HL7 Terminology
2.0.0 - Publication

This page is part of the HL7 Terminology (v2.0.0: Release) based on FHIR R4. The current version which supercedes this version is 5.2.0. For a full list of available versions, see the Directory of published versions

ValueSet: ActClassObservation

Summary

Defining URL:http://terminology.hl7.org/ValueSet/v3-ActClassObservation
Version:2.0.0
Name:ActClassObservation
Status:Active as of 2014-03-26
Definition:

**Description:**An act that is intended to result in new information about a subject. The main difference between Observations and other Acts is that Observations have a value attribute. The code attribute of Observation and the value attribute of Observation must be considered in combination to determine the semantics of the observation.

Discussion:

Structurally, many observations are name-value-pairs, where the Observation.code (inherited from Act) is the name and the Observation.value is the value of the property. Such a construct is also known as a variable (a named feature that can assume a value) hence, the Observation class is always used to hold generic name-value-pairs or variables, even though the variable valuation may not be the result of an elaborate observation method. It may be a simple answer to a question or it may be an assertion or setting of a parameter.

As with all Act statements, Observation statements describe what was done, and in the case of Observations, this includes a description of what was actually observed (results or answers); and those results or answers are part of the observation and not split off into other objects.

The method of action is asserted by the Observation classCode or its subclasses at the least granular level, by the Observation.code attribute value at the medium level of granularity, and by the attribute value of observation.methodCode when a finer level of granularity is required. The method in whole or in part may also appear in the attribute value of Observation.value when using coded data types to express the value of the attribute. Relevant aspects of methodology may also be restated in value when the results themselves imply or state a methodology.

An observation may consist of component observations each having their own Observation.code and Observation.value. In this case, the composite observation may not have an Observation.value for itself. For instance, a white blood cell count consists of the sub-observations for the counts of the various granulocytes, lymphocytes and other normal or abnormal blood cells (e.g., blasts). The overall white blood cell count Observation itself may therefore not have a value by itself (even though it could have one, e.g., the sum total of white blood cells). Thus, as long as an Act is essentially an Act of recognizing and noting information about a subject, it is an Observation, regardless of whether it has a simple value by itself or whether it has sub-observations.

Even though observations are professional acts (see Act) and as such are intentional actions, this does not require that every possible outcome of an observation be pondered in advance of it being actually made. For instance, differential white blood cell counts (WBC) rarely show blasts, but if they do, this is part of the WBC observation even though blasts might not be predefined in the structure of a normal WBC.

Clinical documents commonly have Subjective and Objective findings, both of which are kinds of Observations. In addition, clinical documents commonly contain Assessments, which are also kinds of Observations. Thus, the establishment of a diagnosis is an Observation.

Examples:

  • Recording the results of a Family History Assessment
  • Laboratory test and associated result
  • Physical exam test and associated result
  • Device temperature
  • Soil lead level
OID:2.16.840.1.113883.1.11.11529 (for OID based terminology systems)
Source Resource:XML / JSON / Turtle

References

Logical Definition (CLD)

 

Expansion

This value set contains 23 concepts

Expansion based on ActClass v3.0.0 (CodeSystem)

All codes from system http://terminology.hl7.org/CodeSystem/v3-ActClass

LvlCodeDisplayDefinition
0OBSobservation**Description:**An act that is intended to result in new information about a subject. The main difference between Observations and other Acts is that Observations have a value attribute. The **code** attribute of Observation and the **value** attribute of Observation must be considered in combination to determine the semantics of the observation. **Discussion:** Structurally, many observations are name-value-pairs, where the Observation.code (inherited from Act) is the name and the Observation.value is the value of the property. Such a construct is also known as a variable (a named feature that can assume a value) hence, the Observation class is always used to hold generic name-value-pairs or variables, even though the variable valuation may not be the result of an elaborate observation method. It may be a simple answer to a question or it may be an assertion or setting of a parameter. As with all Act statements, Observation statements describe what was done, and in the case of Observations, this includes a description of what was actually observed (results or answers); and those results or answers are part of the observation and not split off into other objects. The method of action is asserted by the Observation classCode or its subclasses at the least granular level, by the Observation.code attribute value at the medium level of granularity, and by the attribute value of observation.methodCode when a finer level of granularity is required. The method in whole or in part may also appear in the attribute value of Observation.value when using coded data types to express the value of the attribute. Relevant aspects of methodology may also be restated in value when the results themselves imply or state a methodology. An observation may consist of component observations each having their own Observation.code and Observation.value. In this case, the composite observation may not have an Observation.value for itself. For instance, a white blood cell count consists of the sub-observations for the counts of the various granulocytes, lymphocytes and other normal or abnormal blood cells (e.g., blasts). The overall white blood cell count Observation itself may therefore not have a value by itself (even though it could have one, e.g., the sum total of white blood cells). Thus, as long as an Act is essentially an Act of recognizing and noting information about a subject, it is an Observation, regardless of whether it has a simple value by itself or whether it has sub-observations. Even though observations are professional acts (see Act) and as such are intentional actions, this does not require that every possible outcome of an observation be pondered in advance of it being actually made. For instance, differential white blood cell counts (WBC) rarely show blasts, but if they do, this is part of the WBC observation even though blasts might not be predefined in the structure of a normal WBC. Clinical documents commonly have Subjective and Objective findings, both of which are kinds of Observations. In addition, clinical documents commonly contain Assessments, which are also kinds of Observations. Thus, the establishment of a diagnosis is an Observation. **Examples:** * Recording the results of a Family History Assessment * Laboratory test and associated result * Physical exam test and associated result * Device temperature * Soil lead level
1  _ActClassROIActClassROIRegions of Interest (ROI) within a subject Act. Primarily used for making secondary observations on a subset of a subject observation. The relationship between a ROI and its referenced Act is specified through an ActRelationship of type "subject" (SUBJ), which must always be present.
2    ROIBNDbounded ROIA Region of Interest (ROI) specified for a multidimensional observation, such as an Observation Series (OBSSER). The ROI is specified using a set of observation criteria, each delineating the boundary of the region in one of the dimensions in the multidimensional observation. The relationship between a ROI and its referenced Act is specified through an ActRelationship of type subject (SUBJ), which must always be present. Each of the boundary criteria observations is connected with the ROI using ActRelationships of type "has component" (COMP). In each boundary criterion, the Act.code names the dimension and the Observation.value specifies the range of values inside the region. Typically the bounded dimension is continuous, and so the Observation.value will be an interval (IVL) data type. The Observation.value need not be specified if the respective dimension is only named but not constrained. For example, an ROI for the QT interval of a certain beat in ECG Lead II would contain 2 boundary criteria, one naming the interval in time (constrained), and the other naming the interval in ECG Lead II (only named, but not constrained).
2    ROIOVLoverlay ROIA Region of Interest (ROI) specified for an image using an overlay shape. Typically used to make reference to specific regions in images, e.g., to specify the location of a radiologic finding in an image or to specify the site of a physical finding by "circling" a region in a schematic picture of a human body. The units of the coordinate values are in pixels. The origin is in the upper left hand corner, with positive X values going to the right and positive Y values going down. The relationship between a ROI and its referenced Act is specified through an ActRelationship of type "subject" (SUBJ), which must always be present.
1  _SubjectPhysicalPositionsubject physical positionThe spatial relationship of a subject whether human, other animal, or plant, to a frame of reference such as gravity or a collection device.
2    _ImagingSubjectOrientationimaging subject orientationA code specifying qualitatively the spatial relation between imaged object and imaging film or detector.
1  ALRTdetected issueAn observation identifying a potential adverse outcome as a result of an Act or combination of Acts. *Examples:* Detection of a drug-drug interaction; Identification of a late-submission for an invoice; Requesting discharge for a patient who does not meet hospital-defined discharge criteria. *Discussion:* This class is commonly used for identifying 'business rule' or 'process' problems that may result in a refusal to carry out a particular request. In some circumstances it may be possible to 'bypass' a problem by modifying the request to acknowledge the issue and/or by providing some form of mitigation. *Constraints:* the Act or Acts that may cause the the adverse outcome are the target of a subject ActRelationship. The subbtypes of this concept indicate the type of problem being detected (e.g. drug-drug interaction) while the Observation.value is used to repesent a specific problem code (e.g. specific drug-drug interaction id).
1  BATTERYbattery**Definition:** An observation that is composed of a set of observations. These observations typically have a logical or practical grouping for generally accepted clinical or functional purposes, such as observations that are run together because of automation. A battery can define required and optional component observations and, in some cases, will define complex rules that determine whether or not a particular observation is made. BATTERY is a constraint on the Observation class in that it is understood to always be composed of component observations. **UsageNotes:** The focus in a BATTERY is that it is composed of individual observations. In request (RQO) mood, a battery is a request to perform the component observations. In event (EVN) mood a battery is a reporting of associated set of observation events. In definition mood a battery is the definition of the associated set of observations. **Examples:** Vital signs, Full blood count, Chemistry panel.
1  CLNTRLclinical trialThe set of actions that define an experiment to assess the effectiveness and/or safety of a biopharmaceutical product (food, drug, device, etc.). In definition mood, this set of actions is often embodied in a clinical trial protocol; in event mood, this designates the aggregate act of applying the actions to one or more subjects.
1  DGIMGdiagnostic imageClass for holding attributes unique to diagnostic images.
1  GENgenomic observation**Description:**An observation of genomic phenomena.
2    DETPOLdeterminant peptide**Description:**A determinant peptide in a polypeptide as described by polypeptide.
2    EXPexpression level**Description:**An expression level of genes/proteins or other expressed genomic entities.
2    LOClocus**Description:**The position of a gene (or other significant sequence) on the genome.
2    PHNphenotype**Description:**A genomic phenomenon that is expressed externally in the organism.
2    POLpolypeptide**Description:**A polypeptide resulting from the translation of a gene.
2    SEQbio sequence**Description:**A sequence of biomolecule like the DNA, RNA, protein and the like.
2    SEQVARbio sequence variation**Description:**A variation in a sequence as described by BioSequence.
1  INVSTGinvestigationAn formalized inquiry into the circumstances surrounding a particular unplanned event or potential event for the purposes of identifying possible causes and contributing factors for the event. This investigation could be conducted at a local institutional level or at the level of a local or national government.
1  OBSSERobservation seriesContainer for Correlated Observation Sequences sharing a common frame of reference. All Observations of the same cd must be comparable and relative to the common frame of reference. For example, a 3-channel ECG device records a 12-lead ECG in 4 steps (3 leads at a time). Each of the separate 3-channel recordings would be in their own "OBSCOR". And, all 4 OBSCOR would be contained in one OBSSER because all the times are relative to the same origin (beginning of the recording) and all the ECG signals were from a fixed set of electrodes.
2    OBSCORcorrelated observation sequencesContainer for Observation Sequences (Observations whose values are contained in LIST<>'s) having values correlated with each other. Each contained Observation Sequence LIST<> must be the same length. Values in the LIST<>'s are correlated based on index. E.g. the values in position 2 in all the LIST<>'s are correlated. This is analogous to a table where each column is an Observation Sequence with a LIST<> of values, and each row in the table is a correlation between the columns. For example, a 12-lead ECG would contain 13 sequences: one sequence for time, and a sequence for each of the 12 leads.
1  POSpositionAn observation denoting the physical location of a person or thing based on a reference coordinate system.
2    POSACCposition accuracy**Description:**An observation representing the degree to which the assignment of the spatial coordinates, based on a matching algorithm by a geocoding engine against a reference spatial database, matches true or accepted values.
2    POSCOORDposition coordinate**Description:**An observation representing one of a set of numerical values used to determine the position of a place. The name of the coordinate value is determined by the reference coordinate system.
1  SPCOBSspecimen observationAn observation on a specimen in a laboratory environment that may affect processing, analysis or result interpretation
1  VERIFVerificationAn act which describes the process whereby a 'verifying party' validates either the existence of the Role attested to by some Credential or the actual Vetting act and its details.

Explanation of the columns that may appear on this page:

Level A few code lists that FHIR defines are hierarchical - each code is assigned a level. In this scheme, some codes are under other codes, and imply that the code they are under also applies
Source The source of the definition of the code (when the value set draws in codes defined elsewhere)
Code The code (used as the code in the resource instance)
Display The display (used in the display element of a Coding). If there is no display, implementers should not simply display the code, but map the concept into their application
Definition An explanation of the meaning of the concept
Comments Additional notes about how to use the code

History

DateActionCustodianAuthorComment
2020-05-06reviseVocabulary WGTed KleinMigrated to the UTG maintenance environment and publishing tooling.
2014-03-26revise2014T1_2014-03-26_001283 (RIM release ID)Vocabulary (Woody Beeler) (no record of original request)Lock all vaue sets untouched since 2014-03-26 to trackingId 2014T1_2014_03_26