class: observation

public class: observation
Author:
Project: Phase: 1.0; Status: Proposed; Version: 1.0; Complexity: 1
Dates: Created: 30/12/2005 16:30:54; Modified: 09/02/2006 14:59:30;
Flags: Active: false; IsRoot: false; IsLeaf: false;
Extension Points:
UUID: {31F452BA-BDDF-4b6d-A204-2D242000A7D0}
An observation statement is used to carry most elements of a referral. This includes problem being referred, investigations, examinations, diagnoses, social history and family history.

There shall be an observation statement that carries the problem being referred.
 

Goto: Custom Properties, Fields

Extends: statement

See also: statement

Appears in: Communication Description, Choose and Book Referral Status

Connections
 
Custom Properties
 
observation Attributes
Attribute Details
public interval
  activityTime
Range:0 to 1
Notes: Date/time of the observation.
public complexCode
  code
Notes: A code specifying the nature of the observation.

Observation shall be coded with additional information held in Observation Commentary.

Any of the Concept Descriptor datatype flavours can be used and will include the following attributes:

The code attribute shall contain a value
The codeSystem attribute shall contain an OID as defined below.

The data fields in the message are constructed to support future strategic use of SNOMED CT codes. If these codes are not currently available to populate the message, a suitable alternative from an identified coding scheme should be found.
public timestamp
  effectiveTime
Range:0 to 1
Notes: The clinically relevant date and time.

Eg. For an investigation result it is the time of sampling not the time of analysis or reporting.
public int
  interpretationCode
Range:0 to 1
Notes: A Interpretation code indicating whether a set of observations were interpreted as abnormal by the party responsible for undertaking the original observations.
public detailItem
  pertinentObservationCommentary
Range:0 to 1
Notes: This is an attribute of type detailItem that is represented elsewhere in the diagram.

Additional comments about an observation. This SHALL NOT contradict any coded information.
public normalRange
  referenceNormalRange
Range:0 to *
Notes: Information about the normal reference range for a laboratory result.

This is an attribute of type normalRange that is represented elsewhere in the diagram.
public string
  text
Range:0 to 1
Notes: Text specifying the nature of the observation.

MIM states: "Text shall only be used if no code value is available and SHALL NOT be used in conjunction with Observation Commentary."

The intention is for the text to be an alternative to the coded description. Regardless of whether a code or text is used to describe the observation, the observation commentary can be provided. However, the text, if provided, shall not be used to contradict or describe the same information as the observation commentary.
public string
  uncertaintyCode
Range:0 to 1
Notes: Allows the author to indicate using an ActUncertainty code that the components within a statement are in some way uncertain.
public ANY
  value
Range:0 to 1
Notes: The result value of an observation action.The result value of an observation action. The following are the approved uses for clinical observations within the NPfIT:

Quantitative measurement - PQ::Physical quantity (real number with unit. This includes time periods, e.g. 30 minutes, 2 days)

Titre (eg.,1:64) and other ratios - RTO :: A ratio of two integer numbers

Index (number without unit) - PQ with a dimensionless unit (e.g., an integer or real number

Ranges (eg.,<3;12-20) - IVL<PQ> :: Interval of physical quantity)

Ordinals (eg.,stage lIa. ++) - CO - coded ordinals

Non-ordinal Values represented using a controlled terminology (e.g. organism type shigella.. Note such values are of the concept given by the observation.code, and do not replace it.

CV, with mandatory code & coding system id, version id required (i.e. must be used where relevant), display name optional, original text not applicable, and code system name optional . This would include binary codes, which should be given more specific meaning such as present / absent, true / false by this means.

Uncoded nominal results (eg.,organism type)

ST a string (This representation is deprecated, and CV should be used in it's stead wherever possible)

Blobs(images, scanned documents, biosignals, audio recordings)

ED - the reference and thumbnail properties are not applicable.