Observations
Observations are a central element in healthcare, used to support diagnosis, monitor progress, determine baselines and patterns and even capture demographic characteristics, as well as capture results of tests performed on products and substances. 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.
Overview
| Filter name in app | Priority | FHIR field (PFS) | Brief description | Example data |
|---|---|---|---|---|
| ID | Must have | Observation.identifier.value | Unique identifier for report. | |
| Description | Must have | Observation.code.coding.display | Name of the observation that was measured / tested. | Weight, BMI, SpO2, LDL Cholesterol, albumin. |
| Method | Should have | Observation.method.coding.display | Method used to get to the observation result. | Spirometry, PCR, ELISA, biochemistry. |
| Specimen | Must have | Observation.specimen | Sample or material on which the measurement or test was performed. Especially used for lab tests, microbiology-, histological- or cytological tests. | Blood, urine, sputum, needle biopsy. |
| Subcategory | Should have | Not yet mapped | A subcategory that gives more details on the type of observation you are looking at. | Lab result, vital sign, physical examination. |
| Textual value | Must have | Observation.value[x].valueString or Observation.component.value[x].valueString | Textual expression of the result of the measurement or test. | Positive; +; above average |
| Numeric value | Must have | Observation.value[x].valueQuantity.value or Observation.component.value[x].valueQuantity.value | Numerical expression of the result of the measurement or test. | 2.6 mM; 5.6 mmol/L, 50 units |
| Unit | Must have | Observation.value[x].valueQuantity.unit or Observation.component.value[x].valueQuantity.unit | Unit linked to the numerical value. | mM, mmol/L, units |
| Age at time of event | Must have | Derived from Patient (Observation.subject) | Age of the patient, in years, when the observation was made. | |
| Status | Could have | Observation.status | Status of the measurement / test | Planned, accepted, completed. |
| Specialism | Should have | Derived from performer (Observation.performer) | Specialism that recorded the observation. | Gastroenterology, endocrinology, oncology |
| Department | Could have | Observation.department (extension) | Department that recorded the observation. | Dietetics, diabetes outpatient clinic, MS clinic. |
| Location | Could have | Not yet mapped | The location (hospital building) where the observation was recorded. | Location oost, location south. |
| Performed by | Could have | Observation.performer (Practitioner) | Name of the care provider that executed the test or measurement. | |
| Body site | Should have | Observation.bodySite.coding.display | The body part on which the test was performed or where the specimen was taken fromm | (Needle biopsy of) breast, skin, femur |
| Device | Could have | Observation.device | Device used to perform the observation or the test. | Spirometer, specific kind of echo device |
| Interpretation | Could have | Not yet mapped | Interpretation or explanation of the result of the observation, measurement or test by the person that analysed the results. | |
| Start date | Must have | Observation.effective[x].effectiveDateTime or Observation.effective[x].effectivePeriod.start | Date on which the test was performed to get to the numerical or textual result. | DD-MM-YYYY hh:mm |
| Registration date | Should have | Not yet mapped | Date on which the results was recorded in the system (EHR or separate lab result system such as GLIMS). | DD-MM-YYYY hh:mm |