WARNING
This guidance is under active development by NHS England and content may be added or updated on a regular basis. The implementation guide is currently in draft and SHOULD NOT be used for development or implementation without consulting the NHS England Pathology Standards and Implementation team.PATH-R4-30: UKCore-Observation-Lab (Test Result) Snippets
An example of how each key UKCore-Observation-Lab
data element may be populated is provided below. Please note that the examples are provided to illustrate individual data element usage; the full set of data elements may not necessarily be consistent with one another or illustrate a single, complete clinical scenario.
Refer to the UKCore-Observation-Lab profile definition for a detailed description of the supported data elements.
<Observation xmlns="http://hl7.org/fhir"> <id value="Pathology-Observation-Lab-Sn-Example" /> <!-- The canonical URL for the UKCore-Observation-Lab profile. --> <meta> <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-Observation-Lab" /> </meta> <!-- A business identifier supplied by the laboratory that performed the test. --> <identifier> <system value="https://tools.ietf.org/html/rfc4122" /> <value value="2af46949-4938-4c57-bad4-c4363e1965d5" /> </identifier> <!-- The status of the test result. --> <status value="final" /> <!-- The general type of test result. --> <category> <coding> <system value="http://terminology.hl7.org/CodeSystem/observation-category" /> <code value="laboratory" /> <display value="Laboratory" /> </coding> </category> <!-- The clinical code and name of the test that was performed. --> <code> <coding> <!-- SNOMED CT Observable Entity --> <system value="http://snomed.info/sct" /> <code value="1110441000000100" /> <display value="White blood cell count in blood" /> </coding> </code> <!-- Reference to the subject that the test relates to. --> <subject> <reference value="urn:uuid:ab87a3f8-1d37-44a9-804e-5e962598a6e4" /> <display value="MOXEY, Judy" /> </subject> <!-- The date and time that the test was performed. --> <effectiveDateTime value="2022-02-09T08:03:00+00:00" /> <!-- The date and time that the test result was issued. --> <issued value="2022-02-09T11:17:00+00:00" /> <!-- Reference(s) to the entity/entities that performed the test. --> <performer> <reference value="urn:uuid:8a6d85b8-9837-4fed-a257-4cf207988338" /> <display value="TD008362 PATH LAB 001" /> </performer> <!-- The reason why a test result value has been omitted. --> <dataAbsentReason> <coding> <system value="http://snomed.info/sct" /> <code value="125154007" /> <display value="Specimen unsatisfactory for evaluation" /> </coding> </dataAbsentReason> <!-- A coded, categorical assessment of a test result value. --> <interpretation> <coding> <system value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation" /> <code value="H" /> <display value="High" /> </coding> </interpretation> <!-- Comments relating to the test result. --> <note> <text value="Further tests advised." /> </note> <!-- The body part that was tested/observed. --> <bodySite> <coding> <system value="http://snomed.info/sct" /> <code value="49852007" /> <display value="Structure of median cubital vein" /> </coding> </bodySite> <!-- The method of testing/observation that was used. --> <method> <coding> <system value="http://snomed.info/sct" /> <code value="702659008" /> <display value="Automated count" /> </coding> </method> <!-- Reference to the specimen that was used for testing. --> <specimen> <reference value="urn:uuid:bab0eaec-1ec5-4598-b660-90bb38a1030d" /> </specimen> <!-- Guidance on how to interpret the test result value by comparison to a normal or recommended range. --> <referenceRange> <low> <value value="4.00" /> <unit value="10*9/L" /> <system value="http://unitsofmeasure.org" /> <code value="10^9/L" /> </low> <high> <value value="11.00" /> <unit value="10*9/L" /> <system value="http://unitsofmeasure.org" /> <code value="10^9/L" /> </high> </referenceRange> </Observation>
{ "resourceType": "Observation", "id": "Pathology-Observation-Lab-Sn-Example", "meta": { "profile": [ "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Observation-Lab" ] }, "identifier": [ { "system": "https://tools.ietf.org/html/rfc4122", "value": "2af46949-4938-4c57-bad4-c4363e1965d5" } ], "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "1110441000000100", "display": "White blood cell count in blood" } ] }, "subject": { "reference": "urn:uuid:ab87a3f8-1d37-44a9-804e-5e962598a6e4", "display": "MOXEY, Judy" }, "effectiveDateTime": "2022-02-09T08:03:00+00:00", "issued": "2022-02-09T11:17:00+00:00", "performer": [ { "reference": "urn:uuid:8a6d85b8-9837-4fed-a257-4cf207988338", "display": "TD008362 PATH LAB 001" } ], "dataAbsentReason": { "coding": [ { "system": "http://snomed.info/sct", "code": "125154007", "display": "Specimen unsatisfactory for evaluation" } ] }, "interpretation": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation", "code": "H", "display": "High" } ] } ], "note": [ { "text": "Further tests advised." } ], "bodySite": { "coding": [ { "system": "http://snomed.info/sct", "code": "49852007", "display": "Structure of median cubital vein" } ] }, "method": { "coding": [ { "system": "http://snomed.info/sct", "code": "702659008", "display": "Automated count" } ] }, "specimen": { "reference": "urn:uuid:bab0eaec-1ec5-4598-b660-90bb38a1030d" }, "referenceRange": [ { "low": { "value": 4.00, "unit": "10*9/L", "system": "http://unitsofmeasure.org", "code": "10^9/L" }, "high": { "value": 11.00, "unit": "10*9/L", "system": "http://unitsofmeasure.org", "code": "10^9/L" } } ] }
Observation.id[0] | Pathology-Observation-Lab-Sn-Example |
Observation.meta[0].profile[0] | https://fhir.hl7.org.uk/StructureDefinition/UKCore-Observation-Lab |
Observation.identifier[0].system[0] | https://tools.ietf.org/html/rfc4122 |
Observation.identifier[0].value[0] | 2af46949-4938-4c57-bad4-c4363e1965d5 |
Observation.status[0] | final |
Observation.category[0].coding[0].system[0] | http://terminology.hl7.org/CodeSystem/observation-category |
Observation.category[0].coding[0].code[0] | laboratory |
Observation.category[0].coding[0].display[0] | Laboratory |
Observation.code[0].coding[0].system[0] | http://snomed.info/sct |
Observation.code[0].coding[0].code[0] | 1110441000000100 |
Observation.code[0].coding[0].display[0] | White blood cell count in blood |
Observation.subject[0].reference[0] | urn:uuid:ab87a3f8-1d37-44a9-804e-5e962598a6e4 |
Observation.subject[0].display[0] | MOXEY, Judy |
Observation.effective[0] | 2022-02-09T08:03:00+00:00 |
Observation.issued[0] | 2022-02-09T11:17:00+00:00 |
Observation.performer[0].reference[0] | urn:uuid:8a6d85b8-9837-4fed-a257-4cf207988338 |
Observation.performer[0].display[0] | TD008362 PATH LAB 001 |
Observation.dataAbsentReason[0].coding[0].system[0] | http://snomed.info/sct |
Observation.dataAbsentReason[0].coding[0].code[0] | 125154007 |
Observation.dataAbsentReason[0].coding[0].display[0] | Specimen unsatisfactory for evaluation |
Observation.interpretation[0].coding[0].system[0] | http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation |
Observation.interpretation[0].coding[0].code[0] | H |
Observation.interpretation[0].coding[0].display[0] | High |
Observation.note[0].text[0] | Further tests advised. |
Observation.bodySite[0].coding[0].system[0] | http://snomed.info/sct |
Observation.bodySite[0].coding[0].code[0] | 49852007 |
Observation.bodySite[0].coding[0].display[0] | Structure of median cubital vein |
Observation.method[0].coding[0].system[0] | http://snomed.info/sct |
Observation.method[0].coding[0].code[0] | 702659008 |
Observation.method[0].coding[0].display[0] | Automated count |
Observation.specimen[0].reference[0] | urn:uuid:bab0eaec-1ec5-4598-b660-90bb38a1030d |
Observation.referenceRange[0].low[0].value[0] | 4.00 |
Observation.referenceRange[0].low[0].unit[0] | 10*9/L |
Observation.referenceRange[0].low[0].system[0] | http://unitsofmeasure.org |
Observation.referenceRange[0].low[0].code[0] | 10^9/L |
Observation.referenceRange[0].high[0].value[0] | 11.00 |
Observation.referenceRange[0].high[0].unit[0] | 10*9/L |
Observation.referenceRange[0].high[0].system[0] | http://unitsofmeasure.org |
Observation.referenceRange[0].high[0].code[0] | 10^9/L |