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  1. FHIR Specification Feedback
  2. FHIR-34408

Add Observation Category Value for Signs/Symptoms

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    • Icon: Change Request Change Request
    • Resolution: Persuasive with Modification
    • Icon: Medium Medium
    • FHIR Core (FHIR)
    • R4
    • Orders & Observations
    • Observation
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      We will make the following changes:

      1. Add symptom to the category ValueSet with the display "Symptom" and the definition: "A symptom is a manifestation of a disease apparent to and communicated by the patient."

      2. Update the description for "exam" code to the following:

      "Observations generated by physical exam findings including direct observations made by a clinician and use of simple instruments and the result of simple maneuvers performed directly on the patient's body (e.g. signs)."

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      We will make the following changes: 1. Add symptom to the category ValueSet with the display "Symptom" and the definition: "A symptom is a manifestation of a disease apparent to and communicated by the patient." 2. Update the description for "exam" code to the following: "Observations generated by physical exam findings including direct observations made by a clinician and use of simple instruments and the result of simple maneuvers performed directly on the patient's body (e.g. signs)."
    • Rob Hausam / Elliot Silver : 4 - 0 - 1
    • Clarification
    • Non-substantive
    • R6

    Description

      When documenting signs/symptoms it is unclear which of the preferred categories should be used.  It seems that "exam" is reasonable, but too broad.  Rather a more specific category would be appropriate in light of the other values.

      This code system/value set is very much subject to implementers local requirements to categorize observations for enhance organization and access, but this concept seems reasonable seems to be appropriate to recognize in the core specification, or clarify that "exam" encompasses signs/symptoms.

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            jdlnolen John D.L. Nolen
            hbuitendijk Hans Buitendijk
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              Updated:
              Resolved: