Gives information about examination findings
Important: This specification is based on the Professional Records Standards Body's Community Pharmacy Standard V2.2 standard which provides further information on document headings and content for messages:
Examination Findings Section Content
This is an examination findings record entry.
There may be 0 TO MANY record entry/entries under a section. Each record entry is made up of a number of elements or data items.
- Height/Length
- Weight
- BMI
- Blood Pressure
- Heart Rate
- Temperature
- Oxygen Saturation
- Pain Score
- Level of Consciousness
- Respiratory Rate
- Air or Oxygen
- National early warning score (NEWS 2)
Example Section
Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.
Examples are illustrative only.
<!--<xml>-->
<!--Examination findings-->
<section>
<title value="Examination findings"/>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="715851000000102"/>
<display value="Examination findings"/>
</coding>
</code>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table width="100%">
Examination Finding Date: 2021-09-04T12:35
<tbody>
<tr>
<th>Observation</th>
<th>Performed</th>
<th>Reading</th>
</tr>
<tr>
<td>Height/Length</td>
<td>1.7 m</td>
</tr>
<tr>
<td>Weight</td>
<td>82.5 kg</td>
</tr>
<tr>
<td>BMI</td>
<td>22</td>
</tr>
<tr>
<td>Blood pressure</td>
<td>84/120 mmHg</td>
</tr>
<tr>
<td>Heart rate</td>
<td>92 /min</td>
</tr>
<tr>
<td>Temperature</td>
<td>37.5 C</td>
</tr>
<tr>
<td>Oxygen saturation</td>
<td>98%</td>
</tr>
<tr>
<td>Pain score</td>
<td>6</td>
</tr>
<tr>
<td>Level of Consciousness</td>
<td>voice</td>
</tr>
<tr>
<td>Respiration rate</td>
<td>38 /min</td>
</tr>
<tr>
<td>Air or oxygen</td>
<td>Air</td>
</tr>
<tr>
<td>National early warning score (NEWS 2)</td>
<td>6</td>
</tr>
</tbody>
</table>
</div>
</text>
</section>
<!--</xml>-->
Coded Resources
The text section should be linked to the following FHIR resources to provide the textual information in a coded format.
Blood Pressure Observation
The coded form of each blood pressure reading follows the codes and structure for CareConnect-BloodPressure-Observation-1.
| CareConnect-Observation-1 element | Cardinality | Notes |
|---|---|---|
| meta.profile | 1..1 | Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-BloodPressure-Observation-1’ |
| status | 1..1 | Fixed to final |
| category | 1..1 | Fixed as per profile |
| code | 1..1 | Loinc slice – fixed as per profile SNOMED slice – fixed as per profile |
| subject | 1..1 | Link to Patient |
| effectiveDateTime | 1..1 | The date and time the blood pressure reading took place |
| bodySite | 0..1 | <442083009 - Anatomical or acquired body structure |
| component systolic | ||
| - code | 1..1 | SNOMED «271649006 Systolic blood pressure |
| - valueQuantity | 0..1 | Recorded as per the profile |
| component diastolic | ||
| - code | 1..1 | SNOMED «271650006 Diastolic blood pressure |
| - valueQuantity | 0..1 | Recorded as per the profile |
Blood Pressure Observation Example
Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.
Examples are illustrative only.
<!--<xml>-->
<Observation xmlns="http://hl7.org/fhir">
<id value="e0818279-51da-4e82-ab44-7798cdab8ccc"/>
<meta>
<!--claim conformance to CareConnect-BloodPressure-Observation-1-->
<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-BloodPressure-Observation-1"/>
</meta>
<!--a fixed value for status-->
<status value="final"/>
<!--fixed value for category-->
<category>
<coding>
<system value="http://hl7.org/fhir/observation-category"/>
<code value="vital-signs"/>
<display value="Vital Signs"/>
</coding>
</category>
<!--fixed values for code-->
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="75367002"/>
<display value="Blood pressure"/>
</coding>
</code>
<!--a link to the Patient-->
<subject>
<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
</subject>
<!--the date and time of the reading-->
<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
<!--body site of reading-->
<bodySite>
<coding>
<system value="http://snomed.info/sct"/>
<code value="368209003"/>
<display value="Right arm"/>
</coding>
</bodySite>
<!--systolic-->
<component>
<!--fixed values for code-->
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="271649006"/>
<display value="Systolic blood pressure"/>
</coding>
</code>
<!--the systolic reading-->
<valueQuantity>
<value value="120"/>
<unit value="mmHg"/>
<system value="http://unitsofmeasure.org"/>
</valueQuantity>
</component>
<!--diastolic-->
<component>
<!--fixed values for code-->
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="271650006"/>
<display value="Diastolic blood pressure"/>
</coding>
</code>
<!--the diastolic reading-->
<valueQuantity>
<value value="60"/>
<unit value="mmHg"/>
<system value="http://unitsofmeasure.org"/>
</valueQuantity>
</component>
</Observation>
<!--</xml>-->
Temperature Observation
The coded form of each temperature reading follows follows the codes and structure for CareConnect-BodyTemperature-Observation-1
| CareConnect-BodyTemperature-Observation-1 element | Cardinality | Notes |
|---|---|---|
| meta.profile | 1..1 | Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-BodyTemperature-Observation-1’ |
| status | 1..1 | Fixed to final |
| category | 1..1 | Fixed as per profile |
| code | 1..1 | SNOMED CT «386725007 - Body temperature |
| subject | 1..1 | Link to Patient |
| effectiveDateTime | 1..1 | The date and time the reading took place |
| valueQuantity | 0..1 | The temperature recorded in Celsius |
Temperature Observation Example
Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.
Examples are illustrative only.
<!--<xml>-->
<Observation xmlns="http://hl7.org/fhir">
<id value="b8287484-53eb-4ae4-b040-c56fcb58df8f"/>
<meta>
<!--claims conformance to CareConnect-BodyTemperature-Observation-1-->
<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-BodyTemperature-Observation-1"/>
</meta>
<!--fixed value for status-->
<status value="final"/>
<!--fixed value for category-->
<category>
<coding>
<system value="http://hl7.org/fhir/observation-category"/>
<code value="vital-signs"/>
<display value="Vital Signs"/>
</coding>
</category>
<!--fixed values for code-->
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="386725007"/>
<display value="Body temperature"/>
</coding>
</code>
<!--link to patient-->
<subject>
<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
</subject>
<!--date time when reading occurred-->
<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
<!--the reading-->
<valueQuantity>
<value value="38.5"/>
<unit value="Cel"/>
<system value="http://unitsofmeasure.org"/>
</valueQuantity>
</Observation>
<!--</xml>-->
Heart Rate Observation
The coded form of each pulse rate reading follows the codes and structure for CareConnect-HeartRate-Observation-1.
| CareConnect-Observation-1 element | Cardinality | Notes |
|---|---|---|
| meta.profile | 1..1 | Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-HeartRate-Observation-1’ |
| status | 1..1 | Fixed to final |
| category | 1..1 | Fixed as per profile |
| code | 1..1 | SNOMED slice – fixed as per profile |
| subject | 1..1 | Link to Patient |
| effectiveDateTime | 1..1 | The date and time the reading took place |
| valueQuantity | 0..1 | The heart rate recorded in beats per minute (/min) |
Heart Rate Observation Example
Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.
Examples are illustrative only.
<!--<xml>-->
<Observation xmlns="http://hl7.org/fhir">
<id value="ce6a7522-8285-4e0d-9d93-c928d21f512b"/>
<meta>
<!--claims conformance to CareConnect-HeartRate-Observation-1-->
<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-HeartRate-Observation-1"/>
</meta>
<!--fixed value for status-->
<status value="final"/>
<!--fixed value for category-->
<category>
<coding>
<system value="http://hl7.org/fhir/observation-category"/>
<code value="vital-signs"/>
<display value="Vital Signs"/>
</coding>
</category>
<!--fixed values for code, plus an extra SNOMED code for pulse rate-->
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="364075005"/>
<display value="Heart rate"/>
</coding>
</code>
<!--link to patient-->
<subject>
<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
</subject>
<!--the date and time of the reading-->
<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
<!--the pulse rate reading-->
<valueQuantity>
<value value="95"/>
<unit value="/min"/>
<system value="http://unitsofmeasure.org"/>
</valueQuantity>
</Observation>
<!--</xml>-->
Height/Length Observation
The coded form of each height reading follows the codes and structure for CareConnect-Observation-1.
| CareConnect-VitalSigns-Observation-1 element | Cardinality | Notes |
|---|---|---|
| meta.profile | 1..1 | Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-VitalSigns-Observation-1’ |
| status | 1..1 | Fixed to final |
| category | 1..1 | Fixed as demonstrated in example below |
| code | 1..1 | SNOMED CT: - 50373000 - Body height measure (observable entity) OR 248334005 - Length of body (observable entity) |
| subject | 1..1 | Link to Patient |
| valueQuantity | 0..1 | The height recorded in metres or centimetres |
Height/Length Observation Example
Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.
Examples are illustrative only.
<!--<xml>-->
<Observation xmlns="http://hl7.org/fhir">
<id value="bf235b3a-e513-47d0-a76e-b2390aff655b"/>
<meta>
<!--claims conformance to CareConnect-Observation-1-->
<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1"/>
</meta>
<!--fixed value for status-->
<status value="final"/>
<!--fixed value for category-->
<category>
<coding>
<system value="http://hl7.org/fhir/observation-category"/>
<code value="vital-signs"/>
<display value="Vital Signs"/>
</coding>
</category>
<!--fixed values for code-->
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="50373000"/>
<display value="Body height"/>
</coding>
</code>
<!-- for Length the code is
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="248334005"/>
<display value="Length of body"/>
</coding>
</code> -->
<!--link to patient-->
<subject>
<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
</subject>
<!--date time when reading occurred-->
<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
<!--the reading-->
<valueQuantity>
<value value="175"/>
<unit value="cm"/>
<system value="http://unitsofmeasure.org"/>
</valueQuantity>
</Observation>
<!--</xml>-->
BMI Observation
The coded form of each BMI reading follows the codes and structure for CareConnect-Observation-1.
| CareConnect-VitalSigns-Observation-1 element | Cardinality | Notes |
|---|---|---|
| meta.profile | 1..1 | Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-VitalSigns-Observation-1’ |
| status | 1..1 | Fixed to final |
| category | 1..1 | Fixed as demonstrated in example below |
| code | 1..1 | Fixed as demonstrated in example below |
| subject | 1..1 | Link to Patient |
| valueQuantity | 0..1 | The height recorded in metres or centimetres |
BMI Observation Example
Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.
Examples are illustrative only.
<!--<xml>-->
<Observation xmlns="http://hl7.org/fhir">
<id value="f6db2df2-abe3-4e17-80f8-e5bc06c7f92b"/>
<meta>
<!--claims conformance to CareConnect-Observation-1-->
<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1"/>
</meta>
<!--fixed value for status-->
<status value="final"/>
<!--fixed value for category-->
<category>
<coding>
<system value="http://hl7.org/fhir/observation-category"/>
<code value="vital-signs"/>
<display value="Vital Signs"/>
</coding>
</category>
<!--fixed values for code-->
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="60621009"/>
<display value="Body mass index"/>
</coding>
</code>
<!--link to patient-->
<subject>
<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
</subject>
<!--date time when reading occurred-->
<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
<!--the reading-->
<valueQuantity>
<value value="25"/>
<unit value="kg/m2"/>
<system value="http://unitsofmeasure.org"/>
</valueQuantity>
</Observation>
<!--</xml>-->
Weight Observation
The coded form of each weight reading follows the code and structure for CareConnect-Observation-1.
| CareConnect-Observation-1 element | Notes | |
|---|---|---|
| meta.profile | 1..1 | Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1’ |
| status | 1..1 | Fixed to final |
| category | 1..1 | Fixed as demonstrated in example below |
| code | 1..1 | Fixed as demonstrated in example below |
| subject | 1..1 | Link to Patient |
| effectiveDateTime | 1..1 | The date and time the reading took place |
| valueQuantity | 0..1 | The weight recorded in kilogrammes |
Weight Observation Example
Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.
Examples are illustrative only.
<!--<xml>-->
<Observation xmlns="http://hl7.org/fhir">
<id value="2e96ba1e-49a4-4964-9a54-3b055873fb07"/>
<meta>
<!--claims conformance to CareConnect-Observation-1-->
<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1"/>
</meta>
<!--fixed value for status-->
<status value="final"/>
<!--fixed value for category-->
<category>
<coding>
<system value="http://hl7.org/fhir/observation-category"/>
<code value="vital-signs"/>
<display value="Vital Signs"/>
</coding>
</category>
<!--fixed values for code-->
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="27113001"/>
<display value="Body weight"/>
</coding>
</code>
<!--link to patient-->
<subject>
<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
</subject>
<!--date time when reading occurred-->
<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
<!--the reading-->
<valueQuantity>
<value value="82.7"/>
<unit value="kg"/>
<system value="http://unitsofmeasure.org"/>
</valueQuantity>
</Observation>
<!--</xml>-->
Oxygen Saturation Observation
The coded form of each oxygen saturation reading follows the codes and structure for CareConnect-OxygenSaturation-Observation-1.
| CareConnect-Observation-1 element | Cardinality | Notes |
|---|---|---|
| meta.profile | 1..1 | Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-OxygenSaturation-Observation-1’ |
| status | 1..1 | Fixed to final |
| category | 1..1 | Fixed as per profile |
| code | 1..1 | SNOMED slice – fixed as per profile |
| subject | 1..1 | Link to Patient |
| effectiveDateTime | 1..1 | The date and time the reading took place |
| valueQuantity | 0..1 | The temperature recorded in percent |
Oxygen Saturation Observation Example
Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.
Examples are illustrative only.
<!--<xml>-->
<Observation xmlns="http://hl7.org/fhir">
<id value="e3890ae3-db3e-4104-824c-f9636950866e"/>
<meta>
<!--claims conformance to CareConnect-OxygenSaturation-Observation-1-->
<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-OxygenSaturation-Observation-1"/>
</meta>
<!--fixed to final-->
<status value="final"/>
<!--fixed value for category-->
<category>
<coding>
<system value="http://hl7.org/fhir/observation-category"/>
<code value="vital-signs"/>
<display value="Vital Signs"/>
</coding>
</category>
<!--fixed values for code-->
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="431314004"/>
<display value="Peripheral oxygen saturation"/>
</coding>
</code>
<!--link to patient-->
<subject>
<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
</subject>
<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
<!--the reading-->
<valueQuantity>
<value value="93"/>
<unit value="%"/>
<system value="http://unitsofmeasure.org"/>
</valueQuantity>
</Observation>
<!--</xml>-->
Pain Score Observation
The coded form of each pain score reading follows the codes and structure for CareConnect-Observation-1.
| CareConnect-Observation-1 element | Cardinality | Notes |
|---|---|---|
| meta.profile | 1..1 | Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1’ |
| status | 1..1 | Fixed to final |
| code | 1..1 | Fixed as demonstrated in example below |
| subject | 1..1 | Link to Patient |
| effectiveDateTime | 1..1 | The date and time the reading took place |
| valueQuantity | 0..1 | The recorded pain score value |
Pain Score Observation Example
Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.
Examples are illustrative only.
<!--<xml>-->
<Observation xmlns="http://hl7.org/fhir">
<id value="f3dc3143-0f3a-49f4-9da8-67a5e1492145"/>
<meta>
<!--claims conformance to CareConnect-BodyTemperature-Observation-1-->
<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1"/>
</meta>
<!--fixed value for status-->
<status value="final"/>
<!--fixed values for code-->
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="225908003"/>
<display value="Pain score"/>
</coding>
</code>
<!--link to patient-->
<subject>
<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
</subject>
<!--date time when reading occurred-->
<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
<!--the reading-->
<valueQuantity>
<value value="4"/>
</valueQuantity>
</Observation>
<!--</xml>-->
Level of Consciousness Observation
The coded form of each Level of Consciousness reading follows the codes and structure the codes and structure for CareConnect-ACVPU-Observation-1.
| CareConnect-Observation-1 element | Cardinality | Notes |
|---|---|---|
| meta.profile | 1..1 | Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-ACVPU-Observation-1’ |
| status | 1..1 | Fixed to final |
| code | 1..1 | SNOMED slice – fixed as per profile |
| subject | 1..1 | Link to Patient |
| effectiveDateTime | 1..1 | The date and time the reading took place |
| valueCodeableConcept | 0..1 | The Consciousness recorded in percent – one of - alert - confusion - voice - pain - unresponsive |
Level of Consciousness Observation Example
Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.
Examples are illustrative only.
<!--<xml>-->
<Observation xmlns="http://hl7.org/fhir">
<id value="a4c394ac-b0d8-44e9-8125-38e7d28c8193"/>
<meta>
<!--claims conformance to CareConnect-ACVPU-Observation-1-->
<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-ACVPU-Observation-1"/>
</meta>
<!--fixed value for status-->
<status value="final"/>
<!--fixed values for code-->
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="1104441000000107"/>
<display value="ACVPU (Alert Confusion Voice Pain Unresponsive) scale score"/>
</coding>
</code>
<!--link to patient-->
<subject>
<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
</subject>
<!--date time when reading occurred-->
<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
<!--the reading-->
<valueCodeableConcept>
<code>
<coding>
<code value="voice"/>
</coding>
</code>
</valueCodeableConcept>
</Observation>
<!--</xml>-->
Respiratory Rate Observation
The coded form of each respiratory rate reading follows the codes and structure for CareConnect-RespiratoryRate-Observation-1.
| CareConnect-Observation-1 element | Cardinality | Notes |
|---|---|---|
| meta.profile | 1..1 | Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-RespiratoryRate-Observation-1’ |
| status | 1..1 | Fixed to final |
| category | 1..1 | Fixed as per profile |
| code | 1..1 | Loinc slice – fixed as per profile SNOMED slice – fixed as per profile |
| subject | 1..1 | Link to Patient |
| effectiveDateTime | 1..1 | The date and time the reading took place |
| valueQuantity | 0..1 | The respiratory rate recorded in /min |
Respiratory Rate Observation Example
Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.
Examples are illustrative only.
<!--<xml>-->
<Observation xmlns="http://hl7.org/fhir">
<id value="771d0d98-7988-4e7b-b0eb-021d094c2b33"/>
<meta>
<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-RespiratoryRate-Observation-1"/>
</meta>
<status value="final"/>
<category>
<coding>
<system value="http://hl7.org/fhir/observation-category"/>
<code value="vital-signs"/>
<display value="Vital Signs"/>
</coding>
</category>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="86290005"/>
<display value="Respiratory rate"/>
</coding>
</code>
<subject>
<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
</subject>
<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
<valueQuantity>
<value value="21"/>
<unit value="/min"/>
<system value="http://unitsofmeasure.org"/>
</valueQuantity>
</Observation>
<!--</xml>-->
Air or Oxygen Observation
| CareConnect-Observation-1 element | Cardinality | Notes |
|---|---|---|
| meta.profile | 1..1 | Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1’ |
| status | 1..1 | Fixed to final |
| code | 1..1 | Use the text element of CodeableConcept to indicate an ‘Air or Oxygen Observation’ |
| subject | 1..1 | Link to Patient |
| effectiveDateTime | 1..1 | The date and time the reading took place |
| valueCodeableConcept | 0..1 | One of - 722742002 ‘Breathing room air’ OR - 371825009 ‘Patient on oxygen’ OR - 315041000 ‘High concentration oxygen therapy (procedure)’ OR - 9999016 ‘High flow oxygen therapy (procedure)’ |
Air or Oxygen Observation Example
Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.
Examples are illustrative only.
<!--<xml>-->
<Observation xmlns="http://hl7.org/fhir">
<id value="c4211cc4-1bca-4a95-9fc7-dbd64062c01f"/>
<meta>
<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1"/>
</meta>
<status value="final"/>
<code>
<text value=”Air or Oxygen Observation”>
</code>
<subject>
<reference value="Patient/4f78d392-c9e0-4f1f-9ab6-57d387838690"/>
</subject>
<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
<valueCodeableConcept>
<system value="http://snomed.info/sct"/>
<code value="722742002"/>
<display value="Breathing room air"/>
</valueCodeableConcept >
</Observation>
<!--</xml>-->
NEWS2 Score Observation
The coded form of each NEWS2 observation follows the code and structure for CareConnect-Observation-1.
| CareConnect-Observation-1 element | Cardinality | Notes |
|---|---|---|
| meta.profile | 1..1 | Claim conformance to ‘https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1’ |
| status | 1..1 | Fixed to final |
| category | 1..1 | Fixed as demonstrated in example below |
| code | 1..1 | Fixed as demonstrated in example below |
| subject | 1..1 | Link to Patient |
| effectiveDateTime | 1..1 | The date and time the reading took place |
| valueQuantity | 0..1 | The NEWS2 score recorded |
| related | 0..* | Links to the Observations that make up the NEWS2 score |
| component | 0..* | Components detailing the sub-score – as demonstrated in example below. The values for the sub-score codes are: - 1104351000000103 ‘Royal College of Physicians NEWS2 (National Early Warning Score 2) - pulse score’ - 1104311000000102 ‘Royal College of Physicians NEWS2 (National Early Warning Score 2) - oxygen saturation scale 1 score’ - 1104331000000105 ‘Royal College of Physicians NEWS2 (National Early Warning Score 2) - air or oxygen score’ - 1104371000000107 ‘Royal College of Physicians NEWS2 (National Early Warning Score 2) - temperature score’ - 1104341000000101 ‘Royal College of Physicians NEWS2 (National Early Warning Score 2) - systolic blood pressure score’ - 1104361000000100 ‘Royal College of Physicians NEWS2 (National Early Warning Score 2) - consciousness score’ |
NEWS2 Score Observation Example
Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.
Examples are illustrative only.
<!--<xml>-->
<Observation>
<id value="db001012-74ee-4809-962c-e938e3e9dde2"/>
<meta>
<profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1"/>
</meta>
<identifier>
<system value="https://tools.ietf.org/html/rfc4122"/>
<value value="7188c7ad-7802-4d43-9775-4d9d684600d5"/>
</identifier>
<status value="final"/>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/observation-category"/>
<code value="survey"/>
<display value="Survey"/>
</coding>
</category>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="1104051000000101"/>
<display value="Royal College of Physicians NEWS2 (National Early Warning Score 2) total score"/>
</coding>
</code>
<subject>
<reference value="Patient/ad2c58ab-ffab-4366-9c76-b0322e22e881"/>
</subject>
<effectiveDateTime value="2018-10-04T14:17:59+01:00"/>
<valueQuantity>
<value value="6"/>
<system value="http://unitsofmeasure.org"/>
<code value="score"/>
</valueQuantity>
<related>
<type value="derived-from"/>
<target>
<reference value="Observation/e0818279-51da-4e82-ab44-7798cdab8ccc"/>
</target>
</related>
<related>
<type value="derived-from"/>
<target>
<reference value="Observation/b8287484-53eb-4ae4-b040-c56fcb58df8f"/>
</target>
</related>
<related>
<type value="derived-from"/>
<target>
<reference value="Observation/5a1625e8-938e-4c19-9d3e-a235bfb4b37d"/>
</target>
</related>
<related>
<type value="derived-from"/>
<target>
<reference value="Observation/c756fd32-f04e-45a9-b02f-2461ed53c736"/>
</target>
</related>
<related>
<type value="derived-from"/>
<target>
<reference value="Observation/1a1273f4-dd78-4bb4-bb98-ed6456caa2a2"/>
</target>
</related>
<related>
<type value="derived-from"/>
<target>
<reference value="Observation/f0d26102-3a50-4993-9203-6089b625fc2f"/>
</target>
</related>
<related>
<type value="derived-from"/>
<target>
<reference value="Observation/dbf6ec86-ebd7-4490-8586-596328519ed2"/>
</target>
</related>
<!-- Respiratory Rate Sub-Score -->
<component>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="1104301000000104"/>
<display value="Royal College of Physicians NEWS2 (National Early Warning Score 2) - respiration rate score"/>
</coding>
</code>
<valueQuantity>
<value value="2"/>
<system value="http://unitsofmeasure.org"/>
<code value="score"/>
</valueQuantity>
</component>
<!-- Pulse Sub-Score -->
<component>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="1104351000000103"/>
<display value="Royal College of Physicians NEWS2 (National Early Warning Score 2) - pulse score"/>
</coding>
</code>
<valueQuantity>
<value value="1"/>
<system value="http://unitsofmeasure.org"/>
<code value="score"/>
</valueQuantity>
</component>
<!-- Oxygen Saturation scale 1 Sub-Score -->
<component>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="1104311000000102"/>
<display value="Royal College of Physicians NEWS2 (National Early Warning Score 2) - oxygen saturation scale 1 score"/>
</coding>
</code>
<valueQuantity>
<value value="2"/>
<system value="http://unitsofmeasure.org"/>
<code value="score"/>
</valueQuantity>
</component>
<!-- Air or Oxygen Sub-Score -->
<component>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="1104331000000105"/>
<display value="Royal College of Physicians NEWS2 (National Early Warning Score 2) - air or oxygen score"/>
</coding>
</code>
<valueQuantity>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="score"/>
</valueQuantity>
</component>
<!-- Temperature Sub-Score -->
<component>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="1104371000000107"/>
<display value="Royal College of Physicians NEWS2 (National Early Warning Score 2) - temperature score"/>
</coding>
</code>
<valueQuantity>
<value value="1"/>
<system value="http://unitsofmeasure.org"/>
<code value="score"/>
</valueQuantity>
</component>
<!-- Systolic Blood Pressure Sub-Score -->
<component>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="1104341000000101"/>
<display value="Royal College of Physicians NEWS2 (National Early Warning Score 2) - systolic blood pressure score"/>
</coding>
</code>
<valueQuantity>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="score"/>
</valueQuantity>
</component>
<!-- Consciousness Sub-Score -->
<component>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="1104361000000100"/>
<display value="Royal College of Physicians NEWS2 (National Early Warning Score 2) - consciousness score"/>
</coding>
</code>
<valueQuantity>
<value value="0"/>
<system value="http://unitsofmeasure.org"/>
<code value="score"/>
</valueQuantity>
</component>
</Observation>
<!--</xml>-->