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draft Template  Simple Observation

Template 1.3.6.1.4.1.19376.1.5.3.1.4.13 - EntrySimpleObservation
Id 1.3.6.1.4.1.19376.1.5.3.1.4.13
Version valid from 2013‑12‑20 status draft Under develeopment
Classification CDA Entry Level Template
Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.13
Open/Closed Open (other than defined elements are allowed)
Description

The simple observation entry is meant to be an abstract representation of many of the observations used in this specification. It can be made concrete by the specification of a few additional constraints, namely the vocabulary used for codes, and the value representation. A simple observation may also inherit constraints from other specifications (e.g., ASTM/HL7 Continuity of Care Document).

Used by / Uses
Used by / Uses 3 templates
Used by Template id as Name Version
1.3.6.1.4.1.19376.1.5.3.1.3.28 Containment SectionCodedResults Section Coded Results 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link epSOS-PS epSOS-Patient Summary 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 link epSOS-HCER epSOS-Health Care Encounter Report 2013‑12‑20
Item DT Card Conf Description Label
hl7:observation
1 .. 1 R

These acts are simply observations that have occurred, and so are recored using the <observation> element as shown above.

(EntrySimpleObservation)
treetree @classCode
1 .. 1 F OBS
treetree @moodCode
1 .. 1 F EVN
  Example <observation classCode="OBS" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
  <id root="" extension=""/>
  <code code="" displayName="" codeSystem="" codeSystemName=""/>
  <text>
    <reference value="#xxx"/>
  </text>  <statusCode code="completed"/>
  <effectiveTime value=""/>
  <repeatNumber value=""/>
  <value xsi:type=""/>
  <interpretationCode code="" codeSystem="" codeSystemName=""/>
  <methodCode code="" codeSystem="" codeSystemName=""/>
  <targetSiteCode code="" codeSystem="" codeSystemName=""/>
  <author typeCode="AUT">
    <assignedAuthor typeCode="ASSIGNED">
      <id root="" extension=""/>
    </assignedAuthor>  </author></observation>
treetree hl7:templateId
II.EPSOS 1 .. 1 M (EntrySimpleObservation)
treeblank treetree @root
1 .. 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.13
treetree hl7:templateId
II.EPSOS 1 .. * R (EntrySimpleObservation)
treetree hl7:id
II.EPSOS 1 .. 1 M

Each observation shall have an identifier.

(EntrySimpleObservation)
treetree hl7:code
CD 1 .. 1 M

Observations shall have a code describing what was measured. The code system used is determined by the vocabulary constraints on the types of measurements that might be recorded in a section. Content modules that are derived from the Simple Observation content module may restrict the code system and code values used for the observation.

(EntrySimpleObservation)
treeblank treetree @code
1 .. 1 F 34530-6
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (LOINC)
treetree hl7:text
ED 1 .. * R

Each observation measurement entry may contain a <text> element providing the free text that provides the same information as the observation within the narrative portion of the document with a <text> element. For CDA based uses of Simple Observations, this element SHALL be present, and SHALL contain a <reference> element that points to the related string in the narrative portion of the document. For HL7 Version 3 based uses, the <text> element MAY be included.

(EntrySimpleObservation)
treetree hl7:statusCode
CD 1 .. 1 M

The status code of all observations shall be completed.

(EntrySimpleObservation)
treeblank treetree @code
1 .. 1 F completed
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.5.14 (ActStatus)
treetree hl7:effectiveTime
IVL_TS 1 .. * R

The <effectiveTime> element shall be present in standalone observations , and shall record the date and time when the measurement was taken. This element should be precise to the day. If the date and time is unknown, this element should record that using the nullFlavor attribute.

(EntrySimpleObservation)
treetree hl7:value
ANY 1 .. * R

The value of the observation shall be recording using a data type appropriate to the observation. Content modules derived from the Simple Observation content module may restrict the allowable data types used for the observation.

(EntrySimpleObservation)
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.20 epSOSBloodGroup (DYNAMIC)
treetree hl7:interpretationCode
CD 1 .. * R

If there is an interpretation that can be performed using an observation result (e.g., high, borderline, normal, low), these may be recorded within the interpretationCode element.

(EntrySimpleObservation)
treetree hl7:methodCode
CD 1 .. * R

The methodCode element may be used to record the specific method used to make an observation when this information is not already pre-coordinated with the observation code .

(EntrySimpleObservation)
treetree hl7:targetSiteCode
CD 1 .. * R

The targetSiteCode may be used to record the target site where an observation is made when this information is not already pre-coordinated with the observation code.

(EntrySimpleObservation)
treetree hl7:author
1 .. * R

In CDA uses, SimpleObservations are assumed to be authored by the same author as the document through context conduction. However specific authorship of observation may be represented by listing the author in the header and referencing the author in a <author> relationship. If authors are explicitly listed in documents, an <id> element SHOULD reference the ID of the author in the header through an assignedAuthor Role. If the author of the observation is not an author of the document the <person> object including a name and ID SHALL be included.

(EntrySimpleObservation)