Interweave Implementation Guide
0.1.0 - ci-build
Interweave Implementation Guide - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the R4 profiles here.
Official URL: https://fhir.yhcr.nhs.uk/StructureDefinition/Interweave-Observation-ACVPU | Version: 0.1.0 | |||
Active as of 2024-07-17 | Computable Name: InterweaveObservationACVPU |
Interweave ACVPU Observation resource profile.
Status: Active: Approved (STU)
This profile sets out the expectations for the interweave ACVPU observation resource. The base for this profile is the CareConnect-ACVPU-Observation-1. We have enforced the use of SNOMED codes where possible and have removed the component field. This is to ensure that the valueCodeableConcept field is used to provide the result.
The following mandatory fields are defined:
status – Fixed value of ‘final’.
category – Fixed value of ‘vital-signs’.
code – Fixed value of SCT: 1104441000000107 (ACVPU (Alert Confusion Voice Pain Unresponsive) scale score).
subject – Reference to the patient who is the subject of this measurement.
effective – An important field to provide details of the time/time period during which the observation was taken.
In addition the following fields are “Must Support” - ie they must be populated if relevant and known.
valueCodeableConcept – The actual result recorded. This is a required binding to the Care Connect ACVPU code system which Include codes from SNOMED_CT where constraint Equal (248234008 (Mentally alert) OR 300202002 (Responds to voice) OR 450847001 (Responds to pain) OR 422768004 (Unresponsive) OR 130987000 (Acute confusion))
dataAbsentReason - The reason why the result is missing, this is valuable if a value has not been obtained for some reason e.g. a patient refused. This field can only be provided when there is no value present.
identifier - A Local Id should be provided, such that could be quoted if manually getting in touch to find out more.
performer - We limit this field to reference practitioner resources only. The organization responsible for the observation can be obtained via the provenance tag.
interpretation - This is also known as the ‘abnormal flag’ and is regularly recorded alongside the actual result. It is used to signal the meaning of the result.
referenceRange - To aid the interpretation of a result, it is important to include the reference range.
comment - Comments in addition to the result are often recorded for observations, it is therefore important to provide this field when available to give the consumer the full result information.
Other fields are optional and may be populated if known - on the understanding that not all data consumers will necessarily make use of them. Points of note include:
reasonCondition (care connect extension) – An optional care connect extension that allows the reason for an observation being performed/recorded to be specified. This can be a reference to a condition resource or a coded entity.
bodySite – A long list of SNOMED codes which represent the observed parts of the body.
context – Optional link to an encounter resource.
method – Option to provide the mechanism used to perform the observation
specimen – Opportunity to provide a link to a specimen resource from which the observation was obtained.
device – Opportunity to provide a link to a device resource from which was used to obtain the observation.
related – To reduce complexity, we limit the related field’s usage to only allow links to observation resources, from which the primary observation’s value was derived. E.g. An observation may have a value which is a score, and that score may have been derived from several other observations.
basedOn – This field is discouraged as it does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer.
issued – This field has been removed as this information can be taken from the mandatory meta.lastUpdated field, and to also avoid any confusion with the other date fields.
Component – Removed to aid the data consumer, we ask that the result is provided in the valueCodeableConcept field and not in the component field.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CareConnect-ACVPU-Observation-1
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | CareConnect-ACVPU-Observation-1 | Measurements and simple assertions | |
id | S | 0..1 | id | Logical id of this artifact |
meta | ||||
versionId | S | 0..1 | id | Version specific identifier |
lastUpdated | S | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. |
profile | S | 0..* | uri | Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile |
security | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers | |
Slices for tag | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system | |
tag:Source | S | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data |
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source | |
code | S | 1..1 | code | The Data Provider Id of the system supplying the data |
display | S | 1..1 | string | Name of the system supplying the data |
tag:Provenance | S | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data |
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance | |
code | S | 1..1 | code | The ODS Code of the organisation responsible for the data |
display | S | 1..1 | string | Name of the organisation supplying the data |
implicitRules | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | |
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) | |
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
reason | 0..* | CodeableConcept, Reference(CareConnect-Condition-1) | Reason resource added/performed/given. URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-ReasonCondition-1 | |
identifier | S | 0..* | Identifier | Business Identifier for observation |
basedOn | 0..* | Reference(CareConnect-CarePlan-1 | DeviceRequest | ImmunizationRecommendation | NutritionOrder | CareConnect-ReferralRequest-1 | CareConnect-MedicationRequest-1 | CareConnect-ProcedureRequest-1) | DISCOURAGED - This field does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer. | |
status | S | 1..1 | code | Fixed value of ‘final’. |
Slices for category | S | 1..1 | CodeableConcept | Classification of type of observation. Slice: Unordered, Open by value:coding.system |
category:All Slices | Content/Rules for all slices | |||
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
category:observationCategory | 1..1 | CodeableConcept | Classification of type of observation. Binding: Observation Category Codes (required): Codes for high level observation categories. | |
coding | ||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/observation-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: vital-signs | |
display | 1..1 | string | Representation defined by the system Fixed Value: Vital Signs | |
code | S | 1..1 | CodeableConcept | Type of observation (code / type) |
subject | S | 1..1 | Reference(CareConnectPatient1) | The patient whose characteristics (direct or indirect) are described by the observation and into whose record the observation is placed. |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
context | 0..1 | Reference(CareConnect-Encounter-1) | The encounter during which this observation is made. | |
effective[x] | S | 1..1 | dateTime, Period | This is the time/time period during which the observation was taken. |
issued | 0..0 | |||
performer | S | 0..* | Reference(CareConnect-Practitioner-1) | Who is responsible for the observation. |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
value[x] | S | 0..1 | CodeableConcept | Actual result. |
dataAbsentReason | S | 0..1 | CodeableConcept | Why the result is missing Binding: Observation Value Absent Reason (required) |
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
interpretation | S | 0..1 | CodeableConcept | High, low, normal, etc. Binding: Observation Interpretation Codes (required) |
comment | S | 0..1 | string | Comments about the result |
bodySite | S | 0..1 | CodeableConcept | Observed body part Binding: SNOMED CT Body Structures (required) |
method | 0..1 | CodeableConcept | How it was done Binding: Observation Methods (required) | |
specimen | 0..1 | Reference(CareConnect-Specimen-1) | Specimen used for this observation. | |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 0..1 | string | If relevant, description of the referenced resource | |
device | 0..1 | Reference(Device) | Measurement device. | |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 0..1 | string | If relevant, description of the referenced resource | |
referenceRange | S | 0..* | BackboneElement | Provides guide for interpretation |
related | 0..* | BackboneElement | Resources related to this observation | |
type | S | 1..1 | code | Fixed value: derived-from |
target | S | 1..1 | Reference(CareConnect-Observation-1) | we limit the related field’s usage to only allow links to observation resources, from which the primary observation’s value was derived. E.g. An observation may have a value which is a score, and that score may have been derived from several other observations. |
component | 0..0 | |||
Documentation for this format |
Path | Conformance | ValueSet |
Observation.category:observationCategory | required | Observation Category Codes |
Observation.dataAbsentReason | required | Observation Value Absent Reason |
Observation.interpretation | required | Observation Interpretation Codes |
Observation.bodySite | required | SNOMED CT Body Structures |
Observation.method | required | Observation Methods |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | CareConnect-ACVPU-Observation-1 | Measurements and simple assertions | ||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
versionId | SΣ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. | ||||
profile | SΣ | 0..* | uri | Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile | ||||
security | Σ | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Slices for tag | Σ | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones" | ||||
tag:Source | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones" | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source | ||||
code | SΣ | 1..1 | code | The Data Provider Id of the system supplying the data | ||||
display | SΣ | 1..1 | string | Name of the system supplying the data | ||||
tag:Provenance | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones" | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance | ||||
code | SΣ | 1..1 | code | The ODS Code of the organisation responsible for the data | ||||
display | SΣ | 1..1 | string | Name of the organisation supplying the data | ||||
implicitRules | ?!Σ | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | ||||
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) Binding: Common Languages (extensible): A human language.
| |||||
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
reason | 0..* | CodeableConcept, Reference(CareConnect-Condition-1) | Reason resource added/performed/given. URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-ReasonCondition-1 | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | SΣ | 0..* | Identifier | Business Identifier for observation | ||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||
basedOn | Σ | 0..* | Reference(CareConnect-CarePlan-1 | DeviceRequest | ImmunizationRecommendation | NutritionOrder | CareConnect-ReferralRequest-1 | CareConnect-MedicationRequest-1 | CareConnect-ProcedureRequest-1) | DISCOURAGED - This field does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer. | ||||
status | ?!SΣ | 1..1 | code | Fixed value of ‘final’. Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: final | ||||
Slices for category | S | 1..1 | CodeableConcept | Classification of type of observation. Slice: Unordered, Open by value:coding.system Binding: Observation Category Codes (preferred): Codes for high level observation categories. | ||||
category:observationCategory | 1..1 | CodeableConcept | Classification of type of observation. Binding: Observation Category Codes (required): Codes for high level observation categories. | |||||
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: http://snomed.info/sct (required): A code from SNOMED Clinical Terminology UK | ||||
coding | Σ | 1..1 | Coding | Code defined by a terminology system | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1104441000000107 | ||||
display | Σ | 1..1 | string | Representation defined by the system Fixed Value: ACVPU (Alert Confusion Voice Pain Unresponsive) scale score | ||||
subject | SΣ | 1..1 | Reference(CareConnectPatient1) | The patient whose characteristics (direct or indirect) are described by the observation and into whose record the observation is placed. | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
context | 0..1 | Reference(CareConnect-Encounter-1) | The encounter during which this observation is made. | |||||
effective[x] | SΣ | 1..1 | This is the time/time period during which the observation was taken. | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
performer | SΣ | 0..* | Reference(CareConnect-Practitioner-1) | Who is responsible for the observation. | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
Slices for value[x] | SΣC | 0..1 | CodeableConcept | Actual result. Slice: Unordered, Closed by type:$this | ||||
value[x]:valueCodeableConcept | ΣC | 0..1 | CodeableConcept | Actual result Binding: Care Connect ACVPU (required): A code from the SNOMED Clinical Terminology UK coding system which describes whether a patient is mentally alert, unresponsive, responds to voice, responds to pain or is acutely confused. | ||||
coding | Σ | 1..1 | Coding | Code defined by a terminology system | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: Observation Value Absent Reason (required) | ||||
interpretation | S | 0..1 | CodeableConcept | High, low, normal, etc. Binding: Observation Interpretation Codes (required) | ||||
comment | S | 0..1 | string | Comments about the result | ||||
bodySite | S | 0..1 | CodeableConcept | Observed body part Binding: SNOMED CT Body Structures (required) | ||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system Binding: Care Connect Body Site (preferred): A code from the SNOMED Clinical Terminology UK with the expression (<<442083009 |anatomical or acquired body structure|). | ||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
method | 0..1 | CodeableConcept | How it was done Binding: Observation Methods (required) | |||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system Binding: Care Connect Observation Method (preferred): A code from SNOMED Clinical Terminology UK | ||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
specimen | 0..1 | Reference(CareConnect-Specimen-1) | Specimen used for this observation. | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 0..1 | string | If relevant, description of the referenced resource | ||||
device | 0..1 | Reference(Device) | Measurement device. | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 0..1 | string | If relevant, description of the referenced resource | ||||
referenceRange | SC | 0..* | BackboneElement | Provides guide for interpretation | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
related | Σ | 0..* | BackboneElement | Resources related to this observation | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
type | S | 1..1 | code | Fixed value: derived-from Binding: ObservationRelationshipType (required): Codes specifying how two observations are related. | ||||
target | S | 1..1 | Reference(CareConnect-Observation-1) | we limit the related field’s usage to only allow links to observation resources, from which the primary observation’s value was derived. E.g. An observation may have a value which is a score, and that score may have been derived from several other observations. | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | ||||
Observation.meta.security | extensible | All Security Labels | ||||
Observation.meta.tag | example | Common Tags | ||||
Observation.meta.tag:Source | example | Common Tags | ||||
Observation.meta.tag:Provenance | example | Common Tags | ||||
Observation.language | extensible | Common Languages
| ||||
Observation.identifier.use | required | IdentifierUse | ||||
Observation.status | required | Fixed Value: final | ||||
Observation.category | preferred | Observation Category Codes | ||||
Observation.category:observationCategory | required | Observation Category Codes | ||||
Observation.code | required | http://snomed.info/sct | ||||
Observation.value[x]:valueCodeableConcept | required | Care Connect ACVPU | ||||
Observation.dataAbsentReason | required | Observation Value Absent Reason | ||||
Observation.interpretation | required | Observation Interpretation Codes | ||||
Observation.bodySite | required | SNOMED CT Body Structures | ||||
Observation.bodySite.coding:snomedCT | preferred | Care Connect Body Site | ||||
Observation.method | required | Observation Methods | ||||
Observation.method.coding:snomedCT | preferred | Care Connect Observation Method | ||||
Observation.related.type | required | ObservationRelationshipType | ||||
Observation.component.code | example | LOINC Codes (a valid code from LOINC) | ||||
Observation.component.code.coding:snomedCT | extensible | Care Connect Observation Type |
Id | Grade | Path(s) | Details | Requirements |
dom-1 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain any narrative : contained.text.empty() | |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource : contained.where(('#'+id in %resource.descendants().reference).not()).empty() | |
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() | |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() | |
obs-7 | error | Observation | If code is the same as a component code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where( (coding.code = %resource.code.coding.code) and (coding.system = %resource.code.coding.system)).empty() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | CareConnect-ACVPU-Observation-1 | Measurements and simple assertions | ||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | SΣ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. | ||||
profile | SΣ | 0..* | uri | Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile | ||||
security | Σ | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Slices for tag | Σ | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones" | ||||
tag:Source | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones" | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | SΣ | 1..1 | code | The Data Provider Id of the system supplying the data | ||||
display | SΣ | 1..1 | string | Name of the system supplying the data | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
tag:Provenance | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones" | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | SΣ | 1..1 | code | The ODS Code of the organisation responsible for the data | ||||
display | SΣ | 1..1 | string | Name of the organisation supplying the data | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
implicitRules | ?!Σ | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | ||||
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) Binding: Common Languages (extensible): A human language.
| |||||
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
reason | 0..* | CodeableConcept, Reference(CareConnect-Condition-1) | Reason resource added/performed/given. URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-ReasonCondition-1 | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | SΣ | 0..* | Identifier | Business Identifier for observation | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(CareConnect-Organization-1) | Organization that issued id (may be just text) | ||||
basedOn | Σ | 0..* | Reference(CareConnect-CarePlan-1 | DeviceRequest | ImmunizationRecommendation | NutritionOrder | CareConnect-ReferralRequest-1 | CareConnect-MedicationRequest-1 | CareConnect-ProcedureRequest-1) | DISCOURAGED - This field does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer. | ||||
status | ?!SΣ | 1..1 | code | Fixed value of ‘final’. Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: final | ||||
Slices for category | S | 1..1 | CodeableConcept | Classification of type of observation. Slice: Unordered, Open by value:coding.system Binding: Observation Category Codes (preferred): Codes for high level observation categories. | ||||
category:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
category:observationCategory | 1..1 | CodeableConcept | Classification of type of observation. Binding: Observation Category Codes (required): Codes for high level observation categories. | |||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/observation-category | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: vital-signs | ||||
display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Vital Signs | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: http://snomed.info/sct (required): A code from SNOMED Clinical Terminology UK | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 1..1 | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1104441000000107 | ||||
display | Σ | 1..1 | string | Representation defined by the system Fixed Value: ACVPU (Alert Confusion Voice Pain Unresponsive) scale score | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
subject | SΣ | 1..1 | Reference(CareConnectPatient1) | The patient whose characteristics (direct or indirect) are described by the observation and into whose record the observation is placed. | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
context | 0..1 | Reference(CareConnect-Encounter-1) | The encounter during which this observation is made. | |||||
effective[x] | SΣ | 1..1 | This is the time/time period during which the observation was taken. | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
performer | SΣ | 0..* | Reference(CareConnect-Practitioner-1) | Who is responsible for the observation. | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
Slices for value[x] | SΣC | 0..1 | CodeableConcept | Actual result. Slice: Unordered, Closed by type:$this | ||||
value[x]:valueCodeableConcept | ΣC | 0..1 | CodeableConcept | Actual result Binding: Care Connect ACVPU (required): A code from the SNOMED Clinical Terminology UK coding system which describes whether a patient is mentally alert, unresponsive, responds to voice, responds to pain or is acutely confused. | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 1..1 | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
dataAbsentReason | SC | 0..1 | CodeableConcept | Why the result is missing Binding: Observation Value Absent Reason (required) | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
interpretation | S | 0..1 | CodeableConcept | High, low, normal, etc. Binding: Observation Interpretation Codes (required) | ||||
comment | S | 0..1 | string | Comments about the result | ||||
bodySite | S | 0..1 | CodeableConcept | Observed body part Binding: SNOMED CT Body Structures (required) | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system Binding: Care Connect Body Site (preferred): A code from the SNOMED Clinical Terminology UK with the expression (<<442083009 |anatomical or acquired body structure|). | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
method | 0..1 | CodeableConcept | How it was done Binding: Observation Methods (required) | |||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system Binding: Care Connect Observation Method (preferred): A code from SNOMED Clinical Terminology UK | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
specimen | 0..1 | Reference(CareConnect-Specimen-1) | Specimen used for this observation. | |||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 0..1 | string | If relevant, description of the referenced resource | ||||
device | 0..1 | Reference(Device) | Measurement device. | |||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 0..1 | string | If relevant, description of the referenced resource | ||||
referenceRange | SC | 0..* | BackboneElement | Provides guide for interpretation | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
low | C | 0..1 | SimpleQuantity | Low Range, if relevant | ||||
high | C | 0..1 | SimpleQuantity | High Range, if relevant | ||||
type | 0..1 | CodeableConcept | Reference range qualifier Binding: Observation Reference Range Meaning Codes (extensible): Code for the meaning of a reference range. | |||||
appliesTo | 0..* | CodeableConcept | Reference range population Binding: Observation Reference Range Applies To Codes (example): Codes identifying the population the reference range applies to. | |||||
age | 0..1 | Range | Applicable age range, if relevant | |||||
text | 0..1 | string | Text based reference range in an observation | |||||
related | Σ | 0..* | BackboneElement | Resources related to this observation | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
type | S | 1..1 | code | Fixed value: derived-from Binding: ObservationRelationshipType (required): Codes specifying how two observations are related. | ||||
target | S | 1..1 | Reference(CareConnect-Observation-1) | we limit the related field’s usage to only allow links to observation resources, from which the primary observation’s value was derived. E.g. An observation may have a value which is a score, and that score may have been derived from several other observations. | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | ||||
Observation.meta.security | extensible | All Security Labels | ||||
Observation.meta.tag | example | Common Tags | ||||
Observation.meta.tag:Source | example | Common Tags | ||||
Observation.meta.tag:Provenance | example | Common Tags | ||||
Observation.language | extensible | Common Languages
| ||||
Observation.identifier.use | required | IdentifierUse | ||||
Observation.identifier.type | extensible | Identifier Type Codes | ||||
Observation.status | required | Fixed Value: final | ||||
Observation.category | preferred | Observation Category Codes | ||||
Observation.category:observationCategory | required | Observation Category Codes | ||||
Observation.code | required | http://snomed.info/sct | ||||
Observation.value[x]:valueCodeableConcept | required | Care Connect ACVPU | ||||
Observation.dataAbsentReason | required | Observation Value Absent Reason | ||||
Observation.interpretation | required | Observation Interpretation Codes | ||||
Observation.bodySite | required | SNOMED CT Body Structures | ||||
Observation.bodySite.coding:snomedCT | preferred | Care Connect Body Site | ||||
Observation.method | required | Observation Methods | ||||
Observation.method.coding:snomedCT | preferred | Care Connect Observation Method | ||||
Observation.referenceRange.type | extensible | Observation Reference Range Meaning Codes | ||||
Observation.referenceRange.appliesTo | example | Observation Reference Range Applies To Codes | ||||
Observation.related.type | required | ObservationRelationshipType | ||||
Observation.component.code | example | LOINC Codes (a valid code from LOINC) | ||||
Observation.component.code.coding:snomedCT | extensible | Care Connect Observation Type | ||||
Observation.component.dataAbsentReason | extensible | Observation Value Absent Reason | ||||
Observation.component.interpretation | extensible | Observation Interpretation Codes |
Id | Grade | Path(s) | Details | Requirements |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() |
This structure is derived from CareConnect-ACVPU-Observation-1
Summary
Mandatory: 6 elements (21 nested mandatory elements)
Must-Support: 25 elements
Fixed Value: 5 elements
Prohibited: 2 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CareConnect-ACVPU-Observation-1
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | CareConnect-ACVPU-Observation-1 | Measurements and simple assertions | |
id | S | 0..1 | id | Logical id of this artifact |
meta | ||||
versionId | S | 0..1 | id | Version specific identifier |
lastUpdated | S | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. |
profile | S | 0..* | uri | Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile |
security | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers | |
Slices for tag | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system | |
tag:Source | S | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data |
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source | |
code | S | 1..1 | code | The Data Provider Id of the system supplying the data |
display | S | 1..1 | string | Name of the system supplying the data |
tag:Provenance | S | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data |
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance | |
code | S | 1..1 | code | The ODS Code of the organisation responsible for the data |
display | S | 1..1 | string | Name of the organisation supplying the data |
implicitRules | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | |
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) | |
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
reason | 0..* | CodeableConcept, Reference(CareConnect-Condition-1) | Reason resource added/performed/given. URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-ReasonCondition-1 | |
identifier | S | 0..* | Identifier | Business Identifier for observation |
basedOn | 0..* | Reference(CareConnect-CarePlan-1 | DeviceRequest | ImmunizationRecommendation | NutritionOrder | CareConnect-ReferralRequest-1 | CareConnect-MedicationRequest-1 | CareConnect-ProcedureRequest-1) | DISCOURAGED - This field does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer. | |
status | S | 1..1 | code | Fixed value of ‘final’. |
Slices for category | S | 1..1 | CodeableConcept | Classification of type of observation. Slice: Unordered, Open by value:coding.system |
category:All Slices | Content/Rules for all slices | |||
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
category:observationCategory | 1..1 | CodeableConcept | Classification of type of observation. Binding: Observation Category Codes (required): Codes for high level observation categories. | |
coding | ||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/observation-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: vital-signs | |
display | 1..1 | string | Representation defined by the system Fixed Value: Vital Signs | |
code | S | 1..1 | CodeableConcept | Type of observation (code / type) |
subject | S | 1..1 | Reference(CareConnectPatient1) | The patient whose characteristics (direct or indirect) are described by the observation and into whose record the observation is placed. |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
context | 0..1 | Reference(CareConnect-Encounter-1) | The encounter during which this observation is made. | |
effective[x] | S | 1..1 | dateTime, Period | This is the time/time period during which the observation was taken. |
issued | 0..0 | |||
performer | S | 0..* | Reference(CareConnect-Practitioner-1) | Who is responsible for the observation. |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
value[x] | S | 0..1 | CodeableConcept | Actual result. |
dataAbsentReason | S | 0..1 | CodeableConcept | Why the result is missing Binding: Observation Value Absent Reason (required) |
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
interpretation | S | 0..1 | CodeableConcept | High, low, normal, etc. Binding: Observation Interpretation Codes (required) |
comment | S | 0..1 | string | Comments about the result |
bodySite | S | 0..1 | CodeableConcept | Observed body part Binding: SNOMED CT Body Structures (required) |
method | 0..1 | CodeableConcept | How it was done Binding: Observation Methods (required) | |
specimen | 0..1 | Reference(CareConnect-Specimen-1) | Specimen used for this observation. | |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 0..1 | string | If relevant, description of the referenced resource | |
device | 0..1 | Reference(Device) | Measurement device. | |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 0..1 | string | If relevant, description of the referenced resource | |
referenceRange | S | 0..* | BackboneElement | Provides guide for interpretation |
related | 0..* | BackboneElement | Resources related to this observation | |
type | S | 1..1 | code | Fixed value: derived-from |
target | S | 1..1 | Reference(CareConnect-Observation-1) | we limit the related field’s usage to only allow links to observation resources, from which the primary observation’s value was derived. E.g. An observation may have a value which is a score, and that score may have been derived from several other observations. |
component | 0..0 | |||
Documentation for this format |
Path | Conformance | ValueSet |
Observation.category:observationCategory | required | Observation Category Codes |
Observation.dataAbsentReason | required | Observation Value Absent Reason |
Observation.interpretation | required | Observation Interpretation Codes |
Observation.bodySite | required | SNOMED CT Body Structures |
Observation.method | required | Observation Methods |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | CareConnect-ACVPU-Observation-1 | Measurements and simple assertions | ||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
versionId | SΣ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. | ||||
profile | SΣ | 0..* | uri | Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile | ||||
security | Σ | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Slices for tag | Σ | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones" | ||||
tag:Source | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones" | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source | ||||
code | SΣ | 1..1 | code | The Data Provider Id of the system supplying the data | ||||
display | SΣ | 1..1 | string | Name of the system supplying the data | ||||
tag:Provenance | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones" | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance | ||||
code | SΣ | 1..1 | code | The ODS Code of the organisation responsible for the data | ||||
display | SΣ | 1..1 | string | Name of the organisation supplying the data | ||||
implicitRules | ?!Σ | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | ||||
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) Binding: Common Languages (extensible): A human language.
| |||||
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
reason | 0..* | CodeableConcept, Reference(CareConnect-Condition-1) | Reason resource added/performed/given. URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-ReasonCondition-1 | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | SΣ | 0..* | Identifier | Business Identifier for observation | ||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||
basedOn | Σ | 0..* | Reference(CareConnect-CarePlan-1 | DeviceRequest | ImmunizationRecommendation | NutritionOrder | CareConnect-ReferralRequest-1 | CareConnect-MedicationRequest-1 | CareConnect-ProcedureRequest-1) | DISCOURAGED - This field does not appear to provide information which would be beneficial in a shared care record. It also allows references to a raft of request/order resources which introduces a lot of complexity for a data consumer. | ||||
status | ?!SΣ | 1..1 | code | Fixed value of ‘final’. Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: final | ||||
Slices for category | S | 1..1 | CodeableConcept | Classification of type of observation. Slice: Unordered, Open by value:coding.system Binding: Observation Category Codes (preferred): Codes for high level observation categories. | ||||
category:observationCategory | 1..1 | CodeableConcept | Classification of type of observation. Binding: Observation Category Codes (required): Codes for high level observation categories. | |||||
code | SΣ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: http://snomed.info/sct (required): A code from SNOMED Clinical Terminology UK | ||||
coding | Σ | 1..1 | Coding | Code defined by a terminology system | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1104441000000107 | ||||
display | Σ | 1..1 | string | Representation defined by the system Fixed Value: ACVPU (Alert Confusion Voice Pain Unresponsive) scale score | ||||
subject | SΣ | 1..1 | Reference(CareConnectPatient1) | The patient whose characteristics (direct or indirect) are described by the observation and into whose record the observation is placed. | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
context | 0..1 | Reference(CareConnect-Encounter-1) | The encounter during which this observation is made. | |||||
effective[x] | SΣ | 1..1 | This is the time/time period during which the observation was taken. | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
performer | SΣ | 0..* | Reference(CareConnect-Practitioner-1) | Who is responsible for the observation. | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
Slices for value[x] | SΣC | 0..1 | CodeableConcept | Actual result. Slice: Unordered, Closed by type:$this | ||||
value[x]:valueCodeableConcept | ΣC | 0..1 | CodeableConcept | Actual result Binding: Care Connect ACVPU (required): A code from the SNOMED Clinical Terminology UK coding system which describes whether a patient is mentally alert, unresponsive, responds to voice, responds to pain or is acutely confused. | ||||
coding | Σ | 1..1 | Coding | Code defined by a terminology system | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||