Observation

This topic describes information for the Observation resource.

To interact with the REST endpoints in the Observation resource, see Observation.

Overview

The Observation resource provides measurements or simple assertions about a patient that are useful for establishing baselines or trends, monitoring a patient's progress, and establishing diagnoses. Most observations are simple name and value pair assertions, but some observations, such as blood pressure, group other observations together logically. Examples of common observations are laboratory results (blood sugar, hemoglobin), vital signs (temperature, blood pressure), personal characteristics (height, weight), and social history (tobacco and alcohol use, employment status). Pathology reports, radiology reports, and other textual reports are represented by the DiagnosticReport resource.

This resource supports the following HL7 FHIR US Core Implementation Guide STU 4.0.0 profiles:

• US Core Smoking Status Observation Profile

• US Core Laboratory Result Observation Profile

• US Core Vital Signs Profile

• US Core Blood Pressure Profile

• US Core BMI Profile

• US Core Head Circumference Profile

• US Core Body Height Profile

• US Core Body Weight Profile

• US Core Body Temperature Profile

• US Core Heart Rate Profile

• US Core Pediatric BMI for Age Observation Profile

• US Core Pediatric Head Occipital-frontal Circumference Percentile Profile

• US Core Pediatric Weight for Height Observation Profile

• US Core Pulse Oximetry Profile

• US Core Respiratory Rate Profile

Fields

• ID

• Identifier

• Status

• Category (laboratory, social history, vital-signs)

• Code (Observation name or text)

• Subject (Patient)

• Encounter

• Effective date/time (collection date/time for laboratory)

• Extensions (for more information, see the Extensions section of this topic)

• Issued (date/time observation made available, entered, verified)

• Performer

• Observation value or result

• For Observations with valueQuantity

• Quantity comparator (<, <=, >, >=)

• Quantity units

• For Observations with valueCodeableConcept

• Codeable concept

• Data absent reason

• Interpretation (abnormal flagging)

• Note (comments)

• Reference range

• low

• high

• type

• text

• Member Observations (for limited use cases)

• Component (eg: systolic and diastolic for blood pressure)

Terminology Bindings

• Observation.category

  Description: Codes for high level observation categories.

  Details: Observation Category Codes

  System: http://terminology.hl7.org/CodeSystem/observation-category

• Observation.code

  Description: Codes identifying names of simple observations.

  • Details: LOINC

    System: http://loinc.org

  • Details: SNOMED CT

    System: http://snomed.info/sct

  • Details: For more information, see Code Set 72 Clinical Event Codes under the List of Code Sets section in Proprietary Codes and Systems.

    System: https://fhir.cerner.com/<EHR_source_id>/codeSet/72

• Observation.performer.extension

  Description: Codes identifying the function of the performer.

  • Details: Performer function codes

    System: http://terminology.hl7.org/CodeSystem/v3-ParticipationType

  • Details: Participation codes

    System: http://terminology.hl7.org/CodeSystem/v2-0912

• Observation.dataAbsentReason

  Description: Codes for reasons data is absent.

  Details: v4 data absentreason

  System: http://terminology.hl7.org/CodeSystem/data-absent-reason

• Observation.valueCodeableConcept

  Description: Codes for value of the observation.

  Details: SNOMED CT

  System: http://snomed.info/sct

• Observation.interpretation

  Description: Codes identifying interpretations of observations.

  • Details: v3 Interpretation Codes

    System: http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation

  • Details: For more information, see Code Set 52 Interpretation Result under the List of Code Sets section in Proprietary Codes and Systems.

    System: https://fhir.cerner.com/<EHR_source_id>/codeSet/52

• Observation.component.code

  Description: Codes identifying names of simple observations.

  • Details: LOINC

    System: http://loinc.org

  • Details: SNOMED CT

    System: http://snomed.info/sct

  • Details: For more information, see Code Set 72 Clinical Event Codes under the List of Code Sets section in Proprietary Codes and Systems.

    System: https://fhir.cerner.com/<EHR_source_id>/codeSet/72

• Observation.component.interpretation

  Description: Codes identifying interpretations of observations.

  • Details: v3 Interpretation Codes

    System: http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation

  • Details: For more information, see Code Set 52 Interpretation Result under the List of Code Sets section in Proprietary Codes and Systems.

    System: https://fhir.cerner.com/<EHR_source_id>/codeSet/52

• Observation.component.dataAbsentReason

  Description: Codes for reasons data is absent.

  Details: v4 data absentreason

  System: http://terminology.hl7.org/CodeSystem/data-absent-reason

Extensions

• convertedMeasurement This extension returns a converted measurement of a different measurement system than the original quantity.

• performerFunction

• valueAttachment: URL for this extension is defined as: https://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.valueAttachment This extension is defined and referenced from the newer version of FHIR. See Extensions for converting between versions and R5 Snapshot of Observation.value for more information.