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 summary

The Clinical summary section carries a narrative summary of the episode, where possible very brief. PRSB Elements should be formatted as subheadings in any HTML sent.

Section Description Card. MRO* FHIR Target and Guidance
Clinical summary A brief description of the encounter. 1 only M Carried in the CodeableConcept of Composition.section.code FHIR element. ValueSet UKCoreCompositionSectionCode
PRSB Element Description Card. MRO* FHIR Target and Guidance
Clinical summary Summary of the encounter. Where possible, very brief. This may include interpretation of findings and results; differential diagnoses, opinion and specific action(s). Planned actions will be recorded under 'plan'. 1 only M Free text
Formulation An account, shared by a therapist and person, of the personal meaning and origins of a person’s difficulties. This is viewed in the context of multiple factors including relationships, social circumstances and life events and will indicate the most helpful way forward. 0 to 1 R Free text
Treatments and interventions and changes made to treatments. The relevant treatments and interventions which the patient received during the inpatient stay. Include psychological therapies. All medications should be recorded under the medications section. 0 to 1 R Free text
* M=Mandatory R=Required O=Optional

Example Clinical Summary Section

{
    "resourceType": "Composition",
    "meta": {
        "profile":  [
            "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Composition"
        ]
    },
    "status": "final",
    "type": {
        "coding":  [
            {
                "system": "http://snomed.info/sct",
                "code": "373942005",
                "display": "Discharge summary"
            }
        ]
    },
    "subject": {
        "reference": "urn:uuid:2c0bca60-1873-46f7-a462-5733feaf32c9"
    },
    "encounter": {
        "reference": "urn:uuid:5a9f67fa-9343-40cc-8fde-0dd91822b7fd"
    },
    "date": "2023-01-28T10:00:00+00:00",
    "author":  [
        {
            "reference": "urn:uuid:2a32666e-84a2-4f90-a6a6-d5451ae2e32f"
        }
    ],
    "title": "Cardiology Service Discharge Summary",
    "section":  [
        {
            "title": "Clinical summary",
            "code": {
                "coding":  [
                    {
                        "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
                        "code": "clinical-summary",
                        "display": "Clinical summary"
                    }
                ]
            },
            "text": {
                "status": "additional",
                "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Clinical Summary</th></tr><tr><td><p>56 yr old carpenter witha history of an underactive thyroid gland who has to take thyroxine every day.</p><p>Getting him on the correct dose has been difficult, so he is on a slightly unusual dose.</p><p>Had a heart attack 2 weeks ago, and had a coronary stent inserted, since when he has needed to take daily Aspirin to prevent blood clotting and Atorvastatin to lower his cholesterol level.</p><p>Has had problems in the past with alcohol misuse and on the advice of the local substance misuse service has been started on Acromposate.</p><p>Recently started to feel more breathless at night. GP diagnosed heart failure, and started Ramipril but after discussion with the cardiologist, admitted for further investigations.</p><p>Discharged again after 3 days, on unchanged medication, awaiting the result of the tests.</p></td></tr></tbody></table></div>"
            }
        }
    ]
}
<Composition xmlns="http://hl7.org/fhir">
    <!--   optional elements removed for readability   -->
    <meta>
        <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-Composition" />
    </meta>
    <status value="final" />
    <type>
        <coding>
            <system value="http://snomed.info/sct" />
            <code value="373942005" />
            <display value="Discharge summary" />
        </coding>
    </type>
    <subject>
        <reference value="urn:uuid:2c0bca60-1873-46f7-a462-5733feaf32c9" />
    </subject>
    <encounter>
        <reference value="urn:uuid:5a9f67fa-9343-40cc-8fde-0dd91822b7fd" />
    </encounter>
    <date value="2023-01-28T10:00:00+00:00" />
    <author>
        <reference value="urn:uuid:2a32666e-84a2-4f90-a6a6-d5451ae2e32f" />
    </author>
    <title value="Cardiology Service Discharge Summary" />
    <section>
        <title value="Clinical summary" />
        <code>
            <coding>
                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                <code value="clinical-summary" />
                <display value="Clinical summary" />
            </coding>
        </code>
        <text>
            <status value="additional" />
            <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Clinical Summary</th></tr><tr><td><p>56 yr old carpenter witha history of an underactive thyroid gland who has to take thyroxine every day.</p><p>Getting him on the correct dose has been difficult, so he is on a slightly unusual dose.</p><p>Had a heart attack 2 weeks ago, and had a coronary stent inserted, since when he has needed to take daily Aspirin to prevent blood clotting and Atorvastatin to lower his cholesterol level.</p><p>Has had problems in the past with alcohol misuse and on the advice of the local substance misuse service has been started on Acromposate.</p><p>Recently started to feel more breathless at night. GP diagnosed heart failure, and started Ramipril but after discussion with the cardiologist, admitted for further investigations.</p><p>Discharged again after 3 days, on unchanged medication, awaiting the result of the tests.</p></td></tr></tbody></table></div>
        </text>
    </section>
    <!--   other sections removed for readability   -->
</Composition>

Example Coded Resources

TBC - potentially ClinicalImpression

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