UK Core Clinical and Technical Assurance Sprint 8 Documentation Pack

UK Core Clinical and Technical Assurance Sprint 8 Documentation Pack

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

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