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.

Reference Model Abstract Class: OBSERVATION_ELEMENT

The OBSERVATION_ELEMENT class is a BOUND_DATA_ELEMENT whose coded meaning is constrained to represent a SNOMED CT finding situation or observable situation. Clinical findings are observations about a patient made by a Care Professional, patient, or a carer. Types of information represented by OBSERVATION_ELEMENT includes:

  • clinical observations,
  • clinical findings on examination,
  • investigation results,
  • decisions arrived at as a result of a synthesis of signs, symptoms, investigations (i.e. findings) and clinical knowledge,
  • findings resulting from formal assessment procedures such as whether a patient has been assessed under a section of the Mental Health Act,
  • administrative findings and
  • events.
The OBSERVATION_ELEMENT class is defined as abstract and therefore can only be instantiated only through one of its non-abstract specialisations.

Specializes

BOUND_DATA_ELEMENT