Details
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Change Request
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Resolution: Persuasive with Modification
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Highest
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US Core (FHIR)
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Cross-Group Projects
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US Core Observation Clinical Test Result Profile [deprecated]
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many
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Eric Haas/Brett Marquard: 13-0-1
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Enhancement
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Compatible, substantive
Description
Existing wording: This profile sets minimum expectations for the Observation resource to record, search, and fetch non-imaging and non-laboratory clinical tests results for a patient.
Proposed Wording: This profile sets minimum expectations for the Observation resource to record, search, and fetch non-imaging and non-laboratory clinical tests results (clinical procedure results) for a patient. As per the definition of the Procedure category, Observations generated by other procedures. This category includes observations resulting from interventional and non-interventional procedures excluding laboratory and imaging (e.g., cardiology catheterization, endoscopy, electrodiagnostics, etc.). Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure. An example would be when a gastroenterologist reports the size of a polyp observed during a colonoscopy. It should not include content associated with any other ObservationCategoryCodes (e.g. social-history, vital-signs, imaging, laboratory, survey, exam, therapy, activity).
Comments: Naming and description for what is and isn't a "Clinical Test Result" is ambiguous. "Non-imaging and non-laboratory clinical test results" could functionally be more than just "procedure" observations; could potentially mean any of the other categories (social-history, vital-signs, procedure, survey, exam, therapy, activity). So this feels ambiguous. You'd have to notice that the other categories have there own profiles and realize "Clinical Test Result" JUST means observation category= procedure results. If this profile were named "Clinical Procedure Results" instead, it would be a bit better.