The patient who is the subject of this observation - the individual about whom the finding, measurement, or assessment was made

Example: "patient-12345"

The healthcare encounter or episode of care during which this observation was made, providing context for when and where the observation occurred

Example: "encounter-67890"

The lifecycle status of the observation indicating the degree of validation and finality, from initial registration through final verification or potential cancellation

Values: registered, preliminary, final, amended, corrected, cancelled, entered-in-error

Example: "final"

High-level classification of the type of observation being made, enabling filtering and organization of observations by clinical domain or data source

Values: vital-signs, laboratory, imaging, exam, survey, social-history, activity

Example: "vital-signs"

The standardized code that defines what was observed - the question being answered or the parameter being measured, typically from LOINC for observations and measurements or SNOMED-CT for clinical findings

Example: {"code":"8867-4","system":"LOINC","display":"Heart rate"}

The specific date and time when the observation was made or the specimen was collected - represents the clinically relevant time for point-in-time observations

Example: "2024-03-15T10:30:00Z"

The time interval during which the observation applies when the observation represents a state or finding that persists over time rather than a single point measurement

Example: {"start":"2024-03-01T00:00:00Z","end":"2024-03-31T23:59:59Z"}

The date and time when the observation result was published, verified, or made available - typically later than the effective time for laboratory or imaging results

Example: "2024-03-15T14:30:00Z"

The healthcare professional(s) responsible for making the observation, performing the measurement, or validating the result - can include multiple performers for complex procedures

Example: ["practitioner-11111","practitioner-22222"]

The numeric result value for quantitative observations and measurements - must be accompanied by valueUnit to provide complete semantic meaning

Example: 72

The unit of measurement for valueQuantity expressed using standardized units (UCUM preferred) - examples include beats/min, mg/dL, mmHg, kg, cm

Example: "beats/min"

A textual result value used for free-text observations, descriptive findings, or when the result cannot be adequately expressed in structured form

Example: "Patient reports occasional chest discomfort on exertion"

A yes/no or true/false result for binary observations such as presence/absence of a finding, positive/negative test results, or boolean assessments

Example: true

A result expressed as a standardized coded value from a controlled terminology - used when the observation result itself is a coded concept rather than a number or text

Example: {"code":"LA18632-2","system":"LOINC","display":"Former smoker"}

Clinical interpretation or assessment of the observation result indicating whether the finding is within normal limits, abnormal, or critically abnormal - critical for alerting and clinical decision support

Values: normal, abnormal, high, low, critical-high, critical-low, positive, negative

Example: "normal"

The anatomical location or body site where the observation was made, particularly relevant for physical examination findings, imaging studies, and localized assessments

Example: {"code":"HEART","label":"Heart","system":"cardiovascular"}

The technique, methodology, or protocol used to obtain the observation - important for interpreting results when multiple measurement methods exist with different reference ranges

Example: {"code":"113011001","system":"SNOMED-CT","display":"Auscultation"}

Additional comments, annotations, or contextual information about the observation that doesn't fit into structured fields - may include clinical context, caveats, or explanatory notes

Example: "Patient was anxious during measurement which may have elevated reading"

Computed indicator showing whether this observation contains a numeric result (valueQuantity is not null) - useful for filtering quantitative observations for trending and analytics

Computed flag indicating whether the observation interpretation is critical-high or critical-low, requiring immediate clinical attention - triggers alerts and escalation workflows