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Version: 3.1

Observation Definition

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​

ComponentsWhat it captures
TitleThe name of the test that staff see in Care. This attribute is required.
SlugA short unique name for the test. Care builds the slug from the title, and you can change it. This attribute is required.
DescriptionA short explanation of what the test measures. This attribute is required.
StatusThe stage of the template, from first draft to retirement. This attribute is required. Care selects Active for a new template.
CategoryThe type of service that the test belongs to, such as Laboratory or Vital Signs. This attribute is required.
LOINC CodeThe standard LOINC code of the test. This attribute is required.
Data TypeThe kind of value that a result holds, for example a number or a yes or no answer. This attribute is required.
UnitThe unit of measure for the result, for example millimoles per litre. This attribute is optional.
Body SiteThe part of the body that the test examines. This attribute is optional.
MethodThe technique that staff use to do the test. This attribute is optional.
ComponentsThe separate parts of a test that gives more than one value. This attribute is optional.
Observation InterpretationThe rules that Care uses to flag each result. This attribute is optional.

Category​

An observation definition has one category. Care has these categories:

  • Social History
  • Vital Signs
  • Imaging
  • Laboratory
  • Procedure
  • Survey
  • Exam
  • Therapy
  • Activity

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​

StatusDescription
DraftYou still prepare the template.
ActiveStaff can use the template for results.
RetiredThe template is out of use. Care keeps it for the results that already use it.
UnknownThe stage of the template is not known.