A_VitalSigns - tabular view

Refers to the person or device responsible for authorising the VitalSigns observation.

Only required if author is different to author inherited via context conduction

Only required if informant is different to informant inherited via context conduction

Information about a clinical statement that describes an observation relating to vital signs.

Indicates that this is an observation.

• Fixed value: "OBS"

Indicates that is an event

• Fixed value: "EVN"

A set of unique identifiers for this instance of an observation of a vital sign.

The first is mandatory and is a unique identifier for this instance of a specific clinical statement. The second is optional and allows an observation to be identified by a local identifier.

The Identifier Global datatype flavour is used to carry the first identifier as follows:

• The root attribute shall contain a DCE UUID

The Identifier External datatype flavour is used to carry the second identifier as follows:

• The root carries an OID for the local identifier scheme
• The extension carries a human-readable identifier from that scheme.

A SnomedCT code identifying the type of vital sign observation.

 The Concept Descriptor (CD) dataype shall be used to carry this information as follows:

• The code attribute shall contain a code from the relevant vocabulary
• The code System attribute shall contain the OID for SnomedCT
• The display text shall carry a description associated with the code in SnomedCT
• the original text attribute may be used if required
• qualifier(s) may be used if required.

The (optional) status of the Observation, e.g. active, suspended, completed.

Shall be present if status is aborted or cancelled.

The Coded Only datatype flavour is used to carry this information as follows:

• The code attribute will contain a value from the list of codes in the Act Status vocabulary.

The clinically relevant date and time.

For this release the effective time shall be constrained to (IVL<TS>)

A date range shall be carried as follows:

If both a start date and an end date are present the Date or Time Interval Complete datatype shall be used:

• The low attribute shall contain the start date
• The high attribute shall contain the end date.

If only a start date is present the Date or Time Interval After datatype shall be used:

• The low attribute shall contain the start date.

If only an end date is present the Date or Time Interval Before datatype shall be used:

• The high attribute shall contain the end date.

If the observation occurs more than once, multiple dates / date ranges shall be recorded.

The date and time that the observation relating to vital signs was recorded on the source system.

The value of the observation.

An organizer contains a collection of related clinical statements which are observations related to vital signs.

For example Blood pressure  Diastolic and Systolic Pressure observations.

The class code of the vital signs organizer

• Fixed value: "ORGANIZER"

Indicates that this is an event.

• Fixed value: "EVN"

This allows for two identifiers of an organizer.

The first is mandatory and is a unique identifier for this instance of a specific clinical statement. The second is optional and allows an organizer to be identified by a local identifier.

The Identifier Global datatype flavour is used to carry the first identifier as follows:

• The root attribute shall contain a DCE UUID

The Identifier External datatype flavour is used to carry the second identifier as follows:

• The root carries an OID for the local identifier scheme
• The extension carries a human-readable identifier from that scheme

A SnomedCT code identifying the vital signs organizer type.

 The Concept Descriptor (CD) dataype shall be used to carry this information as follows:

• The code attribute shall contain a code from the relevant vocabulary
• The code System attribute shall contain the OID for SnomedCT
• The display text shall carry a description associated with the code in SnomedCT
• the original text attribute may be used if required
• qualifier(s) may be used if required.

The clinically relevant date and time.

Refers to the clinical statements grouped within an organizer.

This mechanism uses the 'Containment' method of linking clinical statements.

The type of grouping is determined by the value of Organizer. code.  

NOTE: In the P1R2 version of PSIS, any component of an Organizer will not be explicitly indexed, and cannot be progressed in its own right.  For this reason clinically important statements (e.g. medication and allergy statements) must NOT be organizer components in P1R2. 

Refers to the choice of CMETs that can be used to identify the author of the VitalSigns observation. The author can be a person or a device.

The participating person 

NPfIT CMET to identify a device.

The tabular view for this CMET describes its usage.

NPfIT CMET to identify the person who is participating.

The tabular view for this CMET describes its usage.

A role played by a person who is not an agent  (i.e. not a care professional).

Indicates this is a role.

• Fixed value: "ROL"

An optional unique identifier of the role-player.  May be used to convey the NHS number of a patient who is playing a role.  It shall be an OID for the identification scheme and the identifier within that scheme (e.g. for patient NHS number).

A code identifying the relationship of the non-agent person to the patient, e.g. parent  or carer.

The Coded  Plain flavour of the Coded Value (CV) datatype shall be used to carry this information as follows:

• The code attribute shall contain a value from the list of codes in the  vocabulary
• The code System attribute shall contain the OID for the vocabulary
• The display text attribute will carry a description for the code from the vocabulary.

An optional link to the person playing the non-agent role.

Indicates that the entity is a person

• Fixed value: "PSN"

Indicates that the entity is a single identifiable person.

• Fixed value: "INSTANCE"

The name(s) of the person