Guidance for populating and consuming the Observation profile for uncategorised data

Introduction

The headings below list the elements of the Observation profile and describe how to populate and consume them for uncategorised data.

Important: Any element not specifically listed below MUST NOT be populated or consumed.

Tip: You’ll find it helpful to read it in conjunction with the underlying Observation profile definition.

Observation Elements

id

Data type: Id

Optionality: Mandatory

Cardinality: 1..1

The logical identifier of the uncategorised data Observation profile.

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 system identifier for this 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 profile to their local system, they MUST also persist this GUID at the same time.

status

Data type: status

Optionality: Mandatory

Cardinality: 1..1

Fixed value of final.

code

Data type: CodeableConcept

Optionality: Mandatory

Cardinality: 1..1

The clinical code that represents the data within the observation.

Were the uncategorised data is free text without any clinical code set to 37331000000100 Comment note (record artifact).

subject

Data type: Reference(Patient)

Optionality: Mandatory

Cardinality: 1..1

Reference to Patient profile representing the Patient against whom the data was recorded.

context

Data type: Reference(Encounter)

Optionality: Required

Cardinality: 0..1

Optional reference to the Encounter profile representing the consultation context in which the uncategorised data was recorded.

effectiveDateTime

Data type: DateTime

Optionality: Required

Cardinality: 0..1

The datetime the observation was believed to be true.

The effective datetime is when the observation related to the patient was asserted. In many cases, this will be when the observation is recorded onto the system however there are situations where they can differ. For example, if an observation is asserted during a home visit that is then recorded on the clinical system the following day, the effective datetime is the when the consultation took place, not the date it was recorded.

Where no asserted date is available, the recorded date is used.

issued

Data type: Instance

Optionality: Mandatory

Cardinality: 1..1

The audit trail timestamp representing when the data was recorded.

performer

Data type: Reference(Practitioner)

Optionality: Mandatory

Cardinality: 1..1

The Practitioner profile representing the person responsible for recording the data item. Where this is not available, the person who recorded the data item is used.

value[x]

Data type: Many

Optionality: Required

Cardinality: 0..1

The value of the observation. This may be in any of the forms defined in the profile.

comment

Data type: String

Optionality: Required

Cardinality: 0..1

This MUST include any qualifiers to the code element that were present in the sending system. These should be reported as a code and value pair as specified in the uncategorised data guidance.

It MUST also include any text relating to the observation.

referenceRange

Data type: BackboneElement

Optionality: Required

Cardinality: 0..*

The reference range provides a guide for interpretation of the results.

related

Data type: BackboneElement

Optionality: Required

Cardinality: 0..*

Contains any hierarchical information between uncategorised data items.

• Populate related.target with a reference to the related item of uncategorised data
• Where the related item is a child of this item set related.type to has-member
• Where the related item is a parent of this item set related.type to derived-from

component

Data type: BackboneElement

Optionality: Required

Cardinality: 0..*

The only type of data that MAY use the component element is when a blood pressure is recorded as a pair of results.

Elements not in use

The following elements MUST NOT be populated:

basedOn

Data type: Reference

category

Data type: CodeableConcept

dataAbsentReason

Data type: CodeableConcept

interpretation

Data type: CodeableConcept

bodysite

Data type: CodeableConcept

method

Data type: CodeableConcept

specimen

Data type: Reference

device

Data type: BackboneElement