Observations are a central element in healthcare, used to support diagnosis, monitor progress, determine baselines and patterns and even capture demographic characteristics. Note that the Diagnostic Report resource provides a clinical or workflow context for a set of observations and the Observation resource is referenced by Diagnostic Report to represent laboratory, imaging, and other clinical and diagnostic data to form a complete report.
Uses for the Observation resource include:
– Vital signs such as body weight, blood pressure, and temperature
– Laboratory Data like blood glucose, or an estimated Glomerular Filtration Rate (GFR)
– Imaging results like bone density or fetal measurements
– Clinical Findings such as abdominal tenderness
– Device measurements such as Electrocardiogram (EKG) data or Pulse Oximetry data
– Clinical assessment tools such as ‘Appearance, Pulse, Grimace, Activity, and Respiration (APGAR)’ or a Glasgow Coma Score
– Personal characteristics: such as eye-color
– Social history like tobacco use, family support, or cognitive status
– Core characteristics like pregnancy status, or a death assertion
The boundaries between clinical findings and disorders remains a challenge in medical ontology. These boundaries can be clarified by profiling Observation for a particular use case.
The Media resource captures a specific type of observation whose value is audio, video or image data. This resource is used instead of Observation to represent such forms of information as it exposes the metadata relevant for interpreting the information.
In contrast to the Observation resource, the Diagnostic Report resource typically includes additional clinical context and some mix of atomic results, images, imaging reports, textual and coded interpretation, and formatted representations. Laboratory reports, pathology reports, and imaging reports should be represented using the Diagnostic Report resource. The Observation resource is referenced by the Diagnostic Report to provide the atomic results for a particular investigation. “Laboratories routinely have a variable that is summative across a series of discrete variables – these are usually called ‘impressions’ or ‘interpretations’. Sometimes they are algorithmically specified and sometimes they have the imprimatur of pathologists and they are conveyed in Observation or Diagnostic Report instead of the Clinical Impression resource. The Observation resource should not be used to record clinical diagnosis about a patient or subject.