C.10 - EHDS refined base model for Observation information

Date and time of the observation

Code representing the observation using the agreed code systems.

SNOMED CT

Full name of the observation according to the used test coding standard.

Original (conventional) name of the observation 

Observation method (measurement principle) to obtain the result.

SNOMED CT

Device (e.g. analyser) that generates the measurements

Identifies order and order placer this observation belongs to. 

Identifies the originator/author and provides provenance information about the source of the results data that may have not originated with the source of the whole Laboratory Report document. 

With certain observation results, e.g. there may also be an interpreter or a person responsible for validation.

Result of the observation including text, numeric and coded results of the measurement and measurement uncertainty. Content of the observation result will vary according to the type of the observation.

Narrative text result

A numeric value or interval (open or closed) of the result, result units of the measurement should be provided Measurement uncertainty interval are provided if needed.

A numeric value or interval (open or closed) of the result

Result units of the measurement

UCUM

Measurement uncertainty type and interval should be provided if needed.

A coded result from a selected coding system(s). This could be a code describing bacteria or other microorganism identified, description of urinary concernment, code explaining technical reason why the test could not be done etc.

SNOMED CT (for ordinal or nominal scale results and result interpretation)UCUM (for units)

Provides a reason why the expected value in the element Observation.value[x] is missing.

HL7 Data absent reason

Reference range, multilple reference ranges of different types culd by providedProvides guide for interpretation of result. Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

Information about reference intervals and result interpretation.

SNOMED CT, HL7 ObservationInterpretation

Identifies the observation(s) that triggered the performance of this observation.

This observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group.

Comments and narrative representation of the observation result and findings.

Anatomic location and laterality where the observation should be or was performed.

SNOMED CT

C.10 - EHDS refined base model for Observation information

Date and time of the observation

Code representing the observation using the agreed code systems.

SNOMED CT

Full name of the observation according to the used test coding standard.

Original (conventional) name of the observation 

Observation method (measurement principle) to obtain the result.

SNOMED CT

Device (e.g. analyser) that generates the measurements

Identifies order and order placer this observation belongs to. 

Identifies the originator/author and provides provenance information about the source of the results data that may have not originated with the source of the whole Laboratory Report document. 

With certain observation results, e.g. there may also be an interpreter or a person responsible for validation.

Result of the observation including text, numeric and coded results of the measurement and measurement uncertainty. Content of the observation result will vary according to the type of the observation.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Narrative text result

A numeric value or interval (open or closed) of the result, result units of the measurement should be provided Measurement uncertainty interval are provided if needed.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A numeric value or interval (open or closed) of the result

Result units of the measurement

UCUM

Measurement uncertainty type and interval should be provided if needed.

A coded result from a selected coding system(s). This could be a code describing bacteria or other microorganism identified, description of urinary concernment, code explaining technical reason why the test could not be done etc.

SNOMED CT (for ordinal or nominal scale results and result interpretation)UCUM (for units)

Provides a reason why the expected value in the element Observation.value[x] is missing.

HL7 Data absent reason

Reference range, multilple reference ranges of different types culd by providedProvides guide for interpretation of result. Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

Information about reference intervals and result interpretation.

SNOMED CT, HL7 ObservationInterpretation

Identifies the observation(s) that triggered the performance of this observation.

This observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group.

Comments and narrative representation of the observation result and findings.

Anatomic location and laterality where the observation should be or was performed.

SNOMED CT

C.10 - EHDS refined base model for Observation information

Date and time of the observation

Code representing the observation using the agreed code systems.

SNOMED CT

Full name of the observation according to the used test coding standard.

Original (conventional) name of the observation 

Observation method (measurement principle) to obtain the result.

SNOMED CT

Device (e.g. analyser) that generates the measurements

Identifies order and order placer this observation belongs to. 

Identifies the originator/author and provides provenance information about the source of the results data that may have not originated with the source of the whole Laboratory Report document. 

With certain observation results, e.g. there may also be an interpreter or a person responsible for validation.

Result of the observation including text, numeric and coded results of the measurement and measurement uncertainty. Content of the observation result will vary according to the type of the observation.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Narrative text result

A numeric value or interval (open or closed) of the result, result units of the measurement should be provided Measurement uncertainty interval are provided if needed.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A numeric value or interval (open or closed) of the result

Result units of the measurement

UCUM

Measurement uncertainty type and interval should be provided if needed.

A coded result from a selected coding system(s). This could be a code describing bacteria or other microorganism identified, description of urinary concernment, code explaining technical reason why the test could not be done etc.

SNOMED CT (for ordinal or nominal scale results and result interpretation)UCUM (for units)

Provides a reason why the expected value in the element Observation.value[x] is missing.

HL7 Data absent reason

Reference range, multilple reference ranges of different types culd by providedProvides guide for interpretation of result. Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

Information about reference intervals and result interpretation.

SNOMED CT, HL7 ObservationInterpretation

Identifies the observation(s) that triggered the performance of this observation.

This observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group.

Comments and narrative representation of the observation result and findings.

Anatomic location and laterality where the observation should be or was performed.

SNOMED CT