Clinical Categorization Module
Context
This is the administration module for clinical categorization. It captures concepts the entire admission or case, individual services, surveys, and discharge events.
FHIR Focus Resource Types
Name | Aliases | Description |
---|---|---|
Structure Definition: EpisodeOfCare Profile | Admission, case, program, problem, episode | An association between a patient and an organization / healthcare provider(s) during which time encounters may occur. The managing organization assumes a level of responsibility for the patient during this time. |
Structure Definition: Encounter Profile | Visit | An interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient. |
Structure Definition: ServiceRequest Profile | Referral | A record of a request for service such as diagnostic investigations, treatments, or operations to be performed. |
Structure Definition: Procedure Profile | Service, codes | An action that is or was performed on or for a patient, practitioner, device, organization, or location. |
Structure Definition: Simple Observation Profile | Clinical notes, notes | Measurements and simple assertions made about a patient, device or other subject. |
Structure Definition: Condition Problems Profile | Condition, problem, diagnosis | A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern. Used to query for a Patient’s current or historical problems and health concerns. |
Structure Definition: Condition Encounter Diagnosis Profile | Condition, problem, piagnosis | A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern. Used for Structure Definition: Encounter Profile diagnosis. |
Structure Definition: Organization Profile | Provider, Provider Agency, Provider Location | Organization providing services. See Organization Services Module |
Structure Definition: Patient Profile | Client | See Patient Administration Module |
Structure Definition: Practitioner Profile | Clinician, provider (individual) physician, doctor, nurse, user | See Organization Services Module |
Structure Definition: PractitionerRole Profile | --- | See Organization Services Module |
Structure Definition: ChargeItem Profile | --- | See Finance Module |
Structure Definition: Questionnaire Profile | Survey (e.g. DACODS, CCAR, etc.) | Contains questions asked on screening or assessment |
Structure Definition: QuestionnaireResponse Profile | Survey response, answers | Contains answers for questions asked on screening or assessment |
Conceptual Model
Structured Screening and Assessments - Survey, Questionnaire, and Questionnaire Response
Following HL7.FHIR.US.CORE\Screening and Assessments - FHIR v4.0.01 guidance. Using the following resources:
In addition, we are utilizing the US Core Screening and Assessments guidance.
Notes
EpisodeOfCare and Encounters
Per EpisodeOfCare Boundaries and Relationships:
The primary difference between the EpisodeOfCare and the Encounter is that the Encounter records the details of an activity directly relating to the patient, while the EpisodeOfCare is the container that can link a series of Encounters together for problems/issues.
For this implementation, modifications will be made to the Clinical Categorization Resources in the Administration module:
- Admission defines a Parent (top-level)
EpisodeOfCare
resource that will record Admission and Discharge Dates. EspisodeOfCare
is loosely based on the service category, previously defined as modality.Encounter
resources will be child (lower-level) pointing to a relatedEpisodeOfCare
will collect individual service codes/procedures during a case.Encounter
will also be created for each event or transaction including but not limited to admission, discharge, survey, notes, and more.
Examples
Example 1 - Patient receives 2 weeks of therapy an is discharged
A patient is referred into or presents relevant healthcare issue(s), e.g., signs, symptoms, and defined conditions applicable to the Substance Use Disorder (SUD) program. A Patient and EpisodeOfCare resource will be instantiated. When that patient is associated with a managing provider (organization), the EpisodeOfCare.managingOrganization
and Patient.managingOrganization
SHALL be assigned to that organization.
Day 1: The patient arrives at the provider location for assessment which requires a screening and urinary analysis.
- An Encounter is created for the overall assessment and a reasonReference is assocaited with the Procedure
Encounter.length
is assigned a value based on the associated Procedure- EITHER
- (Preferred) A new encounter is created for the urinary Procedure, assgined via reasonReference, with a reference in partOf pointing to the parent encounter
- OR
- Another reasonReference is assigned to the urinary Procedure
- This establishes the first contact with the patient and
EpisodeOfCare.period.start
is assigned the same value as thisEncounter.period
- If the patient was a referral and already spoke to an agent, there may have been an Encounter for that conversation and that MAY be used as the first point of contact
Encounter.episodeOfCare
is assigned a reference to the top-level EpisodeOfCare for each encounter- (WIP)
Encounter.account
references the Account with the main payer information.
Day 8: The patient returns to the provider location receive an in-peron therapy session.
- A new Encounter is created and has a reasonReference to a Procedure with the applicable code for the therapy session
Encounter.episodeOfCare
is assigned a reference to the top-level EpisodeOfCare- A reasonReference is created linking to a simple observation with notes from the practitioner
Day 15: The patient returns to a different provider location with the same provider to receiving a therapy session and subsequently receives a discharge, which requires a discharge survey.
- A new Encounter is created and has a reasonReference to a Procedure with the applicable code for the therapy session
Encounter.episodeOfCare
is assigned a reference to the top-level EpisodeOfCareEncounter.length
is assigned a value based on the associated Procedure- EITHER
- (Preferred) A new encounter is created for the discharge survey with a reasonReference assigned for discharge survey Procedure code AND a reasonReference assigned for the disarge observation screening assessment
- OR
- Another reasonReference is assigned for the discharge survey Procedure AND a reasonReference assigned for the disarge observation screening assessment
EpisodeOfCare.period.end
is assigned the same values as this Encounter.period date andEpisodeOfCare.status
is changed tocomplete