Introduction
There are many instances of uncoded free text narrative notes within patient records.
- Paragraphs of free text consultation notes perhaps associated with codes via the wider consultation context but not otherwise explicitly coded.
- Text which may or may not be associated with codes but where the association is inexact and it is considered better to express the notes text as a standalone item rather than bind the text (possibly incorrectly) to an associated coded resource. See Consultation guidance for further information.
- Representing uncoded or structural elements in patient records for which no suitable resource or is currently available to represent the information and for which falling back to a coded
Observationresource as the ‘uncategorised’ representation is inappropriate (for example, no appropriate codes are available to represent the source record entry as an observation).
Because FHIR® does not provide an underlying resource suitable for representing this information, a profile of Observation is utilised to represent narrative text as an Observation Narrative.
Approach
The approach for all of these cases is to use an appropriate coded Observation resource to represent the free text.
Instances of Observation narrative are identified by Observation.code of 37331000000100 Comment note (record artifact)
Observation Elements
id
Data type: Id |
Optionality: Mandatory | Cardinality: 1..1 |
The logical identifier of the Observation narrative resource.
meta.profile
Data type: uri |
Optionality: Mandatory | Cardinality: 1..1 |
The Observation narrative 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.
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 finished.
code
Data type: CodeableConcept |
Optionality: Mandatory | Cardinality: 1..1 |
Fixed value of 37331000000100 Comment note (record artifact)
subject
Data type: Reference(Patient) |
Optionality: Mandatory | Cardinality: 1..1 |
Reference to Patient resource representing the patient against whom the narrative text was recorded.
context
Data type: Reference(Encounter) |
Optionality: Optional | Cardinality: 0..1 |
Optional reference to the Encounter resource representing the consultation context in which the narrative free text was recorded. Will not be populated where the free text was recorded outside of a consultation context.
effectiveDateTime
Data type: DateTime |
Optionality: Optional | Cardinality: 0..1 |
The clinically relevant effective data or datetime for the narrative record entry.
Where the effective date is unknown or not recorded will be absent, otherwise it should be populated.
issued
Data type: Instance |
Optionality: Mandatory | Cardinality: 1..1 |
The audit trail timestamp representing when the narrative was last modified.
performer
Data type: Reference(Practitioner) |
Optionality: Mandatory | Cardinality: 1..1 |
The Practitioner resource representing the person responsible for recording the narrative.
comment
Data type: String |
Optionality: Mandatory | Cardinality: 1..1 |
The free text narrative as plain text.
related
Data type: BackboneElement |
Optionality: Required | Cardinality: 0..* |
This attribute is used to specify the sequence of the narrative in relation to other resources (for example, when an ordered set of resource is being used to express the structure of a consultation displayed at source). See Consultation guidance for further information.
The related.type and related.target are used to represent the sequence. Only the related.type value of ‘sequel-to’ is utilised.
