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	Roles are granted through a user's organization, facility, or patient memberships, and permissions cascade down the organization tree — so access to a patient's observations follows from access to the patient.		Roles are granted through a user's organization, facility, or patient memberships, and permissions cascade down the organization tree — so access to a patient's observations follows from access to the patient.

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{{Doc header
|type=concept
|domain=clinical
|title=Observation
|order=5
|introduced=3.0
|fhir=Observation
|concept=Concepts/Patient
|reference=References/Observation
}}

An '''observation''' is a single recorded fact about a patient — a blood pressure of 120/80, a body temperature, a coded answer to a screening question. It is the smallest unit of clinical data in Care: the structured building block that, gathered over time, becomes a patient's chart.

== What it represents ==

In Care's FHIR-aligned model, an observation maps to the '''Observation''' resource. Each one captures:

* '''What was observed''' — a coded concept, typically a LOINC code, that names the thing, such as "systolic blood pressure" or "body temperature"
* '''The result''' — the value itself: a number, a piece of text, a yes/no, or a coded answer, with a unit where one applies
* '''Context''' — the patient it belongs to, the encounter it was recorded in, when it was effective, and who recorded it
* '''Clinical qualifiers''' — optional detail such as the body site, the collection method, a reference range, and an interpretation of high, low, or normal

An observation is a snapshot, not a running tally. It records one fact at one point in time. A trend — a patient's temperature over a week — is many observations read together, never a single record that gets updated in place.

== How it is captured ==

Observations are rarely entered field by field. Most are produced as a side effect of submitting a [[Concepts/Questionnaire|questionnaire]]: each answer on the form becomes an observation, and that observation keeps a link back to the questionnaire response that produced it. This is also why every observation carries both a ''value'' and a ''value type'' — the value type tells any reader how to interpret what the form captured, whether it was a number, a date, a yes/no, or a coded choice.

Care strongly prefers '''structured, coded''' observations over free text. Downstream safety logic — allergy checks, medication interactions, alerting — reads coded values, so a temperature stored as a number with a LOINC code is far more useful than the same reading typed into a note.

== Status lifecycle ==

An observation's <code>status</code> signals how much to trust the record:

<syntaxhighlight lang="text">final → amended
final → entered_in_error</syntaxhighlight>
* '''final''' — recorded, complete, and verified. Observations created from a questionnaire start here.
* '''amended''' — was final, then corrected. The earlier value is superseded, but the change stays auditable.
* '''entered_in_error''' — recorded by mistake; readers should disregard it. Care keeps the row rather than deleting it, so the audit trail stays intact.

== How it connects ==

An observation rarely stands alone. It links to the primitives around it:

* '''Patient''' — every observation belongs to one [[Concepts/Patient|patient]]; this anchor is what makes it part of a chart.
* '''Encounter''' — it is normally recorded within an [[Concepts/Encounter|encounter]], tying the fact to a specific visit or admission.
* '''Observation definition''' — an [[Concepts/Observation Definition|observation definition]] can act as the template, supplying expected codes, units, and reference ranges.
* '''Diagnostic report''' — lab and imaging results are observations grouped under a [[Concepts/Diagnostic Report|diagnostic report]].
* '''Other observations''' — observations can nest. A panel such as a blood-pressure reading is a grouping observation whose components each carry their own code and value.

== Permissions ==

Observations are exposed through a read-only API, so the viewset only gates reading. Access is governed by clinical-data permissions: a reader is allowed if they hold the patient-level <code>can_view_clinical_data</code> permission, or, when querying a specific encounter, the encounter-level <code>can_read_encounter_clinical_data</code> permission. Observations are recorded as a side effect of submitting questionnaires, so creating them is gated by those questionnaire flows rather than by this viewset.

{| class="wikitable"
|-
! Permission
! Description
! System Roles
|-
| <code>can_view_clinical_data</code>
| View clinical data about a patient, including their observations
| Staff, Doctor, Nurse, Admin, Facility Admin
|-
| <code>can_read_encounter_clinical_data</code>
| Read clinical data recorded within a specific encounter; used as the encounter-scoped fallback when reading observations
| Admin, Doctor, Nurse, Facility Admin
|}

Roles are granted through a user's organization, facility, or patient memberships, and permissions cascade down the organization tree — so access to a patient's observations follows from access to the patient.

{{Related}}

Concepts/Observation - Revision history

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