Introduction
The headings below list the elements of the Observation resource and describe how to populate and consume them.
Test result - 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 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 (that is, it doesn’t change between requests and is 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.
category
Data type: CodableConcept |
Optionality: Required | Cardinality: 0..* |
The general type of test result. A default value of Laboratory should be used if a more specific value is not available - for example, pathology, microbiology, and so on.
code
Data type: CodableConcept |
Optionality: Mandatory | Cardinality: 1..1 |
The clinical code that represents the name of the test result or test analyte.
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: Required | Cardinality: 0..1 |
The date and time when the test was performed.
issued
Data type: instant |
Optionality: Required | Cardinality: 0..1 |
The date and time that the result was issued by the laboratory or other report provider.
performer
Data type: Reference (Practitioner/Organisation) |
Optionality: Required | Cardinality: 0..* |
Reference to the resource for the organisation and/or practitioner that performed the test.
value[x]
Data type: Many |
Optionality: Required | Cardinality: 0..1 |
The value of the test. This may be in the form of, but is not limited to, one of the following datatypes: a quantity, string or an attachment.
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 |
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 |
Lab notes in addition to the interpretation. For example, the sample has haemolysed or has leaked.
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..* |
The reference range provides a guide for interpretation of the results.
related
Data type: BackboneElement |
Optionality: Required | Cardinality: 0..1 |
Reference to the test group header observation if the result is part of a test group.
This MUST be qualified using the related.type ‘derived-from’.
Elements not in use
The following elements MUST NOT be populated:
basedOn
Data type: reference |
context
| Data type: BackboneElement |
device
| Data type: BackboneElement |
component
| Data type: BackboneElement |
