# Logical Record Architecture for Health and Social Care
## Discharge Summary Release 0.02

Contents
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: GenericFindingObservation
An ELEMENT to represent a generic clinical finding observation made by a Care Professional, patient, or carer with or without specific examination. This includes information provided by the patient or carer. A finding on examination can be the interpretation of a clinical examination of any sort1. 1 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
--- | --- | --- | ---
HasReason | GenericFindingObservation | 0..* | INDEPENDENT
HasAnnotation | Text | 0..* | INDEPENDENT
IsClinicalContextOf | GenericProblemAndIssue | 0..* | INDEPENDENT
HasFindingCharacteristic | GenericFindingObservation | 0..* | INDEPENDENT
HasClinicalContext | GenericFindingObservation | 0..* | INDEPENDENT
HasAssociation | GenericPropertyObservation | 0..* | INDEPENDENT
HasAssociation | GenericPropertyObservation2 | 0..* | INDEPENDENT
HasAssociation | RisksExpectationsOrGoals | 0..* | INDEPENDENT
HasAnnotation | Text | 0..* | INDEPENDENT
HasComplication | GenericFindingObservation | 0..* | INDEPENDENT
IsIndicationOf | GenericProcedure | 0..* | INDEPENDENT
IsIndicationOf | ProductOrSubstanceRelatedActivity | 0..* | INDEPENDENT
HasClinicalContext | TreatmentDevice | 0..* | INDEPENDENT
HasClinicalContext | GenericPropertyObservation | 0..* | INDEPENDENT
HasClinicalContext | GenericTreatment | 0..* | INDEPENDENT
IsDerivedObservation | GenericPropertyObservation | 0..* | INDEPENDENT
IsDerivedObservation | GenericPropertyObservation2 | 0..* | INDEPENDENT
HasInterpretation | DiagnosisName | 0..* | INDEPENDENT
Complicates | GenericProcedure | 0..* | INDEPENDENT
### Object of relationships
Name | Subject of relationship | Occurs | Dependency
--- | --- | --- | ---
HasClinicalContext | GenericAdmissionEvent | 0..* | INDEPENDENT
HasIndication | GenericAdmissionEvent | 0..* | INDEPENDENT
IsInterpretationOf | AllergyOrAdverseReactionEvent | 0..* | INDEPENDENT
HasInterpretation | AllergyOrAdverseReactionPropensity | 0..* | INDEPENDENT
HasClinicalContext | BloodPressureMeasurement | 0..* | DEPENDENT_OBJECT
HasParameterSetting | BloodPressureMeasurement | 0..* | DEPENDENT_OBJECT
HasClinicalContext | BloodPressureObservation | 0..* | DEPENDENT_OBJECT
HasClinicalContext | BodyHeightMeasurement | 0..* | DEPENDENT_OBJECT
HasClinicalContext | BodyHeightObservation | 0..* | DEPENDENT_OBJECT
HasClinicalContext | BodyWeightMeasurement | 0..* | DEPENDENT_OBJECT
HasClinicalContext | BodyWeightObservation | 0..* | DEPENDENT_OBJECT
IsInterpretationOf | DiagnosisName | 0..* | INDEPENDENT
HasReason | GenericAssessment | 0..* | INDEPENDENT
HasPart | GenericAssessment | 0..* | INDEPENDENT
HasClinicalContext | GenericAssessment | 0..* | INDEPENDENT
HasOutcome | GenericAssessment | 0..* | INDEPENDENT
HasClinicalContext | GenericDischargeEvent | 0..* | INDEPENDENT
HasContext | GenericDischargeEvent | 0..* | INDEPENDENT
HasFindingCharacteristic | GenericFindingObservation | 0..* | INDEPENDENT
HasIndication | GenericProcedure | 0..* | INDEPENDENT
IsComplicatedBy | GenericProcedure | 0..* | INDEPENDENT
IsAssociationOf | GenericProblemAndIssue | 0..* | INDEPENDENT
HasParameterSetting | ProductOrSubstanceRelatedActivity | 0..* | INDEPENDENT
HasIndication | GenericTreatment | 0..* | INDEPENDENT
HasOutcome | GenericTraining | 0..* | INDEPENDENT
HasComplication | GenericFindingObservation | 0..* | INDEPENDENT
HasClinicalContext | GenericFindingObservation | 0..* | INDEPENDENT
HasComplication | GenericTreatment | 0..* | INDEPENDENT
HasClinicalContext | TemperatureMeasurement | 0..* | DEPENDENT_OBJECT
HasReason | GenericFindingObservation | 0..* | INDEPENDENT
HasClinicalContext | TemperatureObservation | 0..* | DEPENDENT_OBJECT
IsAssociationOf | GenericPropertyObservation | 0..* | INDEPENDENT
HasOutcome | GenericTreatment | 0..* | INDEPENDENT
IsAssociationOf | RisksExpectationsOrGoals | 0..* | INDEPENDENT
IsDerivedObservation | GenericPropertyObservation | 0..* | DEPENDENT_SUBJECT
HasClinicalContext | GenericProblemAndIssue | 0..* | INDEPENDENT
HasIndication | ProductOrSubstanceRelatedActivity | 0..* | INDEPENDENT
## Item of ENTRY Domain Models ### GenericAdmissionEvent ### GenericFinding ### GenericProblemAndIssue ### GenericProcedure ### GenericProperty ### ProductOrSubstanceRelatedActivity ### AllergyOrAdverseReactionEvent ### AllergyOrAdverseReactionPropensity ### GenericDischargeEvent ### BloodPressure ### BodyHeight ### RisksExpectationsAndGoals ### BodyWeight ### Diagnosis ### GenericAssessment ### GenericTraining ### GenericTreatment ### Temperature ## Reference Model Type ## FINDING_OBSERVATION_ELEMENT