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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    "id": "1b36355c-ee52-4d1a-ae06-45c6f08380td",
    "meta": {
        "versionId": "9b2459d6-ffa8-4ecb-97e5-7bf0fac15e87",
        "lastUpdated": "2020-12-23T14:39:37.969+00:00"
    },
    "type": "collection",
    "entry":  [
        {
            "fullUrl": "Observation/6e963159-6b55-4793-9a26-a87bf4dd45e8",
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                        "value": "7188c7ad-7802-4d43-9775-4d9d684600d5"
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                "status": "final",
                "category":  [
                    {
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