1.3.6.1.4.1.19376.1.5.3.1.4.13

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Trial.gif Simple Observations 1.3.6.1.4.1.19376.1.5.3.1.4.13

The simple observation entry is meant to be an abstract representation of many of the observations used in this specification. It can be made concrete by the specification of a few additional constraints, namely the vocabulary used for codes, and the value representation. A simple observation may also inherit constraints from other specifications (e.g., ASTM/HL7 Continuity of Care Document).


Uses

See Templates using Simple Observations

Specification
Simple Observations Example
<observation classCode='OBS' moodCode='EVN'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
  <id root='' extension=''/>
  <code code='' displayName='' codeSystem='' codeSystemName=''/>
  <!-- for CDA -->
  <text><reference value='#xxx'/></text>
  <!-- For HL7 Version 3 Messages
  <text>text</text> 
  -->
  <statusCode code='completed'/>
  <effectiveTime value=''/>
  <repeatNumber value=''/>
  <value xsi:type='' …/>
  <interpretationCode code='' codeSystem='' codeSystemName=''/>
  <methodCode code='' codeSystem='' codeSystemName=''/>
  <targetSiteCode code='' codeSystem='' codeSystemName=''/>
	<author typeCode='AUT'>
    <assignedAuthor typeCode='ASSIGNED'><id ... /></assignedAuthor> <!-- for CDA -->
    <!-- For HL7 Version 3 Messages 
    <assignedEntity typeCode='ASSIGNED'>
       <Person classCode='PSN'>
          <determinerCode root=''>
          <name>…</name>
       </Person>
    <assignedEntity>
     -->
  </author>
</observation>


<observation classCode='OBS' moodCode='EVN'>

These acts are simply observations that have occurred, and so are recored using the <observation> element as shown above.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>

The <templateId> element identifies this <observation> as a simple observation, allowing for validation of the content. The templateId must appear as shown above.

<id root=' ' extension=' '/>

Each observation shall have an identifier.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

Observations shall have a code describing what was measured. The code system used is determined by the vocabulary constraints on the types of measurements that might be recorded in a section. Content modules that are derived from the Simple Observation content module may restrict the code system and code values used for the observation.

<text><reference value='#xxx'/></text> -OR- <text>text</text>

Each observation measurement entry may contain a <text> element providing the free text that provides the same information as the observation within the narrative portion of the document with a <text> element. For CDA based uses of Simple Observations, this element SHALL be present, and SHALL contain a <reference> element that points to the related string in the narrative portion of the document. For HL7 Version 3 based uses, the <text> element MAY be included.

<statusCode code='completed'/>

The status code of all observations shall be completed.

<effectiveTime value=' '/>

The <effectiveTime> element shall be present in standalone observations , and shall record the date and time when the measurement was taken. This element should be precise to the day. If the date and time is unknown, this element should record that using the nullFlavor attribute.

<value xsi:type=' ' …/>

The value of the observation shall be recording using a data type appropriate to the observation. Content modules derived from the Simple Observation content module may restrict the allowable data types used for the observation.

<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>

If there is an interpretation that can be performed using an observation result (e.g., high, borderline, normal, low), these may be recorded within the interpretationCode element.

<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>

The methodCode element may be used to record the specific method used to make an observation when this information is not already pre-coordinated with the observation code .

<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The targetSiteCode may be used to record the target site where an observation is made when this information is not already pre-coordinated with the observation code.

<author><assignedAuthor classCode='ASSIGNED'>...<assignedAuthor></author>

In CDA uses, SimpleObservations are assumed to be authored by the same author as the document through context conduction. However specific authorship of observation may be represented by listing the author in the header and referencing the author in a <author> relationship. If authors are explicitly listed in documents, an <id> element SHOULD reference the ID of the author in the header through an assignedAuthor Role. If the author of the observation is not an author of the document the <person> object including a name and ID SHALL be included.

For HL7 Version 3 purposes, the <author> element SHOULD be present unless it can be determined by conduction from organizers or higher level structures. When used for HL7 Version 3 the role element name is <assignedEntity> and the author is represented a <assignedPerson> element.