Definition

The CareRecord_Observation extract provides a comprehensive record of coded clinical observations recorded in EMIS Web. It captures the broadest category of clinical entries — including diagnoses, test results, procedures, vital signs, family history, and template-based data — and forms the backbone of a patient’s longitudinal care record within the IM1 extract.

Information

The CareRecord_Observation extract contains all clinical observations associated with patients within the agreement scope. Each observation is linked to a clinical code, a consultation, the responsible and entering clinicians, and the organisation. From schema version 8.0 onwards, the model includes enriched fields for numeric measurements, qualifiers, episodicity, and abnormality flags. Version 8.0 also reintroduced associatedtext following its temporary removal for Information Governance review.

Each observation is uniquely identified by observationguid within the agreement scope.

Key Identifiers

• observationguid: The unique EMIS identifier for this observation.
• patientguid: References the patient in Admin_Patient.
• organisationguid: References the practice in Admin_Organisation.
• clinicianuserinroleguid: References the clinician who recorded the observation.
• enteredbyuserinroleguid: References the staff member who entered the record.
• codeid: References the clinical code in Coding_ClinicalCode.
• consultationguid: References the parent consultation in CareRecord_Consultation.
• parentobservationguid: References a parent observation (for hierarchical coded entries).

Clinical Dates

• effectivedate: The clinical date of the observation.
• effectivedateprecision: The precision of the effective date.
• entereddate, enteredtime: When the observation was entered into EMIS.

Numeric Measurements

• numericvalue: The numeric value of the observation (e.g., blood pressure reading, test result).
• numericunit: The unit of measure for the value.
• numericrangelow, numericrangehigh: Reference range bounds.
• numericoperator: The comparison operator for the numeric value (e.g., >, <, =).

Clinical Context

• associatedtext: Free-text narrative associated with the observation.
• qualifiers: Qualifier codes providing additional clinical context.
• abnormal, abnormalreason: Flags and description for abnormal results.
• episodicity: Indicates whether this is a first occurrence, review, or update of the clinical condition.
• originalterm: The clinical term as originally recorded by the clinician (added in schema v8.3).

Practical Use

flowchart TB
  subgraph container["Data Collection"]
    n1["Clinical Code"]
    n2["Observation Date & Value"]
    n3["Episodicity & Context"]
  end

  n17["Organisation 1"] --> n7
  n17["Organisation 1"] --> n5
  n18["Organisation 2"] --> n6
  n18["Organisation 2"] --> n8
  n18["Organisation 2"] --> n4

  n7["Patient 123"] --> container
  n5["Patient 98"] --> container
  n6["Patient 456"] --> container
  n4["Patient 20"] --> container
  n8["Patient 47"] --> container

  container --> n16["Gather observation data"]
  n16 --> n14["ETL"]
  n14 --> n15["CareRecord_Observation Model"]

  n7:::rect
  n5:::rect
  n6:::rect
  n4:::rect
  n8:::rect