Observation - uncategorised data

Guidance for populating and consuming the Observation profile for uncategorised data

Introduction

The headings below list the elements of the Observation profile and describe how to populate and consume them for uncategorised data.

Important: Any element not specifically listed below MUST NOT be populated or consumed.

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

Observation elements

id

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

The logical identifier of the uncategorised data Observation profile.

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.

There may be more than one identifier where data has been migrated across practices or provider systems and different provider specific identifiers have been assigned.

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 final.

code

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

The clinical code that represents the data within the observation.

For free text without any clinical code set to 37331000000100 Comment note.

subject

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

Reference to Patient profile representing the Patient against whom the data was recorded.

context

Data type: Reference(Encounter) Optionality: Required Cardinality: 0..1

Optional reference to the Encounter profile representing the consultation context in which the uncategorised data was recorded.

effectiveDateTime

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

Clinically relevant time/time-period for observation

issued

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

The audit trail timestamp representing when the data was recorded.

performer

Data type: Reference(Practitioner, Organization) Optionality: Required Cardinality: 0..*

The Practitioner profile representing the clinician responsible for making the observation.

Where the observation was performed at another organisation and an Organization profile can be populated then that MUST be populated here. This will be in addition to the clinical practitioner if both are available.

If neither the performing organisation or the clinical practitioner is known then this MUST be populated with the details of the person who recorded the data in the system.

Additional criteria apply for representation of an inbound referral. See the guidance page for details.

value[x]

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

The value of the observation. This may be in any of the forms defined in the profile.

Where applicable the value MUST use the units specified as part of the FHIR vital signs specification.

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

This MUST include any qualifiers to the code element that were present in the sending system. These should be reported as a code and value pair as specified in the uncategorised data guidance.

It MUST also include any text relating to the observation.

bodySite

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

This MAY be populated where a suitably coded body site is captured with an appropriate terminology. Alternatievly, the comment can be populated as described above.

referenceRange

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

The reference range provides a guide for interpretation of the results.

Where a reference range contains a less than ‘<’ or greater than ‘>’ operator it should be written to the referenceRange.text element as these operators are not supported in this context.

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

Can be used to reference another resource related to this observation

component

Data type: BackboneElement

Optionality: Required

Cardinality: 0..*

This MAY be used for the component part of a blood pressure that is recorded as a triple or to carry qualifying data to the main observation code.

This MAY be used for inbound referrals. See the guidance page for details.

Elements not in use

The following elements MUST NOT be populated:

basedOn

Data type: Reference

dataAbsentReason

Data type: CodeableConcept

method