1.3.6.1.4.1.19376.1.5.3.1.4.13

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==== [[Image:Comment .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 typeCode='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=''/>
  <text><reference value='#xxx'/></text>
  <statusCode code='completed'/>
  <effectiveTime value=''/>
  <repeatNumber value=''/>
  <value xsi:type='' …/>
  <interpretationCode code='' codeSystem='' codeSystemName=''/>
  <methodCode code='' codeSystem='' codeSystemName=''/>
  <targetSiteCode code='' codeSystem='' codeSystemName=''/>
</observation>

<observation typeCode='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 shonw 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>

Each measurement entry shall contain a <text> element providing a <reference> to the text that provides the same information as the observation within the narrative portion of the document.

<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.