This page is part of the FHIR Specification (v0.0.82: DSTU 1). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2 Observation.profile.xml Profile for observation Raw XML &lt; &lt;!-- from --&gt; &lt;&lt;/name&gt; &lt;The information determined as a result of making the observation, if the information has a simple value.| &lt;/value[x]&gt; &lt;&lt;/interpretation&gt; &lt;May include statements about significant, unexpected or unreliable values, or information about the source of the value where this may be relevant to the interpretation of the result. &lt;The time or time-period the observed value is asserted as being true. For biological subjects - e.g. human patients - this is usually called the &quot;physiologically relevant time&quot;. This is usually either the time of the procedure or of specimen collection, but very often the source of the date/time is not known, only the date/time itself. Physiologically Relevant time/time-period for observation&lt;/applies[x]&gt; &lt; &lt; &lt;An estimate of the degree to which quality issues have impacted on the value reported (this element modifies the meaning of other elements) &lt;&lt;/bodySite&gt; &lt;&lt;/method&gt; &lt;&lt;/identifier&gt; &lt;&lt;/subject&gt; &lt;&lt;/specimen&gt; &lt;&lt;/performer&gt; &lt; &lt;The value of the low bound of the reference range. If this is omitted, the low bound of the reference range is assumed to be meaningless. E.g. &lt;2.3.&lt;/low&gt; &lt;The value of the high bound of the reference range. If this is omitted, the high bound of the reference range is assumed to be meaningless. E.g. &gt;5.&lt;/high&gt; &lt;&lt;/meaning&gt; &lt;The age at which this reference range is applicable. This is a neonatal age (e.g. number of weeks at term) if the meaning says so.&lt;/age&gt; &lt;/referenceRange&gt; &lt; &lt; &lt;&lt;/target&gt; &lt;/related&gt; &lt;/Observation&gt; Basic Profile. Measurements and simple assertions made about a patient, device or other subject. Scope and Usage Observations are a central element in healthcare, used to support diagnosis, monitor progress, determine baselines and patterns and even capture demographic characteristics. Most observations are simple name/value pair assertions with some metadata, but some observations group other observations together logically, or even are multi-component observations. Note that the resources DiagnosticReport and DeviceObservationReport provide a clinical or workflow context for a set of observations. Expected uses for the Observation resource include: * Vital signs: temperature, blood pressure, respiration rate * Laboratory Data and other Diagnostic Measures * Measurements emitted by Devices * Clinical assessments such as APGAR * Personal characteristics: height, weight, eye-color * Diagnoses (Note: trackable conditions, allergies, adverse reactions and more complex structures are handled elsewhere) * Social history: tobacco use, family supports, cognitive status * Core characteristics: pregnancy status, death assertion Used for simple observations such as device measurements, laboratory atomic results, vital signs, height, weight, smoking status, comments, etc. Other resources are used to provide context for observations such as Lab reports, etc. May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict governance applied to the definition and use of extensions. Though any implementer is allowed to 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 simplicity for everyone. May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict governance applied to the definition and use of extensions. Though any implementer is allowed to 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. 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 simplicity for everyone. A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it &quot;clinically safe&quot; for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. The information determined as a result of making the observation, if the information has a simple value. Normally, an observation will have either a value or a set of related observations. A few observations (e.g. apgar store) may have both a value and related observations (for apgar, the observations from which the measure is derived). If a value is present, the datatype for this element should be determined by Observation.name. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.name defines a coded value. The element, Observation.val ue[x], has a variable name depending on the type as follows: valueQuantity, valueCodeableConcept, valueRatio, valueChoice, valuePeriod, valueSampleData, or valueString (The name format is &quot;'value' + the type name&quot; with a capital on the first letter of the type). May include statements about significant, unexpected or unreliable values, or information about the source of the value where this may be relevant to the interpretation of the result. The time or time-period the observed value is asserted as being true. For biological subjects - e.g. human patients - this is usually called the &quot;physiologically relevant time&quot;. This is usually either the time of the procedure or of specimen collection, but very often the source of the date/time is not known, only the date/time itself. OBX-14-date/time of the observation, and/or OBX-19 after v2.4 (depends on who observation made) status Amended &amp; Final are differentiated by whether it is the subject of a ControlAct event with a type of &quot;revise&quot; Note that in most contexts, unreliable results are not recorded, deleted, or otherwise excluded, but it's not always possible to exclude them from the record. Interpreters of a result, whether human or machine, SHALL always either be aware of the status, or prevented from using the observation without being unaware that the reliability is not &quot;ok&quot;. The only circumstance in which the subject can be missing is when the observation is made by a device that does not know the patient. In this case, the observation SHALL be matched to a patient through some context/channel matching technique, and at this point, the observation should be updated. Observations are not made on specimens themselves; they are made on a subject, but usually by the means of a specimen. Note that although specimens are often involved, they are not always tracked and reported explicitly. Also note that observation resources are often used in contexts that track the specimen explicity (e.g. Diagnostic Report). This would only be &quot;Device&quot; if the device is responsible for the measurement, not to capture the device used by a human to make the measurement. (The latter could be captured as an extension.). OBX.15 / (Practitioner) OBX-16-responsible observer, PRT-5-participation person:PRT-4-participatio n='RO' / (Device) OBX-18-equipment instance identifier , PRT-10-participation device:PRT-4-particip ation='EQUIP' / (Organization) OBX-23-performing organization name, PRT-8-participation organization:PRT-4-participation='PO' Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g. specific to the patient's age, gender, weight and other factors), but this may not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties. (exists(f:low) or exists(f:high)) and not(exists(f:low/f:comparator)) and not(exists(f:high/f:compar ator)) May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict governance applied to the definition and use of extensions. Though any implementer is allowed to 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 simplicity for everyone. May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict governance applied to the definition and use of extensions. Though any implementer is allowed to 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. 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 simplicity for everyone. The value of the low bound of the reference range. If this is omitted, the low bound of the reference range is assumed to be meaningless. E.g. &lt;2.3. The value of the high bound of the reference range. If this is omitted, the high bound of the reference range is assumed to be meaningless. E.g. &gt;5. The age at which this reference range is applicable. This is a neonatal age (e.g. number of weeks at term) if the meaning says so. Normally, an observation will have either a value or a set of related observations. A few observations (e.g. apgar store) may have both a value and related observations (for apgar, the observations from which the measure is derived). May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict governance applied to the definition and use of extensions. Though any implementer is allowed to 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 simplicity for everyone. May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict governance applied to the definition and use of extensions. Though any implementer is allowed to 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. 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 simplicity for everyone. A relationship type SHOULD be provided. If the relationship type is &quot;COMP&quot; (composed), then the observation should not be displayed/interpreted in the absence of the related observations. The value of the observation, if the value is a Quantity, or a SampledData (just search on the bounds of the values in sampled data) </Profile> © HL7.org 2011+. FHIR DSTU (v0.0.82.2943) generated on Tue, Sep 30, 2014 18:10+1000. Links: What's a DSTU? | Version History | | Propose a change var _gaq = _gaq || []; _gaq.push(['_setAccount', 'UA-676355-1']); _gaq.push(['_setDomainName', '.hl7.org']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })();