MyHealthEu refined model for observation in the context of hospital discharge report.

Basic metadata for this information

Patient/subject information

Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).

Author(s) responsible for the provided information. The exact role of the responsible author varies across use cases and is specific to individual models.

Date and optionally time of authoring/issuing

Status of the resource or document

HL7 Observation status

Source of information (e.g. patient, patient's proxy). Used in case the patient has authored the information or the author has submitted patient-stated information.

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

BCP 47

The direct subject of the observation if different from the patient (subject of care), e.g. an observation of an implanted device. Additional types of subject may be allowed in implementations.

Clinically relevant time or time period for the observation

Observation type. Code and name representing the type of the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Original (conventional) name of the observation as used in the local laboratory or clinical system.

Observation method (measurement principle) to obtain the result.

SNOMED CT

Specimen used for this observation.

Identifies order and order placer this observation belongs to

Performer of the observation. Some test could be performed by the patient himself or by a care giver. Those are in the scope of this deliverable under specified conditions.

Anatomic location and laterality where the observation was performed.

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

Observation result value according to the type of observation. Model covers only most frequently used data types but other data types can be used as well. Text result value should be used only if coded result value is not expected otherwise use valueCodeableConcept.text. For Quantity, Range and Ratio, result units of the measurement should be provided.

UCUM for units, SNOMED CT for coded results

Measurement uncertainty information about the observation result.

The numerical value of the measurement uncertainty.

Probability Distribution Type for uncertainty

HL7 ProbabilityDistributionType

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 could by provided. Provides guide for interpretation of the result.

Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

Low limit of the reference range.

UCUM for units

High limit of the reference range.

UCUM for units

Normal value, if relevant for the reference range.

SNOMED CT

Type of reference range.

HL7 Observation Reference Range Meaning Codes

Codes to indicate the target population this reference range applies to. For example, a reference range may be based on the normal population or a particular sex or race. Multiple appliesTo are interpreted as an "AND" of the target populations.

Multiple appliesTo are interpreted as an "AND" of the target populations.

SNOMED CT, HL7 v3-Race

Age range to which this reference range applies if applicable.

UCUM for units

Text based reference range in an observation which may be used when a quantitative range is not appropriate for an observation. An example would be a reference value of "Negative" or a list or table of "normals".

Information about reference intervals and result interpretation.

SNOMED CT, HL7 ObservationInterpretation

Comments and narrative representation of the observation result and findings.

Component in case the observation consists of multiple sub-observations (e.g. blood pressure).

Code representing the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Original (user-friendly) name of the observation as used in the local laboratory or clinical system.

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

Observation result value according to the type of observation. Model covers only most frequently used data types but other data types can be used as well. Text result value should be used only if coded result value is not expected otherwise use valueCodeableConcept.text. For Quantity, Range and Ratio, result units of the measurement should be provided.

UCUM for units, SNOMED CT for coded results

Measurement uncertainty information about the observation result.

The numerical value of the measurement uncertainty.

Probability Distribution Type for uncertainty

HL7 ProbabilityDistributionType

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

HL7 Data absent reason

Reference range, multiple reference ranges of different types could by provided. Provides guide for interpretation of the result.

Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

Low limit of the reference range.

UCUM for units

High limit of the reference range.

UCUM for units

Normal value, if relevant for the reference range.

SNOMED CT

Type of reference range.

HL7 Observation Reference Range Meaning Codes

Codes to indicate the target population this reference range applies to. For example, a reference range may be based on the normal population or a particular sex or race. Multiple appliesTo are interpreted as an "AND" of the target populations.

Multiple appliesTo are interpreted as an "AND" of the target populations.

SNOMED CT, HL7 v3-Race

Age range to which this reference range applies if applicable.

UCUM for units

Text based reference range in an observation which may be used when a quantitative range is not appropriate for an observation. An example would be a reference value of "Negative" or a list or table of "normals".

Information about reference intervals and result interpretation.

SNOMED CT, HL7 ObservationInterpretation

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

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.

MyHealthEu refined model for observation in the context of hospital discharge report.

MyHealthEu refined model for observation in the context of hospital discharge report.

Basic metadata for this information

Patient/subject information

Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).

Author(s) responsible for the provided information. The exact role of the responsible author varies across use cases and is specific to individual models.

Date and optionally time of authoring/issuing

Status of the resource or document

HL7 Observation status

Source of information (e.g. patient, patient's proxy). Used in case the patient has authored the information or the author has submitted patient-stated information.

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

BCP 47

The direct subject of the observation if different from the patient (subject of care), e.g. an observation of an implanted device. Additional types of subject may be allowed in implementations.

Clinically relevant time or time period for the observation

Observation type. Code and name representing the type of the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Original (conventional) name of the observation as used in the local laboratory or clinical system.

Observation method (measurement principle) to obtain the result.

SNOMED CT

Specimen used for this observation.

Identifies order and order placer this observation belongs to

Performer of the observation. Some test could be performed by the patient himself or by a care giver. Those are in the scope of this deliverable under specified conditions.

Anatomic location and laterality where the observation was performed.

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

Observation result value according to the type of observation. Model covers only most frequently used data types but other data types can be used as well. Text result value should be used only if coded result value is not expected otherwise use valueCodeableConcept.text. For Quantity, Range and Ratio, result units of the measurement should be provided.

UCUM for units, SNOMED CT for coded results

Measurement uncertainty information about the observation result.

The numerical value of the measurement uncertainty.

Probability Distribution Type for uncertainty

HL7 ProbabilityDistributionType

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 could by provided. Provides guide for interpretation of the result.

Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

Low limit of the reference range.

UCUM for units

High limit of the reference range.

UCUM for units

Normal value, if relevant for the reference range.

SNOMED CT

Type of reference range.

HL7 Observation Reference Range Meaning Codes

Codes to indicate the target population this reference range applies to. For example, a reference range may be based on the normal population or a particular sex or race. Multiple appliesTo are interpreted as an "AND" of the target populations.

Multiple appliesTo are interpreted as an "AND" of the target populations.

SNOMED CT, HL7 v3-Race

Age range to which this reference range applies if applicable.

UCUM for units

Text based reference range in an observation which may be used when a quantitative range is not appropriate for an observation. An example would be a reference value of "Negative" or a list or table of "normals".

Information about reference intervals and result interpretation.

SNOMED CT, HL7 ObservationInterpretation

Comments and narrative representation of the observation result and findings.

Component in case the observation consists of multiple sub-observations (e.g. blood pressure).

Code representing the observation using the agreed code systems.

LOINC, NPU, SNOMED CT

Original (user-friendly) name of the observation as used in the local laboratory or clinical system.

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

Observation result value according to the type of observation. Model covers only most frequently used data types but other data types can be used as well. Text result value should be used only if coded result value is not expected otherwise use valueCodeableConcept.text. For Quantity, Range and Ratio, result units of the measurement should be provided.

UCUM for units, SNOMED CT for coded results

Measurement uncertainty information about the observation result.

The numerical value of the measurement uncertainty.

Probability Distribution Type for uncertainty

HL7 ProbabilityDistributionType

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

HL7 Data absent reason

Reference range, multiple reference ranges of different types could by provided. Provides guide for interpretation of the result.

Reference ranges are usually implied only for a numeric scale type. Use of the same units for reference range and value is implied.

Low limit of the reference range.

UCUM for units

High limit of the reference range.

UCUM for units

Normal value, if relevant for the reference range.

SNOMED CT

Type of reference range.

HL7 Observation Reference Range Meaning Codes

Codes to indicate the target population this reference range applies to. For example, a reference range may be based on the normal population or a particular sex or race. Multiple appliesTo are interpreted as an "AND" of the target populations.

Multiple appliesTo are interpreted as an "AND" of the target populations.

SNOMED CT, HL7 v3-Race

Age range to which this reference range applies if applicable.

UCUM for units

Text based reference range in an observation which may be used when a quantitative range is not appropriate for an observation. An example would be a reference value of "Negative" or a list or table of "normals".

Information about reference intervals and result interpretation.

SNOMED CT, HL7 ObservationInterpretation

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

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.