Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02

The content of this release is not comprehensive and is not fully validated and must not be used in live system implementations.

ELEMENT Domain Model: GenericFindingObservation2

An ELEMENT to represent a generic finding. A finding on examination can be the interpretation of a clinical examination of any sort2. 2: NPFIT-NCR-DES-0135.07 NHS Care Record Elements

Attributes

Name Data type Occurs Description Value Constraints
name SC 1..1 The name, expressed as a coded value or as plain text, specifies the clinical or administrative concept to which this EHR node corresponds, as labelled in the EHR system in which it was first committed.

value
Literal value(s): FINDING_OBSERVATION_ELEMENT
rc_id II 1..1 The globally-unique identifier by which this node in the EHR hierarchy is referenced in the EHR system to which the data were first committed. This identifier shall be retained by the EHR Recipient and re-used whenever this RECORD_COMPONENT is subsequently included in another EHR_EXTRACT.
meaning CD.CV 1..1 A coded representation of the type of finding.

code
Semantic expression constraint
synthesised BL 1..1 This attribute value shall be TRUE if this RECORD_COMPONENT has been created in order to comply with this standard , but this point in the EHR hierarchy has no corresponding node in the EHR from which it was extracted.

obs_time IVL_TS 0..1 The date and time, or interval, of the finding.
value ANY 1..1 An ELEMENT has a single DATA_VALUE containing the value, unless this is indicated as absent by a null_flavour attribute.

nullFlavor
Literal value(s): NA


COMPONENT RELATIONSHIPS

Subject of relationships

Name Object of relationship Occurs Dependency
HasAssociation HaemodialysisAccessFlowRateObservation 0..* INDEPENDENT
HasAssociation HaemodialysisAccessRecirculationObservation 0..* INDEPENDENT
HasFindingCharacteristic GenericFindingObservation2 0..* INDEPENDENT
IsDerivedObservation GenericPropertyObservation2 0..* INDEPENDENT


Object of relationships

Name Subject of relationship Occurs Dependency
HasClinicalContext GenericAdmissionEvent 0..* INDEPENDENT
HasIndication GenericAdmissionEvent 0..* INDEPENDENT
HasClinicalContext GenericAdmissionEvent2 0..* INDEPENDENT
HasIndication GenericAdmissionEvent2 0..* INDEPENDENT
IsInterpretationOf AllergyOrAdverseReactionEvent 0..* INDEPENDENT
HasInterpretation AllergyOrAdverseReactionPropensity 0..* INDEPENDENT
HasClinicalContext BodyHeightMeasurement 0..* DEPENDENT_OBJECT
HasClinicalContext BodyHeightObservation 0..* DEPENDENT_OBJECT
IsInterpretationOf DiagnosisName 0..* INDEPENDENT
HasClinicalContext GenericAssessment 0..* INDEPENDENT
HasClinicalContext GenericDischargeEvent 0..* INDEPENDENT
HasContext GenericDischargeEvent 0..* INDEPENDENT
HasIndication ProductOrSubstanceRelatedActivity2 0..* INDEPENDENT
HasParameterSetting ProductOrSubstanceRelatedActivity2 0..* INDEPENDENT
HasClinicalContext TemperatureMeasurement 0..* DEPENDENT_OBJECT
HasFindingCharacteristic GenericFindingObservation2 0..* INDEPENDENT

Item of ENTRY Domain Models

GenericAdmissionEvent2

Diagnosis

SubjectOfCareObservations

ProductOrSubstanceRelatedActivity2

Diagnosis

Reference Model Type

FINDING_OBSERVATION_ELEMENT