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Assessment Scales List

The FHIR profiles used for the Assessment Scales List structure

Heading Description

Details of the woman’s assessment scales.

The following FHIR profiles are used to form the Assessment scales list structure:

The following profiles are referenced from the Assessment scales list structure:

Assessment Scales Structure

Assessment scales Encounter Resource Encounter Resource Encounter Resource Practitioner Resource Practitioner Resource Practitioner Resource Observation Resource Observation Resource ObservationResource PractitionerRole Resource PractitionerRole Resource PractitionerRole Resource Location Resource Location Resource Location Resource 0..* R entry.item 0..* R entry.item 0..* Rentry.item 0..1 R context 0..1 R context 0..1 Rcontext 0..1 R location 0..1 R location 0..1 Rlocation 0..1 R performer 0..1 R performer 0..1 Rperformer 0..1 R practitioner 0..1 R practitioner 0..1 Rpractitioner Assessment Scales List Resource Assessment Scales List Resource Assessment ScalesList Resource Reference to Patient resource Reference to Patient resource Reference to Patient resource 1..1 M subject 1..1 M subject 1..1 Msubject

Maternity Data Standard Mapping to FHIR profiles

Mapping Overview

Data Standard Element FHIR Profile Mapping FHIR Element
Date/Time Recorded List entry.date
ODS/ORD Site Code Location identifier
Performing Professional Practitioner name
SDS Job Role Name PractitionerRole code
Coded Assessment Tool Type Observation code
value
component.code
component.value
Comment Observation comment

Mapping for Assessment Scales List

> Level 1 List Resource > Level 2 CareConnect-List-1 > Level 3 None
View Used FHIR Elements View All FHIR Elements
Name Card. Conformance Type Description, Constraints and mapping for Implementation
List     Information summarized from a list of other resources
Constraint (dom-2): If the resource is contained in another resource, it SHALL NOT contain nested Resources
Constraint (dom-1): If the resource is contained in another resource, it SHALL NOT contain any narrative
Constraint (dom-4): If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
Constraint (dom-3): If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
Constraint (lst-2): The deleted flag can only be used if the mode of the list is “changes”
Constraint (lst-1): A list can only have an emptyReason if it is empty
- id 0..1 Optional Id Logical id of this artifact
- meta 0..1 Mandatory Meta Metadata about the resource
The value attribute of the profile element MUST contain the value 'https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-List-1'
- identifier 0..* Required Identifier Business identifier
An identifier for this Assessment scales list
- - system 1..1 Required Uri The namespace for the identifier value
The system from which the identifier came from
- - value 1..1 Mandatory String The value that is unique
Business identifier
An identifier for this Assessment scales list
- - - display 0..1 Required String Text alternative for the resource
The organization that allocated the identifier
- status 1..1 Mandatory Code current : retired : entered-in-error
Binding (required): The current state of the list ListStatus
The status of the list MUST contain the value 'current'
- mode 1..1 Mandatory Code working : snapshot : changes
Binding (required): The processing mode that applies to this list ListMode
The mode of the list MUST contain the value 'snapshot'
- title 0..1 Mandatory String Descriptive name for the list
This MUST contain the value 'Assessment scales'
Mapping to Maternity data item = 'PSRB Heading Assessment scales'
- code 0..1 Mandatory CodeableConcept What the purpose of this list is
Binding (preferred): What the purpose of a list is CareConnect-ListCode-1
The PRSB heading for this list. Note: for Maternity the value stated below is used which is not from the preferred value set
- - coding 0..* Mandatory Coding Code defined by a terminology system
The SNOMED CT concept for the PRSB heading type
- - - system 0..1 Mandatory Uri Identity of the terminology system
This MUST contain the value 'http://snomed.info/sct'
- - - code 0..1 Mandatory Code Symbol in syntax defined by the system
This MUST contain the value '887141000000103'
- - - display 0..1 Mandatory String Representation defined by the system
This MUST contain the value 'Assessment scales'
Mapping to Maternity data item = 'PSRB Heading Assessment scales'
- subject 0..1 Mandatory Reference If all resources have the same subject
Constraint (ref-1): SHALL have a contained resource if a local reference is provided
This is a reference to the Patient who is the subject of the list.
    Mandatory CareConnect-Patient-1 This is the subject of the Assessment scales List.
This MUST use the CareConnect patient profile.
See patient resource reference for information on how to populate the resource.
- - reference 0..1 Mandatory String Literal reference, Relative, internal or absolute URL
A reference to the patient resource included in the Patient demographics list within the FHIR Bundle. Note the Patient demographics list is mandatory in the FHIR bundle
- date 0..1 Mandatory dateTime When the list was prepared
This MUST contain a system date to indicate when the list was created or updated
Mapping to Maternity data item = 'Date/Time Recorded'
- note 0..* Optional Annotation Comments about the list
    Required String Who authored the comment on the list.
- - time 0..1 Required dateTime When the annotation was made
- - text 1..1 Required String The annotation - text content
- entry 0..* Mandatory BackboneElement Entries in the list
The entries MUST be as per the diagram for this PRSB headings list with the Observation resource being the focal resource. Multiple resources MAY be present
- - date 0..1 Required dateTime When item added to list
The SHOULD contain a system time of when the item was added to the list.
- - item 1..1 Required Reference Actual entry
Constraint (ref-1): SHALL have a contained resource if a local reference is provided
A reference to an Observation resource included in the list
This MUST use the CareConnect Observation profile.
See Observation resource for information on how to populate the resource.
- - - reference 0..1 Mandatory String Literal reference, Relative, internal or absolute URL
The reference to the included Observation resource.

Mapping for Assessment Scales Observation

> Level 1 Observation Resource > Level 2 CareConnect-Observation-1 > Level 3 None
View Used FHIR Elements View All FHIR Elements
Name Card. Conformance Type Description, Constraints and mapping for Implementation
Observation     Measurements and simple assertions
Constraint (dom-2): If the resource is contained in another resource, it SHALL NOT contain nested Resources
Constraint (dom-1): If the resource is contained in another resource, it SHALL NOT contain any narrative
Constraint (dom-4): If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
Constraint (dom-3): If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
Constraint (obs-7): If code is the same as a component code then the value element associated with the code SHALL NOT be present
Constraint (obs-6): dataAbsentReason SHALL only be present if Observation.value[x] is not present
- id 0..1 Optional Id Logical id of this artifact
- meta 0..1 Mandatory Meta Metadata about the resource
The value attribute of the profile element MUST contain the value 'https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1'
- identifier 0..* Required Identifier Business Identifier for observation
An identifier for this Assessment scales observation
- - - text 0..1 Required String Plain text representation of the concept
- - system 1..1 Mandatory Uri The namespace for the identifier value
- - value 1..1 Mandatory String The value that is unique
- - assigner 0..1 Required Reference Organization that issued id (may be just text)
Constraint (ref-1): SHALL have a contained resource if a local reference is provided
- status 1..1 Mandatory Code registered : preliminary : final : amended +
Binding (required): Codes providing the status of an observation. ObservationStatus
MUST contain the value 'final'.
- code 1..1 Mandatory CodeableConcept Type of observation (code / type)
Binding (example): Codes identifying names of simple observations. LOINC Codes
This example ValueSet is not used by Maternity record. The following SNOMED reference is used Assessment scale observables simple reference set
Mapping to Maternity data item = 'Coded Assessment Tool Type'
- - coding 0..* Required Coding Code defined by a terminology system
Slicing: Discriminator: code, Ordering: false, Rules: Open
- - coding (snomedCT) 0..1 Required Coding Code defined by a terminology system
Binding (extensible): A code from the SNOMED Clinical Terminology UK coding system describing a type of observation CareConnect-ObservationType-1
This SNOMED ValueSet SHOULD be constrained to the ValueSet as indicated in the code element above.
- - - system 1..1 Mandatory Uri Identity of the terminology system
The element MUST contain the value 'http://snomed.info/sct'
- - - code 1..1 Mandatory Code Symbol in syntax defined by the system
A SNOMED concept from the ValueSet indicated.
- - - display 1..1 Mandatory String Representation defined by the system
The display associated with the SNOMED CT concept. This SHOULD be the preferred term
- context 0..1 Required Reference Healthcare event during which this observation is made
Constraint (ref-1): SHALL have a contained resource if a local reference is provided
This MUST be a reference to Encounter resource
    Required CareConnect-Encounter-1 The Encounter where the assessment was carried out.
This MUST use the Encounter resource.
See Encounter resource for information on how to populate the resource.
- - reference 0..1 Required String Literal reference, Relative, internal or absolute URL
A reference to the Encounter resource included in the Assessment scales list
- effective[x] 0..1 Required dateTime Clinically relevant time/time-period for observation
The date on which the assessment scale was recorded.
- performer 0..* Required Reference Who is responsible for the observation
Constraint (ref-1): SHALL have a contained resource if a local reference is provided
The professional performing the assessment scale.
    Mandatory CareConnect-Practitioner-1 The professional performing the Assessment. This MUST use the Practitioner resource. See Practitioner resource for information on how to populate the resource.
- - reference 0..1 Required String Literal reference, Relative, internal or absolute URL
A reference to the Practitioner resource included in the Assessment scales list
- value[x] 0..1 Required Quantity Actual result
Constraint (qty-3): If a code for the unit is present, the system SHALL also be present
The value of the assessment scales where one is required to recorded.
    Required CodeableConcept  
    Required String  
    Required Boolean  
    Required Range  
- comment 0..1 Required String Comments about result
Supporting text may be given regarding the assessment scale as a whole or a subscale. code.text and component.code.text SHOULD be used when the scale cannot be coded using SNOMED, value.string and component.value.string should be used for the values where no suitable data type is available or applicable.
Mapping to Maternity data item = 'Comment'
- component 0..* Required BackboneElement Component results. Component Assessment scales
- - code 1..1 Required CodeableConcept Type of component observation (code / type)
Binding (example): Codes identifying names of simple observations. LOINC Codes
This example ValueSet is not used by Maternity record. The following SNOMED reference is used Assessment scale observables simple reference set
Mapping to Maternity data item = 'Coded Assessment Tool Type'
- - coding 0..* Required Coding Code defined by a terminology system
Slicing: Discriminator: code, Ordering: false, Rules: Open
- - coding (snomedCT) 0..1 Required Coding Code defined by a terminology system
Binding (extensible): A code from the SNOMED Clinical Terminology UK coding system describing a type of observation CareConnect-ObservationType-1
This SNOMED ValueSet SHOULD be constrained to the ValueSet as indicated in the code element above.
- - - system 1..1 Required Uri Identity of the terminology system
The element MUST contain the value 'http://snomed.info/sct'
- - - code 1..1 Required Code Symbol in syntax defined by the system
A SNOMED concept from the ValueSet indicated.
- - - display 1..1 Required String Representation defined by the system
The display associated with the SNOMED CT concept. This SHOULD be the preferred term
- value[x] 0..1 Required Quantity Actual component result
Constraint (qty-3): If a code for the unit is present, the system SHALL also be present
The value of the assessment scales where one is required to be recorded.
    Required CodeableConcept  
    Required String  
    Required Range  

Mapping for Assessment Scales Encounter

> Level 1 Encounter Resource > Level 2 CareConnect-Encounter-1 > Level 3 None
View Used FHIR Elements View All FHIR Elements
Name Card. Conformance Type Description, Constraints and mapping for Implementation
Encounter     An interaction during which services are provided to the patient
Constraint (dom-2): If the resource is contained in another resource, it SHALL NOT contain nested Resources
Constraint (dom-1): If the resource is contained in another resource, it SHALL NOT contain any narrative
Constraint (dom-4): If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
Constraint (dom-3): If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
- id 0..1 Optional Id Logical id of this artifact
- meta 0..1 Mandatory Meta Metadata about the resource
The value attribute of the profile element MUST contain the value 'https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Encounter-1'
- identifier 0..* Required Identifier Identifier(s) by which this encounter is known
An identifier for this Encounter
- - system 1..1 Required Uri The namespace for the identifier value
The system from which the identifier came from
- - value 1..1 Required String The value that is unique
An identifier for this Assessment scales encounter
- status 1..1 Mandatory Code planned : arrived : triaged : in-progress : onleave : finished : cancelled +
Binding (required): Current state of the encounter EncounterStatus
The status of the Encounter MUST contain the value 'finished'
- - - start 0..1 Required dateTime Starting time with inclusive boundary
- - - end 0..1 Required dateTime End time with inclusive boundary, if not ongoing
- location 0..1 Required BackboneElement List of locations where the patient has been
- - location 1..1 Mandatory Reference Location the encounter takes place
Constraint (ref-1): SHALL have a contained resource if a local reference is provided
The site code of the unit to which the person was admitted
    Mandatory CareConnect-Location-1 The location
This MUST use the CareConnect Location profile.
See Location resource for information on how to populate the resource.”
- - - reference 1..1 Mandatory String Literal reference, Relative, internal or absolute URL
A reference to the Location resource included in the Assessment scales list

Patient Reference

The assessment scales details list has a mandated subject reference to the Patient resource. This means that any exchange of the assessment scales details heading data must also include the Patient demographics List.

Mapping for Assessment Scales Location

The assessment scales details has reference(s) to the Location resource. This means that any exchange of the assessment scales details heading data must also include the Location Details.

Mapping for Assessment Scales Practitioner

The assessment scales details has reference(s) to the Practitioner resource. This means that any exchange of the assessment scales details heading data must also include the Practitioner Details.

Mapping for Assessment Scales PractitionerRole

The assessment scales details has reference(s) to the Practitioner Role resource. This means that any exchange of the assessment scales details heading data must also include the Practitioner Role Details.

Assessment Scales Heading Example

Tags: fhir

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