Id1.3.6.1.4.1.19376.1.5.3.1.4.13
ref
epsos-
Effective Date2013‑12‑20
Statusretired RetiredVersion Label
NameEntrySimpleObservationDisplay NameSimple Observation
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).

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: 
https://art-decor.ihe-europe.net/art-decor/decor-templates--IHE-PCC-?section=templates&id=1.3.6.1.4.1.19376.1.5.3.1.4.13

ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.13
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 27 concepts
IdNameData Set
ehr4cr2ehsdi-dataelement-498draft Body Mass Index (BMI) draft Test
ehr4cr2ehsdi-dataelement-499draft Cardiac function draft Test
ehr4cr2ehsdi-dataelement-503draft Forced expiratory volume in 1 second / forced vital capacity (FEV1/FVC) ratio draft Test
ehr4cr2ehsdi-dataelement-508draft Intraocular pressure draft Test
ehr4cr2ehsdi-dataelement-512draft Percent predicted forced expiratory volume in 1 second (FEV1) draft Test
ehr4cr2ehsdi-dataelement-523draft RR Interval draft Test
ehr4cr2ehsdi-dataelement-392draft Heart rate draft Test
ehr4cr2ehsdi-dataelement-394draft Sinus Rhythm draft Test
ehr4cr2ehsdi-dataelement-395draft PR Interval draft Test
ehr4cr2ehsdi-dataelement-396draft ECG Clinical Findings draft Test
ehr4cr2ehsdi-dataelement-397draft QRS Interval / Complex draft Test
ehr4cr2ehsdi-dataelement-398draft QT Interval draft Test
ehr4cr2ehsdi-dataelement-399draft QTCB Interval draft Test
ehr4cr2ehsdi-dataelement-400draft QTCF Interval draft Test
ehr4cr2ehsdi-dataelement-522draft Date Of Assessment draft Test
ehr4cr2ehsdi-dataelement-552draft X-ray Finding draft Test
ehr4cr2ehsdi-dataelement-551draft LVEF draft Test
ehr4cr2ehsdi-dataelement-548draft CT Scan Finding draft Test
ehr4cr2ehsdi-dataelement-541draft Abdominal Ultrasound Finding draft Test
ehr4cr2ehsdi-dataelement-540draft Date / Time of Finding draft Test
ehr4cr2ehsdi-dataelement-542draft Weight draft Test
ehr4cr2ehsdi-dataelement-543draft Height draft Test
ehr4cr2ehsdi-dataelement-544draft Temperature draft Test
ehr4cr2ehsdi-dataelement-545draft Pulse draft Test
ehr4cr2ehsdi-dataelement-549draft ECOG draft Test
ehr4cr2ehsdi-dataelement-550draft Heart rate draft Test
ehr4cr2ehsdi-dataelement-515draft Spirometry draft Test
Example
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>
ItemDTCardConfDescriptionLabel
hl7:observation
1 … 1R

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

Entrdotstion
@classCode
cs1 … 1FOBS
@moodCode
cs1 … 1FEVN
hl7:templateId
II.EPSOS1 … 1MEntrdotstion
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.13
hl7:id
II.EPSOS1 … 1M

Each observation shall have an identifier.

Entrdotstion
hl7:code
CD1 … 1R

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.

Entrdotstion
 
target
ehr4cr2ehsdi-dataelement-498draft Body Mass Index (BMI) draft Test
ehr4cr2ehsdi-dataelement-499draft Cardiac function draft Test
ehr4cr2ehsdi-dataelement-503draft Forced expiratory volume in 1 second / forced vital capacity (FEV1/FVC) ratio draft Test
ehr4cr2ehsdi-dataelement-508draft Intraocular pressure draft Test
ehr4cr2ehsdi-dataelement-512draft Percent predicted forced expiratory volume in 1 second (FEV1) draft Test
ehr4cr2ehsdi-dataelement-515draft Spirometry draft Test
ehr4cr2ehsdi-dataelement-541draft Abdominal Ultrasound Finding draft Test
ehr4cr2ehsdi-dataelement-542draft Weight draft Test
ehr4cr2ehsdi-dataelement-543draft Height draft Test
ehr4cr2ehsdi-dataelement-544draft Temperature draft Test
ehr4cr2ehsdi-dataelement-545draft Pulse draft Test
ehr4cr2ehsdi-dataelement-548draft CT Scan Finding draft Test
ehr4cr2ehsdi-dataelement-549draft ECOG draft Test
ehr4cr2ehsdi-dataelement-550draft Heart rate draft Test
ehr4cr2ehsdi-dataelement-551draft LVEF draft Test
ehr4cr2ehsdi-dataelement-552draft X-ray Finding draft Test
ehr4cr2ehsdi-dataelement-392draft Heart rate draft Test
ehr4cr2ehsdi-dataelement-523draft RR Interval draft Test
ehr4cr2ehsdi-dataelement-394draft Sinus Rhythm draft Test
ehr4cr2ehsdi-dataelement-395draft PR Interval draft Test
ehr4cr2ehsdi-dataelement-396draft ECG Clinical Findings draft Test
ehr4cr2ehsdi-dataelement-397draft QRS Interval / Complex draft Test
ehr4cr2ehsdi-dataelement-398draft QT Interval draft Test
ehr4cr2ehsdi-dataelement-399draft QTCB Interval draft Test
ehr4cr2ehsdi-dataelement-400draft QTCF Interval draft Test
hl7:text
ED1 … 1M

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.

Entrdotstion
hl7:statusCode
CS1 … 1M

The status code of all observations shall be completed.

Entrdotstion
@code
CONF1 … 1Fcompleted
hl7:effectiveTime
IVL_TS1 … 1R

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.

Entrdotstion
 
target
ehr4cr2ehsdi-dataelement-522draft Date Of Assessment draft Test
ehr4cr2ehsdi-dataelement-540draft Date / Time of Finding draft Test
hl7:value
ANY1 … *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.

Entrdotstion
 
target
ehr4cr2ehsdi-dataelement-498draft Body Mass Index (BMI) draft Test
ehr4cr2ehsdi-dataelement-499draft Cardiac function draft Test
ehr4cr2ehsdi-dataelement-503draft Forced expiratory volume in 1 second / forced vital capacity (FEV1/FVC) ratio draft Test
ehr4cr2ehsdi-dataelement-508draft Intraocular pressure draft Test
ehr4cr2ehsdi-dataelement-512draft Percent predicted forced expiratory volume in 1 second (FEV1) draft Test
ehr4cr2ehsdi-dataelement-523draft RR Interval draft Test
ehr4cr2ehsdi-dataelement-392draft Heart rate draft Test
ehr4cr2ehsdi-dataelement-394draft Sinus Rhythm draft Test
ehr4cr2ehsdi-dataelement-395draft PR Interval draft Test
ehr4cr2ehsdi-dataelement-396draft ECG Clinical Findings draft Test
ehr4cr2ehsdi-dataelement-397draft QRS Interval / Complex draft Test
ehr4cr2ehsdi-dataelement-398draft QT Interval draft Test
ehr4cr2ehsdi-dataelement-399draft QTCB Interval draft Test
ehr4cr2ehsdi-dataelement-400draft QTCF Interval draft Test
ehr4cr2ehsdi-dataelement-552draft X-ray Finding draft Test
ehr4cr2ehsdi-dataelement-551draft LVEF draft Test
ehr4cr2ehsdi-dataelement-548draft CT Scan Finding draft Test
ehr4cr2ehsdi-dataelement-541draft Abdominal Ultrasound Finding draft Test
ehr4cr2ehsdi-dataelement-542draft Weight draft Test
ehr4cr2ehsdi-dataelement-543draft Height draft Test
ehr4cr2ehsdi-dataelement-544draft Temperature draft Test
ehr4cr2ehsdi-dataelement-545draft Pulse draft Test
ehr4cr2ehsdi-dataelement-549draft ECOG draft Test
ehr4cr2ehsdi-dataelement-550draft Heart rate draft Test
ehr4cr2ehsdi-dataelement-515draft Spirometry draft Test