UK Core Clinical and Technical Assurance Sprint 7 Documentation Pack

UK Core Clinical and Technical Assurance Sprint 7 Documentation Pack

Clinical Observations - NHSE

The following derived vital signs are part of the NHS England Clinical Observations IG:

  • Oxygen Saturation
  • Heart Rate
  • Respiration Rate
  • Blood Pressure
  • Temperature
  • Height / Length
  • Head Circumference
  • Weight
  • Body Mass Index (BMI)

along derived survey based vital signs, that is any vital sign recorded by the health care worker using an assessment scale or survey tool:

  • Baseline Oxygen Saturation
  • Baseline Systolic
  • Baseline Diastolic
  • Target Oxygen Saturation
  • Consciousness
  • Respiration Distress
  • Air or Oxygen
  • Capiliary Refill Time
  • Patient Concern
  • Birth Weight
  • Gestational Age at Birth
  • NCMP Withdrawal Reason

and the with the derived score observations:

  • Baseline NEWS2 Score
  • Baseline NPEWS1 Score
  • Score Chart Used
  • Respiration Rate Score
  • Respiration Distress Score
  • Oxygen Saturation Score
  • Air or Oxygen Score
  • Systolic Score
  • Pulse Rate Score
  • Capiliary Refill Time Score
  • Consciousness Score
  • Temperature Score



It is our intent to create these within the UK Core IG so that they are standardised thoughout the UK.

These will be derived from the UK Core Observation VitalSigns profile and should align with the derived profiles from the base HL7 and IPS where practicable. Any relevant profiles merged where possible, for instance the Oxygen Saturation vital signs and the Oxygen Saturation survey vital signs.


Profiles to be put forward for Sprint 7

VitalSigns

url1..1System.StringFixed Value
valueReferenceReference(UK Core Observation)
url1..1System.StringFixed Value
valueCodecode
url1..1System.StringFixed Value
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recordingSettingI0..*Extension(code)
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assignerΣ I0..1Reference(UK Core Organization)
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assignerΣ I0..1Reference(UK Core Organization)
displayΣ0..1string
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typeΣ0..1uriBinding
useΣ ?!0..1codeBinding
typeΣ0..1CodeableConceptBinding
systemΣ0..1uri
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periodΣ I0..1Period
assignerΣ I0..1Reference(UK Core Organization)
displayΣ0..1string
statusΣ ?!1..1codeBindingFixed Value
systemΣ0..1uriFixed Value
versionΣ0..1string
codeΣ0..1codeFixed Value
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assignerΣ I0..1Reference(UK Core Organization)
displayΣ0..1string
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useΣ ?!0..1codeBinding
typeΣ0..1CodeableConceptBinding
systemΣ0..1uri
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displayΣ0..1string
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useΣ ?!0..1codeBinding
typeΣ0..1CodeableConceptBinding
systemΣ0..1uri
valueΣ0..1string
periodΣ I0..1Period
assignerΣ I0..1Reference(UK Core Organization)
displayΣ0..1string
effectiveDateTimedateTime
effectivePeriodPeriod
effectiveTimingTiming
effectiveInstantinstant
issuedΣ0..1instant
referenceΣ I0..1string
typeΣ0..1uriBinding
useΣ ?!0..1codeBinding
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systemΣ0..1uri
valueΣ0..1string
periodΣ I0..1Period
assignerΣ I0..1Reference(UK Core Organization)
displayΣ0..1string
valueQuantityQuantity
valueCodeableConceptCodeableConcept
valueStringstring
valueBooleanboolean
valueIntegerinteger
valueRangeRange
valueRatioRatio
valueSampledDataSampledData
valueTimetime
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valuePeriodPeriod
dataAbsentReasonI0..1CodeableConceptBinding
interpretation0..*CodeableConceptBinding
authorStringstring
authorReferenceReference(UK Core Organization | UK Core Patient | UK Core Practitioner | UK Core RelatedPerson)
timeΣ0..1dateTime
textΣ1..1markdown
bodySite0..1CodeableConceptBinding
method0..1CodeableConceptBinding
referenceΣ I0..1string
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lowI0..1SimpleQuantity
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type0..1CodeableConceptBinding
appliesTo0..*CodeableConcept
ageI0..1Range
text0..1string
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useΣ ?!0..1codeBinding
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systemΣ0..1uri
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assignerΣ I0..1Reference(UK Core Organization)
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systemΣ0..1uri
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assignerΣ I0..1Reference(UK Core Organization)
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systemΣ0..1uriFixed Value
versionΣ0..1string
codeΣ0..1code
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userSelectedΣ0..1boolean
systemΣ0..1uriFixed Value
versionΣ0..1string
codeΣ0..1code
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userSelectedΣ0..1boolean
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valueCodeableConceptCodeableConcept
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dataAbsentReasonI0..1CodeableConceptBinding
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referenceRange0..*see (referenceRange)

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Profile Specific Implementation Guidance:

This is a derived profile of UKCore-Observation and this page only shows the differences between the two. Refer to the base Profile for more implementation guidance.

This guidance is also designed to align with https://build.fhir.org/observation-vitalsigns.html where possible.

Minimum Viable Content

The minimum viable content that all provider and consumer systems SHALL support are the elements within the corresponding UKCore-Observation table, along with the following.

Element Reason
Observation.category A category of Vital Signs or Survey SHALL be present.
Observation.code.coding If the category is Vital Signs, a LOINC "magic code" SHALL be present in addition to the SNOMED CT concept for the observation type.
Observation.subject A UKCore-Patient SHALL be present.
Observation.effective[x] A an effective time or date SHALL be present.
Observation.component.copde.coding If the category is Vital Signs, a LOINC "magic code" SHALL be present in addition to the SNOMED CT concept for the observation type.

Bindings (differential)

More information about the bindings to UK Core ValueSets, and other ValueSets different to UK Core Observation can be found below.

Context Strength Link
Observation.code.coding:loinc Extensible http://hl7.org/fhir/ValueSet/observation-vitalsignresult
Observation.code.coding:snomedCT Preferred https://fhir.hl7.org.uk/ValueSet/UKCore-ObservationVitalSignsTyp

Constraints (differential)

More information about the constraints on the UKCore-Observation-VitalSigns profile can be found below.

Key Severity Expression Human Description
ukcore-obs-vs-001 error category.where(code='vital-signs').exists() implies code.coding.where(system='http://loinc.org').exists() Where the category is Vital Signs the code.coding SHALL include a LOINC "magic code"

status

The following value SHALL be used:

  • Observation.status = final

category

The cardinality of this element is 1..1, and it SHALL be present. The following SHALL be used for this profile:

  • Observation.category.coding.system = http://terminology.hl7.org/CodeSystem/observation-category
  • Observation.category.coding.code = vital-signs
  • Observation.category.coding.display = Vital Signs

code

This element has an open slice on Observation.code.coding, and MAY be used to send a SNOMED CT concept for the type of observation, and where the Observation.category is Vital Signs, SHALL also contain a LOINC "magic code" for the type of vital sign observation.

Observation.code.coding:loinc

The following SHALL be used for this profile, where the Observation.category is Vital Signs:

Observation.code.coding:snomedCT

The following SHOULD be used for this profile:


subject

The cardinality of this element is 1..1, and the resource being referenced SHALL conform to the UKCore-Patient profile.


effective[x]

The cardinality of this element is 1..1, and it SHALL be present.


Derived Profiles

Proposed derived profiles for vital signs: Blood Pressure, BMI, Head Circumference, Heart Rate, Height, Oxygen Saturation Respiratory Rate, Temperature, and Weight. These will all be derived from UKCore-Observation-VitalSigns, and SHALL have a LOINC "magic code".

Blood Pressure

The UKCore-Observation-VitalSigns-BloodPressure will further derive from UKCore-Observation-VitalSigns, and this section only shows the differences between the two.

Observation.code.coding:loinc

The following SHALL be used for this profile:

  • Observation.code.coding.system = http://loinc.org
  • Observation.code.coding.code = 85354-9
  • Observation.code.coding.display = Blood pressure panel with all children optional

Observation.code.coding:snomedCT

The following SHALL be used for this profile:

  • Observation.code.coding.system = http://snomed.info/sct
  • Observation.code.coding.code = 75367002
  • Observation.code.coding.display = Blood pressure

Observation.value[x]

This element has a cardinality of 0..0, and SHALL NOT be present.

Observation.component:SystolicBP.code.coding:loinc

The following SHALL be used for this profile:

  • Observation.code.coding.system = http://loinc.org
  • Observation.code.coding.code = 8480-6
  • Observation.code.coding.display = Systolic blood pressure

Observation.component:SystolicBP.code.coding:snomedCT

The following SHALL be used for this profile:

Observation.component:SystolicBP.value[x]

The following SHALL be a Quantity, and the following used for this profile:

  • Observation.component.valueQuantity.system = http://unitsofmeasure.org
  • Observation.component.valueQuantityg.code = mm[Hg]
  • Observation.component.valueQuantity.unit = millimeter of mercury

Observation.component:DiastolicBP.code.coding:loinc

The following SHALL be used for this profile:

  • Observation.component.code.coding.system = http://loinc.org
  • Observation.component.code.coding.code = 8462-4
  • Observation.component.code.coding.display = Diastolic blood pressure

Observation.component:DiastolicBP.code.coding:snomedCT

The following SHALL be used for this profile:

Observation.component:DiastolicBP.value[x]

The following SHALL be a Quantity, and the following used for this profile:

  • Observation.component.valueQuantity.system = http://unitsofmeasure.org
  • Observation.component.valueQuantity.code = mm[Hg]
  • Observation.component.valueQuantity.unit = millimeter of mercury

BMI

The UKCore-Observation-VitalSigns-BMI further derives from UKCore-Observation-VitalSigns, and this section only shows the differences between the two.

Observation.code.coding:loinc

The following SHALL be used for this profile:

  • Observation.code.coding.system = http://loinc.org
  • Observation.code.coding.code = 39156-5
  • Observation.code.coding.display = Body mass index (BMI) [Ratio]

Observation.code.coding:snomedCT

The following SHALL be used for this profile:

  • Observation.code.coding.system = http://snomed.info/sct
  • Observation.code.coding.code = A SNOMED CT concept Id from https://fhir.hl7.org.uk/ValueSet/UKCore-BMI
  • Observation.code.coding.display = The “preferred term” associated with the SNOMED CT concept

Observation.value[x]

For Adult BMI measurements, a valueQuantity SHALL be present, and the following used for this profile:

  • Observation.valueQuantity.system = http://unitsofmeasure.org
  • Observation.valueQuantity.code = kg/m2
  • Observation.valueQuantity.unit = kilogram / (meter ^ 2)

For Child BMI measurements, a valueQuantity SHALL be present, and the following used for this profile:

  • Observation.valueQuantity.system = http://unitsofmeasure.org
  • Observation.valueQuantity.code = {percentile}
  • Observation.valueQuantity.unit = 'Percentile`

Head Circumference

The UKCore-Observation-VitalSigns-HeadCircumference further derives from UKCore-Observation-VitalSigns, and this section only shows the differences between the two.

Observation.code.coding:loinc

The following SHALL be used for this profile:

  • Observation.code.coding.system = http://loinc.org
  • Observation.code.coding.code = 9843-4
  • Observation.code.coding.display = Head Occipital-frontal circumference

Observation.code.coding:snomedCT

The following SHALL be used for this profile:

Observation.value[x]

The following SHALL be a Quantity, and the following used for this profile:

  • Observation.valueQuantity.system = http://unitsofmeasure.org
  • Observation.valueQuantityg.code = cm
  • Observation.valueQuantity.unit = centimeter

Heart Rate

The UKCore-Observation-VitalSigns-HeartRate further derives from UKCore-Observation-VitalSigns, and this section only shows the differences between the two.

Observation.code.coding:loinc

The following SHALL be used for this profile:

  • Observation.code.coding.system = http://loinc.org
  • Observation.code.coding.code = 8867-4
  • Observation.code.coding.display = Heart rate

Observation.code.coding:snomedCT

The following SHALL be used for this profile:

  • Observation.code.coding.system = http://snomed.info/sct
  • Observation.code.coding.code = A SNOMED CT concept Id from https://fhir.hl7.org.uk/ValueSet/UKCore-HeartRate
  • Observation.code.coding.display = The “preferred term” associated with the SNOMED CT concept

Observation.value[x]

The following SHALL be a Quantity, and the following used for this profile:

  • Observation.valueQuantity.system = http://unitsofmeasure.org
  • Observation.valueQuantity.code = {beats}/min
  • Observation.valueQuantity.unit = heart beats per minute

Height

he UKCore-Observation-VitalSigns-Height will further derive from UKCore-Observation-VitalSigns, and this section only shows the differences between the two.

Observation.code.coding:loinc

The following SHALL be used for this profile:

  • Observation.code.coding.system = http://loinc.org
  • Observation.code.coding.code = 8302-2
  • Observation.code.coding.display = Body height

Observation.code.coding:snomedCT

The following SHALL be used for this profile:

Observation.value[x]

The following SHALL be a Quantity, and the following used for this profile:

  • Observation.valueQuantity.system = http://unitsofmeasure.org
  • Observation.valueQuantityg.code = m
  • Observation.valueQuantity.unit = meter

Oxygen Saturation

he UKCore-Observation-VitalSigns-Height will further derive from UKCore-Observation-VitalSigns, and this section only shows the differences between the two.

Observation.code.coding:loinc

The following SHALL be used for this profile:

  • Observation.code.coding.system = http://loinc.org
  • Observation.code.coding.code = 2708-6
  • Observation.code.coding.display = Oxygen saturation in Arterial blood

Observation.code.coding:snomedCT

The following SHALL be used for this profile:

Observation.value[x]

The following SHALL be a Quantity, and the following used for this profile:

  • Observation.valueQuantity.system = http://unitsofmeasure.org
  • Observation.valueQuantity.code = %
  • Observation.valueQuantity.unit = percentage

Respiratory Rate

The UKCore-Observation-VitalSigns-RespiratoryRate further derives from UKCore-Observation-VitalSigns, and this section only shows the differences between the two.

Observation.code.coding:loinc

The following SHALL be used for this profile:

  • Observation.code.coding.system = http://loinc.org
  • Observation.code.coding.code = 9279-1
  • Observation.code.coding.display = Respiratory Rate

Observation.code.coding:snomedCT

The following SHALL be used for this profile:

Observation.value[x]

The following SHALL be a Quantity, and the following used for this profile:

  • Observation.valueQuantity.system = http://unitsofmeasure.org
  • Observation.valueQuantity.code = {breaths}/min
  • Observation.valueQuantity.unit = breaths per minute

Temperature

The UKCore-Observation-VitalSigns-Temperature further derives from UKCore-Observation-VitalSigns, and this section only shows the differences between the two.

Observation.code.coding:loinc

The following SHALL be used for this profile:

  • Observation.code.coding.system = http://loinc.org
  • Observation.code.coding.code = 8310-5
  • Observation.code.coding.display = Body temperature

Observation.code.coding:snomedCT

The following SHALL be used for this profile:

  • Observation.code.coding.system = http://snomed.info/sct
  • Observation.code.coding.code = A SNOMED CT concept Id from https://fhir.hl7.org.uk/ValueSet/UKCore-Temperature
  • Observation.code.coding.display = The “preferred term” associated with the SNOMED CT concept

Observation.value[x]

The following SHALL be a Quantity, and the following used for this profile:

  • Observation.valueQuantity.system = http://unitsofmeasure.org
  • Observation.valueQuantity.code = Cel
  • Observation.valueQuantity.unit = degree Celsius

Weight

The UKCore-Observation-VitalSigns-Weight will further derive from UKCore-Observation-VitalSigns, and this section only shows the differences between the two.

Observation.code.coding:loinc

The following SHALL be used for this profile:

  • Observation.code.coding.system = http://loinc.org
  • Observation.code.coding.code = 29463-7
  • Observation.code.coding.display = Body weight

Observation.code.coding:snomedCT

The following SHALL be used for this profile:

Observation.value[x]

The following SHALL be a Quantity, and the following used for this profile:

  • Observation.valueQuantity.system = http://unitsofmeasure.org
  • Observation.valueQuantityg.code = kg
  • Observation.valueQuantity.unit = kilogram

Clinical Observations

Proposed derived profiles for clinical observations: ACVPU, Alcohol Consumption, Average blood Pressure, Blood Glucose, Inspired Oxygen and Tobacco Consumption. These will all be derived from UKCore-Observation, and do not have a LOINC "magic code".

All these derived profiles will share the following constraints to the UKCore-Observation:

status

The following value SHALL be used:

  • Observation.status = final

subject

The cardinality of this element is 1..1, and the resource being referenced SHALL conform to the UKCore-Patient profile.

effective[x]

The cardinality of this element is 1..1, and it SHALL be present.


ACVPU

The UKCore-Observation-ACVPU derives from UKCore-Observation, and this section only shows the differences between the two.

Observation.code.coding

The following SHALL be used for this profile:

  • Observation.code.coding.system = http://snomed.info/sct
  • Observation.code.coding.code = 1104441000000107
  • Observation.code.coding.display = Alert Confusion Voice Pain Unresponsive scale score

Observation.value[x]

A valueCodeableConcept SHALL be present, and the following used for this profile:

  • Observation.valueCodeableConcept.system = http://snomed.info/sct
  • Observation.valueCodeableConcept.code = A SNOMED CT concept Id from https://fhir.hl7.org.uk/ValueSet/UKCore-ACVPU
  • Observation.valueCodeableConcept.display = The “preferred term” associated with the SNOMED CT concept

Alcohol Consumption

The UKCore-Observation-AlcoholConsumption derives from UKCore-Observation, and this section only shows the differences between the two.

Observation.category

The following values SHALL be used:

  • Observation.category.coding.system = http://terminology.hl7.org/CodeSystem/observation-category
  • Observation.category.coding.code = social-history
  • Observation.category.coding.display = Social History

Observation.code.coding

The following SHALL be used for this profile:

Observation.value[x]

A valueQuantity SHALL be present, and the following used for this profile:

  • Observation.valueQuantity.system = http://unitsofmeasure.org
  • Observation.valueQuantity.code = {drinks}/d
  • Observation.valueQuantity.unit = drinks per day

Average Blood Pressure

The UKCore-Observation-AverageBloodPressure derives from UKCore-Observation, and this section only shows the differences between the two.

Observation.code.coding

The following SHALL be used for this profile:

Observation.component:SystolicBP.code.coding

The following SHALL be used for this profile:

Observation.component:SystolicBP.value[x]

The following SHALL be a Quantity, and the following used for this profile:

  • Observation.component.valueQuantity.system = http://unitsofmeasure.org
  • Observation.component.valueQuantityg.code = mm[Hg]
  • Observation.component.valueQuantity.unit = millimeter of mercury

Observation.component:DiastolicBP.code.coding

The following SHALL be used for this profile:

Observation.component:DiastolicBP.value[x]

The following SHALL be a Quantity, and the following used for this profile:

  • Observation.component.valueQuantity.system = http://unitsofmeasure.org
  • Observation.component.valueQuantity.code = mm[Hg]
  • Observation.component.valueQuantity.unit = millimeter of mercury

Blood Glucose

The UKCore-Observation-BloodGlucose derives from UKCore-Observation, and this section only shows the differences between the two.

Observation.code.coding

The following SHALL be used for this profile:

  • Observation.code.coding.system = http://snomed.info/sct
  • Observation.code.coding.code = A SNOMED CT concept Id from https://fhir.hl7.org.uk/ValueSet/UKCore-BloodGlucose
  • Observation.code.coding.display = The “preferred term” associated with the SNOMED CT concept

Observation.value[x]

A valueQuantity SHALL be present, and the following used for this profile:

  • Observation.valueQuantity.system = http://unitsofmeasure.org
  • Observation.valueQuantity.code = mmol/L
  • Observation.valueQuantity.unit = millimoles per litre

Inspired Oxygen

The UKCore-Observation-InspiredOxygen derives from UKCore-Observation, and this section only shows the differences between the two.

Observation.code.coding

The following SHALL be used for this profile:

Observation.value[x]

A valueQuantity SHOULD be present, and the following used for this profile:

  • Observation.valueQuantity.system = http://unitsofmeasure.org
  • Observation.valueQuantity.code = l/min
  • Observation.valueQuantity.unit = litre per minute

Tobacco Consumption

The UKCore-Observation-TobaccoConsumption derives from UKCore-Observation, and this section only shows the differences between the two.

Observation.category

The following values SHALL be used:

  • Observation.category.coding.system = http://terminology.hl7.org/CodeSystem/observation-category
  • Observation.category.coding.code = social-history
  • Observation.category.coding.display = Social History

Observation.code.coding

The following SHALL be used for this profile:

Observation.value[x]

A valueQuantity SHALL be present, and the following used for this profile:

  • Observation.valueQuantity.system = http://unitsofmeasure.org
  • Observation.valueQuantity.code = {#}/d
  • Observation.valueQuantity.unit = number smoked per day

Early Warning Scores

Proposed derived profiles for early warning scores: Early Warning Total Score. This will all be derived from UKCore-Observation, and does not have a LOINC "magic code".

All these derived profiles will share the following constraints to the UKCore-Observation:

status

The following value SHALL be used:

  • Observation.status = final

category

The following values SHALL be used:

  • Observation.category.coding.system = http://terminology.hl7.org/CodeSystem/observation-category
  • Observation.category.coding.code = survey
  • Observation.category.coding.display = Survey

code

The following SHALL be used for this profile:

subject

The cardinality of this element is 1..1, and the resource being referenced SHALL conform to the UKCore-Patient profile.

effective[x]

The cardinality of this element is 1..1, and it SHALL be present.

value[x]

A valueQuantity SHALL be present, and the following used for this profile:

  • Observation.valueQuantity.system = http://unitsofmeasure.org
  • Observation.valueQuantity.code = {ScoreOf}

derivedFrom

This element SHOULD be populated with a referenced resources conforming to UKCore-Observation, and these resources should be the observations used to determine the Early warning Score component sub scores.

component

This element SHOULD be used to record the component sub scores used to determine the total score

The following values SHALL be used:

component.code.coding

The following SHALL be used for this profile:

  • Observation.component.code.coding.system = http://snomed.info/sct
  • Observation.component.code.coding.code = A SNOMED CT concept Id from https://fhir.hl7.org.uk/ValueSet/UKCore-EarlyWarningSubScore
  • Observation.component.code.coding.display = The “preferred term” associated with the SNOMED CT concept

component.value[x]

The following SHALL be a Quantity, and the following used for this profile:

  • Observation.component.valueQuantity.system = http://unitsofmeasure.org
  • Observation.component.valueQuantityg.code = {ScoreOf}
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