Clinical Observations

This guidance is under active development by NHS Digital and content may be added or updated on a regular basis.

PEWS Total Score With Observations Bundle Example

<Bundle xmlns="http://hl7.org/fhir">
<id value="1b36355c-ee52-4d1a-ae06-45c6f08380td" />
<meta>
<versionId value="9b2459d6-ffa8-4ecb-97e5-7bf0fac15e87" />
<lastUpdated value="2020-12-23T14:39:37.969+00:00" />
</meta>
<type value="collection" />
<entry>
<fullUrl value="Observation/6e963159-6b55-4793-9a26-a87bf4dd45e8" />
<resource>
<Observation>
<id value="21344a45-2660-45d1-9fb3-49e54d14b662" />
<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="1363261000000104" />
<display value="NPEWS (National Paediatric Early Warning Score) - total score" />
</coding>
</code>
<subject>
<reference value="Patient/40b4f492-48ed-4181-97a7-452adc31580c" />
</subject>
<effectiveDateTime value="2018-10-04T14:17:59+01:00" />
<performer>
<reference value="Practitioner/7096e518-2638-4c00-ab0e-504c20cd50b6" />
</performer>
<performer>
<reference value="Organization/25d5ad55-5657-4cbe-9b8b-2e993f19286e" />
</performer>
<valueQuantity>
<value value="12" />
<unit value="ScoreOf" />
<system value="http://unitsofmeasure.org" />
<code value="{ScoreOf}" />
</valueQuantity>
<derivedFrom>
<reference value="Observation/fc6c6fa5-d8e8-4634-a19a-985325077cb2" />
</derivedFrom>
<derivedFrom>
<reference value="Observation/638c6821-eb51-4f1b-b8c0-5269d1df9b7c" />
</derivedFrom>
<derivedFrom>
<reference value="Observation/5a1625e8-938e-4c19-9d3e-a235bfb4b37d" />
</derivedFrom>
<derivedFrom>
<reference value="Observation/c756fd32-f04e-45a9-b02f-2461ed53c736" />
</derivedFrom>
<derivedFrom>
<reference value="Observation/1a1273f4-dd78-4bb4-bb98-ed6456caa2a2" />
</derivedFrom>
<derivedFrom>
<reference value="Observation/f0d26102-3a50-4993-9203-6089b625fc2f" />
</derivedFrom>
<derivedFrom>
<reference value="Observation/dbf6ec86-ebd7-4490-8586-596328519ed2" />
</derivedFrom>
<component>
<code>
<coding>
<system value="http://snomed.info/sct" />
<code value="1363271000000106" />
<display value="NPEWS (National Paediatric Early Warning Score) - respiration rate score" />
</coding>
</code>
<valueQuantity>
<value value="1" />
<unit value="ScoreOf" />
<system value="http://unitsofmeasure.org" />
<code value="{ScoreOf}" />
</valueQuantity>
</component>
<component>
<code>
<coding>
<system value="http://snomed.info/sct" />
<code value="1363301000000109" />
<display value="NPEWS (National Paediatric Early Warning Score) - respiratory distress score" />
</coding>
</code>
<valueQuantity>
<value value="1" />
<unit value="ScoreOf" />
<system value="http://unitsofmeasure.org" />
<code value="{ScoreOf}" />
</valueQuantity>
</component>
<component>
<code>
<coding>
<system value="http://snomed.info/sct" />
<code value="1363311000000106" />
<display value="NPEWS (National Paediatric Early Warning Score) - peripheral oxygen saturation score" />
</coding>
</code>
<valueQuantity>
<value value="1" />
<unit value="ScoreOf" />
<system value="http://unitsofmeasure.org" />
<code value="{ScoreOf}" />
</valueQuantity>
</component>
<component>
<code>
<coding>
<system value="http://snomed.info/sct" />
<code value="1363321000000100" />
<display value="NPEWS (National Paediatric Early Warning Score) - inspired oxygen score" />
</coding>
</code>
<valueQuantity>
<value value="2" />
<unit value="ScoreOf" />
<system value="http://unitsofmeasure.org" />
<code value="{ScoreOf}" />
</valueQuantity>
</component>
<component>
<code>
<coding>
<system value="http://snomed.info/sct" />
<code value="1363331000000103" />
<display value="NPEWS (National Paediatric Early Warning Score) - heart rate score" />
</coding>
</code>
<valueQuantity>
<value value="1" />
<unit value="ScoreOf" />
<system value="http://unitsofmeasure.org" />
<code value="{ScoreOf}" />
</valueQuantity>
</component>
<component>
<code>
<coding>
<system value="http://snomed.info/sct" />
<code value="1363291000000105" />
<display value="NPEWS (National Paediatric Early Warning Score) - systolic blood pressure score" />
</coding>
</code>
<valueQuantity>
<value value="1" />
<unit value="ScoreOf" />
<system value="http://unitsofmeasure.org" />
<code value="{ScoreOf}" />
</valueQuantity>
</component>
<component>
<code>
<coding>
<system value="http://snomed.info/sct" />
<code value="1363341000000107" />
<display value="NPEWS (National Paediatric Early Warning Score) - capillary refill time score" />
</coding>
</code>
<valueQuantity>
<value value="3" />
<unit value="ScoreOf" />
<system value="http://unitsofmeasure.org" />
<code value="{ScoreOf}" />
</valueQuantity>
</component>
<component>
<code>
<coding>
<system value="http://snomed.info/sct" />
<code value="1363351000000105" />
<display value="NPEWS (National Paediatric Early Warning Score) - consciousness score" />
</coding>
</code>
<valueQuantity>
<value value="1" />
<unit value="ScoreOf" />
<system value="http://unitsofmeasure.org" />
<code value="{ScoreOf}" />
</valueQuantity>
</component>
<component>
<code>
<coding>
<system value="http://snomed.info/sct" />
<code value="1363361000000108" />
<display value="NPEWS (National Paediatric Early Warning Score) - temperature score" />
</coding>
</code>
<valueQuantity>
<value value="1" />
<unit value="ScoreOf" />
<system value="http://unitsofmeasure.org" />
<code value="{ScoreOf}" />
</valueQuantity>
</component>
</Observation>
</resource>
</entry>
<entry>
<fullUrl value="Observation/f47cb818-29e1-49db-ae6c-19ddf0303ead" />
<resource>
<Observation>
<id value="f47cb818-29e1-49db-ae6c-19ddf0303ead" />
<identifier>
<system value="https://tools.ietf.org/html/rfc4122" />
<value value="15135902-f182-4b73-a53d-f621670194be" />
</identifier>
<status value="final" />
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/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>
<coding>
<system value="http://loinc.org" />
<code value="9279-1" />
<display value="Respiratory Rate" />
</coding>
</code>
<subject>
<reference value="Patient/40b4f492-48ed-4181-97a7-452adc31580c" />
</subject>
<effectiveDateTime value="2018-10-04T14:17:59+01:00" />
<performer>
<reference value="Practitioner/7096e518-2638-4c00-ab0e-504c20cd50b6" />
</performer>
<performer>
<reference value="Organization/25d5ad55-5657-4cbe-9b8b-2e993f19286e" />
</performer>
<valueQuantity>
<value value="21" />
<unit value="Breaths / minute" />
<system value="http://unitsofmeasure.org" />
<code value="{Breaths}/min" />
</valueQuantity>
</Observation>
</resource>
</entry>
<entry>
<fullUrl value="Observation/f0d26102-3a50-4993-9203-6089b625fc2f" />
<resource>
<Observation>
<id value="f0d26102-3a50-4993-9203-6089b625fc2f" />
<identifier>
<system value="https://tools.ietf.org/html/rfc4122" />
<value value="5c376658-6818-4e6f-86b2-c2495626bc47" />
</identifier>
<status value="final" />
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/observation-category" />
<code value="vital-signs" />
<display value="Vital Signs" />
</coding>
</category>
<code>
<coding>
<system value="http://snomed.info/sct" />
<code value="364075005" />
<display value="Heart rate" />
</coding>
<coding>
<system value="http://loinc.org" />
<code value="8867-4" />
<display value="Heart rate" />
</coding>
</code>
<subject>
<reference value="Patient/40b4f492-48ed-4181-97a7-452adc31580c" />
</subject>
<effectiveDateTime value="2018-10-04T14:17:59+01:00" />
<performer>
<reference value="Practitioner/7096e518-2638-4c00-ab0e-504c20cd50b6" />
</performer>
<performer>
<reference value="Organization/25d5ad55-5657-4cbe-9b8b-2e993f19286e" />
</performer>
<valueQuantity>
<value value="48" />
<unit value="heart beats per minute" />
<system value="http://unitsofmeasure.org" />
<code value="{beats}/min" />
</valueQuantity>
</Observation>
</resource>
</entry>
<entry>
<fullUrl value="Observation/1a1273f4-dd78-4bb4-bb98-ed6456caa2a2" />
<resource>
<Observation>
<id value="1a1273f4-dd78-4bb4-bb98-ed6456caa2a2" />
<identifier>
<system value="https://tools.ietf.org/html/rfc4122" />
<value value="deaa6c1a-b5d6-40a9-b12c-3f87e2b89105" />
</identifier>
<status value="final" />
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/observation-category" />
<code value="vital-signs" />
<display value="Vital Signs" />
</coding>
</category>
<code>
<coding>
<system value="http://snomed.info/sct" />
<code value="103228002" />
<display value="Hemoglobin saturation with oxygen" />
</coding>
<coding>
<system value="http://loinc.org" />
<code value="2708-6" />
<display value="Oxygen saturation in Arterial blood" />
</coding>
</code>
<subject>
<reference value="Patient/40b4f492-48ed-4181-97a7-452adc31580c" />
</subject>
<effectiveDateTime value="2018-10-04T14:17:59+01:00" />
<performer>
<reference value="Practitioner/7096e518-2638-4c00-ab0e-504c20cd50b6" />
</performer>
<performer>
<reference value="Organization/25d5ad55-5657-4cbe-9b8b-2e993f19286e" />
</performer>
<valueQuantity>
<value value="95" />
<unit value="percent" />
<system value="http://unitsofmeasure.org" />
<code value="%" />
</valueQuantity>
</Observation>
</resource>
</entry>
<entry>
<fullUrl value="Observation/c756fd32-f04e-45a9-b02f-2461ed53c736" />
<resource>
<Observation>
<id value="c756fd32-f04e-45a9-b02f-2461ed53c736" />
<identifier>
<system value="https://tools.ietf.org/html/rfc4122" />
<value value="021ad131-5740-4090-a4ad-6f07506d17e7" />
</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="722742002" />
<display value="Breathing room air" />
</coding>
</code>
<subject>
<reference value="Patient/40b4f492-48ed-4181-97a7-452adc31580c" />
</subject>
<effectiveDateTime value="2018-10-04T14:17:59+01:00" />
<performer>
<reference value="Practitioner/7096e518-2638-4c00-ab0e-504c20cd50b6" />
</performer>
<performer>
<reference value="Organization/25d5ad55-5657-4cbe-9b8b-2e993f19286e" />
</performer>
</Observation>
</resource>
</entry>
<entry>
<fullUrl value="Observation/5a1625e8-938e-4c19-9d3e-a235bfb4b37d" />
<resource>
<Observation>
<id value="5a1625e8-938e-4c19-9d3e-a235bfb4b37d" />
<identifier>
<system value="https://tools.ietf.org/html/rfc4122" />
<value value="07907fc7-4a38-49af-b1cf-17503fdd1fa5" />
</identifier>
<status value="final" />
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/observation-category" />
<code value="vital-signs" />
<display value="Vital Signs" />
</coding>
</category>
<code>
<coding>
<system value="http://snomed.info/sct" />
<code value="276885007" />
<display value="Core body temperature" />
</coding>
<coding>
<system value="http://loinc.org" />
<code value="8310-5" />
<display value="Body temperature" />
</coding>
</code>
<subject>
<reference value="Patient/40b4f492-48ed-4181-97a7-452adc31580c" />
</subject>
<effectiveDateTime value="2018-10-04T14:17:59+01:00" />
<performer>
<reference value="Practitioner/7096e518-2638-4c00-ab0e-504c20cd50b6" />
</performer>
<performer>
<reference value="Organization/25d5ad55-5657-4cbe-9b8b-2e993f19286e" />
</performer>
<valueQuantity>
<value value="36.5" />
<unit value="degree Celsius" />
<system value="http://unitsofmeasure.org" />
<code value="Cel" />
</valueQuantity>
</Observation>
</resource>
</entry>
<entry>
<fullUrl value="Observation/638c6821-eb51-4f1b-b8c0-5269d1df9b7c" />
<resource>
<Observation>
<id value="638c6821-eb51-4f1b-b8c0-5269d1df9b7c" />
<identifier>
<system value="https://tools.ietf.org/html/rfc4122" />
<value value="068c5c3c-cf11-4f7a-a58a-c445e9848657" />
</identifier>
<status value="final" />
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/observation-category" />
<code value="vital-signs" />
<display value="Vital Signs" />
</coding>
</category>
<code>
<coding>
<system value="http://snomed.info/sct" />
<code value="75367002" />
<display value="Blood pressure" />
</coding>
<coding>
<system value="http://loinc.org" />
<code value="85354-9" />
<display value="Blood pressure panel with all children optional" />
</coding>
</code>
<subject>
<reference value="Patient/40b4f492-48ed-4181-97a7-452adc31580c" />
</subject>
<effectiveDateTime value="2018-10-04T14:17:59+01:00" />
<performer>
<reference value="Practitioner/7096e518-2638-4c00-ab0e-504c20cd50b6" />
</performer>
<performer>
<reference value="Organization/25d5ad55-5657-4cbe-9b8b-2e993f19286e" />
</performer>
<component>
<code>
<coding>
<system value="http://snomed.info/sct" />
<code value="72313002" />
<display value="Systolic arterial pressure" />
</coding>
<coding>
<system value="http://loinc.org" />
<code value="8480-6" />
<display value="Systolic blood pressure" />
</coding>
</code>
<valueQuantity>
<value value="120" />
<unit value="millimeter of mercury" />
<system value="http://unitsofmeasure.org" />
<code value="mm[Hg]" />
</valueQuantity>
</component>
<component>
<code>
<coding>
<system value="http://snomed.info/sct" />
<code value="1091811000000102" />
<display value="Diastolic arterial pressure" />
</coding>
<coding>
<system value="http://loinc.org" />
<code value="8462-4" />
<display value="Diastolic blood pressure" />
</coding>
</code>
<valueQuantity>
<value value="80" />
<unit value="millimeter of mercury" />
<system value="http://unitsofmeasure.org" />
<code value="mm[Hg]" />
</valueQuantity>
</component>
</Observation>
</resource>
</entry>
<entry>
<fullUrl value="Observation/fc6c6fa5-d8e8-4634-a19a-985325077cb2" />
<resource>
<Observation>
<id value="fc6c6fa5-d8e8-4634-a19a-985325077cb2" />
<identifier>
<system value="https://tools.ietf.org/html/rfc4122" />
<value value="9b9bc394-4a40-4f02-97fc-049ff8d0776b" />
</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="300202002" />
<display value="Responds to voice" />
</coding>
</code>
<subject>
<reference value="Patient/40b4f492-48ed-4181-97a7-452adc31580c" />
</subject>
<effectiveDateTime value="2018-10-04T14:17:59+01:00" />
<performer>
<reference value="Practitioner/7096e518-2638-4c00-ab0e-504c20cd50b6" />
</performer>
<performer>
<reference value="Organization/25d5ad55-5657-4cbe-9b8b-2e993f19286e" />
</performer>
</Observation>
</resource>
</entry>
<entry>
<fullUrl value="Practitioner/7096e518-2638-4c00-ab0e-504c20cd50b6" />
<resource>
<Practitioner>
<id value="7096e518-2638-4c00-ab0e-504c20cd50b6" />
<identifier>
<system value="https://fhir.nhs.uk/Id/sds-user-id" />
<value value="G61224777" />
</identifier>
<name>
<family value="Rastall" />
<given value="Paul" />
<prefix value="Dr" />
</name>
<telecom>
<system value="phone" />
<value value="01136323200" />
<use value="work" />
</telecom>
<gender value="male" />
</Practitioner>
</resource>
</entry>
<entry>
<fullUrl value="Organization/25d5ad55-5657-4cbe-9b8b-2e993f19286e" />
<resource>
<Organization>
<id value="25d5ad55-5657-4cbe-9b8b-2e993f19286e" />
<identifier>
<system value="https://fhir.nhs.uk/Id/ods-organization-code" />
<value value="ABC123" />
</identifier>
<name value="ANYTOWN ROYAL INFIRMARY" />
<telecom>
<system value="phone" />
<value value="01134875516" />
</telecom>
<address>
<line value="1 High Street" />
<city value="ANYTOWN" />
<postalCode value="LS1 9AM" />
</address>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="Patient/40b4f492-48ed-4181-97a7-452adc31580c" />
<resource>
<Patient>
<id value="40b4f492-48ed-4181-97a7-452adc31580c" />
<identifier>
<system value="https://fhir.nhs.uk/Id/nhs-number" />
<value value="9378954319" />
</identifier>
<name>
<use value="official" />
<text value="Tim Tiny" />
<family value="Tiny" />
<given value="Tim" />
</name>
<gender value="male" />
<birthDate value="1966-02-04" />
<address>
<use value="home" />
<line value="14 Sunny Mews" />
<city value="ANYTOWN" />
<district value="WEST YORKSHIRE" />
<postalCode value="LS17 4NK" />
</address>
</Patient>
</resource>
</entry>
</Bundle>
{
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"display": "Survey"
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"code": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "1363261000000104",
"display": "NPEWS (National Paediatric Early Warning Score) - total score"
}
]
},
"subject": {
"reference": "Patient/40b4f492-48ed-4181-97a7-452adc31580c"
},
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"component": [
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"code": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "1363271000000106",
"display": "NPEWS (National Paediatric Early Warning Score) - respiration rate score"
}
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