Official Website of the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health IT
Findings or other clinical data collected about a patient during care.
Data Element |
Applicable Vocabulary Standard(s) |
|---|---|
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Advance Directive Observation
Information about a patient or provider authored document indicating its location, content, type, and verification status. Usage note: May include structured or unstructured data, whether a person has one or more advance directive documents, the type of advance directive, the location of the document, and whether it has been verified. Such documents may be used should a person be unable to communicate their wishes, preferences, or priorities to their provider. Examples include but are not limited to an indication that a living will is on file, a reference to the location of durable medical power of attorney, and the validating provider. |
Data Element |
Applicable Vocabulary Standard(s) |
|---|---|
|
Advance Directive Observation
Information about a patient or provider authored document indicating its location, content, type, and verification status. Usage note: May include structured or unstructured data, whether a person has one or more advance directive documents, the type of advance directive, the location of the document, and whether it has been verified. Such documents may be used should a person be unable to communicate their wishes, preferences, or priorities to their provider. Examples include but are not limited to an indication that a living will is on file, a reference to the location of durable medical power of attorney, and the validating provider. |
Submitted by cmcdonald on
An especially useful field in the Observation resource. Almost universally included in laboratory results and other measurements. Especially useful in research studies for equivalencing tests about the same analyte across labs AND across numeric and ordinal valued tests. From FHIR, see: https://www.hl7.org/implement/standards/fhir/observation-definitions.html#Observation.interpretation
Submitted by Riki Merrick on
APHL supports this suggestion - observation interpretation is highly used in clinical care; the proposed vocabulary has been harmonized across all HL7 product families - it is using this code system, from which appropriate value sets can be created: https://terminology.hl7.org/4.0.0/CodeSystem-v3-ObservationInterpretation.html
Submitted by cmcdonald on
Store the observation code with the results in the EHRs
The observation code is often stored in one of many mapping tables that researchers cannot find. Suggest storing it as part of the result as defined in FHIR, CDA and HL7 V2. Apple health does so, making it easy to find and to verify its correctness.