{"id":"CH_07","title":"Observation Reporting","description":"This chapter describes the transaction set required for sending structured patient-oriented clinical data from one computer system to another.  A common use of these transaction sets will be to transmit observations and results of diagnostic studies from the producing system (e.g., clinical laboratory system, EKG system) (the filler), to the ordering system (e.g., HIS order entry, physician’s office system) (the placer).   Observations can be sent from producing systems to clinical information systems (not necessarily the order placer) and from such systems to other systems that were not part of the ordering loop, e.g., an office practice system of the referring physician for inpatient test results ordered by an inpatient surgeon.  This chapter also provides mechanisms for registering clinical trials and methods for linking orders and results to clinical trials and for reporting experiences with drugs and devices. These transaction sets permit the transmission of clinical observations including(but not limited to) clinical laboratory results, measures of patient status and condition, vital signs, intake and output, severity and / or frequency of symptoms. If the observation being reported meets one or more of the following criteria, then the content would qualify as a medical document management message(MDM) rather than an observation message(ORU).The reader is referred to the MDM message type in Chapter 9."}