Observation - test group header

Guidance for populating and consuming Observation resource where used in a test group header GP Connect

Introduction

The headings below list the elements of the Observation resource and describe how to populate and consume them.

Important: Any element not specifically listed below MUST NOT be populated or consumed. A full list of elements not used is available here.

Tip: You’ll find it helpful to read it in conjunction with the underlying Observation profile definition.

Test group header - `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 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: Code Optionality: Mandatory Cardinality: 1..1

The status of the test group header.

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.

code

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

The clinical code that represents the name of the test group - for example, Full blood count.

subject

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

A reference to the patient who the observation is about.

context

Data type: reference Optionality: Optional Cardinality: 0..1

A reference to the Encounter profile representing the consultation the test group is associated to.

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: Manadatory Cardinality: 1..1

The date and time that the result was issued by the laboratory or other report provider.

Is this is not provided for a test group header result then it should inherit the date from the DiagnosticReport.

performer

Data type: Reference (Practitioner/Organisation) Optionality: Required Cardinality: 0..*

Reference to the resource for the Organization that carried out the tests. A Practitioner resource may also be referenced here but only where an organization is reference is provided.

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

Notes that relate to the test group header that were written by the performing organization.

For example, the sample has haemolysed or has leaked.

specimen

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

Reference to the specimen on which these results were based.

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

Reference(s) to the test result(s) observation(s) that make up the test group.

This MUST be qualified using the related.type ‘has-member’.

Elements not in use

The following elements MUST NOT be populated: