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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