CCTOS Common : Observation

• 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, ...