Observation Definition

$10 / year

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.

Complexity

At its core, Observation allows expressing a name-value pair or structured collection of name-value pairs. As such, it can support conveying any type of information desired. However, that is not its intent. Observation is intended for capturing measurements and subjective point-in-time assessments. It is not intended to be used for those specific contexts and use cases already covered by other FHIR resources. For example, the Allergy Intolerance resource represents patient allergies, Medication Statement resource: medications taken by a patient, Family Member History resource: a patient’s family history, Procedure resource: information about a procedure, and Questionnaire Response resource: a set of answers to a set of questions.

The Observation resource should not be used to record clinical diagnosis about a patient or subject that are typically captured in the Condition resource or the Clinical Impression resource. The Observation resource is often referenced by the Condition resource to provide specific subjective and objective data to support its assertions. There will however be situations of overlap. For example, a response to a question of “have you ever taken illicit drugs” could in principle be represented using Medication Statement, but most systems would treat such an assertion as an Observation. In some cases, such as when source data is coming from an Health Level Seven International (HL7) volume two feed, a system might not have information that allows it to distinguish diagnosis, allergy and other “specialized” types of observations from laboratory, vital sign and other observation types intended to be conveyed with this resource. In those circumstances, such specialized observations may also appear using this resource. Adhering to such convention is an appropriate use of Observation. If implementers are uncertain whether a proposed use of Observation is appropriate, they’re encouraged to consult with implementers.

Date Created

2018-09-20

Last Modified

2019-11-01

Version

4.0.1

Update Frequency

Annual

Temporal Coverage

N/A

Spatial Coverage

United States

Source

John Snow Labs; Health Level Seven International;

Source License URL

Source License Requirements

N/A

Source Citation

N/A

Keywords

FHIR, HL7, Medical Terminology, Processes Data, Processes Information, Processes Documentation, Health Information Exchange, Electronic Health Records, FHIR Smart, Smart on FHIR

Other Titles

FHIR Observation Definition Resource, Electronic Health Records Exchange Through FHIR

NameDescriptionTypeConstraints
Concept_NameName of the concept in the FHIR structure.stringrequired : 1
Computer_Ready_NameA Computer-ready name (e.g. a token) that identifies the structure - suitable for code generation. Note that this name (and other names relevant for code generation, including element & slice names, codes etc) may collide with reserved words in the relevant target language, and code generators will need to handle this.string-
TypeThe type the structure describes.string-
Dollar_RefThe "$ref" string value contains a Uniform Resource Identifier (URI) which identifies the location of the JSON value being referenced.string-
DescriptionA free text natural language description of the structure and its use.string-
ItemsThe value of the keyword should be an object or an array of objects. If the keyword value is an object, then for the data array to be valid each item of the array should be valid according to the schema in this value.string-
EnumThe enum is used to restrict a value to a fixed set of values. It must be an array with at least one element, where each element is unique.string-
RequiredThe value of the keyword should be an array of unique strings. The data object to be valid should contain all properties with names equal to the elements in the keyword value.string-
ConstThe value of this keyword can be anything. The data is valid if it is deeply equal to the value of the keyword.string-
Concept NameComputer Ready NameTypeDollar RefDescriptionItemsEnumRequiredConst
ObservationDefinitionresourceTypeThis is a ObservationDefinition resourceObservationDefinition
ObservationDefinitionid#/definitions/idThe logical id of the resource as used in the URL for the resource. Once assigned this value never changes.
ObservationDefinitionmeta#/definitions/MetaThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
ObservationDefinitionimplicitRules#/definitions/uriA reference to a set of rules that were followed when the resource was constructed and which must be understood when processing the content. Often this is a reference to an implementation guide that defines the special rules along with other profiles etc.
ObservationDefinition_implicitRules#/definitions/ElementExtensions for implicitRules
ObservationDefinitionlanguage#/definitions/codeThe base language in which the resource is written.
ObservationDefinition_language#/definitions/ElementExtensions for language
ObservationDefinitiontext#/definitions/NarrativeA human-readable narrative that contains a summary of the resource and can 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 "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
ObservationDefinitioncontainedarrayThese 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.{'$ref': '#/definitions/ResourceList'}
ObservationDefinitionextensionarrayMay be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension there is a set of requirements that SHALL be met as part of the definition of the extension.{'$ref': '#/definitions/Extension'}
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