A patient event record containing a patient report or symptom, a physical finding, a laboratory or test result pertaining to the patient or the patient medical history.
| Template Slots |
| |
Slot Name |
Documentation |
Type |
Cardinality |
 |
code |
The value of this slot answers the question "what was looked for?". Examples include: "Serum sodium concentration", "heart rate", "admitting diagnosis".The code (in a terminology system) that represents a concept |
CodedValue, ConceptExpression |
1:1 |
 |
effectiveTime |
Time during which the information is valid |
TimeInterval, Function, VMR_Query, Variable |
0:1 |
|
encounter |
The encounter associated with the observation.The encounter that is associated with each VMR record |
Encounter |
0:1 |
|
interpretationCode |
One or more codes specifying a rough qualitative interpretation of the observation, such as "normal", "abnormal", "below normal", "change up", "resistant", "susceptible", etc. |
SetOfCS, ConceptExpression |
0:1 |
 |
label |
A short human readable string indicating the content of the instancehuman-readable string for the instance |
String |
0:1 |
|
methodCode |
A code that provides additional detail about the means or technique used to ascertain the observation. |
SetOfCE, ConceptExpression |
0:1 |
|
statusCode |
A code specifying the state of the Act. |
CodedValue |
0:1 |
|
subject |
The subject of the observation. In other words, who is this observation about. Examples include: "patient", "mother", "donor", and "family member".The person to which the observation or probelm applies. The default is a patient. |
CodedValue, ConceptExpression |
0:1 |
|
text |
This slot is meant to contain a human readable, complete, textual description of the observation.Textual description of the act |
EncapsulatedData |
0:1 |
|
value |
The value of this slot answers the question, "what was found?". This slot is tightly bound the the "code" slot to describe an observation.A data value |
Expression |
0:1 |
