Release Date: 2018-08-12

Level	Code	Display	Definition
1	exam	Exam	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.
1	imaging	Imaging	Observations generated by imaging. The scope includes observations, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine.
1	laboratory	Laboratory	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, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory.
1	procedure	Procedure	Observations generated by other procedures. This category includes observations resulting from interventional and non-interventional procedures excluding lab 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, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy.
1	social-history	Social History	The Social History Observations define the patient's occupational, personal (e.g. lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity and religious affiliation.
1	survey	Survey	Assessment tool/survey instrument observations (e.g. Apgar Scores, Montreal Cognitive Assessment (MoCA))
1	therapy	Therapy	Observations generated by non-interventional treatment protocols (e.g. occupational, physical, radiation, nutritional and medication therapy)
1	vital-signs	Vital Signs	Clinical observations measure the body's basic functions such as such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area.