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UEC Digital Integration Programme | Observation implementation guidance

Observation resource implementation guidance

Observation: Implementation Guidance


The Observation resource is used to carry a clinical assertion in a CDS context and is created and populated by a CDSS, which will work from clinical assertions to reach decisions.
Due to the nature of triage in unscheduled care, these assertions are often time-bounded and limited, so are appropriate to capture as Observations. The assertions are normally based on input from the patient, captured as QuestionnaireResponses.
A single QuestionnaireResponse can drive a single assertion, or multiple assertions.
Similarly, an assertion may need multiple QuestionnaireResponses to be validated.

Detailed implementation guidance for an Observation resource in the CDS context is given below:

Name Cardinality Type FHIR Documentation CDS Implementation Guidance
identifier 0..* Identifier Business Identifier for observation A unique identifier for the Observation.
basedOn 0..* Reference
(Careplan |
DeviceRequest |
Recommendation |
MedicationRequest |
NutritionOrder |
ProcedureRequest |
Fulfils plan, proposal or order
status 1..1 code registered | preliminary | final | amended + ObservationStatus (Required). This will normally be 'final', but may be 'amended' (where a user has amended his/her answers to a question).
category 0..* CodeableConcept Classification of type of observation Observation Category Codes (Preferred).
code 1..1 CodeableConcept Type of observation (code/type) LOINC Codes (Example). Snomed CT code for the Observation.
subject 0..1 Reference
(Patient |
Group |
Device |
Who and/or what this is about This SHOULD be populated with a reference to the Patient resource.
context 0..1 Reference
(Encounter |
Healthcare event during which this observation is made
effective[x] 0..1 dateTime |
Clinically relevant time/time-period for observation This SHOULD be populated.
issued 0..1 instant Date/Time this was made available This SHOULD be populated.
performer 0..* Reference
(Practitioner |
Organization |
Patient |
Who is responsible for the observation This SHOULD be populated with a reference to the organisation of the service provider which would be taken from the ServiceDefinition.
value[x] 0..1 Quantity | CodeableConcept | string | boolean | Range | Ratio | SampledData | Attachment | time | dateTime | Period Actual result This may be of any type, but will often be of type valueBoolean to indicate the presence or absence of the Observation type recorded in the Observation.code element.
dataAbsentReason 0..1 CodeableConcept Why the result is missing Observation Value Absent Reason (Extensible)
interpretation 0..1 CodeableConcept High, low, normal, etc. Observation Interpretation Codes (Extensible)
comment 0..1 string Comments about result
bodySite 0..1 CodeableConcept Observed body part SNOMED CT Body Structures (Example)
method 0..1 CodeableConcept How it was done Observation Methods (Example)
specimen 0..1 Reference(Specimen) Specimen used for this observation
device 0..1 Reference
(Device |
(Measurement) Device
referenceRange 0..* BackboneElement Provides guide for interpretation
+ Must have at least a low or a high or text
referenceRange.low 0..1 SimpleQuantity Low Range, if relevant
referenceRange.high 0..1 SimpleQuantity High Range, if relevant
referenceRange.type 0..1 CodeableConcept Reference range qualifier Observation Reference Range Meaning Codes (Extensible)
referenceRange.appliesTo 0..* CodeableConcept Reference range population Observation Reference Range Applies To Codes (Example)
referenceRange.age 0..1 Range Applicable age range, if relevant
referenceRange.text 0..1 string Text based reference range in an observation
related 0..* BackboneElement Resource related to this observation This SHOULD be populated with the QuestionnaireResponse resources which affected the population of this Observation.
related.type 0..1 code has-member | derived-from | sequel-to | replaces | qualified-by | interfered-by ObservationRelationshipType (Required) This should be populated with the value 'derived-from'. 1..1 Reference
(Observation |
Response |
Resource that is related to this one This SHOULD only be populated with a reference to the QuestionnaireResponse resource.
component 0..* BackboneElement Component results
component.code 1..1 CodeableConcept Type of component observation (code/type) LOINC Codes (Example) Snomed CT code for the Observation.
component.value[x] 0..1 Quantity | CodeableConcept | string | Range | Ratio | SampledData | Attachment | time | dateTime | Period Actual component result
component.dataAbsentReason 0..1 CodeableConcept Why the component result is missing Observation Value Absent Reason (Extensible)
component.interpretation 0..1 CodeableConcept High, low, normal, etc. Observation Interpretation Codes (Extensible)
component.referenceRange 0..* see referenceRange Provides guide for interpretation of component result
Tags: rest fhir api

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