OpenEHR Base package
0.1.0 - First Draft International flag

OpenEHR Base package, published by openEHR + HL7. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/FHIR/openehr-base-ig/ and changes regularly. See the Directory of published versions

Logical Model: OBSERVATION

Official URL: http://openehr.org/fhir/StructureDefinition/OBSERVATION Version: 0.1.0
Standards status: Informative Maturity Level: 3 Computable Name: OBSERVATION

Entry subtype for all clinical data in the past or present, i.e. which (by the time it is recorded) has already occurred. OBSERVATION data is expressed using the class HISTORY, which guarantees that it is situated in time. OBSERVATION is used for all notionally objective (i.e. measured in some way) observations of phenomena, and patient-reported phenomena, e.g. pain. Not to be used for recording opinion or future statements of any kind, including instructions, intentions, plans etc.

Original Source: specifications.openehr.org

Usages:

  • This Logical Model is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. OBSERVATION 0..* CARE_ENTRY
Elements defined in Ancestors:name, archetype_node_id, uid, links, archetype_details, feeder_audit, name, archetype_node_id, uid, links, archetype_details, feeder_audit, language, encoding, other_participations, workflow_id, subject, provider, protocol, guideline_id
Entry subtype for all clinical data in the past or present, i.e. which (by the time it is recorded) has already occurred
... name 1..1 DV_TEXT Runtime name of this fragment, used to build runtime paths
... archetype_node_id 1..1 string Design-time archetype identifier of this node taken from its generating archetype
... uid 0..1 UID_BASED_ID Optional globally unique object identifier for root points of archetyped structures
... archetype_details 0..1 ARCHETYPED Details of archetyping used on this node
... feeder_audit 0..1 FEEDER_AUDIT Audit trail from non-openEHR system of original commit of information forming the content of this node
... language 1..1 CODE_PHRASE Mandatory indicator of the localised language in which this Entry is written. Coded from openEHR Code Set languages
Binding: AllLanguages (required)
... encoding 1..1 CODE_PHRASE Name of character set in which text values in this Entry are encoded
Binding: Character Set (required)
... other_participations 0..* PARTICIPATION Other participations at ENTRY level
... workflow_id 0..1 OBJECT_REF Identifier of externally held workflow engine data for this workflow execution, for this subject of care
... subject 1..1 PARTY_PROXY Id of human subject of this ENTRY, e.g. organ donor, foetus, a family member, or another clinically relevant person
... provider 0..1 PARTY_PROXY Optional identification of provider of the information in this ENTRY, which might be the patient, a patient agent, the clinician, a device
... protocol 0..1 ITEM_STRUCTURE Description of the method (i.e. how) the information in this entry was arrived at
... guideline_id 0..1 OBJECT_REF Optional external identifier of guideline creating this Entry if relevant
... data 1..1 HISTORY<ITEM_STRUCTURE> The data of this observation, in the form of a history of values which may be of any complexity
... state 0..1 HISTORY<ITEM_STRUCTURE> Optional recording of the state of subject of this observation during the observation process

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
OBSERVATION.languagerequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
From the FHIR Standard
OBSERVATION.encodingrequiredcharacter_sets(a valid code from Character Set)
https://specifications.openehr.org/fhir/valueset-character_sets
From this IG

This structure is derived from CARE_ENTRY

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. OBSERVATION 0..* CARE_ENTRY
Elements defined in Ancestors:name, archetype_node_id, uid, links, archetype_details, feeder_audit, name, archetype_node_id, uid, links, archetype_details, feeder_audit, language, encoding, other_participations, workflow_id, subject, provider, protocol, guideline_id
Entry subtype for all clinical data in the past or present, i.e. which (by the time it is recorded) has already occurred
... data 1..1 HISTORY<ITEM_STRUCTURE> The data of this observation, in the form of a history of values which may be of any complexity
... state 0..1 HISTORY<ITEM_STRUCTURE> Optional recording of the state of subject of this observation during the observation process

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. OBSERVATION 0..* CARE_ENTRY
Elements defined in Ancestors:name, archetype_node_id, uid, links, archetype_details, feeder_audit, name, archetype_node_id, uid, links, archetype_details, feeder_audit, language, encoding, other_participations, workflow_id, subject, provider, protocol, guideline_id
Entry subtype for all clinical data in the past or present, i.e. which (by the time it is recorded) has already occurred
... name 1..1 DV_TEXT Runtime name of this fragment, used to build runtime paths
... archetype_node_id 1..1 string Design-time archetype identifier of this node taken from its generating archetype
... uid 0..1 UID_BASED_ID Optional globally unique object identifier for root points of archetyped structures
... archetype_details 0..1 ARCHETYPED Details of archetyping used on this node
... feeder_audit 0..1 FEEDER_AUDIT Audit trail from non-openEHR system of original commit of information forming the content of this node
... language 1..1 CODE_PHRASE Mandatory indicator of the localised language in which this Entry is written. Coded from openEHR Code Set languages
Binding: AllLanguages (required)
... encoding 1..1 CODE_PHRASE Name of character set in which text values in this Entry are encoded
Binding: Character Set (required)
... other_participations 0..* PARTICIPATION Other participations at ENTRY level
... workflow_id 0..1 OBJECT_REF Identifier of externally held workflow engine data for this workflow execution, for this subject of care
... subject 1..1 PARTY_PROXY Id of human subject of this ENTRY, e.g. organ donor, foetus, a family member, or another clinically relevant person
... provider 0..1 PARTY_PROXY Optional identification of provider of the information in this ENTRY, which might be the patient, a patient agent, the clinician, a device
... protocol 0..1 ITEM_STRUCTURE Description of the method (i.e. how) the information in this entry was arrived at
... guideline_id 0..1 OBJECT_REF Optional external identifier of guideline creating this Entry if relevant
... data 1..1 HISTORY<ITEM_STRUCTURE> The data of this observation, in the form of a history of values which may be of any complexity
... state 0..1 HISTORY<ITEM_STRUCTURE> Optional recording of the state of subject of this observation during the observation process

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
OBSERVATION.languagerequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
From the FHIR Standard
OBSERVATION.encodingrequiredcharacter_sets(a valid code from Character Set)
https://specifications.openehr.org/fhir/valueset-character_sets
From this IG

This structure is derived from CARE_ENTRY

Summary

Mandatory: 0 element(1 nested mandatory element)

Maturity: 3

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. OBSERVATION 0..* CARE_ENTRY
Elements defined in Ancestors:name, archetype_node_id, uid, links, archetype_details, feeder_audit, name, archetype_node_id, uid, links, archetype_details, feeder_audit, language, encoding, other_participations, workflow_id, subject, provider, protocol, guideline_id
Entry subtype for all clinical data in the past or present, i.e. which (by the time it is recorded) has already occurred
... name 1..1 DV_TEXT Runtime name of this fragment, used to build runtime paths
... archetype_node_id 1..1 string Design-time archetype identifier of this node taken from its generating archetype
... uid 0..1 UID_BASED_ID Optional globally unique object identifier for root points of archetyped structures
... archetype_details 0..1 ARCHETYPED Details of archetyping used on this node
... feeder_audit 0..1 FEEDER_AUDIT Audit trail from non-openEHR system of original commit of information forming the content of this node
... language 1..1 CODE_PHRASE Mandatory indicator of the localised language in which this Entry is written. Coded from openEHR Code Set languages
Binding: AllLanguages (required)
... encoding 1..1 CODE_PHRASE Name of character set in which text values in this Entry are encoded
Binding: Character Set (required)
... other_participations 0..* PARTICIPATION Other participations at ENTRY level
... workflow_id 0..1 OBJECT_REF Identifier of externally held workflow engine data for this workflow execution, for this subject of care
... subject 1..1 PARTY_PROXY Id of human subject of this ENTRY, e.g. organ donor, foetus, a family member, or another clinically relevant person
... provider 0..1 PARTY_PROXY Optional identification of provider of the information in this ENTRY, which might be the patient, a patient agent, the clinician, a device
... protocol 0..1 ITEM_STRUCTURE Description of the method (i.e. how) the information in this entry was arrived at
... guideline_id 0..1 OBJECT_REF Optional external identifier of guideline creating this Entry if relevant
... data 1..1 HISTORY<ITEM_STRUCTURE> The data of this observation, in the form of a history of values which may be of any complexity
... state 0..1 HISTORY<ITEM_STRUCTURE> Optional recording of the state of subject of this observation during the observation process

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
OBSERVATION.languagerequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
From the FHIR Standard
OBSERVATION.encodingrequiredcharacter_sets(a valid code from Character Set)
https://specifications.openehr.org/fhir/valueset-character_sets
From this IG

Differential View

This structure is derived from CARE_ENTRY

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. OBSERVATION 0..* CARE_ENTRY
Elements defined in Ancestors:name, archetype_node_id, uid, links, archetype_details, feeder_audit, name, archetype_node_id, uid, links, archetype_details, feeder_audit, language, encoding, other_participations, workflow_id, subject, provider, protocol, guideline_id
Entry subtype for all clinical data in the past or present, i.e. which (by the time it is recorded) has already occurred
... data 1..1 HISTORY<ITEM_STRUCTURE> The data of this observation, in the form of a history of values which may be of any complexity
... state 0..1 HISTORY<ITEM_STRUCTURE> Optional recording of the state of subject of this observation during the observation process

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. OBSERVATION 0..* CARE_ENTRY
Elements defined in Ancestors:name, archetype_node_id, uid, links, archetype_details, feeder_audit, name, archetype_node_id, uid, links, archetype_details, feeder_audit, language, encoding, other_participations, workflow_id, subject, provider, protocol, guideline_id
Entry subtype for all clinical data in the past or present, i.e. which (by the time it is recorded) has already occurred
... name 1..1 DV_TEXT Runtime name of this fragment, used to build runtime paths
... archetype_node_id 1..1 string Design-time archetype identifier of this node taken from its generating archetype
... uid 0..1 UID_BASED_ID Optional globally unique object identifier for root points of archetyped structures
... archetype_details 0..1 ARCHETYPED Details of archetyping used on this node
... feeder_audit 0..1 FEEDER_AUDIT Audit trail from non-openEHR system of original commit of information forming the content of this node
... language 1..1 CODE_PHRASE Mandatory indicator of the localised language in which this Entry is written. Coded from openEHR Code Set languages
Binding: AllLanguages (required)
... encoding 1..1 CODE_PHRASE Name of character set in which text values in this Entry are encoded
Binding: Character Set (required)
... other_participations 0..* PARTICIPATION Other participations at ENTRY level
... workflow_id 0..1 OBJECT_REF Identifier of externally held workflow engine data for this workflow execution, for this subject of care
... subject 1..1 PARTY_PROXY Id of human subject of this ENTRY, e.g. organ donor, foetus, a family member, or another clinically relevant person
... provider 0..1 PARTY_PROXY Optional identification of provider of the information in this ENTRY, which might be the patient, a patient agent, the clinician, a device
... protocol 0..1 ITEM_STRUCTURE Description of the method (i.e. how) the information in this entry was arrived at
... guideline_id 0..1 OBJECT_REF Optional external identifier of guideline creating this Entry if relevant
... data 1..1 HISTORY<ITEM_STRUCTURE> The data of this observation, in the form of a history of values which may be of any complexity
... state 0..1 HISTORY<ITEM_STRUCTURE> Optional recording of the state of subject of this observation during the observation process

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
OBSERVATION.languagerequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
From the FHIR Standard
OBSERVATION.encodingrequiredcharacter_sets(a valid code from Character Set)
https://specifications.openehr.org/fhir/valueset-character_sets
From this IG

This structure is derived from CARE_ENTRY

Summary

Mandatory: 0 element(1 nested mandatory element)

Maturity: 3

 

Other representations of profile: CSV, Excel