Schema: Observation - 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 will 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

The logical identifier of the uncategorised data Observation profile.

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

Fixed value of final.

code

The clinical code that represents the data within the observation.

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

subject

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

context

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

effectiveDateTime

Clinically relevant time/time-period for observation

issued

The audit trail timestamp representing when the data was recorded.

performer

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 will 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 will be populated with the details of the person who recorded the data in the system.

Additional criteria apply for representation of an inbound referral.

value[x]

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

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

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

This will 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 will also include any text relating to the observation.

referenceRange

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.

related

Can be used to reference another resource related to this observation

component

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.