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Vital Sign Observation

[Observation: templateId 2.16.840.1.113883.10.20.22.4.27]

Vital signs are represented as are other results, with additional vocabulary constraints.

  1. SHALL contain exactly one [1..1] templateId ( (CONF:7299, CONF:10527 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.27"
  2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) (CONF:7297)
  3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: 2.16.840.1.113883.5.1001 HL7ActMood) (CONF:7298)
  4. SHALL contain at least one [1..*] id (CONF:7300)
  5. SHALL contain exactly one [1..1] code (CONF:7301), where the @code SHOULD be selected from ValueSet HITSP Vital Sign Result Type 2.16.840.1.113883.3.88.12.80.62 STATIC 1 (CONF:7301)
  6. SHALL contain exactly one [1..1] statusCode/@code="completed" (CodeSystem: 2.16.840.1.113883.5.14 ActStatus) (CONF:7303)
  7. SHALL contain exactly one [1..1] effectiveTime (CONF:7304)
    • Represents the biologically relevant time (e.g. time the specimen was obtained from the patient).

  8. SHALL contain exactly one [1..1] value with data type PQ (CONF:7305)
  9. MAY contain zero or one [0..1] interpretationCode (CONF:7307)
    • The interpretation code may be present to provide an interpretation of the vital signs measure (e.g., High, Normal, Low, et cetera).

  10. MAY contain zero or one [0..1] methodCode (CONF:7308)
    • The method code element may be present to indicate the method used to obtain the measure. Note that method used is distinct from, but possibly related to the target site.

  11. MAY contain zero or one [0..1] targetSiteCode (CONF:7309)
    • The target site of the measure may be identified in the targetSiteCode element (e.g., Left arm [blood pressure], oral [temperature], et cetera).

  12. SHOULD contain zero or one [0..1] text (CONF:7302)
  13. MAY contain zero or one [0..1] author (CONF:7310)
    1. Contains exactly one [1..1] CDA Author
  14. text, if present, SHOULD contain zero or one [0..1] reference (CONF:15943)
  15. reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15944)
  16. reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15945)

Vital Sign Observation example

<observation xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3">
  <id root="MDHT" extension="244310014"/>
  <code code="913944047"/>
  <text>Text Value</text>
  <effectiveTime>
    <low value="2013"/>
    <high value="2013"/>
  </effectiveTime>
  <value xsi:type="PQ"/>
  <interpretationCode code="1247860939"/>
  <methodCode code="1069131086"/>
  <targetSiteCode code="488138582"/>
  <author/>
</observation>