Concepts/Observation Definition: Difference between revisions

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conceptdefinitionsCARE 3.0+

Definition

An observation definition in Care is a reusable template for one laboratory test or clinical test. The template records what the test measures and the type of value that a result holds. It also records the rules that Care uses to flag a result as normal or abnormal. Your facility creates each observation definition one time. Staff then use the template for every result of that test.

Key Attributes

Components	What it captures
Title	The name of the test that staff see in Care. This attribute is required.
Slug	A short unique name for the test. Care builds the slug from the title, and you can change it. This attribute is required.
Description	A short explanation of what the test measures. This attribute is required.
Status	The stage of the template, from first draft to retirement. This attribute is required. Care selects Active for a new template.
Category	The type of service that the test belongs to, such as Laboratory or Vital Signs. This attribute is required.
LOINC Code	The standard LOINC code of the test. This attribute is required.
Data Type	The kind of value that a result holds, for example a number or a yes or no answer. This attribute is required.
Unit	The unit of measure for the result, for example millimoles per litre. This attribute is optional.
Body Site	The part of the body that the test examines. This attribute is optional.
Method	The technique that staff use to do the test. This attribute is optional.
Components	The separate parts of a test that gives more than one value. This attribute is optional.
Observation Interpretation	The rules that Care uses to flag each result. This attribute is optional.

Data Type

The data type sets the kind of value that staff can record. Care has these data types:

Boolean
Decimal
Integer
DateTime
Time
String
Quantity

Components

Some tests give more than one value. Blood pressure is an example, because it gives a systolic value and a diastolic value. For a test of this type, add one component for each value. Each component has its own code, data type, unit, and interpretation rules.

Observation Interpretation

Observation Interpretation holds the qualified ranges of the test. Each rule has a title, conditions, value ranges, and an optional fallback. Care checks the rules in the order that you add them. Care skips a rule when the conditions do not match the patient or the encounter.

For a rule that matches, Care flags the result with the interpretation of the range that holds the value. If no range holds the value, Care uses the fallback of that rule. If that rule has no fallback, Care checks the next rule. For more detail, see Set up qualified ranges.

📝 Note

You can add interpretation rules to the observation definition, or to its components. You cannot add rules to both.

Scope

An observation definition can belong to one facility. Staff at that facility can then use the template. A Care superuser can also share an observation definition with every facility.

Status

Status	Description
Draft	You still prepare the template.
Active	Staff can use the template for results.
Retired	The template is out of use. Care keeps it for the results that already use it.
Unknown	The stage of the template is not known.

Pages that link here:

Concept: Concepts/Service Request
Reference: References/Value Set

@@ Line 9: / Line 9: @@
 }}
+== Definition ==
-An '''observation definition''' is the master-data blueprint for a measurement — it describes ''how'' a particular observation, such as blood pressure or blood glucose, should be captured and interpreted. It is the reusable rulebook that keeps the same observation consistent every time it is recorded, no matter which form or facility collects it.
+An '''[https://build.fhir.org/observationdefinition.html observation definition]''' in Care is a reusable template for one laboratory test or clinical test. The template records what the test measures and the type of value that a result holds. It also records the rules that Care uses to flag a result as normal or abnormal. Your facility creates each observation definition one time. Staff then use the template for every result of that test.
-== What it represents ==
+== Key Attributes ==
-In Care's FHIR-aligned model, an observation definition maps to the '''ObservationDefinition''' resource. It captures:
+{| class="wikitable"
-* '''What is measured''' — the observation's clinical code (LOINC) and its category, such as vital signs, laboratory, or survey
+! Components !! What it captures
-* '''How it is measured''' — the permitted data type (number, text, choice, date, and so on), the unit of measurement, the collection method, and the body site
+|-
-* '''How to read the result''' — reference ranges and interpretations that flag a value as normal, abnormal, or critical, optionally varying by patient condition
+| Title || The name of the test that staff see in Care. This attribute is required.
-* '''Multiple parts of one reading''' — components, so a single definition like blood pressure can hold both systolic and diastolic values
+|-
+| Slug || A short unique name for the test. Care builds the slug from the title, and you can change it. This attribute is required.
+|-
+| Description || A short explanation of what the test measures. This attribute is required.
+|-
+| Status || The stage of the template, from first draft to retirement. This attribute is required. Care selects Active for a new template.
+|-
+| Category || The type of service that the test belongs to, such as Laboratory or Vital Signs. This attribute is required.
+|-
+| LOINC Code || The standard LOINC code of the test. This attribute is required.
+|-
+| Data Type || The kind of value that a result holds, for example a number or a yes or no answer. This attribute is required.
+|-
+| Unit || The unit of measure for the result, for example millimoles per litre. This attribute is optional.
+|-
+| Body Site || The part of the body that the test examines. This attribute is optional.
+|-
+| Method || The technique that staff use to do the test. This attribute is optional.
+|-
+| Components || The separate parts of a test that gives more than one value. This attribute is optional.
+|-
+| Observation Interpretation || The rules that Care uses to flag each result. This attribute is optional.
+|}
+=== Category ===
-The key distinction is that a definition is a template, not a recorded result. It says &quot;a temperature is a number in degrees Celsius that reads normal between these bounds&quot; — the actual reading taken from a patient is an [[Concepts/Observation]]. Because the rules live in one place, the same observation is captured and interpreted identically everywhere it appears. One observation code can have several definitions, and each definition lives either at the instance level (shared across the deployment) or scoped to a single facility.
+An observation definition has one category. Care has these categories:
-== How it connects ==
+* Social History
-Observation definitions are reference data that other primitives draw on rather than something attached directly to a patient:
+* Vital Signs
+* Imaging
+* Laboratory
+* Procedure
+* Survey
+* Exam
+* Therapy
+* Activity
+=== Data Type ===
-* '''Questionnaires''' point at observation definitions so that the questions clinicians fill in collect data in a consistent, coded shape. The definition is referenced, not copied into the form.
-* '''Observations''' are produced from a definition for a specific encounter — Care can turn a definition into a blank observation, carrying over its code and category, ready to hold an actual value.
-* '''Value sets''' back every coded field (code, unit, body site, method). The submitted code is checked against the bound [[References/Value Set|value set]], which is what keeps the data translatable to FHIR.
+The data type sets the kind of value that staff can record. Care has these data types:
-Because they are shared master data, a small library of well-defined observations is reused across many forms and facilities instead of each form inventing its own fields.
+* Boolean
-== Scope ==
+* Decimal
+* Integer
+* DateTime
+* Time
+* String
+* Quantity
+=== Components ===
-Where a definition applies depends on whether it is tied to a facility:
+Some tests give more than one value. Blood pressure is an example, because it gives a systolic value and a diastolic value. For a test of this type, add one component for each value. Each component has its own code, data type, unit, and interpretation rules.
-{| class="wikitable"
-|-
-! Scope
-! Meaning
-|-
-| Instance-wide
-| Not bound to any facility; available across the whole deployment
-|-
-| Facility-scoped
-| Bound to one facility; only that facility uses it
-|}
+=== Observation Interpretation ===
-The scope is set once when the definition is created. This lets a deployment ship a standard catalogue of observations while still allowing an individual facility to define its own.
+Observation Interpretation holds the qualified ranges of the test. Each rule has a title, conditions, value ranges, and an optional fallback. Care checks the rules in the order that you add them. Care skips a rule when the conditions do not match the patient or the encounter.
-== Lifecycle ==
+For a rule that matches, Care flags the result with the interpretation of the range that holds the value. If no range holds the value, Care uses the fallback of that rule. If that rule has no fallback, Care checks the next rule. For more detail, see [[Flows/Set up qualified ranges|Set up qualified ranges]].
-<syntaxhighlight lang="text">draft → active → retired</syntaxhighlight>
-* '''draft''' — the definition is being authored and is not yet ready for use
-* '''active''' — the definition is in use and can be referenced by questionnaires and observations
-* '''retired''' — the definition is withdrawn from use but kept for history
+{{Note|1=You can add interpretation rules to the observation definition, or to its components. You cannot add rules to both.}}
-Observation definitions are never destroyed. When one is no longer wanted it is moved to '''retired''' rather than deleted, so existing records that relied on it stay coherent. A separate '''unknown''' status exists for definitions whose state cannot be determined.
-== Permissions ==
+=== Scope ===
+An observation definition can belong to one facility. Staff at that facility can then use the template. A Care superuser can also share an observation definition with every facility.
-Access to observation definitions is governed by facility-scoped role permissions.
+=== Status ===
 {| class="wikitable"
+! Status !! Description
+|-
+| Draft || You still prepare the template.
 |-
+| Active || Staff can use the template for results.
-! Permission
-! Description
-! System Roles
 |-
+| Retired || The template is out of use. Care keeps it for the results that already use it.
-| <code>can_write_observation_definition</code>
-| Create and update observation definitions for a facility
-| Facility Admin, Admin
 |-
+| Unknown || The stage of the template is not known.
-| <code>can_read_observation_definition</code>
-| View observation definitions available to a facility
-| Facility Admin, Administrator, Admin, Staff, Doctor, Nurse, Volunteer, Pharmacist
 |}
+{{Navbox definitions}}
-Roles are granted through a user's organization, facility, or patient memberships, and permissions cascade down the organization tree — so authoring is restricted to administrators while most clinical roles can read the definitions they need to collect data.
 {{Related}}