EHDS refined base model for Observation information

Common header for all patient-related data

Patient/subject information

Business identifier for the object

Resource authoring details

Author(s) by whom the resource was/were authored. Multiple authors could be provided.

Date and time of authoring/issuing

Date and time of the last update to the resource (may be used for technical corrections).

Status of the resource or document

HL7 Observation status

Reason for the current status of the resource.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

The direct subject of the observation if different from the patient (subject of care), e.g. an observation of an implanted device

Clinically relevant time or time period for the observation

Code representing the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Name of the observation

Original (conventional) name of the observation

Observation method (measurement principle) to obtain the result.

SNOMED CT

Specimen used for this observation.

Identifies order and order placer this observation belongs to

Performer of the observation. Some test could be performed by the patient himself or by a care giver. Those are in the scope of this deliverable under specified conditions.

Anatomic location and laterality where the observation was performed.

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.

Observation result value according to the type of observation.

Observation result value as a text. Should be used only if coded result value is not expected otherwise use valueCodeableConcept.text.

Observation result value as a quantity, result units of the measurement should be provided.

UCUM for units

Observation result value as a range (open or closed). Result units of the measurement should be provided.

UCUM for units

Observation result value from a valid code system

SNOMED CT

Measurement uncertainty type and interval if needed.

Measurement uncertainty type and interval if needed.

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

HL7 Data absent reason

Reference range, multiple reference ranges of different types culd by provided. Provides 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

Comments and narrative representation of the observation result and findings.

Component in case the observation consists of multiple sub-observations (e.g. blood pressure).

Code representing the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Original (conventional) name of the observation

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.

Observation result value according to the type of observation.

Observation result value as a text. Should be used only if coded result value is not expected otherwise use valueCodeableConcept.text.

Observation result value as a quantity, result units of the measurement should be provided.

UCUM for units

Observation result value as a range (open or closed). Result units of the measurement should be provided.

UCUM for units

Observation result value from a valid code system

SNOMED CT

Measurement uncertainty type and interval if needed.

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

HL7 Data absent reason

Reference range, multiple reference ranges of different types culd by provided. Provides 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

Reference to the related resource from which the observation has been made. For example, a calculated anion gap or a fetal measurement based on an ultrasound image.

References to 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.

EHDS refined base model for Observation information

HL7 Observation status

The direct subject of the observation if different from the patient (subject of care), e.g. an observation of an implanted device

Clinically relevant time or time period for the observation

Code representing the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Name of the observation

Original (conventional) name of the observation

Observation method (measurement principle) to obtain the result.

SNOMED CT

Specimen used for this observation.

Identifies order and order placer this observation belongs to

Performer of the observation. Some test could be performed by the patient himself or by a care giver. Those are in the scope of this deliverable under specified conditions.

Anatomic location and laterality where the observation was performed.

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.

Observation result value according to the type of observation.

Observation result value as a text. Should be used only if coded result value is not expected otherwise use valueCodeableConcept.text.

Observation result value as a quantity, result units of the measurement should be provided.

UCUM for units

Observation result value as a range (open or closed). Result units of the measurement should be provided.

UCUM for units

Observation result value from a valid code system

SNOMED CT

Measurement uncertainty type and interval if needed.

Measurement uncertainty type and interval if needed.

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

HL7 Data absent reason

Reference range, multiple reference ranges of different types culd by provided. Provides 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

Comments and narrative representation of the observation result and findings.

Component in case the observation consists of multiple sub-observations (e.g. blood pressure).

Code representing the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Original (conventional) name of the observation

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.

Observation result value according to the type of observation.

Observation result value as a text. Should be used only if coded result value is not expected otherwise use valueCodeableConcept.text.

Observation result value as a quantity, result units of the measurement should be provided.

UCUM for units

Observation result value as a range (open or closed). Result units of the measurement should be provided.

UCUM for units

Observation result value from a valid code system

SNOMED CT

Measurement uncertainty type and interval if needed.

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

HL7 Data absent reason

Reference range, multiple reference ranges of different types culd by provided. Provides 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

Reference to the related resource from which the observation has been made. For example, a calculated anion gap or a fetal measurement based on an ultrasound image.

References to 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.

EHDS refined base model for Observation information

Common header for all patient-related data

Patient/subject information

Business identifier for the object

Resource authoring details

Author(s) by whom the resource was/were authored. Multiple authors could be provided.

Date and time of authoring/issuing

Date and time of the last update to the resource (may be used for technical corrections).

Status of the resource or document

HL7 Observation status

Reason for the current status of the resource.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

The direct subject of the observation if different from the patient (subject of care), e.g. an observation of an implanted device

Clinically relevant time or time period for the observation

Code representing the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Name of the observation

Original (conventional) name of the observation

Observation method (measurement principle) to obtain the result.

SNOMED CT

Specimen used for this observation.

Identifies order and order placer this observation belongs to

Performer of the observation. Some test could be performed by the patient himself or by a care giver. Those are in the scope of this deliverable under specified conditions.

Anatomic location and laterality where the observation was performed.

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.

Observation result value according to the type of observation.

Observation result value as a text. Should be used only if coded result value is not expected otherwise use valueCodeableConcept.text.

Observation result value as a quantity, result units of the measurement should be provided.

UCUM for units

Observation result value as a range (open or closed). Result units of the measurement should be provided.

UCUM for units

Observation result value from a valid code system

SNOMED CT

Measurement uncertainty type and interval if needed.

Measurement uncertainty type and interval if needed.

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

HL7 Data absent reason

Reference range, multiple reference ranges of different types culd by provided. Provides 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

Comments and narrative representation of the observation result and findings.

Component in case the observation consists of multiple sub-observations (e.g. blood pressure).

Code representing the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Original (conventional) name of the observation

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.

Observation result value according to the type of observation.

Observation result value as a text. Should be used only if coded result value is not expected otherwise use valueCodeableConcept.text.

Observation result value as a quantity, result units of the measurement should be provided.

UCUM for units

Observation result value as a range (open or closed). Result units of the measurement should be provided.

UCUM for units

Observation result value from a valid code system

SNOMED CT

Measurement uncertainty type and interval if needed.

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

HL7 Data absent reason

Reference range, multiple reference ranges of different types culd by provided. Provides 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

Reference to the related resource from which the observation has been made. For example, a calculated anion gap or a fetal measurement based on an ultrasound image.

References to 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.