EHDS refined base model for Observation information

Common header for all patient-related data

Patient/subject information

Business identifier for the object

Resource authoring details

Author(s) by whom the resource was/were authored. Multiple authors could be provided.

Date and time of the issuing the document/resource by its author.

Date and time of the last update to the document/information

Status of the resource

HL7 Observation status

Reason for the current status of the resource.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Business version of the resource.

A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document

The patient, or group of patients, location, device, organization, procedure or practitioner this observation is about.

Clinically relevant time or time period for the observation.

Code representing the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Original (conventional) name of the observation 

Observation method (measurement principle) to obtain the result.

SNOMED CT

Identifies order and order placer this observation belongs to. 

Identifies the originator/author and provides provenance information about the source of the results data that may have not originated with the source of the whole Laboratory Report document. 

With certain observation results, e.g. there may also be an interpreter or a person responsible for validation.

Result of the observation including text, numeric and coded results of the measurement and measurement uncertainty. Content of the observation result will vary according to the type of the observation.

Narrative text result

A numeric value or interval (open or closed) of the result, result units of the measurement should be provided Measurement uncertainty interval are provided if needed.

A numeric value or interval (open or closed) of the result

Result units of the measurement

UCUM

Measurement uncertainty type and interval should be provided if needed.

A coded result from a selected coding system(s). This could be a code describing bacteria or other microorganism identified, description of urinary concernment, code explaining technical reason why the test could not be done etc.

SNOMED CT

Provides a reason why the expected value in the element Observation.value[x] is missing.

HL7 Data absent reason

Reference range, multiple reference ranges of different types culd by providedProvides guide for interpretation of result. Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

Information about reference intervals and result interpretation.

SNOMED CT, HL7 ObservationInterpretation

Identifies the observation(s) that triggered the performance of this observation.

This observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group.

Comments and narrative representation of the observation result and findings.

Anatomic location and laterality where the observation should be or was performed.

SNOMED CT

Some observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes.

Code representing the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Narrative text result

A numeric value or interval (open or closed) of the result, result units of the measurement should be provided Measurement uncertainty interval are provided if needed.

A numeric value or interval (open or closed) of the result

Result units of the measurement

UCUM

Measurement uncertainty type and interval should be provided if needed.

A coded result from a selected coding system(s). This could be a code describing bacteria or other microorganism identified, description of urinary concernment, code explaining technical reason why the test could not be done etc.

SNOMED CT

Provides a reason why the expected value in the element Observation.value[x] is missing.

HL7 Data absent reason

Reference range, multiple reference ranges of different types culd by providedProvides guide for interpretation of result. Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

Information about reference intervals and result interpretation.

SNOMED CT, HL7 ObservationInterpretation

Related resource from which the observation has been made. For example, a calculated anion gap or a fetal measurement based on an ultrasound image.

EHDS refined base model for Observation information

HL7 Observation status

The patient, or group of patients, location, device, organization, procedure or practitioner this observation is about.

Clinically relevant time or time period for the observation.

Code representing the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Original (conventional) name of the observation 

Observation method (measurement principle) to obtain the result.

SNOMED CT

Identifies order and order placer this observation belongs to. 

Identifies the originator/author and provides provenance information about the source of the results data that may have not originated with the source of the whole Laboratory Report document. 

With certain observation results, e.g. there may also be an interpreter or a person responsible for validation.

Result of the observation including text, numeric and coded results of the measurement and measurement uncertainty. Content of the observation result will vary according to the type of the observation.

Narrative text result

A numeric value or interval (open or closed) of the result, result units of the measurement should be provided Measurement uncertainty interval are provided if needed.

A numeric value or interval (open or closed) of the result

Result units of the measurement

UCUM

Measurement uncertainty type and interval should be provided if needed.

A coded result from a selected coding system(s). This could be a code describing bacteria or other microorganism identified, description of urinary concernment, code explaining technical reason why the test could not be done etc.

SNOMED CT

Provides a reason why the expected value in the element Observation.value[x] is missing.

HL7 Data absent reason

Reference range, multiple reference ranges of different types culd by providedProvides guide for interpretation of result. Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

Information about reference intervals and result interpretation.

SNOMED CT, HL7 ObservationInterpretation

Identifies the observation(s) that triggered the performance of this observation.

This observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group.

Comments and narrative representation of the observation result and findings.

Anatomic location and laterality where the observation should be or was performed.

SNOMED CT

Some observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes.

Code representing the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Narrative text result

A numeric value or interval (open or closed) of the result, result units of the measurement should be provided Measurement uncertainty interval are provided if needed.

A numeric value or interval (open or closed) of the result

Result units of the measurement

UCUM

Measurement uncertainty type and interval should be provided if needed.

A coded result from a selected coding system(s). This could be a code describing bacteria or other microorganism identified, description of urinary concernment, code explaining technical reason why the test could not be done etc.

SNOMED CT

Provides a reason why the expected value in the element Observation.value[x] is missing.

HL7 Data absent reason

Reference range, multiple reference ranges of different types culd by providedProvides guide for interpretation of result. Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

Information about reference intervals and result interpretation.

SNOMED CT, HL7 ObservationInterpretation

Related resource from which the observation has been made. For example, a calculated anion gap or a fetal measurement based on an ultrasound image.

EHDS refined base model for Observation information

Common header for all patient-related data

Patient/subject information

Business identifier for the object

Resource authoring details

Author(s) by whom the resource was/were authored. Multiple authors could be provided.

Date and time of the issuing the document/resource by its author.

Date and time of the last update to the document/information

Status of the resource

HL7 Observation status

Reason for the current status of the resource.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Business version of the resource.

A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document

The patient, or group of patients, location, device, organization, procedure or practitioner this observation is about.

Clinically relevant time or time period for the observation.

Code representing the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Original (conventional) name of the observation 

Observation method (measurement principle) to obtain the result.

SNOMED CT

Identifies order and order placer this observation belongs to. 

Identifies the originator/author and provides provenance information about the source of the results data that may have not originated with the source of the whole Laboratory Report document. 

With certain observation results, e.g. there may also be an interpreter or a person responsible for validation.

Result of the observation including text, numeric and coded results of the measurement and measurement uncertainty. Content of the observation result will vary according to the type of the observation.

Narrative text result

A numeric value or interval (open or closed) of the result, result units of the measurement should be provided Measurement uncertainty interval are provided if needed.

A numeric value or interval (open or closed) of the result

Result units of the measurement

UCUM

Measurement uncertainty type and interval should be provided if needed.

A coded result from a selected coding system(s). This could be a code describing bacteria or other microorganism identified, description of urinary concernment, code explaining technical reason why the test could not be done etc.

SNOMED CT

Provides a reason why the expected value in the element Observation.value[x] is missing.

HL7 Data absent reason

Reference range, multiple reference ranges of different types culd by providedProvides guide for interpretation of result. Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

Information about reference intervals and result interpretation.

SNOMED CT, HL7 ObservationInterpretation

Identifies the observation(s) that triggered the performance of this observation.

This observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group.

Comments and narrative representation of the observation result and findings.

Anatomic location and laterality where the observation should be or was performed.

SNOMED CT

Some observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes.

Code representing the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Narrative text result

A numeric value or interval (open or closed) of the result, result units of the measurement should be provided Measurement uncertainty interval are provided if needed.

A numeric value or interval (open or closed) of the result

Result units of the measurement

UCUM

Measurement uncertainty type and interval should be provided if needed.

A coded result from a selected coding system(s). This could be a code describing bacteria or other microorganism identified, description of urinary concernment, code explaining technical reason why the test could not be done etc.

SNOMED CT

Provides a reason why the expected value in the element Observation.value[x] is missing.

HL7 Data absent reason

Reference range, multiple reference ranges of different types culd by providedProvides guide for interpretation of result. Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

Information about reference intervals and result interpretation.

SNOMED CT, HL7 ObservationInterpretation

Related resource from which the observation has been made. For example, a calculated anion gap or a fetal measurement based on an ultrasound image.