Using DigiDOT Observation

Purpose

Use DigiDOT Observation for a dental measurement, assessment result, patient-reported score or calculated indicator.

Use DigiDOT Condition for the clinically significant finding, diagnosis or problem. An Observation can provide the measurement or assessment evidence for that Condition.

Care context

Link the observation to the relevant context when known:

  • subject identifies the patient.
  • encounter identifies the dental contact where it was made.
  • basedOn points to the DigiDOT ServiceRequest that planned or requested the examination or assessment.
  • effectiveDateTime records when the result was true.
  • performer identifies the clinician, role, organisation or patient responsible for the result.

Use Condition.evidence.detail to link a confirmed dental finding to the Observation that supports it.

Coding and result

Observation.code states what was measured, assessed, reported or calculated. Prefer a SNOMED CT observable entity when available. The DigiDOT Observation codes ValueSet also includes the small, governed DigiDOT code list for calculated indices and interim observation codes.

Use valueQuantity for a measured quantity with UCUM units, valueCodeableConcept for a coded result, valueInteger for a score or count, and component for related values that share the same context. Use dataAbsentReason when an expected simple result is unavailable.

method records how an observation was made or calculated when that is not implicit in code. Use the preferred Observation method ValueSet during this draft. Source-system and import information belong in Provenance or source metadata, not in method. Use derivedFrom when an observation is derived from an image, document, questionnaire response or another observation.

For a DMFT or DMFS result, make the applicable dentition and calculation convention available in the source or associated assessment documentation. For a pain score, make the instrument and scale available in the source or associated questionnaire documentation.

Tooth, surface and patient-specific anatomy

Observation.bodySite is one FHIR R4 CodeableConcept. It can contain zero or more tooth codings when no surface is recorded. When one or more surface codings are present, the same bodySite must contain exactly one tooth coding.

For surfaces on more than one tooth, record one Observation per tooth. Use component only for values that share the same anatomical context.

When a patient-specific anatomical entity needs its own identifier, image or persistent qualifier, reference the BodyStructure from Observation.focus. The coded bodySite remains the structured tooth and surface context and represents the same anatomy.

Examples