A_Observation - tabular view

Information about a clinical statement that describes an observation.

The following clinical statements are modelled as observation acts:  

This list may need to be constrained depending on the usage of this CMET.                 

Legal Status

Living will  

Religious/Culturally Dependent Needs

Health & Social Issue as described by patient

Health & Social Issue as described by health care professional

Attitude of patient to issue

Attitude of carer to issue

Patient awareness of issue

Carer awareness of issue

Diagnosis

Prognosis

Findings

Goal

Family History

Allergy

Risk Statement

Risk Incident

Smoking

Smoking Future Intentions

Alcohol

Alcohol future intentions

Substance misuse

Exercise habits

Occupation

Employment

Housing

Social network

Religion

Ethnic category

Services

Care provided by carer

Functioning and wellbeing

Indicates that this is an observation.

• Fixed value: "OBS"

The mood code of the observation act.

The value of mood code should be set according to the information and context of the clinical statement information being carried in the observation class. 

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

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

A set of unique identifiers for this instance of an observation.

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 observation.

 The Concept Descriptor (CD) datatype 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.

For each clinical statement that is an observation the usage of Observation.code is described below:

• Patient Legal Status - the informal or Mental Health Act Section current at the time the message is created.
• Living Will - The description of a living will in coded format 
• Religious/Culturally Dependent Needs - a  patient's religious/cultural needs. 
• Health & Social Issue as described by health care professional - a type of issue, it's severity and status as identified by an health care professional.
• Health & Social Issue as described by patient - a type of issue, it's severity and status as identified by the patient.
• Attitude of carer to issue - the carer's attitude to the issue.
• Patient awareness of issue - the patient's awareness of the issue.
• Carer awareness of issue - the carer's awareness of the issue.
• Diagnosis - a diagnosis including certainty of diagnosis and negation.
• Prognosis - a prognosis associated with a diagnosis.
• Finding - a finding including any additional descriptions that can be coded.
• Outcome - an outcome.
• Goal - a goal identified for the future.
• Family History - family history item, including description of relationship of person with family history to patient.
• Risk Statement - an identified risk to others from the patient.
• Risk Incident - the actual risk in a risk incident.
• Smoking - the current status of the smoking habits of the patient including smoking consumption.
• Smoking future intentions - the patient's future intentions to change smoking habits.
• Alcohol - the alcohol status of the patient at the time of recording, includes alcohol consumption.
• Alcohol future intentions - the patient's future intentions with regard to alcohol consumption.
• Substance misuse - a known drug habit.
• Exercise - the exercise habits of the patient.
• Occupation - the patient's occupation .
• Employment - information on the employment status of a patient Housing - information on the housing situation of the patient in coded form.
• Social Network - the nature of the social network of the patient. Religion - information about the patient's religion.
• Ethnic Category - information about the patient's ethnic category . 
• Services - a type of service being provided by other agents to the patient.
• Care provided by Carer - the nature of care provided by the carer to the patient.
• Functioning and wellbeing - the functioning and wellbeing of the patient.

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

Required 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>)

For each observation which has a requirement to carry the clinically relevant date and time the usage of Observation.effectiveTime is described below:

• Patient Legal Status - The start and end date of the latest legal status of the patient - optional. 
• Health & Social Issue as described by patient - The date that the patient noticed the issue and the date that the issue was resolved - optional.
• Diagnosis - The date and time the diagnosis was true of the patient - optional
• Finding - the date and time the finding was true of the patient - optional
• Outcome - The date and time the outcome was assessed - optional.
• Risk Incident - The date and time that the incident occurred - optional.

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 the observation was made.

For each observation which has a requirement to carry the activity date and time the usage of Observation.activityTime is described below:

• Health & Social Issue as described by health care professional - The date and time that the problem was identified by the health care professional - optional.
• Prognosis - The date and time that the health care professional made a diagnosis associated prognosis.
• Family History - The date of stating the family history finding.

The date and time that the observation was recorded on the source system.

The value of the observation.

Refers to a participant in clinical events.

The following participants are modelled using this participation:

Care Event Service Provider Organization - optional

Care Event care professional - required if different to inherited author 

Refers to the choice of location relevant to clinical data conveyed in a clinical statement.

Refers to the agent / person / device acting in the role of informant.  The patient may at as an informant.

Refers to a specimen that has been taken from the patient.

Refers to supporting information which is pertinent to a clinical statement. 

Refers to reference ranges for a laboratory result.

A relationship to another clinical statement by reference.  The clinical statement may be in the message instance carrying the reference, or on PSIS.

Refers to the role of subject where the subject (who must be a person) is not the patient who is the target of the record.

The class code of the subject role.

The value of class code should be set appropriately according to the information and context of the subject being modelled.

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  vocabulary.

To provide an optional  identifier of the subject

To identify the relationship between patient and subject in coded form.

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 of the vocabulary
• The display text attribute will carry a description for the code from the vocabulary.

The person who is playing the role of subject.

The agent / device / non-agent performing this participation.

The participating person 

A CMET identifying the participating device.

AgentDevcie.classCode shall carry a fixed value of  "AGNT"

AgentDevice. id  shall carry a nationally agreed identifier for the role being played.  This shall be a code from a national coding scheme.

A national code is carried in the following way:

• The root attribute shall contain the OID that identifies the coding scheme
• The extension attribute shall contain the code

If the device can be identified by reference to SDS then

DeviceSDS.classcode shall carry a fixed value of "DEV" to indicates that this is a Device. In this context the device can be hardware or software.

DeviceSDS.determinerCode shall carry a fixed value of "INSTANCE"

DeviceSDS.id shall carry an SDS identifier that uniquely identifies the Device.

This is carried in the following way.

• The root attribute shall contain an OID with the appropriate value 
• The extension attribute shall contain the SDS Device ID

If the device cannot be identified by reference to SDS then

Device.classCode shall carry a fixed value of  "DEV"

Device.determinerCode shall carry a fixed value of "INSTANCE"

Device.id  shall carry an optional identifier that uniquely identifies the Device.   This shall be a code from a national scheme.

A national code is carried in the following way:

• The root attribute shall carry the OID that identifies the coding scheme
• The extension attribute shall contain the code

If an id is not present, then a name shall be included .

Device.code shall carry an optional code to describe the type of device.

If a code is not present, then a description shall be included.

Device.name shall carry an optional  name of the device.

This shall be included if an id is not present.

Device.desc shall carry an optional description of the type of device.

This shall be included if a code is not present.

Device.manufacturerModelName shall optionally carry the model name as allocated by the Device manufacturer.

Device.softwareName shall optionally carry the name of the software used by the Device.

If the device is scoped by an organization then and the organization can be identified by reference to SDS then

OrganizationSDS.classCode shall carry a fixed value of  "ORG"

OrganizationSDS.determinerCode shall carry a fixed value of "INSTANCE".

OrganizationSDS.id shall carry an SDS identifier that uniquely identifies the Organization. This is carried in the following way:

• The root attribute shall contain an OID with the value 1.2.826.0.1285.0.1.10
• The extension attribute shall contain the SDS Organization ID

If the device is scoped by an organization then and the organization cannot be identified by reference to SDS then

Organization.classCode shall carry a fixed value of  "ORG"

Organization.determinerCode shall carry a fixed value of "INSTANCE"

Organization.id shall carry an optional identifier that uniquely identifies the Organization. This shall be a code from a national scheme.

A national code is carried in the following way:

• the root attribute shall contain the OID that identifies the coding scheme
• the extension attribute shall contain the code

If an id is not present, then a name shall be included.

Organization.code shall optionally carry a value from the OrganizationType vocabulary  to identify the type of Organization.

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

• The code attribute shall contain a value from the list of codes in the OrganizationType vocabulary.

If a code is not present, then a description shall be included.

Organization.name shall optionally contain the name of the Organization. This shall be included if an id is not present.

Organization.desc shall contain a optional description of the type of Organization. This shall be included if a code is not present.

Organization.telecom shall contain optional  telephone contact details for the Organization.

Organization.addr shall contain an optional address of the Organization

NPfIT CMET to identify the agent person.

The tabular view for this CMETs describes it's usage.

A choice of location relevant to the clinical statement.

The place where the activity took place that is not a organization known to SDS.

NPfIT CMET to identify the organization which is the location.

The tabular view for this CMETs describes it's usage.

NPfIT CMET to identify the agent organization.

The tabular view for this CMETs describes it's usage.

NPfIT CMET to identify the agent person.

The tabular view for this CMETs describes it's usage.

Information about the specimen.

Indicates that this is a specimen.

• Fixed value: "SPEC"

Local identifier of a specimen.

The local identifier is carried using the Identifier External datatype flavour as follows:

• The extension attribute shall contain the local id
• The root attribute shall contain an OID for the local id. system

The type of specimen.

• Fixed value: "P" - taken from the patient

Refers to the specimen material.

An Act holding overflow information from the Act acting as the root of the clinical statement.  Supporting information shall not contradict the content of the source act, only add to it or explain it.

Indicates that this is an observation. Note that SupportingInfo can be used to supply overflow information for any kind of Act included in the ClinicalStatementChoice, not just Observations.

• Fixed value: "OBS"

Indicates this is an event.

• Fixed value: "EVN"

A SnomedCT code indicating the nature of the supporting information.

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 SnomedCT
• The display text attribute will carry a description for the code from the coding system .

A clinically relevant date and time that forms supporting information.

The 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.

A supporting value.

A reference range for a biological measurement, e.g. height, blood haemoglobin.  It may be specific to people of a given sex, age range, etc

Indicates that this is an observation.

• Fixed value: "OBS"

The mood code is fixed as "Criterion"

• Fixed value: "EVN.CRT"

Optional text to explain or otherwise describe the reference range.

The reference range itself, including the units it is expressed in.  It will usually comprise an upper limit and a lower limit.

An optional code from the vocabulary named providing an interpretation of the normality of the Observation it applies to.

Refers to a component using a unique identifier.

"ACT" is the highest level of classCode.

For this ActRef to be utilised properly by the relationships identified within the model, this classCode MUST be changed to the code of the item being referenced.

"ActMood" is the highest level of moodCode.

For this ActRef to be utilised properly by the relationships identified within the model, this moodCode MUST be changed to the code of the item being referenced.

The unique identifier of the target clinical statement.

Information about the person who is the subject where the subject is not the patient who is the target of the record.

Indicates that the entity is a person.

• Fixed value: "PSN"

Indicates that the entity is a single identifiable person.

• Fixed value: "INSTANCE"

One or more names of the person who is the subject.

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 either an OID for the identification scheme and the identifier within that scheme (e.g. for patient NHS number), or a DCE UUID.

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.

A role played by a location that is not an organizational site.

Indicates that the role is a incidental location

• Fixed value: "ISDLOC"

A SnomedCT code identifying the kind of location being described (e.g. normal residence, ambulance, public place)

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 SnomedCT
• The display text attribute will carry a description for the code from the coding system .

Details of the individual place playing the role of the IncidentialLocation

Information about the actual specimen taken.

Indicates a material.

• Fixed value: "MAT"

The determiner code of the entity.

The value of determinerCode should be set according to the specification of the specimen being carried in the entity. 

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

• The code attribute will contain a value from the list of codes in the EntityDeterminer vocabulary;

An optional identifier of the material.  This attribute may only be used if the determinerCode is "INSTANCE"

The Identifier Global datatype flavour is used to carry this information as follows:

• The root attribute shall contain a DCE UUID.

A SnomedCT code identifying the material forming the specimen.

The datatype must be constrained to CD and used as indicated below.

The Concept Descriptor (CD) datatype 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.

Details of the non-agent person.

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

An entity describing a place that is not an organization recognised by SDS.  If Place is used, at least one of the non-structural attributes SHALL be used. 

Indicates that the entity is a place

• Fixed value: "PLC"

Indicates that the entity is a single identifiable place

• Fixed value: "INSTANCE"

The optional name of the place

An optional telecom contact for the place

An optional address of the place

An optional grid reference. It may be as precise as required.

An optional GPS reference.  It may be as precise as required.