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Vital Sign Observation

[Observation: templateId 1.3.6.1.4.1.19376.1.5.3.1.4.13.2]

A vital signs observation is a simple observation that uses a specific vocabulary, and inherits constraints from CCD.

  1. SHALL conform to CCD Result Observation template (templateId: 2.16.840.1.113883.10.20.1.31) (6.3.4.22.2)
  2. SHALL conform to Simple Observation template (templateId: 1.3.6.1.4.1.19376.1.5.3.1.4.13) (6.3.4.22.2)
  3. SHALL contain exactly one [1..1] code (CodeSystem: 2.16.840.1.113883.6.1 LOINC) (6.3.4.22.3)
  4. MAY contain zero or more [0..*] interpretationCode (6.3.4.22.5)
    • The interpretation code may be present to provide an interpretation of the vital signs measure (e.g., High, Normal, Low, et cetera).
  5. MAY contain zero or one [0..1] methodCode (6.3.4.22.6)
    • 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.
  6. MAY contain zero or more [0..*] targetSiteCode (6.3.4.22.7)
    • The target site of the measure may be identified in the targetSiteCode element (e.g., Left arm [blood pressure], oral [temperature], et cetera).
  7. SHALL contain exactly one [1..1] value, where its data type is PQ (6.3.4.22.4)

Vital Sign Observation example

<?xml version="1.0" encoding="UTF-8"?>
<observation xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd" classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.20.1.31"/>
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.2"/>
  <id root="1079599911"/>
  <code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
  <statusCode code="completed"/>
  <effectiveTime>
    <low value="2011"/>
    <high value="2011"/>
  </effectiveTime>
  <interpretationCode code="Value"/>
  <methodCode code="Value"/>
  <targetSiteCode code="323667547"/>
</observation>