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Test Result (Single)

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
- 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:'.

Test (Single) Result Example(s)

Tags: fhir

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