Introduction
The headings below list the elements of the Observation resource and describe how to populate and consume them.
Filing Comments - observation resource elements
id
Data type: Id |
Optionality: Mandatory | Cardinality: 1..1 |
The logical identifier of the observation resource.
meta.profile
Data type: uri |
Optionality: Mandatory | Cardinality: 1..1 |
The observation profile URL.
Fixed value https://fhir.nhs.uk/STU3/StructureDefinition/CareConnect-GPC-Observation-1
identifier
Data type: Identifier |
Optionality: Mandatory | Cardinality: 1..* |
This is for business identifiers.
This is sliced to include a cross care setting identifier which MUST be populated. The codeSystem for this identifier is https://fhir.nhs.uk/Id/cross-care-setting-identifier.
This MUST be a GUID.
Providing systems MUST ensure this GUID is globally unique and a persistent identifier (i.e. doesn’t change between requests and therefore stored with the source data).
Where consuming systems are integrating data from this resource to their local system, they MUST also persist this GUID at the same time.
status
Data type: Code |
Optionality: Mandatory | Cardinality: 1..1 |
The status of the test result.
In GP systems these are most likely to be ‘final’ however ‘preliminary’ reports are possible as for example, some work can be sub-contracted to other labs. If the system is not able to determine the status of a test group header then it should default to the ‘unknown’ value.
code
Data type: CodableConcept |
Optionality: Mandatory | Cardinality: 1..1 |
This is a set value of ‘Filing Comment’ code to be requested from SNOMED UK.
subject
Data type: Reference(Patient) |
Optionality: Mandatory | Cardinality: 1..1 |
A reference to the Patient who the observation is about.
effective[x]
Data type: dateTime/Period |
Optionality: Mandatory | Cardinality: 1..1 |
The dateTime when the test result group or test report was filed into the patient record.
issued
Data type: instant |
Optionality: Mandatory | Cardinality: 1..1 |
The date time that the comment was recorded on the General practice system.
performer
Data type: Reference (Practitioner/Organisation) |
Optionality: Mandatory | Cardinality: 1..* |
Reference to the resource for the organisation and/or practitioner that performed the test.
value[x]
Data type: Many |
Optionality: Required | Cardinality: 0..1 |
If the filing date/comments relate to a test group rather than an entire test report then this MUST match the code element from the test group header observation.
comment
Data type: string |
Optionality: Required | Cardinality: 0..* |
Notes recorded by the clinician at the general practice when they filed the diagnostic report or test group into the patient record.
related
Data type: BackboneElement |
Optionality: Required | Cardinality: 0..1 |
Reference to the test group header observation or diagnostic report that the date/comments relate to.
This MUST be qualified using the related.type ‘derived-from’.
Elements not in use
The following elements MUST NOT be populated:
basedOn
Data type: Boolean |
Optionality: Required | Cardinality: 1..1 |
category
Data type: CodableConcept |
Optionality: Required | Cardinality: 0..1 |
The general type of test result. A default value of Laboratory should be used if a more specific value is not available e.g. pathology, microbiology etc.
context
| Data type: BackboneElement |
dataAbsentReason
Data type: CodeableConcept |
Optionality: Required | Cardinality: 0..1 |
The reason why a result/value has been omitted.
interpretation
Data type: CodeableConcept |
Optionality: Required | Cardinality: 0..1 |
Simple coded interpretation of the results. As provided by the performing HCP. For example - out of range, high, low.
bodysite
Data type: CodeableConcept |
Optionality: Required | Cardinality: 0..1 |
The body part that was tested/observed.
method
Data type: CodeableConcept |
Optionality: Required | Cardinality: 0..1 |
The method of testing/observation that was used.
specimen
Data type: Reference |
Optionality: Required | Cardinality: 0..1 |
Reference to the specimen on which these results were based.
referenceRange
Data type: BackboneElement |
Optionality: Required | Cardinality: 0..1 |
The reference range provides a guide for interpretation of the results.
device
| Data type: BackboneElement |
component
| Data type: BackboneElement |
