 1 or more A categorization of the observation according to how the observation was collected or its clinical area.
Specimen (TBD) not used Description TBD
ObservationCode must be a TestCode 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.
         where  TestCode is 29463-7 The code for a laboratory, radiologic, and other clinical test or measurement that helps to determine the presence, absence, or degree of a condition, or assess the health of an individual.
ObservationMethod must be a TestMethod optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
BodySite optional Location on or in the body.
BodyPosition optional The position or physical attitude of the body.
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Interpretation optional A clinical interpretation of a measurement.
ReferenceRange optional The usual or acceptable range for a test result.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
TestRequest optional A record of a request (order) for a test to be performed.
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.
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.

DiastolicPressure

The blood pressure after the contraction of the heart while the chambers of the heart refill with blood, when the pressure is lowest. 8462-4

Based On QuantitativeObservation

Value:  Quantity Units is mmHg (mm[Hg]) A quantity with units.
ObservationCode is 8462-4 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.

HeadCircumference [Entry]

Circumference of the head (typically 0-2 years). 8287-5

Based On VitalSign

Value:  Quantity Units is cm (cm) A quantity with units.
ObservationCategory includes vital-signs 1 or more A categorization of the observation according to how the observation was collected or its clinical area.
Specimen (TBD) not used Description TBD
ObservationCode must be a TestCode 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.
         where  TestCode is 8287-5 The code for a laboratory, radiologic, and other clinical test or measurement that helps to determine the presence, absence, or degree of a condition, or assess the health of an individual.
ObservationMethod must be a TestMethod optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
BodySite optional Location on or in the body.
BodyPosition optional The position or physical attitude of the body.
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Interpretation optional A clinical interpretation of a measurement.
ReferenceRange optional The usual or acceptable range for a test result.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
TestRequest optional A record of a request (order) for a test to be performed.
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.
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.

HeadTiltAngle

The angle at which the head is tilted relative to a level position while physiologic tests are taken. 8360-0

Value:  Quantity Units is deg (deg) A quantity with units.

HeartRate [Entry]

The number of times the heart ventricles contract per unit of time, usually per minute. 8867-4

Based On VitalSign

Value:  Quantity Units is /min (/min) A quantity with units.
ObservationQualifier from HeartRateQualifierVS 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.
ObservationCategory includes vital-signs 1 or more A categorization of the observation according to how the observation was collected or its clinical area.
Specimen (TBD) not used Description TBD
ObservationCode must be a TestCode 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.
         where  TestCode is 8867-4 The code for a laboratory, radiologic, and other clinical test or measurement that helps to determine the presence, absence, or degree of a condition, or assess the health of an individual.
ObservationMethod must be a TestMethod optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
         where  TestMethod from HeartRateMethodVS optional The technique used to carry out a procedure, if not implicit in the test code.
BodySite optional Location on or in the body.
BodyPosition optional The position or physical attitude of the body.
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Interpretation optional A clinical interpretation of a measurement.
ReferenceRange optional The usual or acceptable range for a test result.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
TestRequest optional A record of a request (order) for a test to be performed.
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.
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.

OxygenSaturation [Entry]

Oxygen saturation in Arterial blood by Pulse oximetry. 59408-5

Based On VitalSign

Value:  Quantity Units is % (%) A quantity with units.
BodySite from OxygenSaturationBodySiteVS optional Location on or in the body.
ObservationCategory includes vital-signs 1 or more A categorization of the observation according to how the observation was collected or its clinical area.
Specimen (TBD) not used Description TBD
ObservationCode must be a TestCode 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.
         where  TestCode is 59408-5 The code for a laboratory, radiologic, and other clinical test or measurement that helps to determine the presence, absence, or degree of a condition, or assess the health of an individual.
ObservationMethod must be a TestMethod optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
BodyPosition optional The position or physical attitude of the body.
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Interpretation optional A clinical interpretation of a measurement.
ReferenceRange optional The usual or acceptable range for a test result.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
TestRequest optional A record of a request (order) for a test to be performed.
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.
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.

RespiratoryRate [Entry]

The rate of breathing (inhalation and exhalation) measured within in a unit time, expressed as breaths per minute. 9279-1

Based On VitalSign

Value:  Quantity Units is /min (/min) A quantity with units.
ObservationQualifier from RespiratoryRateQualifierVS 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.
ObservationCategory includes vital-signs 1 or more A categorization of the observation according to how the observation was collected or its clinical area.
Specimen (TBD) not used Description TBD
ObservationCode must be a TestCode 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.
         where  TestCode is 9279-1 The code for a laboratory, radiologic, and other clinical test or measurement that helps to determine the presence, absence, or degree of a condition, or assess the health of an individual.
ObservationMethod must be a TestMethod optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
         where  TestMethod from RespiratoryRateMethodVS optional The technique used to carry out a procedure, if not implicit in the test code.
BodySite optional Location on or in the body.
BodyPosition optional The position or physical attitude of the body.
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Interpretation optional A clinical interpretation of a measurement.
ReferenceRange optional The usual or acceptable range for a test result.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
TestRequest optional A record of a request (order) for a test to be performed.
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.
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.

SystolicPressure

The blood pressure during the contraction of the left ventricle of the heart, when blood pressure is at its highest. 8480-6

Based On QuantitativeObservation

Value:  Quantity Units is mmHg (mm[Hg]) A quantity with units.
ObservationCode is 8480-6 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.

VitalSign

No Description Vital Sign (8716-3)

Based On Test

Value:  Quantity A quantity with units.
ObservationCategory includes vital-signs 1 or more A categorization of the observation according to how the observation was collected or its clinical area.
Specimen (TBD) not used Description TBD
ObservationCode must be a TestCode 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.
ObservationMethod must be a TestMethod optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
BodySite optional Location on or in the body.
BodyPosition optional The position or physical attitude of the body.
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Interpretation optional A clinical interpretation of a measurement.
ReferenceRange optional The usual or acceptable range for a test result.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
TestRequest optional A record of a request (order) for a test to be performed.
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.
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.