Observation

	Field	Type	Length	Description
1	Record Type ID	String		Indicates the record type. For this record it will always be “Observation”.
2	ID	ID		Surrogate Key
3	Patient ID	REF		Surrogate key to a patientCorresponds to a (Patient line in the same file set)’s ID value
4	Encounter ID	REF		Surrogate Key to an EncounterCorresponds to a (Encounter line in the same file set)’s ID value
5	Observation Date	Date
6	Value	String	50	For Example - 87, WNL, Bedrest. Sending systems need to only use Value field when sending Values of any length and can always leave LongValue empty. Receiving systems will see either Value field populated (length <=50) or LongValue field populated (length > 50)
7	Comment	String	MAX
8	Long Value	String	MAX	Sending systems need to only use Value field when sending Values of any length and can always leave LongValue empty. Receiving systems will see either Value field populated (length <=50) or LongValue field populated (length > 50)
9	Type Term	Term		code\|name\|namespace\|family\|ns desc. Term to describe the actual observation. Example could be Pulse or Blood Pressure or Height or Weight
10	Document Term	Term		code\|name\|namespace\|family\|ns desc. The source Document for a given observation. If it came from a flowsheet or a History and Physical examination. Also a way to logically group observations.
11	Document Date	Date		. The date the given Document was recorded. Example… a daily flowsheet could have the date of Jan 1, but on it could be many observations each having a specific date and time (“Observation Date”) within the Jan 1 document.
12	Patient Identifier	String	128	Natural Key for existing patient. Part of Natural Key Identifier. Typically, the source’s or practice’s key Identifier for a patient
13	Patient Record Authority ID	REF		Surrogate Key to a Record Authority.
14	Encounter Identifier	String	128	Natural Key for existing encounter. Part of Natural Key Identifier. Typically, the source’s or practice’s key Identifier for an encounter
15	Parent Observation ID	REF		The ID of the parent observation
16	Units Term	Term		code\|name\|namespace\|family\|ns desc
17	Observation Sequence	integer
18	Type Term Text	String	200	Type term text
19	Value Type Term	Term		code\|name\|namespace\|family\|ns desc
20	Type Term Alternate	Term		Deprecated – use field 30 below - Type Term Alternates
21	Parent Observation Observation Date	Date
22	Parent Observation Value	String	50	For Example - 87, WNL, Bedrest
23	Parent Observation Document Term	Term		code\|name\|namespace\|family\|ns desc. The source Document for a given observation. If it came from a flowsheet or a History and Physical examination. Also a way to logically group observations.
24	Parent Observation Document Date	Date		The date the given Document was recorded. Example… a daily flowsheet could have the date of Jan 1, but on it could be many observations each having a specific date and time (“Observation Date”) within the Jan 1 document.
25	Parent Observation Type Term	Term		code\|name\|namespace\|family\|ns desc. Term to describe the actual observation. Example could be Pulse or Blood Pressure or Height or Weight
26	Inserted Audit Data	Audit		Audit data for when the record was inserted/created
27	Last Modified Audit Data	Audit		Audit data for when the record was last modified
28	Value Term	Term		code\|name\|namespace\|family\|ns desc
29	Value Term Alternates	Term List		See Term List Format – List of terms
30	Type Term Alternates	Term List		See Term List Format – List of terms
31	Acuity Term Alternates	Term List		See Term List Format – List of terms
32	Data Source	Data Source	50\|MAX	Code\|Name. See Data Source Format - Source of the data