Transfer of Care R4 Hackathon Implementation Guide

This guidance is under active development by NHS England and content may be added or updated on a regular basis.

What is a Coded Clinical Structure?

A coded clinical structure is a FHIR Resource or a number of resources populated with the elements required to define a discreet clinical concept or group of concepts, for example an allergy or a list of allergies. The coded structure will be referenced from a document section and may also reference another coded clinical structure or structures.

Medication List

Overview

This section details the design approach using FHIR Resources to support the PRSB heading model for medication and devices.

Medication Snapshot

The medication list is a “Snapshot” of the medication at a point in time (for example on discharge from hospital). It is not a master list of the patient’s medications. Other lists of medications for the patient may exist on other systems. For Transfer of Care Documents there will a potentially be two lists one for active medication and one for discontinued medication. There are two entries in the FHIR Composition.section.text element:

  • medication item entries which map to the Medication Statements in the active list
  • Medication discontinued entries which map to the Medication Statements in the discontinued list

Resources Used for Profile Design

The FHIR Resources are profiled to create the medication list as below:

  • UKCore-List - A UK Core Profile for recording a snapshot of the list of Medications for the patient.
  • UKCore-MedicationStatement - A UK Core Profile for medication statements. The MedicationStatement Resource is a record of a medication that is being consumed by a patient.
  • UKCore-Medication - A UK Core Profile for medication. The Medication Resource is primarily used for the identification and definition of a medication.
  • UKCore-MedicationDispense - A UK Core Profile derived from the MedicationDispense Profile. Indicates that a medication product is to be or has been dispensed for a named person/patient. This includes a description of the medication product (supply) provided and the instructions for administering the medication.

List

This Resource acts as a container for the medication items. The following is an example of the elements which can be used:

  • identifier - uniquely identifies this list of medication (UUID)
  • code - the type of list (SNOMED CT concept for "active medication" or "discontinued medication")
  • status - should only be "current"
  • mode - should only be "snapshot"
  • title - descriptive name for the list
  • subject - a reference to the patient whose medication list this is
  • encounter - a reference to the context in which the list was created (the inpatient stay)
  • date - when the list was prepared
  • source - who or what defined the list
  • entry - a reference to the MedicationStatement Resource entry or entries
  • flag - MUST NOT be used for Transfer of Care
  • emptyReason - MUST NOT be used for Transfer of Care if list is empty do not send a List.

MedicationStatement

A record of a medication that is being consumed or has been consumed by a patient. The following is an example of the elements that can be used:

  • identifier - uniquely identifies this medication statement (UUID)
  • clinicalStatus - should always be active
  • category - should be inpatient
  • partOf - A reference to the MedicationDispense Resource used to carry the quantity that was dispensed (for example TTO after a hospital provider spell)
  • medication - the medication coded (a SNOMED CT Concept that identifies this medication), this is done by reference to the Medication Resource which details the medication.
  • effective - the date/time or interval when the medication was taken
  • dateAsserted - When the statement was asserted defaults to composition date
  • informationSource - Person or organization that provided the information about the taking of this medication, assumed to be composition author
  • reasonCode - Reason for why the medication is being/was taken
  • subject - The Patient
  • reasonReference - a reference to the Condition Resource that supports why the medication is being/was taken
  • medicationReference - a reference to the Medication Resource
  • dosage - Details of how medication is/was taken or should be taken

Medication

The Medication Resource allows for medications to be characterized by the form of the drug and the ingredient (or ingredients), as well as how it is packaged. The medication will include the ingredient(s) and their strength(s) and the package can include the amount (for example, number of tablets, volume, etc.) that is contained in a particular container (for example, 100 capsules of Amoxicillin 500mg per bottle). The following is an example of the elements that can be used:

  • code - a SNOMED CT Concept that identifies this medication
  • form - powder, tablets, capsule etc SNOMED CT form concepts

MedicationDispense

The main purpose of the MedicationDispense resource is for Medication that is to record the amount of medication which has supplied to the patient. For example TTOs(to take outs). The following is an example of the elements can be used:

  • identifier - uniquely identifies this medication dispense (UUID)
  • status - for ToC should always be completed
  • category - inpatient or outpatient
  • medication - a reference to the medication which was dispensed
  • subject - a reference to the patient
  • performer - who / what dispensed the medication
  • quantity - How much was dispensed

How the Medication List is Constructed

The medication record is constructed as two lists. The diagram below shows the Resources used and the relationship between the Resources.

medication_basic_structure

MedicationStatement Resource

This section gives guidance of the use of the MedicationStatement Resource. Sending Systems should send as much details as they can.

MedicationStatement.partOf

This uses a reference to the MedicationDispense.quantity to indicate the amount of medication that was dispensed, for example TTO after a hospital provider spell.

MedicationStatement.dosage.route

Constraint: NHS e-Prescribing route of administration subset refset 999000051000001100. The route can be any route, and not constrained to a dm+d route for the medication. Separate products are different MedicationStatements in Primary Care if the same product have multiple route options then the routes go in the FHIR element MedicationStatement.dosage.text. When using routes outside the stated ValueSet, then use FHIR element MedicationStatement.dosage.text.

MedicationStatement.dosage.site

Constraint: As per the FHIR ValueSet approach-site-codes. Site may have similar content as Route - There may be some overlap with Route (e.g. intra ocular left eye). If no code, then use the FHIR element MedicationStatement.dosage.text

MedicationStatement.dosage##

This SHALL be used in Transfer of Care, carry in the FHIR element MedicationStatement.dosage

Use of structured Dosage SHALL conform to guidance for the Dosage element in Implementation guide for digital medicines

MedicationStatement.dosage.text

A single plain text phrase describing the entire medication dosage and administration directions, including dose quantity and medication frequency. e.g. "1 tablet at night" or "20mg at 10pm" This is the form of dosage direction text normally available from UK GP systems.

MedicationStatement.effective[x].effectivePeriod

If available may be carried in the FHIR element MedicationStatement.effective[x].effectivePeriod.

MedicationStatement.dosage.patientInstruction

Specific patient instruction may use MedicationStatement.dosage.patientInstruction

MedicationStatement.status

The FHIR element MedicationStatement.status is fixed to "active" for active medication lists and "stopped" for discontinued medication lists.

MedicationStatement.reasonCode

MUST NOT be used in Transfer of Care.

MedicationStatement.effectiveDateTime

Used to indicate when the medication was discontinued or became active.

MedicationStatement.category

This FHIR element should carried the value "inpatient" for Discharge Documents and "outpatient" for Outpatient Letters.

MedicationStatement.taken

This FHIR element should contain a value from the FHIR ValueSet medication-statement-taken to indicate whether the patient has taken the medication. For Transfer of Care the default is unk - unknown or if a value is not applicable then na - not applicable.

Medication Resource

This section gives guidance of the use of the Medication Resource

medication.code

This FHIR element is mapped to the PRSB medication name

constraint: MedicationName. Any AMP/VMP/VTM/AMPP/VMPP subsets from the dm+d terminology.

VTM NHS dm+d virtual therapeutic moiety (DD4C) 999000581000001102
VMP NHS dm+d virtual medicinal product (DD4C) 999000561000001109
VMPP NHS dm+d virtual medicinal product pack (DD4C) 999000571000001104
AMP NHS dm+d actual medicinal product (DD4C) 999000541000001108
AMPP NHS dm+d actual medicinal product pack (DD4C) 999000551000001106

The above as a SNOMED CT expression.

(^999000581000001102
OR ^999000561000001109
OR ^999000571000001104
OR ^999000541000001108
OR ^999000551000001106)
OR with preferred terms
(^999000541000001108 |National Health Service dictionary of medicines and devices actual medicinal product simple reference set|
OR ^999000551000001106 |National Health Service dictionary of medicines and devices actual medicinal product pack simple reference set|
OR ^999000561000001109 |National Health Service dictionary of medicines and devices virtual medicinal product simple reference set|
OR ^999000571000001104 |National Health Service dictionary of medicines and devices virtual medicinal product pack simple reference set|
OR ^999000581000001102 |National Health Service dictionary of medicines and devices virtual therapeutic moiety simple reference set|)

medication.form

This form is on the medication profile. Where VTM has form specified (coded) it goes here. AMP & VMP don't need separate Form (it is optional to populate). For VTM the form could be in MedicationStatement.dosage.text (as it would be part of a dosage string) i.e. not a separately specified code.

Constraint: DrugDoseForm. SNOMED CT CfH DoseForm termset. Constraint binding: [SNOMED CT]subset=CfH DoseForm (refset 999000781000001107)

The above as a SNOMED CT expression

^999000781000001107 |NHS dm+d (dictionary of medicines and devices) dose form simple reference set|

MedicationDispense Resource

This Resource provides details of medication that has been dispensed to the patient, for example TTO(To Take Outs). For Transfer of Care only a small subset of the elements should be used.

status

This should contain the value "completed".

category

This should the value "inpatient" or "outpatient" as appropriate.

quantity

This is mandated when the dispense resource is used. The FHIR element Extension-CareConnect-MedicationQuantityText-1 is used to carry the amount dispensed as a text string. Where supported the quantity may be structured, but there is no guidance at this time.

performer

Who dispensed the medication if available to the sender.

References

The references to the following must be carried:

  • medication
  • subject (patient)
  • context (encounter)

Medication List Examples

The Active List

The Active MedicationStatement

Note: example only shows one item in the list.

The Active Medication.

Note: example only shows one item in the list.

Medication Dispense

Discontinued List

The Discontinued MedicationStatement

Note: example only shows one item in the list.

The Discontinued Medication

Note: example only shows one item in the list.

Allergy List

Overview

This section details the design approach using FHIR Resources to support the PRSB heading model for allergies. It is important to distinguish between two kinds of allergic reaction / adverse reaction entry in the medical record.

Allergic Response or Adverse Reaction Event and Propensity

  1. Recording an Allergic Response or Adverse Reaction to an item of medication or a substance
  2. Recording a clinician’s opinion about future risk of (or propensity to) an Allergy or other Adverse Reaction if the patient is exposed to a substance.

Transfer of Care only records the first type of Allergic Response or Adverse Reaction i.e. the allergic event not the propensity.

Resources Used for Profile Design

The FHIR Resources are profiled to create the allergy list as below:

  • UKCore-List - An NHS Digital Profile derived from the CareConnect Profile for recording a snapshot of the list of Allergies for the patient.
  • UKCore-AllergyIntolerance - A NHS Digital Profile derived from the CareConnect Profile for Allergies and adverse reactions. The AllergyIntolerance Resource records risk of harmful or undesirable, physiological response which is unique to an individual and associated with exposure to a substance.

List

This Resource acts as a container for the allergies. The following is an example of the main elements used:

  • identifier - uniquely identifies this list of allergies (UUIDs)
  • code - the type of list (for example SNOMED CT concept for "ended allergy")
  • status - should always be "current"
  • mode - should always be "snapshot"
  • subject - a reference to the patient whose allergy list this is
  • Encounter - a reference to the context in which the list was created (the inpatient stay)
  • date - when the list was prepared
  • source - who or what defined the list
  • entry - a reference to the allergyIntolerance Resource entry

AllergyIntolerance

This Resource details the actual allergy or adverse reaction. The following is an example of the main elements used:

  • identifier - uniquely identifies this allergy or adverse reaction (UUID)
  • clinicalStatus - should always be active
  • category - whether the allergy or adverse reaction is to food, medication etc
  • criticality - low, high, unable-to-assess etc.
  • code - identifies the allergy
  • patient - a reference to the patient
  • assertedDate - date record was believed accurate
  • asserter - the source of the information about the allergy (patient, related person, practitioner)
  • lastOccurrence - when it last occurred if known
  • reaction - details of the reaction

Causative Agents

Guidance of the use of SNOMED CT for causative agents is as follows

Everything from the Product (373873005|Pharmaceutical/biologic product(product)|) hierarchy and everything from the substance (105590001|substance|) hierarchy.

For pre-coordinated allergy terms use a degrade code - see below:

Degrade codes (196461000000101|transfer-degraded drug allergy(record artifact)|&196471000000108|transfer-degraded non-drug allergy(record artifact)|) can be used if only a text representation of the allergy is known & pre coordinated allergy codes (for example 213020009|egg protein allergy|).

As a SNOMED CT expression

(<<105590001 |Substance|
(OR <<373873005 |Pharmaceutical / biologic product|
(OR <<716186003 |No known allergy|
(OR 196461000000101 |Transfer-degraded drug allergy|
(OR 196471000000108 |Transfer-degraded non-drug allergy|)
(^999000801000001108 |Allergy Archetypes Drug Groups simple reference set|
OR ^999000631000001100|National Health Service dictionary of medicines and devices trade family simple reference set|
OR ^999000641000001107|National Health Service dictionary of medicines and devices trade family group simple reference set|
OR ^999000771000001105|National Health Service dictionary of medicines and devices combination drug virtual therapeutic moiety simple reference set|
OR ^999000561000001109|National Health Service dictionary of medicines and devices virtual medicinal product simple reference set|
OR ^999000541000001108|National Health Service dictionary of medicines and devices actual medicinal product simple reference set|
OR ^999000791000001109|NHS dm+d (dictionary of medicines and devices) ingredient simple reference set|
OR <<716186003 |No known allergy|
OR 196461000000101 |Transfer-degraded drug allergy|
OR 196471000000108 |Transfer-degraded non-drug allergy|)

Severity

PRSB valueSet applicable for severity is as folllows:

Mild [The reaction was mild.][SNOMED-CT::255604002] (Mild (qualifiervalue))
Moderate [The reaction was moderate.][SNOMED-CT::6736007] (Moderate (severity modifier) (qualifier value))
Severe [The reaction was severe.][SNOMED-CT::24484000] (Severe (severity modifier) (qualifier value))
Life threatening [The reaction was life-threatening.][SNOMED-CT::442452003] (Life threatening severity (qualifier value))
Fatal [The reaction was fatal.][SNOMED-CT::399166001] (Fatal (qualifier value))
Important note: reaction.severity is a required terminology binding in FHIR with values (mild | moderate | severe)
"Life threatening" and "Fatal" cannot currently be mapped.

As SNOMED CT Expression but see note above on not using 'life threatening' or 'Fatal':

(255604002 |Mild|
OR 6736007 |Moderate|
OR 24484000 |Severe|
OR 399166001 |Fatal|
442452003 |Life threatening severity|)

Certainty

PRSB valueSet applicable for certainty is as follows:

Unlikely - [The reaction is thought unlikely to have been caused by the agent.][SNOMED-CT::1491118016]
Likely - [The reaction is thought likely to have been caused by the agent.][SNOMED-CT::5961011]
Certain - [The agent is thought to be certain to have caused the reaction but this has not been confirmed by challenge testing.][SNOMED-CT::255545003] (Definite(qualifier value))
Confirmed by challenge testing - [The reaction to the agent has been confirmed by challenge testing or other concrete evidence.][SNOMED-CT::410605003] Confirmed present (qualifier value))
The FHIR element AllergyIntolerance.verificationStatus is mandatory and the ValueSet verificationStatus has a required terminology binding and uses values (unconfirmed | confirmed | refuted | entered-in-error)
the values ( refuted | entered-in-error) MUST NOT be used for Transfer of Care Documents.

The values Certain and Confirmed by Challenge = FHIR value "confirmed". The values Likely and Unlikely = FHIR value "unconfirmed". If AllergyIntolerance.verificationStatus is not known, then set to FHIR value "unconfirmed". If extra information about certainty is known, this should reported as a note. The ValueSet guidance for implementers is to default to FHIR value of "unconfirmed" for all Transfer of Care Document types.

As SNOMED Expressions (Note that 1491118016 |unlikely| and 5961011 |likely| above are description identifiers for synonyms of concepts below)
(385434005 |Improbable diagnosis|
OR 2931005 |Probable diagnosis|
OR 255545003 |Definite|
OR 410605003 |Confirmed present|)

Reaction Details

AllergyIntolerance.reaction.manifestation is a sub-element of AllergyIntolerance.reaction, which is optional (0..*) - so if there is no manifestation known, then don't send a AllergyIntolerance.reaction FHIR element.

Anything from the clinical finding hierarchy ( 404684003 | clinical finding (finding) | ). Plus the HL7 nullFlavors documented here.

The AllergyIntolerance.reaction.manifestation CodeableConcept ValueSet is Extensible. If you have a code, then goes in Manifestation CodeableConcept. Where no code is known (but a manifestation needs to be recorded) then populate the AllergyIntolerance.reaction.manifestation CodeableConcept with the value from the HL7 FHIR NullFlavor ValueSet of "UNC" - "un-encoded" and populate text of manifestation in AllergyIntolerance.reaction.description. When patient is asked about reaction, but doesn't know the reaction then populate the AllergyIntolerance.reaction.manifestation CodeableConcept with the value from the HL7 FHIR NullFlavor ValueSet of "ASKU" - "asked but unknown". When the reaction details cannot be determined/verified, then then populate the AllergyIntolerance.reaction.manifestation CodeableConcept with the value from the HL7 FHIR NullFlavor ValueSet of "NI" - "No Information".

Type of Reaction

For the AllergyIntolerance.type FHIR has a required terminology binding using the values of (allergy | intolerance) - as this is a required ValueSet these values must be used.

The values "Adverse Reaction" and "Not Known" are currently not supported However adverse reaction is closer to intolerance by the FHIR definition. An absence of AllergyIntollerance.type implies Not Known. Advice from FHIR patient care WGM is that adverse reaction should recorded under AllergyIntolerance.reaction.description.

Date first experienced

This is mapped to the "higher level" of the FHIR element AllergyIntolerance.onset[x] estimated or actual date, date-time, or age when allergy or intolerance was identified. The definition of AllergyIntolerance.onset[x] is: Record of the date and/or time of the onset of the Reaction. The reason for mapping to higher onset is that this is the date when the reaction was experienced by the patient for the first time, the onset under reaction could be multiple.

Clinicalstatus

The FHIR element AllergyIntolerance.clinicalStatus for Transfer of Care Documents should if present be set to "active".

AllergyIntolerance.category

The category of the identified substance, this may be of use to receivers and can be populated with a value from the FHIR required ValueSet AllergyIntoleranceCategory.

AllergyIntolerance.criticality

This FHIR element may be used to express life threatening (high) in conjunction with AllergyIntolerance.severity FHIR element.

AllergyIntolerance.lastOccurrence

This FHIR element may be used to represents the date and/or time of the last known occurrence of a reaction event. May be populated if known.

AllergyIntolerance.reaction.substance

This FHIR element SHOULD NOT populated for Transfer of Care Documents.

AllergyIntolerance.reaction.onset

This FHIR element may be populated if known.

AllergyIntolerance.exposureroute

This FHIR element may be populated with a value from dm+d routes refset. As a SNOMED Expression

^999000051000001100 |ePrescribing route of administration simple reference set|

AllergyIntolerance.reaction.note

This FHIR element MUST NOT be used and the information must where available, always be carried in the Composition.section.text FHIR element.

AllergyInterolerance.ReasonEnded

This FHIR element must be supported and is to allow for clinical content for "RESOLVED" status allergies. This is where AllergyIntolerance.clinicalStatus FHIR element contains the value of "resolved" - FHIR definition is "A reaction to the identified substance has been clinically reassessed by testing or re-exposure and considered to be resolved."

Allergy Snapshot

The allergies list is a “Snapshot” of the known allergies at a point in time (for example on discharge from hospital). It is not a master list of the patient’s allergies. Other lists of allergies for the patient may exist on other systems.

How the Allergy List is Constructed

The allergy record is constructed as a single list for Transfer of Care Documents. The diagram below shows the Resources used and relationships between the Resources.

allergy_basic_structure

Handling Negated Codes e.g. “No Known Drug allergy”

When there are negated codes which are explicitly recorded by the clinician then:

  • FHIR element Text.Narrative MUST match text of code e.g. “No known drug allergies”, PRSB guidance to be revised.
  • List is NOT empty therefore the FHIR element List.EmptyReason not needed.
  • Place negated code in the FHIR element AllergyIntolerance.code.

The negated codes to use are:

  • 716186003 - No known allergy
  • 409137002 - No known drug allergy
  • 429625007 - No known food allergy

Handling an EMPTY Allergy list (no allergies recorded in EOR)

Option 1 : Fhir element Text.Narrative = "Information not available" this is the PRSB preferred option.

The FHIR element List.EmptyReason a code from the ValueSet Care Connect List Empty Reason Code which is the code "no-content-recorded".

Option 2 : FHIR element Text.Narrative = displayName of the code in AllergyIntolerance.code and include List Resource and AllergyIntolerance Resource. The FHIR element AllergyIntolerance.code contains a SNOMED CT concept for example "1631000175102:Patient not asked" . The List Resource is not empty and FHIR element List.EmptyReason MUST NOT be populated.

Allergy List Item Example

Example to show an allergy list.

Allergy List

AllergyIntolerance

Condition List

Overview

This section details the design approach using FHIR Resources to support the PRSB heading model for a condition list. The condition Resource is referenced via the List Resource. Implementation guidance on diagnoses from the discharge summary PRSB standard: The discharge summary should inform the GP of the main diagnosis / diagnoses that were important during the admission (or symptom(s) if no diagnosis), including any new diagnosis that came to light during the admission. When a diagnosis has not yet been made, the most granular clinical concept with the highest level of certainty should be recorded. This may be a problem, symptom, sign, or test result, and may evolve over time, as a conventional diagnosis is reached. For example, ‘dyspepsia’ may be the diagnosis when a patient first presents with indigestion, upgraded to 'gastric ulcer' when this is found at endoscopy, and 'gastric cancer' when biopsies reveal this. 'Co-morbidities' should be recorded as separate diagnoses. For example, dementia may be recorded as a primary diagnosis by a psycho-geriatrician, but as a co-morbidity where a patient is admitted for a hip replacement. Unconfirmed or excluded diagnoses should not be recorded in structured code.

Resources Used for Profile Design

The following FHIR Resources are profiled to create the condition list.

  • UKCore-List - A UK Core Profile for recording a snapshot of the list of Conditions for the patient.
  • UKCore-Condition - A UK Core Profile for conditions. The Condition Resource records detailed information about conditions (diagnoses) recognised by a clinician.

List

This Resource acts as a container for the conditions. The following is an example of the main elements used:

  • identifier - uniquely identifies this list of conditions (UUIDs)
  • code - the type of list (for example SNOMED CT concept for "Primary Diagnosis")
  • status - should always be "current"
  • mode - should always be "snapshot"
  • subject - a reference to the patient whose condition list this is
  • Encounter - a reference to the context in which the list was created (the inpatient stay for example)
  • date - when the list was prepared
  • source - who or what defined the list
  • entry - a reference to the condition Resource entry

Condition

This Resource is used to record detailed information about a condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern. The following is an example of the elements that can be used:

  • identifier - uniquely identifies this condition (UUIDs)
  • clinicalStatus - active, recurrence, inactive, remission, resolved etc
  • category - for Emergency Care eDischarge this will normally be encounter-diagnosis
  • code - identification of the condition, problem or diagnosis
  • subject - the patient
  • onset - estimated or actual date, date-time, or age
  • abatement - if/when in resolution/remission
  • stage - stage/grade, usually assessed formally
  • evidence - supporting evidence

Diagnosis Code

Handles information entered for each individual diagnosis. Confirmed diagnosis (or symptom); active diagnosis (or symptom) being treated. Should include the stage of the disease where relevant. The SNOMED CT concept should be from the following ref set:

< 404684003 |Clinical finding|
OR < 413350009 |Finding with explicit context|
OR < 272379006 |Event|

For Inpatient Discharge Summary this is used in conjunction with condition.category with encounter-diagnosis as the ValueSet.

Condition.subject

A reference to the Patient Resource.

Condition.context

A reference to the Encounter Resource.

Condition.onset

The estimated or actual date, date-time, or age of onset which MUST be populated if available using one of the following sub-elements:

  • onsetDateTime
  • onsetAge
  • onsetPeriod
  • onsetRange
  • onsetString

Condition.abatement

The estimated or actual date, date-time, or age of abatement which MUST be populated if available using one of the following sub-elements:

  • abatementDateTime
  • abatementAge
  • abatementBoolean
  • abatementPeriod
  • abatementRange
  • abatementString

How the Condition List is Constructed

The condition list is constructed as a list, there may be one or more list types. The diagram below shows the Resources used and relationships between the Resources.

condition_basic_structure

Condition List Item Example

Example to show a condition list.

Condition List

Condition

Procedure List

Overview

This section details the design approach using FHIR Resources to support the PRSB heading model which use the Procedure Resource. The Procedure Resource is referenced via the List Resource.

Resources Used for Profile Design

The FHIR Resources are profiled to create the procedure list as follows:

  • UKCore-List - A UK Core Profile for recording a snapshot of the list of Procedures for the patient.
  • UKCore-Procedure - A UK Core Profile for procedures. The Procedure Resource is used to record an action that is or was performed on a patient.

List

This Resource acts as a container for the procedures. The following is an example of the main elements used:

  • identifier - uniquely identifies this list of procedures (UUIDs)
  • code - the type of list (for example SNOMED CT concept for "requested procedures")
  • status - should always be "current"
  • mode - should always be "snapshot"
  • subject - a reference to the patient whose procedure list this is
  • Encounter - a reference to the context in which the list was created (the inpatient stay for example)
  • date - when the list was prepared
  • source - who or what defined the list
  • entry - a reference to the Procedure Resource entry

Procedure

This Resource is used to record detailed information about a procedure. The following is an example of the elements that can be used:

  • identifier - uniquely identifies this procedure (UUIDs)
  • status - completed, aborted etc
  • category - Classification of the procedure
  • code - identification of the procedure
  • bodySite - the body site of the procedure
  • complicationDetail - details of any intra-operative complications encountered during the procedure, arising during the patient’s stay in the recovery unit or directly attributable to the procedure
  • anestheticIssues - details of any adverse reaction to any anaesthetic agents including local anaesthesia. Problematic intubation, transfusion reaction, etc.
  • note - any further textual comment to clarify such as statement that information is partial or incomplete
  • performed - when procedure was performed
  • subject - the patient
  • outcome - the result of procedure

Procedure.code

71388002 | Procedure (procedure) | hierarcy AND Procedure with explicit context (situation)
SCTID: 129125009 [EXTENSIBLE]

Terminology binding as a SNOMED Expression:

<<71388002 |Procedure|
<<129125009 |Procedure with explicit context|

Procedure.code can carry combined bodySite expression:

Laterality only - 448243002 | external fixation of femur | :272741003 | laterality | = 7771000 | left |
Refined site and laterality - 448243002 | external fixation of femur | :405813007 | procedure site - Direct | = 41111004 | bone structure of shaft of femur | , 272741003 | laterality | = 7771000 | left |

Procedure.bodySite

<<442083009 |anatomical or acquired body structure|

Note: that this includes the following two sub-hierarchies

  • 91723000 anatomical structure
  • 280115004 acquired body structure

So, an alternative is only:

  • 91723000 anatomical structure

Procedure.complication

References the condition resource.

Procedure.anestheticIssues

Uses the Extension-UKCore-AnaestheticIssues extension to either references the condition resource or carry a SNOMED CT concept to detail the anaesthetic issues the patient had.

Procedure.note

Any further textual comment to clarify such as statement that information is partial or incomplete. MUST be repeated in the FHIR element Composition.section.text.

How the Procedure List is Constructed

The Procedure list is constructed as a single list. The diagram below shows the Resources used and relationships between the Resources.

procedure_basic_structure

Procedure List Item Example

Example to show a procedure list

Procedure List

Procedure Example

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