Guidance for populating and consuming investigations data in GP Connect

• Introduction
• Filing comments - Observation resource elements
  • id
  • meta.profile
  • meta.security
  • identifier
  • status
  • code
  • subject
  • context
  • effective[x]
  • issued
  • performer
  • value[x]
  • comment
  • related
• Elements not in use
  • basedOn
  • category
  • dataAbsentReason
  • interpretation
  • bodysite
  • method
  • specimen
  • referenceRange
  • device
  • component

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.

Filing comments - 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

meta.security

Data type: Coding

Optionality: Optional

Cardinality: 0..*

The security label(s) applicable to the resource.

See FHIR resources for more details on how to populate the element.

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

For filing comments this is a set value of ‘unknown’.

code

Data type: CodableConcept

Optionality: Mandatory

Cardinality: 1..1

Fixed value of 37331000000100 for Comment note.

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: Required

Cardinality: 0..1

A reference to the Encounter profile representing the consultation the test report is filed against.

effective[x]

Data type: dateTime/Period

Optionality: Required

Cardinality: 0..1

The dateTime when the ‘Test report’, ‘Test group’ or ‘Test result’ was filed into the patient record.

issued

Data type: instant

Optionality: Mandatory

Cardinality: 1..1

The date time that the time/comment was recorded in the GP system.

performer

Data type: Reference(Practitioner | Organisation)

Optionality: Mandatory

Cardinality: 1..*

Reference to the resource for the organisation and/or practitioner that filed the ‘Test report’, ‘Test group’ or ‘Test result’ was filed into the patient record.

value[x]

Data type: Many

Optionality: Required

Cardinality: 0..1

Where a ‘Test group’ or ‘Test result’ has been filed the value should match the code from the ‘Test group header’ or ‘Test result’ resource respectively.

comment

Data type: string

Optionality: Required

Cardinality: 0..*

Notes added by the GP practice clinician about the ‘Test report’, ‘Test group’ or ‘Test result’ that has been filed into the patient record.

related

Data type: BackboneElement

Optionality: Required

Cardinality: 0..1

Reference to the test result or test group header that the filing comments resource relates to. Where the filing comments relate to the test report, the reference is made from the ‘Test report’ to the filing comment only.

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

Elements not in use

The following elements MUST NOT be populated:

basedOn

Data type: Boolean

category

Data type: CodableConcept

dataAbsentReason

Data type: CodeableConcept

interpretation

Data type: CodeableConcept

bodysite

Data type: CodeableConcept

method

Data type: CodeableConcept

specimen

Data type: Reference

referenceRange

Data type: BackboneElement

device

Data type: BackboneElement

component

Data type: BackboneElement