Class: Clinical_observation

Description of: Clinical_observation

Class steward is Orders/Observation
Interested committees Information Management (Medical Records)
The information or record secured by an act or instance of viewing or noting a fact or occurrence for some health related purpose.

OpenIssue: Consideration should be given to the identification that the Gen-Spec (clinical_observation is a specialization of Assessment) may be flawed and that it may be replaced with a simple association.

Attribute definitions for: Clinical_observation

abnormal_result_ind

An indication that the observation results are abnormal.

clinically_relevant_begin_dttm

This field is the clinically relevant begin date/time of the observation. In the case of observations taken directly from a subject, it is the actual date and time the observation was obtained. In the case of a specimen-associated study, this field shall represent the date and time the specimen was collected or obtained.

Rationale: This is the definition that has been developed by the committee and balloted. This is the field that is wanted in the message, not separate fields for the specimen collection time and the time of the observation. Often, an interim time is chosen as "clinically relevant". There would be too much overhead in maintaining separate fields for all the possible interim times.

|OBX^14^00582^Date/Time of the Observation|

clinically_relevant_end_dttm

This field is the clinically relevant end date/time of the observation. In the case of observations taken directly from a subject, it is the actual date and time the observation was obtained. In the case of a specimen-associated study, this field shall represent the date and time the specimen was collected or obtained.

Rationale: This is the definition that has been developed by the committee and balloted. This is the field that is wanted in the message, not separate fields for the specimen collection time and the time of the observation. Often, an interim time is chosen as "clinically relevant". There would be too much overhead in maintaining separate fields for all the possible interim times.

|OBX^14^00582^Date/Time of the Observation|

last_observed_normal_values_dttm

This field contains the date and time of changes in the observation methods that would make values obtained from the old method not comparable with those obtained from the new method.

Rationale: alignment with V2.3

OpenIssue: This is being returned to committee to be reworked to remove the inconsistency between the name and the definition.

|OBX^12^00580^Date Last Obs Normal Values|

nature_of_abnormal_testing_cd

Indicates the type of control population against which the observation was tested for abnormalcy. Control population might be age based, sex based, race based, or a generic normal range.

Rationale: previously unmatched V2.3 field

OpenIssue:

|OBX^10^00578^Nature of Abnormal Test|

observation_method_cd

A code indicating the method employed in conducting the observation.

observation_status_cd

The status of the clinical result of the observation.

|OBR^25^00258^Result Status| |OBX^11^00579^Observ Result Status|

observation_status_dttm

The effective date and time of the clinical result.

observation_sub_id

A sub-group identifier for the observation used to group related observations.

|OBX^13^00581^User Defined Access Checks|

observation_value_txt

Observation value.

|OBX^5^00573^Observation Value|

probability_number

The degree of certainty in the clinical observation expressed as a percentage.

Rationale: closer to language used in V2.3

|OBX^9^00577^Probability|

references_range_text

)OR b) > lower limit (if no upper limit, e.g., >10) a) lower limit-upper limit (when both lower and upper limits are defined, e.g., for potassium 3.5 - 4.5) OR c) < upper limit (if no lower limit, e.g., <15FOR ALPHABETIC VALUES: the normal value may be reported in this location When the observation quantifies the amount of a toxic substance, then the upper limit of the range identifies the toxic limit. If the observation quantifies a drug, the lower limits identify the lower therapeutic bounds and the upper limits represent the upper therapeutic bounds above which toxic side effects are common.FOR NUMERIC VALUES

Rationale: previously unmatched V2.3 field

OpenIssue:

|OBX^7^00575^References Range|

universal_service_identifier_suffix_txt

Indicates that the observation is a specific one of the standard narrative report components for the Universal_service_identifier. Examples: Diagnostic Impression (IMP), Gross or General Description (GDT).

Rationale: previously unmatched V2.3 field component

OpenIssue:

|OBX^3^00571^Observation Identifier|

user_defined_access_check_txt

Results-dependent codes for classifying the observation at the receiving system.

Rationale: V2.3 definition specifies that these are code

OpenIssue: Note that this is being returned to committee to be fixed.

|OBX^13^00581^User Defined Access Checks|

value_type_cd

A qualifier of the observation value.

|OBX^2^00570^Value Type| |OM3^7^00570^Value Type|

value_units_code

Unit of measure in which the observation value is reported. When an observation's value is measured on a continuous scale, one must report the measurement units within the units field of the OBX segment. Units have a data type of CE. ISO+ abbr.

Rationale: RT: previously unmatched V2.3 field, see recommendation R037

OpenIssue:

|OBX^6^00574^Units|