Introduction
The headings below list the elements of the Observation
profile and describe how to populate and consume them for uncategorised data.
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 MUST be populated with a globally unique and persistent identifier (that is, it doesn’t change between requests and therefore stored with the source data). This MUST be scoped by a provider specific namespace for the identifier.
There may be more than one identifier where data has been migrated across practices or provider systems and different provider specific identifiers have been assigned.
Where consuming systems are integrating data from this resource to their local system, they MUST also persist this identifier 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.
Where 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 |
Clinically relevant time/time-period for observation
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..* |
The Practitioner
profile representing the clinician responsible for making the observation.
Where the observation was performed at another organisation and an organisation
profile can be populated then that SHALL be populated here. This will be in addition to the clinical practitioner if
both are available.
If neither the performing organisation or the clinical practitioner is known then this MUST be populated with the details of the person that recordeed the data in the system.
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.
interpretation
Data type: CodeableConcept |
Optionality: Required | Cardinality: 0..1 |
A human-readable clinical summary relating to a test result and/or additional notes provided by the laboratory - for example, the specimen has haemolysed or has leaked.
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.
Where a reference range contains a less than ‘<’ or greater than ‘>’ operator it should be written to the referenceRange.text element as these operators are not supported in this context.
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
tohas-member
- Where the related item is a parent of this item set
related.type
toderived-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 |
bodysite
Data type: CodeableConcept |
method
Data type: CodeableConcept |
specimen
Data type: Reference |
device
Data type: BackboneElement |