UK Core Clinical and Technical Assurance Sprint 4 Documentation Pack

UK Core Clinical and Technical Assurance Sprint 4 Documentation Pack

PRSB Logical Model Mappings

PRSB have provided a logical model of Medication and Vaccination relevant data found within the existing standards.

Encounter mappings

Name Description UK Core FHIR Target
Contacts with professionals The details of the personís contact with a professional. N/A Header Row
Contacts with professionals record entry This is a contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items. N/A Header Row
Date and time of contact Date and time of the contact. Encounter.period
Location of contact The location where the contact took place. N/A Header Row
Coded value The coded value for location Encounter.location Referencing location.identifier
Free text Free text field to be used if no code is available Encounter.location Referencing location.name
Seen by The professional that saw the person. N/A Header Row
Name The name of the professional that saw the person Encounter.participant.individual referencing Practitioner.name OR PractitionerRole.practitioner.display
Role The role of the person providing the service. referenced PractitionerRole.code.coding.code
Responsible professional The name and role of the professional that had overall responsibility for the person e.g. consultant, nurse consultant, midwife, allied health professional (may not have actually seen the person). N/A Header Row
Name The name of the responsible professional. Encounter.participant.individual referencing Practitioner.name OR PractitionerRole.practitioner.display
Role The role of the responsible professional referenced PractitionerRole.code.coding.code
Location type The type of location where the contact took place e.g. person's home Encounter.Encounter.location.physicalType
Contact type Type of contact e.g. GP consultation, outpatient attendance Encounter.class or encounter.type
Consultation method Consultation method used e.g. face to face, telephone Encounter.type
Specialty The specialty e.g. physiotherapy, oncology, mental health etc Encounter.serviceType
Service The service that was provided. Encounter.serviceType
Professionals present The name, role of the additional individuals or team members including consultant(s), nurse consultant(s), allied health professional(s), social worker(s) N/A Header Row
Name The name of the professional present Encounter.participant.individual referencing Practitioner.name OR PractitionerRole.practitioner.display
Role The role of the professional present. referenced PractitionerRole.code.coding.code
Outcome of contact This records the outcome of the contact. Encounter.diagnosis.condition orEncounter.appointment referencing appointment.status
Admission details Admission details N/A Header Row
Admission details record entry This is the admission details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items. N/A Header Row
Date of admission Date and time the person was admitted to hospital. Encounter.period
Admitted to The hospital the person was admitted to. N/A Header Row
Coded value The coded value for admission to Encounter.location Referencing location.identifier
Free text Free text field to be used if no code is available Encounter.location Referencing location.name
Responsible care professional The care professional who has overall responsibility for the person (may not actually see the person) N/A Header Row
Name The name of the responsible care professional. Encounter.participant.individual referencing Practitioner.name OR PractitionerRole.practitioner.display
Role The role of the responsible consultant. referenced PractitionerRole.code.coding.code
Reason for admission The health problems and issues experienced by the person that prompted the decision to admit to hospital e.g. chest pain, mental health crisis, blackout, fall, a specific procedure, intervention, investigation or treatment, non compliance with treatment. N/A Header Row
Coded value The coded value for reason for admission Encounter.reasonCode
Free text Free text field to be used if no code is available The FHIR target needs further discussion
Admission method How the person was admitted to hospital e.g. elective, emergency, maternity, transfer etc. N/A Header Row
Coded value The coded value for admission method ExtensionUKCoreAdmissionMethod
Free text Free text field to be used if no code is available The FHIR target needs further discussion
Legal status on admission Whether the person was admitted as informal or formal/detained. Would this be better as an extension on encounter? (e.g legal status on admission)
Source of admission Where the person was immediately prior to admission, e.g. usual place of residence, temporary place of residence, penal establishment. N/A Header Row
Coded value The coded value of source of admission referenced location.identifier
Free text Free text field to be used if no code is available referenced location.name or Encounter.hospitalization.origin or Encounter.hospitalization.admitSource
Individual accompanying person Details of the accompanying individual and the extent to which they have provided the information about the person. N/A Header Row
Name Name of individual accompanying person. Encounter.participant.individual referencing RelatedPerson.Name
Relationship Relationship of individual accompanying the person. N/A Header Row
Coded value The coded value for relationship to person. Encounter.participant.individual referencing RelatedPerson.relationship
Free text Free text field to be used if no code is available Encounter.participant.individual referencing RelatedPerson.identifier or RelatedPerson.name
Comment Information about the extent to which the accompanying individual provided information about the person. The FHIR target needs further discussion
Specialty The specialty e.g. physiotherapy, oncology, mental health etc N/A Header Row
Coded value The coded value for specialty Encounter.participant.individual.Practitioner.PractitionerRole.speciality
Free text Free text field to be used if no code is available The FHIR target needs further discussion
Discharge details Discharge details N/A Header Row
Discharge details record entry This is the discharge details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items. N/A Header Row
Date of discharge The date and time of discharge Encounter.period
Discharge location The hospital the person was discharged from. Encounter.location.location
Discharging consultant The consultant responsible for the person at time of discharge. N/A Header Row
Name The name of the discharging consultant Encounter.participant.individual referencing Practitioner.name OR PractitionerRole.practitioner.display
Role The role of the discharging consultant referenced PractitionerRole.code.coding.code
Discharge method The method of discharge from hospital e.g. person discharged on clinical advice or with clinical consent; person discharged him/herself or was discharged by a relative or advocate. N/A Header Row
Coded value The coded value for discharge method ExtensionUKCoreDischargeMethod
Free text Free text field to be used if no code is available The FHIR target needs further discussion
Discharging specialty The specialty of the consultant responsible for the person at the time of discharge. N/A Header Row
Coded value The coded value for discharge speciality referenced PractitionerRole.specialty.coding.code
Free text Free text field to be used if no code is available referenced PractitionerRole.specialty.text
Discharging department The department from which the person is discharged. The FHIR target needs further discussion Or ExtensionUKCoreEmergencyCareDischargeStatus
Legal status on discharge Whether the person was discharged as informal or formal/detained. Encounter.Subject.Observation
Discharge destination N/A Header Row
Discharge destination The destination of the person on discharge from hospital e.g. usual place of residence, NHS run care home. Encounter.hospitalization.dischargeDisposition
Discharge address Address to which the person is discharged if not the usual place of residence. Encounter.hospitalization.destination referencing Location.address

Problem/Condition mappings

Name Description UK Core FHIR Target
Problem list A summary of the problems that require investigation or treatment. N/A Header Row
Problem list record entry This is a problem list record entry. N/A Header Row
There may be 0 to many record entries under problem list. N/A Header Row
Each record entry is made up of a number of elements or data items. N/A Header Row
Date The date the problem was identified. Condition.recordedDate
Performing professional The professional who identified the problem. Condition.recorder referencing practitioner or Practitioner role
Name The name of the professional. referenced Practitioner.name OR PractitionerRole.practitioner.display
Role The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc referenced PractitionerRole.code.coding.code
Grade The grade of the professional. referenced PractitionerRole.code.coding.code
Speciality The specialty of the professional e.g. physiotherapy, oncology, mental health etc referenced PractitionerRole.specialty.coding.code OR .specialty.text
Professional identifier Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation. referenced Practitioner.identifier
Organisation The name of the organisation the professional works for. referenced PractitionerRole.organization
Contact details Contact details of the professional referenced PractitionerRole.telecom OR Practitioner.telecom
Location The location the problem was identified. N/A Header Row
Coded value The coded value for location. Condition.encounter.location.location
Free text Free text field to be used if no code is available The FHIR target needs further discussion
Problem A condition which needs addressing and so is important for every professional to know about when seeing the person. N/A Header Row
Problems may include diagnoses, symptoms, disabilities and social or behavioural issues N/A Header Row
Coded value The coded value for the problem list. Condition.code
Free text Free text field to be used if no code is available Condition.note
Onset date A date or estimated date that the problem began Condition.onset.onsetDateTime
End Date The date or estimated date the problem was resolved. Condition.abatement.abatementDateTime
Stage of disease The stage of the disease where relevant. Condition.stage.summary
Person completing record Details of the person completing the record. N/A Header Row
Name The name of the person completing the record. Condition.recorder referenced Practitioner.name OR PractitionerRole.practitioner.display
Role The organisational role of the person completing record. referenced PractitionerRole.code.coding.code
Grade The grade of the person completing the record. referenced PractitionerRole.code.coding.code
Specialty The main specialty of the person completing the record. referenced PractitionerRole.specialty.coding.code OR .specialty.text
Organisation The organisation the person completing the record works for. referenced PractitionerRole.organization
Professional identifier Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation. referenced Practitioner.identifier
Date completed The date and time the record was completed. Condition.recordedDate
Contact details Contact details of the person completing the record. referenced PractitionerRole.telecom OR Practitioner.telecom

Procedures and Therapies mappings

Name Description UK Core FHIR Target
Person demographics The person's details and contact information. N/A Header Row
Procedures and therapies The details of any procedures performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, hip replacement) N/A Header Row
Procedure record entry This is a procedure record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items. N/A Header Row
Date The date the procedure was performed. Procedure.performed.performedDateTime
Location The location where the procedure was undertaken. Procedure.location
Coded value The coded value for location. Procedure.location.identifier
Free text Free text field to be used if no code is available Procedure.location.name
Performing professional The professional who performed the procedure. Procedure.performer.actor referencing practitioner or Practitioner role
Name The name of the professional. referenced Practitioner.name OR PractitionerRole.practitioner.display
Role The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc referenced PractitionerRole.code.coding.code
Grade The grade of the professional. referenced PractitionerRole.code.coding.code
Speciality The specialty of the professional e.g. physiotherapy, oncology, mental health etc referenced PractitionerRole.specialty.coding.code OR .specialty.text
Professional identifier Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation. referenced Practitioner.identifier
Organisation The name of the organisation the professional works for. referenced PractitionerRole.organization
Contact details Contact details of the professional referenced PractitionerRole.telecom OR Practitioner.telecom
Procedure The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, or follow-up interventions as a result of physical health checks). Complementary or alternative procedures and therapies should be recorded here. N/A Header Row
Coded value The procedure code. Procedure.code
Free text Free text field to be used if no code is available Procedure.note
Anatomical site The body site of the procedure Procedure.BodySite
Coded value The coded value of the anatomical site. Procedure.BodySite
Free text Free text field to be used if no code is available Procedure.note
Laterality Laterality of the procedure Procedure.bodySite
Coded value The coded value for laterality. Procedure.BodySite
Free text Free text field to be used if no code is available Procedure.note
Complications related to procedure Details of any intra-operative complications encountered during the procedure, arising during the personís stay in the recovery unit or directly attributable to the procedure.
Coded value The coded value for complications relating to procedure. Procedure.complication and Procedure.complicationDetail Reference Condition.code
Free text Free text field to be used if no code is available Reference Condition.note from Procedure.complicationDetail
Specific anesthesia issues Details of any adverse reaction to any anesthetic agents including local anesthesia. Problematic intubation, transfusion reaction, etc.
Coded value The coded value for specific anesthesia issues. ExtensionUKCoreAnaestheticIssues
Free text Free text field to be used if no code is available Reference Condition.note from Procedure.complicationDetail
Person completing record Details of the person completing the record. referenced Practitioner.name OR PractitionerRole.practitioner.display
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