Transfer of Care R4 Hackathon Implementation Guide

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

Investigation results

The Investigation results section carries information about investigation results for the patient. PRSB Elements should be formatted as subheadings in any HTML sent.

Section Description Card. MRO* FHIR Target and Guidance
Investigation results A record of investigations and procedures requested, results and plans. 0 to 1 O Carried in the CodeableConcept of Composition.section.code FHIR element. ValueSet UKCoreCompositionSectionCode
PRSB Element Description Card. MRO* FHIR Target and Guidance
Investigation result For each investigation, the result of the investigation (this includes the result value, with unit of observation and reference interval where applicable and date, and plans for acting upon investigation results. 0 to many O If possible, this should include only results which are important or relevant to communicate to the GP. Hence health professional may need to select them. Text only. (Note that work is underway to standardise recording of pathology investigation results, which will inform content under this heading.) Where the text is format from a actual report the HTML <pre> tag is used for indicating preformatted text. The code tag surrounds the code being marked up. HTML viewers normally render pre text in a fixed-pitched font, with whitespace intact, and without word wrap.
* M=Mandatory R=Required O=Optional

Example Investigation Results Section

{
    "resourceType": "Composition",
    "meta": {
        "profile":  [
            "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Composition"
        ]
    },
    "status": "final",
    "type": {
        "coding":  [
            {
                "system": "http://snomed.info/sct",
                "code": "373942005",
                "display": "Discharge summary"
            }
        ]
    },
    "subject": {
        "reference": "urn:uuid:2c0bca60-1873-46f7-a462-5733feaf32c9"
    },
    "encounter": {
        "reference": "urn:uuid:5a9f67fa-9343-40cc-8fde-0dd91822b7fd"
    },
    "date": "2023-01-28T10:00:00+00:00",
    "author":  [
        {
            "reference": "urn:uuid:2a32666e-84a2-4f90-a6a6-d5451ae2e32f"
        }
    ],
    "title": "Cardiology Service Discharge Summary",
    "section":  [
        {
            "title": "Investigation results",
            "code": {
                "coding":  [
                    {
                        "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
                        "code": "investigation-results",
                        "display": "Investigation results"
                    }
                ]
            },
            "text": {
                "status": "additional",
                "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><th>Investigation result</th></tr><tr><td><pre>Full Blood Count  TestValueUnitsReference RangeWhite Cell Count11.1x10*9/L3.5 - 10.0Red Cell Count5.0x10*12/L4.25 - 5.75 Haemoglobin150g/L13.0 - 17.0Haematocrit0.2300.400 - 0.500Mean Cell Volume90fL84 - 98Mean Cell Hb33.0pg27.5 - 32.0Mean Cell Hb Con34.0pg31.0 - 35.0RDW12.0%&lt; 14.5Platelet Count300x10*9/L150 - 400Machine Differential  Test ValueUnits Reference RangeNeutrophils7.0x10*9/L1.7 - 7.5Lymphocytes3.5x10*9/L1.0 - 3.5 Monocytes0.3x10*9/L&lt; 0.6 Eosinophils0.4x10*9/L&lt; 0.4 Basophils0.1x10*9/L&lt; 0.1 LUCs0.2x10*9/L&lt; 0.4  </pre></td></tr></tbody></table></div>"
            }
        }
    ]
}
<Composition xmlns="http://hl7.org/fhir">
    <!--   optional elements removed for readability   -->
    <meta>
        <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-Composition" />
    </meta>
    <status value="final" />
    <type>
        <coding>
            <system value="http://snomed.info/sct" />
            <code value="373942005" />
            <display value="Discharge summary" />
        </coding>
    </type>
    <subject>
        <reference value="urn:uuid:2c0bca60-1873-46f7-a462-5733feaf32c9" />
    </subject>
    <encounter>
        <reference value="urn:uuid:5a9f67fa-9343-40cc-8fde-0dd91822b7fd" />
    </encounter>
    <date value="2023-01-28T10:00:00+00:00" />
    <author>
        <reference value="urn:uuid:2a32666e-84a2-4f90-a6a6-d5451ae2e32f" />
    </author>
    <title value="Cardiology Service Discharge Summary" />
    <section>
        <title value="Investigation results" />
        <code>
            <coding>
                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                <code value="investigation-results" />
                <display value="Investigation results" />
            </coding>
        </code>
        <text>
            <status value="additional" />
            <div xmlns="http://www.w3.org/1999/xhtml"><table><tbody><tr><th>Investigation result</th></tr><tr><td><pre>Full Blood Count  TestValueUnitsReference RangeWhite Cell Count11.1x10*9/L3.5 - 10.0Red Cell Count5.0x10*12/L4.25 - 5.75 Haemoglobin150g/L13.0 - 17.0Haematocrit0.2300.400 - 0.500Mean Cell Volume90fL84 - 98Mean Cell Hb33.0pg27.5 - 32.0Mean Cell Hb Con34.0pg31.0 - 35.0RDW12.0%&lt; 14.5Platelet Count300x10*9/L150 - 400Machine Differential  Test ValueUnits Reference RangeNeutrophils7.0x10*9/L1.7 - 7.5Lymphocytes3.5x10*9/L1.0 - 3.5 Monocytes0.3x10*9/L&lt; 0.6 Eosinophils0.4x10*9/L&lt; 0.4 Basophils0.1x10*9/L&lt; 0.1 LUCs0.2x10*9/L&lt; 0.4  </pre></td></tr></tbody></table></div>
        </text>
    </section>
    <!--   other sections removed for readability   -->
</Composition>

Example Coded Resources

Refer to National Pathology IG. A UKCore-Observation with member UKCore-Observation(s).

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