Schema: Observation - Test Result

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 will 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 Result - Observation Resource Elements

id

The logical identifier of the Observation resource.

meta.profile

The Observation profile URL.

Fixed value https://fhir.nhs.uk/STU3/StructureDefinition/CareConnect-GPC-Observation-1

identifier

This will be populated with a globally unique and persistent identifier (that is, it doesn’t change between requests and therefore stored with the source data).

status

The status of the test result.

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.

category

The general type of test result. A default value of Laboratory should be used if a more specific value is not available - for example, pathology, microbiology, and so on.

code

The clinical code that represents the name of the test result or test analyte.

subject

A reference to the patient who the observation is about.

context

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

effective[x]

The date and time when the test was performed.

issued

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

Is this is not provided for an individual result then it should inherit the date from the DiagnosticReport.

performer

Reference to the resource for the organisation and/or practitioner that performed the test.

value[x]

The value of the test. This may be in the form of, but is not limited to, one of the following datatypes: a quantity, string or an attachment.

dataAbsentReason

The reason why a result/value has been omitted.

interpretation

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

Lab notes in addition to the interpretation. For example, the sample has haemolysed or has leaked.

bodysite

The body part that was tested/observed.

method

The method of testing/observation that was used.

specimen

Reference to the specimen on which these results were based.

referenceRange

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

related

Reference to the test group header observation if the result is part of a test group.

This will be qualified using the related.type ‘derived-from’.