CCTOS Common : Observation
Version 8.1
- Objective:
- Common properties of reports describing facts.
- Summary:
- Derived from Medical Data.
- Observations of facts
without any assessment of the content.
Usually there are no discussion about reported facts, i.e.
usually just one version.
- Common properties of any descriptive
"document", regardless of the exact kind of content.
- By default, poorly structured legacy document can be
accepted here,
when no more precise attribute are available. In
current medical records there is often no
structure at all, but just a collection of documents about various
facts, many reports of details from lab, radiology, etc...
but
nowhere a synthesis of a global view on the patient.
- The concept of Observation may be extended in many sub
classes, like e.g. anamnesis, lab report, radiology report, pathology
report, ...