This page is part of the HL7 Terminology (v5.4.0: Release) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
Draft as of 2023-11-17 |
{
"resourceType" : "CodeSystem",
"id" : "observation-category",
"meta" : {
"lastUpdated" : "2020-04-09T21:10:28.568+00:00",
"profile" : [
🔗 "http://hl7.org/fhir/StructureDefinition/shareablecodesystem"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>This case-sensitive code system <code>http://terminology.hl7.org/CodeSystem/observation-category</code> defines the following codes:</p><table class=\"codes\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style=\"white-space:nowrap\">social-history<a name=\"observation-category-social-history\"> </a></td><td>Social History</td><td>Social History Observations define the patient's occupational, personal (e.g., lifestyle), social, familial, and environmental history and health risk factors that may impact the patient's health.</td></tr><tr><td style=\"white-space:nowrap\">vital-signs<a name=\"observation-category-vital-signs\"> </a></td><td>Vital Signs</td><td>Clinical observations measure the body's basic functions such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area.</td></tr><tr><td style=\"white-space:nowrap\">imaging<a name=\"observation-category-imaging\"> </a></td><td>Imaging</td><td>Observations generated by imaging. The scope includes observations regarding plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, and nuclear medicine.</td></tr><tr><td style=\"white-space:nowrap\">laboratory<a name=\"observation-category-laboratory\"> </a></td><td>Laboratory</td><td>The results of observations generated by laboratories. Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology (including digital pathology), microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory.</td></tr><tr><td style=\"white-space:nowrap\">procedure<a name=\"observation-category-procedure\"> </a></td><td>Procedure</td><td>Observations generated by other procedures. This category includes observations resulting from interventional and non-interventional procedures excluding laboratory and imaging (e.g., cardiology catheterization, endoscopy, electrodiagnostics, etc.). Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure. An example would be when a gastroenterologist reports the size of a polyp observed during a colonoscopy.</td></tr><tr><td style=\"white-space:nowrap\">survey<a name=\"observation-category-survey\"> </a></td><td>Survey</td><td>Assessment tool/survey instrument observations (e.g., Apgar Scores, Montreal Cognitive Assessment (MoCA)).</td></tr><tr><td style=\"white-space:nowrap\">exam<a name=\"observation-category-exam\"> </a></td><td>Exam</td><td>Observations generated by physical exam findings including direct observations made by a clinician and use of simple instruments and the result of simple maneuvers performed directly on the patient's body.</td></tr><tr><td style=\"white-space:nowrap\">therapy<a name=\"observation-category-therapy\"> </a></td><td>Therapy</td><td>Observations generated by non-interventional treatment protocols (e.g. occupational, physical, radiation, nutritional and medication therapy)</td></tr><tr><td style=\"white-space:nowrap\">activity<a name=\"observation-category-activity\"> </a></td><td>Activity</td><td>Observations that measure or record any bodily activity that enhances or maintains physical fitness and overall health and wellness. Not under direct supervision of practitioner such as a physical therapist. (e.g., laps swum, steps, sleep data)</td></tr></table></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode" : "oo"
}
],
"url" : "http://terminology.hl7.org/CodeSystem/observation-category",
"identifier" : [
{
"system" : "urn:ietf:rfc:3986",
"value" : "urn:oid:2.16.840.1.113883.4.642.1.1125"
}
],
"version" : "1.0.0",
"name" : "ObservationCategoryCodes",
"title" : "Observation Category Codes",
"status" : "draft",
"experimental" : false,
"date" : "2023-11-17T03:23:21-07:00",
"publisher" : "Health Level Seven International",
"contact" : [
{
"telecom" : [
{
"system" : "url",
"value" : "http://hl7.org"
},
{
"system" : "email",
"value" : "hq@HL7.org"
}
]
}
],
"description" : "Observation Category codes.",
"copyright" : "This material derives from the HL7 Terminology (THO). THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license",
"caseSensitive" : true,
"valueSet" : "http://terminology.hl7.org/ValueSet/observation-category",
"content" : "complete",
"concept" : [
{
"code" : "social-history",
"display" : "Social History",
"definition" : "Social History Observations define the patient's occupational, personal (e.g., lifestyle), social, familial, and environmental history and health risk factors that may impact the patient's health."
},
{
"code" : "vital-signs",
"display" : "Vital Signs",
"definition" : "Clinical observations measure the body's basic functions such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area."
},
{
"code" : "imaging",
"display" : "Imaging",
"definition" : "Observations generated by imaging. The scope includes observations regarding plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, and nuclear medicine."
},
{
"code" : "laboratory",
"display" : "Laboratory",
"definition" : "The results of observations generated by laboratories. Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology (including digital pathology), microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory."
},
{
"code" : "procedure",
"display" : "Procedure",
"definition" : "Observations generated by other procedures. This category includes observations resulting from interventional and non-interventional procedures excluding laboratory and imaging (e.g., cardiology catheterization, endoscopy, electrodiagnostics, etc.). Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure. An example would be when a gastroenterologist reports the size of a polyp observed during a colonoscopy."
},
{
"code" : "survey",
"display" : "Survey",
"definition" : "Assessment tool/survey instrument observations (e.g., Apgar Scores, Montreal Cognitive Assessment (MoCA))."
},
{
"code" : "exam",
"display" : "Exam",
"definition" : "Observations generated by physical exam findings including direct observations made by a clinician and use of simple instruments and the result of simple maneuvers performed directly on the patient's body."
},
{
"code" : "therapy",
"display" : "Therapy",
"definition" : "Observations generated by non-interventional treatment protocols (e.g. occupational, physical, radiation, nutritional and medication therapy)"
},
{
"code" : "activity",
"display" : "Activity",
"definition" : "Observations that measure or record any bodily activity that enhances or maintains physical fitness and overall health and wellness. Not under direct supervision of practitioner such as a physical therapist. (e.g., laps swum, steps, sleep data)"
}
]
}
IG © 2020+ HL7 International - Vocabulary Work Group. Package hl7.terminology#5.4.0 based on FHIR 4.0.1. Generated 2023-11-17
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