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= Introduction and overview =


== Background and Purpose of document ==

Discovery receives and hosts health related data and provides health data on request. This document describes the nature of some basic types of data. 
The data is described in conceptual terms in this document.  The layout and concept definitions in this document can be used to inform the content and format of the actual data held.  
It represents a conventional “data set style” approach to the structure of records within Discovery. The actual structure is conceptually specified using the Discovery information model language – OWL2
The scope of this document is limited to the data description. It does not cover the data format or the transmission mechanisms.
The document assumes the reader is familiar with the Discovery programme and the approaches to the Governance of the data and secure means of transmission. In as much as these issues affect data content, this will be described in the appropriate section. However, there are some significant issues in respect of IG that affect the breadth of the data as a whole. These are:
1.	The Discovery Data Service is hosting data on behalf of the trust and the trust retains control of the data.  The data processing agreement enables Discovery to receive personal sensitive data and therefore this is included.
2.	As a result of the above, identifiable data may be transmitted and patient consent is not required beyond the implied consent by the patient for publishers to hold data on their behalf. However, any data marked as especially confidential or private in the source system must also be marked as confidential or private when transmitted.
3.	IG requires that data should not be shared if the patient withdraws consent for their data to be shared. Different organisations and systems have different ways of representing consent (over and above confidential items) but if consent is captured it should be transmitted.

== Generic publisher system data requirements ==
Discovery is neutral as to the data format of data that is sent to it. It is also neutral as to the nature of properties (fields) or terminology subject to the following caveats:
1.	That the data submitted closely represents data as entered into the provider system by the user.
2.	That the provider system supports some kind of event based approach to modelling data e.g. an encounter or observation.
3.	That the provider system is able to generate deletion indicators as well as added data.
4.	That the data submitted is internally consistent, including any referential integrity.
5.	That the meaning of field names and values is either self-evident or documented.
6.	That patients, organisations and health professionals have a reliable internal identifier for tracking the data
7.	That patients will have been assigned NHS numbers within the publisher environment, or will be assigned NHS numbers  in the near future after initial transmission.
8.	That the data will be exported at no less frequency than once a day.
 

== General approach ==
The document is laid out using Word tables in order to provide some categorisation of the data items.  There is no requirement for actual tables or actual fields to be created in this way.
Within Discovery, health data is seen as a set of chronological entries (or items), each entry describing either an event that has occurred and has been recorded by a user or a device or a state described by the entry.
An event may be the observation of a characteristic of a person, or may be a care event, whether that process be an administrative process such a hospital admission, or a clinical process such as an operation.
A state is a statement about the patient that lasts over time. Examples are problems or medication authorisations
All events are characterised by a time (as a point in time or period), an entity responsible for the recording of the event (e.g. a professional, or organisation), the category of the event, and the relevant details of the attributes relating to the event. 
In addition, as data is likely to be received on an incremental basis, the transmission of an  event entry may result in a new entry in Discovery, change a previous entry, or delete an entry, thus there has to be a mechanism of matching an event entry to one sent previously.
Most events are related to a person acting as a service user. Throughout the document the word “patient” is used to represent a person who is a user of the service. It is accepted that within the services themselves, service users may be referred to as patients, clients, service users or other terms and the term used is configurable accordingly.
Events within the Discovery model can be categorised in a way consistent with the FHIR R4 standard set of resources e.g. categorisations of  procedure, observation, medication order, referral request, patient, practitioner. However, the description in this document simplifies the elements using non-technical language, flattens the structure, thus there is no requirement to be familiar with FHIR before reading this document. Cardinality is not documented in this document.
An assumption is made that the data actually produced may not match with a particular field description in this data set, or may map to a number of fields and entry types.   In many cases the field values in this data set may either be inferred or deduced during the Discovery inbound translation process. For example, in some cases dates and times may not be readily available and may need to be inferred. 
The data set in this document forms a major part of the structural part of the Discovery data model which, together with the semantic part, is a freely available model for use by the public domain.
The document uses an element of inheritance, which means that an entry type that inherits from another entry type includes the fields from that entry type. Therefore the fields that are inherited are not repeated in the tables for brevity.
Links represent associations between one entry type and another type either described elsewhere in the document or described in line in the link description.  This data set does not mandate a particular cardinality in respect of the links.
Field values are often labelled as “concepts”. This means that the field value will be treated as a referenceable concept for analysis in Discovery.  Concepts are powerful as they enable concept attributes to be modelled within the data  model thus supporting advanced analytics based around types (i.e. subsumption queries). Concepts may or may not be clinical and cover even simple field value sets.
The next section deals with the issues relating to transmission of information, moves on to fields that are common to many entry types (i.e. will be inherited) and then describes the particular entry types.
 
= Generic properties =
This section deals with properties that are common to many types of data. These elements may be incorporate into the data entities themselves or may be linked via entity relationships
== Transaction ==
When transmitting data from system A to system B, there needs to be a mechanism by which a data item transmitted may be related to the same data item previously transmitted. For example, one entry may supersede another, so there needs to be an indication as to whether an entry has been replaced or deleted. In addition, data items will need to be uniquely identified if linked to other items.  Use of IDs is essential to this process.
It is recognised that the facility is limited to certain publisher systems and the transaction may need to be deduced from data already present in the Discovery data service.
Transactions
Field	Description
Transaction type	Concept : Whether the entry is
a)	Add (i.e. a new entry)
b)	Edit (i.e. a change to a prior entry)
c)	Delete (i.e. the previous entry should be deleted)
In many cases the transaction type may be inferred as “add” e.g. a new observation of “edit” e.g. change to a date of birth.
Identifier	A field within a data item that uniquely identifies that item for a particular system and publisher.  Ideally a GUID but may be an internal system id or may not be available.
N.B The ID is also used to link related items (e.g. foreign keys)


== Provenance ==
Discovery tracks data throughout the pipeline including the receipt of the data and the transformation of the data.
Discovery also retains any provenance related information relating to the item as is was originally recorded in the publisher system, including any provenance information that the publisher may have.
Discovery itself, broadly speaking, follows the W3C PROV standard in that it records Entities, activities and agents.
However, a provenance “summary” is also provided and this records the following data
Provenance
Field	Description
Date and Time entry recorded	The data and time the entry was made into the publisher system. This may not be the same as the date and time the event took place and may be inferred from inbound data if not available
Recorded by	The person or device who recorded the entry. This may or may not be the same as the person responsible for the description of the event. E.g. may be a secretary recording a diagnosis made by a clinician.
Responsible practitioner	The person responsible for the entry, usually a professional health worker
Owning organisation	The organisation or service within an organisation responsible for the entry of the event data into the record. This may be a service or an organisation.
In Discovery this attribute is the attribute that is used for Data sharing agreements with the service acting as a publisher or subscriber. Services may be linked to other organisations to create a hierarchy or organisations or services.
Within Discovery, the service in this field is also linked to the Data controller organisation for the purposes of validation of publisher and subscriber services and the DSA.
This should be differentiated from a service or department as modelled within specialised entries such as encounters as these may have a number of granular organisations services or departments associated with a single encounter
Confidentiality Type	Concept : An indicator of the nature of confidentiality

== Health Event ==
A health event is an abstract class referring to any entity type that represents something that has happened, or may happen, at a point in time, or over a period.
It can be considered separate to a “state” in that the relevant date and time is of significance.

Provenance
Field	Description
Start date and time	The start date and time to which the event refers. It may be unknown, or imprecise (e.g. a year or month). It may be a point in time or a period of time (e.g. an encounter lasting 15 minutes) or a hospital encounter lasting several days
For events that take place over a period of time this refers to the start of the event
End date and time	Optionally, if recorded the end of the event


= Individuals organisations devices and locations =
Most entries are attributed to patients, professionals, their organisations or services, locations or devices. In Discovery there is an attempt to uniquely identify these from the information provided, ideally using standard identifiers but in some cases deducing from names and context. In many cases these may be deduced only at the level of the sending systems by the use of internal identifier matching.
== The patient or person demographic ==
Throughout the document the word “patient” is used to represent a person who is a user of the health or care service. (It is accepted that within the services themselves, service users may be referred to as patients, clients, service users or other terms)
This data covers the core demographics of the patient and their personal identifiers Whilst the table infers a one to one relationship, there is a one to many relationship between the patient and the related items in nearly all cases.  For example the patient may change gender, change name,  move home or acquire languages.
Note that in Discovery, a patient is considered as  person in a role of patient (or client) in relation to ONE publisher.
A person is identified as being linked to many patient demographic records. Thus a person is held independently of the patient resulting in a “master person” register
Patient  / Person
Field	Description
NHS Number	The NHS number allocated to the patient
Name	Name information and title for the patient. Ideally structured as “Family name”, “Given names” (in the correct order of presentation), “prefix” e.g. “Mr”, “Dr” and “suffix” e.g. “Junior”
Administrative Gender	Concept: The administrative Gender of the patient i.e. the gender that they consider themselves to be allocated to. May or not be the  genetic or phenotypic gender
Date of birth	Date of birth of the patient, as far as is known
Death indicator	If a patient has died an indicator that they are now dead
Date of Death	If dead and if available, the date of death
PDS sensitive	Flag to indicate whether the patient is marked as sensitive on the spine 
Linked items
Address	One or more entries including
•	Qualified by  Concept: address type (e.g. home address)
•	The address of the patient relevant to the episode of care.
•	Status of the address
•	The date the address was valid from
•	The date the address was valid to
Contact	potentially used in contacting the patient, each contact qualified by 
•	Concept : contact type e.g. home telephone, mobile, email 
•	Contact details e.g. email  address or telephone number about the patient
Ethnicity	Concept: Held in Discovery as an observation about the patient, indication as to the ethnic group the patient is part of
Language	Concept : Held in Discovery as an observation about the patient, and qualified by whether the patient speaks the language or is their preferred language. May be several entries as language characteristics change
Linked identifiers	Identifiers – qualified by identifier type
Linked relationships	Linked relations 

== The practitioner in role ==
This term refers to any person who provides care or is part of the health care process, excluding personally engaged or family carers.  
 A practitioner in role means a person providing care in the context of an organisation or service. The same person may have a number of roles across a number of organisations in which case it is expected that several entries may be created. This may be inferred by Discovery
Practitioner
Field	Description
Name	Name information and title for the practitioner. Ideally structured as “Family name”, “Given names” (in the correct order of presentation), “prefix” e.g. “Mr”, “Dr” and “suffix” e.g. “Junior”
Gender	Concept : The administrative Gender of the practitioner i.e. the gender that they consider themselves to be allocated to. May or not be the  genetic or phenotypic gender
Date of birth	Date of birth of the patient, as far as is known
Address	Qualified by concept : address type (e.g. work address)
The address of the practitioner relevant to the role
Active/ Inactive	An indication of whether the practitioner is active in the role or not
Service or organisation	The service or organisation that the practitioner is operating in relation to a particular role
Role type	Concept : The type of role e.g. Doctor, nurse, receptionist, secretary that the practitioner operates as in this role
Speciality	Concept: The speciality of the practitioner (e.g. Cardiologist) 
Contract period	Start and end dates of contract with the organisation
Linked items
Contact	potentially used in contacting the practitioner. Each contact qualified by 
Concept : contact type e.g. home telephone, mobile, email 
Contact details e.g. address or telephone number about the patient to be 
Identifiers	Identifiers qualified by identifier type and code

== Family and kin Relationships ==
Patients are related to other people via a variety of relationships, some of which may be genetic and others not. Relationships may also include carer relationships or next of kin.
Relationships (inherits attribution)
Field	Description
Related person information	Information about the target person which may include Name, address, contact details
Relationship type	Concept: Relationship with source. May be a family relationship e.g. Father and may be qualified by genetic relationship. May be a relationship such as a carer or next of kin.
Status	Status of relationship
Related in Discovery	Whether the related person is in Discovery or not
Links
Related patient	Target may be a person in the Discovery Data service


== Related person ==
A related person may not be a patient in the Discovery service in which case the details of that person would be held independently
Related person
Field	Description
Name	Name of related person
Address	Address of related person
Contact	Contact details of related person
Links
Family and kin relationships	Information about the patient and the relationship typ
Identifiers	Identifiers of the related person (e.g. NHS number)


== Device ==
In the context of Discovery a device is normally used to relate to the entry of a record or in relation to its use in a procedure or operation
Devices are categorised and full defined via the information model relationships. Thus each device represents an instance of a kind of device defined in the information model 
Device
Field	Description
Device Name	Device name
UDI human readable	Human readable bar code identifier
UDI machine readable	Machine readable bar code
Manufacturer	Manufacturer of device e.g. business organisation
Serial number	Serial number of device
Device type	Concept: for the nature of the device e.g. cardiac pacemaker
This may be at any level of granularity as the information model uses additional attributes to fully define the device
Device version	Version of the device (e.g. software version if the device is software)


== Organisations departments and services ==
In Discovery, these concepts are amalgamated into a single structure and the entities are differentiated via the category and the relationships with the other entities as described below. In many cases the relationships will be inferred by Discovery from the nature of the information transmitted. There is no expectation that publishers are required to populate the relationships.
Organisation or service
Field	Description
Organisation identifier	The nationally provided identifier or “ODS” code for the organisation or service if it exists
Name	Name of the organisation or service
Address	The address of the organisation or service
Contact details	Main contact for the service itself e.g. main telephone number
Organisation/ service category	Whether this is an organisation (e.g. Barts NHS Trust, Roya London Hospital) or a service e.g. Barts physiotherapy service or cardiology department
May be deduced when populating the organisational structures and relationships
Speciality	The speciality of the service e.g. Cardiology
Links
Linked Organisation	A set of relationships between one organisational service entity and another each consisting of
•	A relationship type such as “part of” or “provided by” e.g. Royal London Hospital is “part of”
•	A target organisation e.g. “Barts NHS Health Trust”
Used to populate the organisational structures in the information model
Contacts	Contact details for a person or team or department associated with the organisation consisting of
•	Name
•	Contact details
Location	Locations associated with the organisation
Identifiers	Other organisational identifiers


== Location ==
Information about an actual location, building or entity that is related to the organisation that operates from it  
Location
Field	Description
Location identifier	The nationally provided identifier for a location
Name	Name of the location
Address	The address of the organisation or service
Location Type	Concept: Describes the location in the context of its purpose e.g. a ward or Branch surgery, a mobile MRI scanning unit. Note that the service may hold the information about what the location is used for rather than the location 
Links
Organisation	A set of relationships between one organisational service and location consisting of
Contacts	Contact details for a person or team or department associated with the location e,g, building maintenance,  consisting of
•	Name
•	Contact details


== Team ==
Teams are named groups of individuals that are linked to one or more services

Team
Field	Description
Team name	Name of the team
Links
Organisation or services	The services or organisations this team reports to
Team members	Practitioners that are part of the team

 

= Health event subtypes =
This section covers events that describe various health or care events, most but not all relating to a patient.
== Patient event ==
A patient event is a subtype of care event relating to a patient and usually recorded in the context of an encounter, a section within an encounter, or as part of another event

Patient event (inherits health event)
Field	Description
Subject	The patient to whom this event relates.
Note that a patient is considered as an individual person in the role of patient with respect of the organisation.
There is no requirement to resolve common person identity in published data
Part of	An event that this event might be part of
Encounter	An encounter that this event might be part of
In section	The section of the encounter that this event is placed in
Part of problem	The problem which this event may be linked to

5	Care process related events
5.1	Episode of care
A care episode is an association between a patient and a healthcare provider during which time care is provided. The association implies that the provider has some responsibility for the provision of care during the period of time covered by the episode.
A care episode may be a concept that is explicitly stated. For example, GP registration is an explicit process by which the patient registers for care and in due course may be de-registered when they move elsewhere.
A care episode may otherwise be deduced from the data provided , usually relating to encounters.  For example the acceptance of a referral or the attendance at accident and emergency provide episode of care start points. Discharge from an outpatient clinical may be used to deduce the end of a care episode.

Care Episode (inherits patient event)
Field	Description
Nature or type of episode	A concept that describes the nature of the episode from a terminology set or ad-hoc information provided by publisher and mapped to a concept
May be inferred or derived from structured entry
For example, a GP regular GMS patient or a temporary resident
Status	Whether currently active (i.e. no end date) or inactive
Links
Initiating Referral	A Link to the originating referral, whether self-referred, ambulance, GP referral etc. 
May be inferred from encounter information e.g. referral accepted, emergency admission
Care episode Administration	One or more links to care episode or registration administration processes that occur during the period of the care episode
Linked Entries	All encounters and many other entries may be linked to the care episode
5.2	General practice registration
General practice does not consider their patients to be related to a particular episode of care. Thus a variation on care episode is designed for GP patients.
This deals with the administration of patient reception and registration in the context of General practice. This is particularly formal in respect of GP practice registration. 
General practice registration 
Field	Description
Status	Status of registration or care episode processing
e.g. registration submitted, notification of registration, deduction received, deducted 
Status sub-type	Granular subtypes of the status e.g. “death”, “embarkation” or “armed forces” when patient is deducted
Patient type	Type of patient from the perspective of administration e.g. GMS patient, temporary resident
5.3	Encounter
An encounter is an interaction between a patient and healthcare provider for the purpose of providing care, including assessment of care needs. Encounters are the mainstay of care provision and the concept covers encounters in any care domain. For example a GP consultation is an encounter and an in-patient stay is an encounter.
Encounters are often defined according to the publisher’s definition or even the nature of the IT system in use.
In Discovery an encounter model is a superset of the different encounter models from the different domains and systems. The different patterns are differentiated by the use of Encounter types or archetypes.
For example, a spell in hospital would be considered an encounter. The admission event is also considered an encounter, subsidiary to the spell encounter, as a discharge would be.
Similarly an accident and emergency attendance may have a subsidiary encounter for the initial assessment.
The additional properties relating to encounter types (e.g. method of admission, critical care function type) etc, are considered as non-core and are referenced via the information model concepts. Each property type has a concept and each value class is considered concept. Consequently these are not specified in this document but are available via the ontology.

Encounter:  (inherits patient event)
Field	Description
Encounter Type	The overall nature of the encounter mapped to the encounter type ontology
Completion Status	Concept: Status of encounter when this event is sent. It may be completed or ongoing or planne.  In some systems encounters are created before they commence
End Date/ time	Date time encounter ended
Duration	In the absence of an explicit start and end time, the duration may be estimated
Providing Organisation/ services or departments	Additional department and/ or services that define the encounter more fully than the main organisation
An entry may have a main organisation of Royal London, but the encounter may take place in the Royal London A&E department
Location	Actual location of the encounter e.g. a physical building, wing , ward, or room or bed  In most cases this may not be known (as the organisation itself implies a location)
For example a branch surgery of a GP practice or bed 1, Ward 10 
Links
Linked appointment	The appointment to which the encounter may be related
Subsidiary of 	An encounter that the encounter may be part of or sub
Linked care episode	The care episode the encounter is linked to.
Additional Practitioners	Additional practitioners other than the main attributed practitioner involved in the encounter

5.4	Context Headings or sections in encounters
A heading is grouping construct that segregates clinical entries within an encounter, episode or a document such as a care plan for establishing human inferred context. Their presence is primarily for the purpose of display and context inference and represent the headings entered via a clinical or care planning system e.g. a form template or consultation.
As a heading is a simple text structure label there is no requirement for attribution as it is assumed that attribution is shared with the parent encounter
Section
Field	Description
Heading type	Concept: for the heading
e.g.
Clinician entry/ Examination/ CVS Examination
CDS Entry/ Primary Diagnosis
Clinician entry/ Past procedures
Parent heading	Link to the parent heading
Order	Order of heading in relation to its parent for display purposes
Linked encounter	The encounter that contains the heading
 
5.5	Referral Request or procedure request
A referral request or (procedure request)  includes request for advice or invitation to participate in care and is not limited to conventional referrals. A referral request often precedes the encounter or care transfer that occurs subsequently. Furthermore a referral request may accompany a care transfer e.g. a request for input from a community health professional during the discharge process. The referral type is considered as the core observation concept 
Referral inherits attribution
Referral request  : inherits patient event
Field	Description
Priority	Concept: Priority of referral request
Referred by type	Concept: The type of source the transfer originated as e.g. self referral, healthcare professional referral
Source organisation	Sender service or organisation
Speciality requested	Concept: the speciality of the referral request
Procedure or Service type requested	Concept: If available, the nature of the service requested e.g. Nephrology, chest xray
Request Reason	e.g. The clinical condition or problem that is reason for referral
Recipient service or organisation	The referral recipient organisation or service e.g. hospital or department
Recipient location	Location of the recipient
Recipient practitioner	If referred to a person, the practitioner
Referral UBRN	Unique referral booking number
Referral mode	Concept: Means of referral e.g. Verbal, written, ERS
Links
Linked episode 	Linked care episode for which this is the originating referrals

 

5.6	Appointment session
An appointment session is an appointment grouping implying a session or a clinic, which incorporates a number of appointments
In the Discovery model, all appointments are linked to a schedule (whether a schedule pre-authored or not) i.e. a standalone appointment would have one schedule for the stand alone appointment
Appointment schedule : inherits attribution
Field	Description
Organisation or service	Organisation or service responsible for this schedule
Location	Location for the schedule
Schedule type	Concept: for the type of schedule e.g. diabetic review
Schedule description	Textual description of the schedule e.g. Dr Jone’s acupuncture clinic
Speciality	Speciality associated with the schedule
Start date/ time	Planned start date/ time of schedule
End date/time	End date time of schedule
Links
Linked appointment slots	Linked appointments to the schedule
Practitioners	Practitioners linked to this schedule

5.7	Appointment
This is information about a particular appointment or slot as planned. The slot creation shares attribution with the schedule
Appointment 
Field	Description
Appointment category	Concept: describing what type of appointment in terms of routine, urgent etc
Planned Reason	Concept: of reason for appointment from the appointment planning perspective 
Description	Any text description for the appointment slot
Start time	Start date and time of slot
End time	End date and time of slot
Planned duration	Planned duration of appointment (may or may not be timed)
Patient	Patient booked into the slot
Slot booking status	Whether booked, reserved, free
Attendance status	Whether the patient arrived, sent for, left
Booking urgency	Indication as to whether it was booked as an urgent appointment (whether the appointment was marked as urgent or not
Interaction type	Whether face to face, telephone, skype etc
Links
Linked schedule	Links to the schedule containing the appointment
Booking history
	Links to booking history including
Booked :cancelled
Date and Time of booking
Attendance history	Links to the attendance status history

 

5.8	Appointment booking history
Information about booking and unbooking of an actual appointment prior to the patient attending
Date and time of booking  and by whom are attributed in attribution fields.
The latest entry represents the information prior to the patient arriving or appointment attendance
Appointment booking: inherits attribution
Field	Description
Booking or cancellation	Whether this is a booking or a cancellation
Patient	Patient booked into slot
Booking urgency	Whether the appointment was urgent (whether or not reserved as an urgent slot)
Patient related reason	Reason for appointment from patient’s perspective (i.e. if booked)
Interaction type	The actual interaction type when booked (e.g. telephone)
Links
Appointment slot	Link to the appointment slot

5.9	Appointment attendance history
Historical Information about an actual attendance for a patient for an appointment i.e. after the patient has arrived for appointment
Appointment attendance history
Field	Description
Status	Concept: the status e.g. 
Patient	Patient
start time	The actual start time of this status
end time	The actual end time of this status
Actual duration	The actual duration of the appointment
Actual interaction type	Nature of the actual interaction
Links
Appointment slot	Links to the appointment slot

 

5.10	Care plan
In the context of Discovery a care plan is a relatively simple data subset of a complex document structure for the purposes of tracking and analysis.  There is no attempt to precisely define a care plan beyond the simple data items listed here
Care plan  : inherits attribution
Field	Description
Document Status	Whether the plan is draft, active, no longer active
Type of plan	Concept: for the type of care plan. For example, Asthma action plan, Cancer management plan
Description	Description of plan
Time period	The start and end date or period of the plan (the start date may precede the effective date)
Linked Headings	Heading categorised, Activities, goals targets, observations linked to the plan
Linked episodes	Care episodes linked to the plan
Parent plan	Care plans this plan is part of
Associated practitioners	Additional practitioners or teams associated with the plan
Associated teams	Links to teams associated with plan 
Linked activities	Links to care activities
 

Care plan activities
These are modelled as observation types such as 
•	Activity
•	Goal
•	Target
 


6	Clinical health events
This section covers data about the patient that is generally considered “clinical” either observed characteristics of the patient or clinical procedures or measurements that have been carried out.
In the Discovery model clinical data is modelled around observations i.e. different types of clinical characteristics inherit from simple observations.
Care records are usually structured according to a series of sections or “headings” a standard having been established by the PRSB. This enables records to be viewed as documents although the headings have no inherent meaning in themselves.
6.1	Observation
An observation is considered a type of health event that records some characteristic of the patient or some procedure performed on the patient, excluding the specialised events such as medication.
An observation in Discovery is much broader than an observation in FHIR. Because observations may be highly specialised, like encounters, only the generic properties are illustrated in this document. 
The type of observation is deduced from the observation concept itself. 
Observations may be linked at any level of nesting. In particular, tests and concept results observations are considered as 2 separate  but linked observations, one for the test, the other for the result. This varies the Discovery observation model from the FHIR model that includes both test and result in the same observation.
For example, a blood pressure would be modelled as 3 observations as follows:
Observation 1	Blood pressure
Observation 2	Systolic blood pressure value= 120, part of observation 1
Observation 3	Diastolic blood pressure value= 80, part of observation 2

6.2	Simple observation
A simple observation is the root for most clinical entries about a patient, ranging from a piece of text or codeable concept including an advanced Snomed expression. Observations may be specialised by purpose (e.g. observation, target, goal, aim, Various specialised observations such as allergies, numeric values, family history, immunisations, reports, documents and referrals extend the simple observation mode 
Observations can be standalone or exist within a collection of observations with a parent observation
Simple Observation : inherits patient event
Field	Description
Observation type	Concept: Nature of the observation, including whether this is a sub-type entry (described elsewhere)  or categorisation within the observation type itself e.g. sign, symptom, aim, target, goal , test header, or specialist type e.g. blood pressure. Equivalent to an archetype
It is inferred by the code within the observation, however it is modelled separately as it drives business logic
Prompt	Text representing a prompt on a form to which the observation represents the nature of the response to the prompt
This should not be confused with a parent observation such as a test order which has this observation as a test result,
Description	Text entry for the observation
Is problem	Whether the observation is part of the problem definition
Problem episode	Concept: Whether the observation is new or a review of a problem or other specialist episode e.g. flare, evolved from
Normality	A flag indicating whether the observation is marked as abormal (e.g. ABN, HI,LOQ)
Links
Linked problems	The problems the observation may be linked to including
•	Concept : Nature of link e.g. evolved from
•	Problem 
Flag	Any flags associated with the entry


6.2.1	Numeric observation
One of the commonest observations are pathology results and they often have numeric values as results. They extend simple observations
Numeric Observation : inherits simple observation
Field	Description
Operator	Operator associated with the value e.g. < or > or =
Value	Numeric value of result 
Range (s)	List of qualified range each consisting of
•	Range qualifier (e.g. normal, normal for males)
•	Lower limit
•	Upper limit
Units	Concept : Units of measurements


6.2.2	Date time observation
A less common observation is one where the result value is a date.
Numeric Observation : inherits simple observation
Field	Description
Result date	Date time of the observation eg. Expected date of delivery or date of last period.


6.2.3	Procedure
Procedure provides more information  beyond a simple observation about an operation or observation relating to the outcome of the procedure.
Within Discovery, unlike FHIR a complex procedure description (that includes body site, laterality, method and nature of device)  is represented by a Snomed expression in the observation concept. 
Procedure: inherits simple observation
Field	Description
Performed period	Period of time the procedure took
End time	Date and Time procedure ended 
Outcome	Concept: Outcome of procedure
Links
Complications	Links  to complication observation entries
Follow ups	Links to care plan follow up entries
Linked problems	Links to the observation reasons for procedure
Devices used	List of devices used in the procedure qualified by “main device” or “used device”

 

6.2.4	Allergy, intolerance and adverse reaction
Allergies, intolerances and adverse substance reactions are grouped together and are extensions of simple observations whereby the simple observation code includes the full concept of the allergy e.g. “allergy to penicillin”
The additional data relates to more specific information about the substance and reaction.

Allergy : inherits simple observation
Field	Description
Status	Whether active or inactive
End date	Date allergy became inactive
Substance	Concept: indicating the substance that created the adverse reaction or allergy
Manifestation	Concept: indicating the nature of the reaction e.g. rash, anaphylactic shock
Manifestation description	More detail about the manifestation 
Severity	Severity of the reaction or allergy
Links
Observations	Observations associated with the allergic reaction

6.2.5	Immunisation
Immunisation extends a simple observation by providing more information about the immunisation procedure and vaccine used.
This is a summary of immunisation, (expected to be extended)
Immunisation : inherits simple observation
Field	Description
	
Manufacturer	Manufacturer of vaccine
Batch number	Batch number of vaccine
Expiry date	Expiry data of vaccine
Vaccine product	Concept: of the actual vaccine product
Dose sequence	Number within a sequence (may be deduced)
Doses required	Number of recommended doses in series
Links
Reaction	Link to observation describing reaction to immunisation

 

6.3	Problem
Problem is a patient and record management construct designed to help manage care. The main purposes of problem structures are to highlight significant issues and to group entries in the record to enable a narrative view categorised by a focus of care. In different care domains different terms are used such as “problem”, “issue” or “need” but from a structural perspective they are the same.
A problem is always associated with at least one observation and therefore automatically shares its attribution.
Problem
Field	Description
Problem type	Concept: for the term that the healthcare worker assigns to this construct e.g. Problem. Issue, need
Status	Terminological construct for the status, whether active inactive, dormant
End Date Time	Date and time problem ended
Significance	Significance assigned to the problem by a user. May be inferred from a knowledge base
Anticipated duration	Whether likely to be temporary permanent, or  duration
Links
Parent problem	A problem that this is a child of
Defining observations
	Observations that form the title of the problem
Linked entries	Entries in the care record linked to this problem, e.g. encounters, observations`

 

6.4	Medication statement
Medication statement entries are templates for describing and authorising a course of medication or an intention to prescribe. Medication entries are precursors to the prescribing of a drug (medication order), dispensing of a drug (e.g. chemist) or the administration of a drug (e.g. medicine administration by nurse).
In General practice, acute prescriptions are based on medication entries with a single authorisation and repeat medications are based on medication entries with multiple authorisations. In hospital, the drug chart contains the medications.
Medication statement: inherits patient event
Field	Description
Status	Whether active or past (inactive)
Medication	Concept: for the drug or appliance.
This may be an actual medicinal product, a virtual medicinal product or a virtual therapeutic moiety
Dosage	May be a free text dosage (one three times a day, or a structured dose concept including:
•	administration times  e.g. 10 am 6 pm)
Either
•	administration quantity e.g. 2
•	administration units e.g. capsules
And.or
•	drug quantity per administration e.g. 250
•	drug quantity units e.g. mg 
                          
Order Quantity – number of units	Quantity and units For the ensuing prescription order Number of tablets or capsules for the course e.g. 28, 1 
Course type	Whether a repeat, acute , automatic repeat, repeat dispensing
Number repeats authorised	Number of prescriptions authorised as a repeat before medication review required e.g. 6
Medication review	Review date for this particular medication
Prescription duration	Anticipated Duration of each prescription e.g. 28
Prescription duration units	Duration units for prescription e.g. days
Additional instructions	Additional instructions to the patient
Pharmacy instructions	Additional instructions to the pharmacist
Order in heading	Order within the heading in encounter
Management authority	Nature of the domain organisation that manages the administration of this medication e.g. hospital only
Originated by	Domain type that originated this medication e.g. Hospital
Reason for ending	Textual or concept reason the medication was ended 
End date time	Date and time medication was ended
Links

 

6.5	Medication order
A medication order is the actual prescription for a medication item. It represents the instance of the order derived from the medication statement. It inherits MOST fields from medication and has some additional items. However, field values for the order may be different from the field values of the medication statement so they are repeated for clarity
Medication order : inherits patient event
Field	Description
Heading	Context heading for entry
Status	Whether active or past (inactive)
Medication	Concept: for the drug or appliance.
This may be an actual medicinal product (e.g. Ventolin HFA 200 mcg inhaler), a virtual medicinal product (e.g. a generic - salbutamol 200 mg inhaler) or a virtual therapeutic moiety (e.g. salbutamol 200 mg inhalation)
Dosage	May be a free text dosage (one three times a day)
or a structured dose concept including:
•	administration times  e.g. 10 am 6 pm)
Either
•	administration quantity e.g. 2
•	administration units e.g. capsules
And.or
•	drug quantity per administration e.g. 250
•	drug quantity units e.g. mg 
                          
Order Quantity – number of units	For the ensuing prescription order Number of tablets or capsules for the course e.g. 28, 1
Order Quantity- units	Unit concept for course e.g.  (28)- capsules, (1) inhaler
Course type	Whether a repeat, acute , automatic repeat, repeat dispensing
Number from authorised count	Number of the prescription as compared to the authorised number in the linked medication (e.g. 2/6)
Prescription duration	Anticipated Duration of each prescription e.g. 28
Prescription duration units	Duration units for prescription e.g. days
Additional instructions	Additional instructions to the patient
Pharmacy instructions	Additional instructions to the pharmacist
Order in heading	Order within the heading in encounter if noted in the encounter
Links

6.6	Document
Used to provide the content of a document A medication order is the actual prescription for a medication item. It represents the instance of the order derived from the medication statement. It inherits MOST fields from medication and has some additional items. However, field values for the order may be different from the field values of the medication statement so they are repeated for clarity
Medication : inherits attribution
Field	Description
Document Type	Concept or Text: Type of document
Document content	Text representation of content
Links
Encounter	Encounter linked to this observation
Heading	The heading in which the observation took place
Linked medication	Links to medication that was used as the template


6.7	Flag
A flag is a warning or notification of some sort presented to the user - who may be a clinician or some other person involve in patient care. It usually represents something of sufficient significance to be warrant a special display of some sort - rather than just a note in an entry
Flag
Field	Description
Status	Status of flag (active, inactive)
Flag category	Concept: Nature of flag for example
•	Flags related to the subject's dietary needs.
•	Flags related to the patient's medications.
Used in business logic to determine when the flag is displayed
Flag type	Concept: to describe the flag e.g.
Do not stop taking this medication without professional advice
Text	Alert text
Links
Linked entry	Entry to which the alert relates