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.

Clinical review of systems

The Clinical review of systems section carries a narrative summary of the information gathered on symptoms related to physiological systems where possible, very brief. PRSB Elements should be formatted as subheadings in any HTML sent.

Section Description Cardinality MRO* Values
Clinical review of systems Information gathered on symptoms related to physiological systems. 0 to 1 O Carried in the CodeableConcept of Composition.section.code FHIR element. ValueSet UKCoreCompositionSectionCode
PRSB Element Description Card. MRO* FHIR Target and Guidance
Clinical review of systems The clinical review of systems. The record of clinical information gathered in responses to questions to the patient about general symptoms from various physiological systems, including food intake (increasing/decreasing) weight change, swallowing difficulties etc. 0 to 1 O This is the record of the review of systems as volunteered by the patient or their representative or carer. Text only.
* M=Mandatory R=Required O=Optional

Example Clinical Narrative Section

This section is not used in the Hackathon examples. Refer to other sections for example. The section text / section.code (ValueSet UKCoreCompositionSectionCode) and any linked coded resources applicable to the section would differ.

Example Coded Resources

TBC

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