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ref Template  Simple Observation

Id Effective Date valid from 2013‑12‑20
Status draft Draft Version Label
Name EntrySimpleObservation Display Name Simple Observation

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).

2017-07-18 Reverted to the original IHE specification of this template.

Note that this template was specified by IHE PCC. Find the referenced specification here:

Context Parent nodes of template element with id
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
<observation classCode="OBS" moodCode="EVN">
  <templateId root=""/>  <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>
notice There are open issues with this item:
Item DT Card Conf Description Label
1 … 1 R

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

cs 1 … 1 F OBS
cs 1 … 1 F EVN
II.EPSOS 1 … 1 M (Entdotsion)
uid 1 … 1 F
II.EPSOS 1 … 1 M

Each observation shall have an identifier.

CD 1 … 1 R

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.

ED 1 … 1 M

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.

CS 1 … 1 M

The status code of all observations shall be completed.

CONF 1 … 1 F completed
IVL_TS 1 … 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.

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.