National Pathology FHIR Message Profiles
Overview
Contains data relating to a clinical test performed on a patient. This information may or may not be linked to a test report or a test group. It is populated by the performing organisation.
Mapping for Observation
How to populate the Observation instance to conform to the profiles below:
Level 1 | Observation Resource | Level 2 | CareConnect-Observation-1 | Level 3 | None |
View Used FHIR Elements | View All FHIR Elements |
Name | Card. | Conformance | Type | Description, Constraints and mapping for National Pathology Implementation |
---|---|---|---|---|
Observation | | Measurements and simple assertions Constraint (dom-2): If the resource is contained in another resource, it SHALL NOT contain nested Resources Constraint (dom-1): If the resource is contained in another resource, it SHALL NOT contain any narrative Constraint (dom-4): If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated Constraint (dom-3): If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource Constraint (obs-7): If code is the same as a component code then the value element associated with the code SHALL NOT be present Constraint (obs-6): dataAbsentReason SHALL only be present if Observation.value[x] is not present |
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- id | 0..1 | Required | Id | Logical id of this artifact Must contain a UUID to identify the instance of a observation |
- meta | 0..1 | Mandatory | Meta | Metadata about the resource The value attribute of the profile element MUST contain the value 'https://fhir.nhs.uk/STU3/StructureDefinition/CareConnect-Observtion-1' |
- identifier | 0..* | Mandatory | Identifier | Business Identifier for observation |
- - system | 1..1 | Mandatory | Uri | The namespace for the identifier value MUST contain the value 'https://tools.ietf.org/html/rfc4122'. |
- - value | 1..1 | Mandatory | String | The value that is unique MUST contain a UUID |
- status | 1..1 | Mandatory | Code | registered : preliminary : final : amended + Binding (required): Codes providing the status of an observation. ObservationStatus |
- category | 0..* | Required | CodeableConcept | Classification of type of observation Binding (preferred): Codes for high level observation categories. Observation Category Codes The general type of test result.A default value of Laboratory should be used if a more specific value is not available e.g. pathology, microbiology etc. |
- - coding | 0..* | Required | Coding | Code defined by a terminology system |
- - - system | 0..1 | Mandatory | Uri | Identity of the terminology system |
- - - code | 0..1 | Mandatory | Code | Symbol in syntax defined by the system |
- - - display | 0..1 | Mandatory | String | Representation defined by the system |
- - text | 0..1 | Optional | String | Plain text representation of the concept |
- code | 1..1 | Mandatory | CodeableConcept | Type of observation (code / type) Binding (example): Codes identifying names of simple observations. ( http://hl7.org/fhir/stu3/valueset-observation-codes.html ) The clinical code that represents the name of the test result or test analyte. |
- - coding | 0..* | Mandatory | Coding | Code defined by a terminology system Slicing: Discriminator: code, Ordering: false, Rules: Open |
- - coding (snomedCT) | 0..1 | Mandatory | Coding | Code defined by a terminology system Binding (extensible): A code from the SNOMED Clinical Terminology UK coding system describing a type of observation CareConnect-ObservationType-1 |
- - - extension (snomedCTDescriptionID) | 0..1 | Optional | Extension-coding-sctdescid | The SNOMED CT Description ID for the display. Constraint (ext-1): Must have either extensions or value[x], not both |
- - - system | 1..1 | Mandatory | Uri | Identity of the terminology system The value attribute of the profile element MUST contain the value 'http://snomed.info/sct' |
- - - code | 1..1 | Mandatory | Code | Symbol in syntax defined by the system A code that identifies the test result. |
- - - display | 1..1 | Mandatory | String | Representation defined by the system SNOMED CT display name. This will be the name of the test that took place |
- - text | 0..1 | Optional | String | Plain text representation of the concept |
- subject | 0..1 | Optional | Reference | Who and/or what this is about Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
Optional | CareConnect-Patient-1 | This MUST be to the Patient resource profiled as CareConnect-Patient-1 | ||
- - reference | 0..1 | Mandatory | String | Literal reference, Relative, internal or absolute URL a reference to the Patient resource instance in the message in the format of a UUID prefixed with 'urn:uuid:'. |
- effective[x] | 0..1 | Required | dateTime | Clinically relevant time/time-period for observation The date and time on which the test was performed. |
- issued | 0..1 | Required | Instant | Date/Time this was made available The date and time that the result was issued by the laboratory or other report provider |
- performer | 0..* | Required | Reference | Who is responsible for the observation Constraint (ref-1): SHALL have a contained resource if a local reference is provided. Reference to the resource for the organisation and/or practitioner that performed the test. |
Required | CareConnect-Organization-1 | This MUST be to the Organization resource profiled as CareConnect-Organization-1 | ||
Required | CareConnect-Practitioner-1 | This MUST be to the Practitioner resource profiled as CareConnect-Practitioner-1 | ||
- - reference | 0..1 | Mandatory | String | Literal reference, Relative, internal or absolute URL a reference to the Organization or Practitioner resource instance in the message in the format of a UUID prefixed with 'urn:uuid:'. |
- value[x] | 0..1 | Required | Quantity ( CareConnect-ApproximateQuantity-1 ) | Actual result Constraint (qty-3): If a code for the unit is present, the system SHALL also be present |
- - extension (valueApproximation) | 0..1 | Required | Extension | “Value Approximation Constraint (ext-1): Must have either extensions or value[x], not both URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-ValueApproximation-1” |
- - value.quantity.value | 0..1 | Mandatory | Decimal | Numerical value (with implicit precision) |
- - value.quantity.comparator | 0..1 | Optional | Code | < : <= : >= : > - how to understand the value Binding (required): How the Quantity should be understood and represented. (http://hl7.org/fhir/stu3/valueset-quantity-comparator.html ) A comparator that may be used to indicate whether the actual value is greater or less than the stated value. |
- - value.quantity.unit | 0..1 | Required | String | Unit representation A human readable form of the unit of measure associated with a test result value. |
- - value.quantity.code | 0..1 | Optional | Code | Coded form of the unit The UCUM code that identifies the unit of measure associated with a test result value. |
- dataAbsentReason | 0..1 | Required | CodeableConcept | Why the result is missing Binding (extensible): Codes specifying why the result (Observation.value[x]) is missing. Observation Value Absent Reason The reason why a test result is missing. |
- - coding | 0..* | Required | Coding | Code defined by a terminology system |
- - - system | 0..1 | Mandatory | Uri | Identity of the terminology system |
- - - code | 0..1 | Mandatory | Code | Symbol in syntax defined by the system |
- - - display | 0..1 | Mandatory | String | Representation defined by the system |
- - text | 0..1 | Optional | String | Plain text representation of the concept |
- interpretation | 0..1 | Required | CodeableConcept | High, low, normal, etc. Binding (extensible): Codes identifying interpretations of observations. Observation Interpretation Codes Simple coded interpretation of the results. It is provided by the performing HCP. For example - out of range, high, low. Use FHIR Value Set for standard interpretation codes and https://fhir.hl7.org.uk/STU3/ValueSet/CareConnect-ExtendedInterpretationCode-1 for additional codes |
- - coding | 0..* | Required | Coding | Code defined by a terminology system |
- - - system | 0..1 | Mandatory | Uri | Identity of the terminology system |
- - - code | 0..1 | Mandatory | Code | Symbol in syntax defined by the system |
- - - display | 0..1 | Mandatory | String | Representation defined by the system |
- - text | 0..1 | Optional | String | Plain text representation of the concept |
- comment | 0..1 | Required | String | Comments about result A human readable clinical summary relating to a test result and/or additional notes provided by the laboratory e.g. the specimen has haemolysed or has leaked. |
- bodySite | 0..1 | Required | CodeableConcept | Observed body part Binding (example): Codes describing anatomical locations. May include laterality. SNOMED CT Body Structures |
- - coding | 0..* | Required | Coding | Code defined by a terminology system Slicing: Discriminator: code, Ordering: false, Rules: Open |
- - coding (snomedCT) | 0..1 | Required | Coding | Code defined by a terminology system |
- - - extension (snomedCTDescriptionID) | 0..1 | Required | Extension-coding-sctdescid | The SNOMED CT Description ID for the display. Constraint (ext-1): Must have either extensions or value[x], not both |
- - - system | 1..1 | Mandatory | Uri | Identity of the terminology system The value attribute of the profile element MUST contain the value 'http://snomed.info/sct' |
- - - code | 1..1 | Mandatory | Code | Symbol in syntax defined by the system |
- - - display | 1..1 | Mandatory | String | Representation defined by the system |
- - text | 0..1 | Optional | String | Plain text representation of the concept |
- method | 0..1 | Required | CodeableConcept | How it was done Binding (example): Methods for simple observations. Observation Methods The method of testing/observation that was used. |
- - coding | 0..* | Required | Coding | Code defined by a terminology system Slicing: Discriminator: code, Ordering: false, Rules: Open |
- - coding (snomedCT) | 0..1 | Required | Coding | Code defined by a terminology system Binding (preferred): A code from SNOMED Clinical Terminology UK CareConnect-ObservationMethod-1 |
- - - extension (snomedCTDescriptionID) | 0..1 | Required | Extension-coding-sctdescid | The SNOMED CT Description ID for the display. Constraint (ext-1): Must have either extensions or value[x], not both |
- - - system | 1..1 | Mandatory | Uri | Identity of the terminology system The value attribute of the profile element MUST contain the value 'http://snomed.info/sct' |
- - - code | 1..1 | Mandatory | Code | Symbol in syntax defined by the system |
- - - display | 1..1 | Mandatory | String | Representation defined by the system |
- - text | 0..1 | Optional | String | Plain text representation of the concept |
- specimen | 0..1 | Required | Reference | Specimen used for this observation Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
Required | CareConnect-Specimen-1 | The value attribute of the profile element MUST contain the value 'https://fhir.nhs.uk/STU3/StructureDefinition/CareConnect-Specimen-1' | ||
- - reference | 0..1 | Mandatory | String | Literal reference, Relative, internal or absolute URL a reference to the Specimen resource instance in the message in the format of a UUID prefixed with 'urn:uuid:'. |
- referenceRange | 0..* | Required | BackboneElement | Provides guide for interpretation Constraint (obs-3): Must have at least a low or a high or text |
- - low | 0..1 | Required | Quantity ( SimpleQuantity ) | Low Range, if relevant Constraint (qty-3): If a code for the unit is present, the system SHALL also be present Constraint (sqty-1): The comparator is not used on a SimpleQuantity |
- - - value | 0..1 | Required | Decimal | Numerical value (with implicit precision) |
- - - unit | 0..1 | Required | String | Unit representation |
- - - system | 0..1 | Required | Uri | System that defines coded unit form |
- - - code | 0..1 | Required | Code | Coded form of the unit |
- - high | 0..1 | Required | Quantity ( SimpleQuantity ) | High Range, if relevant Constraint (qty-3): If a code for the unit is present, the system SHALL also be present Constraint (sqty-1): The comparator is not used on a SimpleQuantity |
- - - value | 0..1 | Required | Decimal | Numerical value (with implicit precision) |
- - - unit | 0..1 | Required | String | Unit representation |
- - - system | 0..1 | Required | Uri | System that defines coded unit form |
- - - code | 0..1 | Required | Code | Coded form of the unit |
- - text | 0..1 | Required | String | Text based reference range in an observation Recommend to use text to describe reference range (i.e. male/female etc) |
- related | 0..* | Required | BackboneElement | Resource related to this observationReference to the test group header observation if the result is part of a test group. |
- - type | 0..1 | Required | Code | has-member : derived-from : sequel-to : replaces : qualified-by : interfered-by Binding (required): Codes specifying how two observations are related. ObservationRelationshipTypeMUST be set to derived-from where test is a component in a group test such as a Full Blood Count (FBC) |
- - target | 1..1 | Mandatory | Reference | Resource that is related to this one Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
Mandatory | CareConnect-Observation-1 | |||
- - - reference | 0..1 | Mandatory | String | Literal reference, Relative, internal or absolute URL a reference to the Observtion resource instance in the message in the format of a UUID prefixed with 'urn:uuid:'. |