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Observation - uncategorised data

Guidance for populating and consuming the Observation profile for uncategorised data


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

Observation Elements


Data type: Id Optionality: Mandatory Cardinality: 1..1

The logical identifier of the uncategorised data Observation profile.


Data type: uri Optionality: Mandatory Cardinality: 1..1

The Observation profile URL.

Fixed value


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.


Data type: status Optionality: Mandatory Cardinality: 1..1

Fixed value of final.


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).


Data type: Reference(Patient) Optionality: Mandatory Cardinality: 1..1

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


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.


Data type: DateTime Optionality: Required Cardinality: 0..1

Clinically relevant time/time-period for observation


Data type: Instance Optionality: Mandatory Cardinality: 1..1

The audit trail timestamp representing when the data was recorded.


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.


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.


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.


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.


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.

Data type: BackboneElement Optionality: Required Cardinality: 0..*

Contains any hierarchical information between uncategorised data items.

  • Populate 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


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:


Data type: Reference


Data type: CodeableConcept


Data type: CodeableConcept


Data type: CodeableConcept


Data type: CodeableConcept


Data type: Reference


Data type: BackboneElement

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