The FHIR profiles used for the Assessment Scales List structure
Heading Description
Details of the woman’s assessment scales.
The following FHIR profiles are used to form the Assessment scales list structure:
- CareConnect-List-1
- CareConnect-Observation-1
- CareConnect-Encounter-1
- CareConnect-Practitioner-1
- CareConnect-PractitionerRole-1
- CareConnect-Location-1
The following profiles are referenced from the Assessment scales list structure:
Assessment Scales Structure
Maternity Data Standard Mapping to FHIR profiles
Mapping Overview
| Data Standard Element | FHIR Profile Mapping | FHIR Element |
| Date/Time Recorded | List | entry.date |
| ODS/ORD Site Code | Location | identifier |
| Performing Professional | Practitioner | name |
| SDS Job Role Name | PractitionerRole | code |
| Coded Assessment Tool Type | Observation | code value component.code component.value |
| Comment | Observation | comment |
Mapping for Assessment Scales List
| > | Level 1 | List Resource | > | Level 2 | CareConnect-List-1 | > | Level 3 | None |
| View Used FHIR Elements | View All FHIR Elements |
| Name | Card. | Conformance | Type | Description, Constraints and mapping for Implementation |
|---|---|---|---|---|
| List | | Information summarized from a list of other resources Constraint (dom-2): If the resource is contained in another resource, it SHALL NOT contain nested Resources Constraint (dom-1): If the resource is contained in another resource, it SHALL NOT contain any narrative Constraint (dom-4): If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated Constraint (dom-3): If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource Constraint (lst-2): The deleted flag can only be used if the mode of the list is “changes” Constraint (lst-1): A list can only have an emptyReason if it is empty |
||
| - id | 0..1 | Optional | Id | Logical id of this artifact |
| - meta | 0..1 | Mandatory | Meta | Metadata about the resource The value attribute of the profile element MUST contain the value 'https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-List-1' |
| - implicitRules | 0..1 | Not Used | Uri | A set of rules under which this content was created |
| - language | 0..1 | Not Used | Code | Language of the resource content Binding (extensible): A human language. Common Languages |
| - text | 0..1 | Not Used | Narrative | Text summary of the resource, for human interpretation |
| - contained | 0..* | Not Used | Resource | Contained, inline Resources |
| - extension (clinicalSetting) | 0..1 | Not Used | Extension-CareConnect-ClinicalSetting-1 | To record the clinical setting of a problem list Constraint (ext-1): Must have either extensions or value[x], not both |
| - extension (warningCode) | 0..1 | Not Used | Extension-CareConnect-ListWarningCode-1 | To capture warnings that the list may be incomplete Constraint (ext-1): Must have either extensions or value[x], not both |
| - modifierExtension | 0..* | Not Used | Extension | Extensions that cannot be ignored Constraint (ext-1): Must have either extensions or value[x], not both Slicing: Description: Extensions are always sliced by (at least) url, Discriminator: url, Ordering: false, Rules: Open |
| - identifier | 0..* | Required | Identifier | Business identifier An identifier for this Assessment scales list |
| - - use | 0..1 | Not Used | Code | usual : official : temp : secondary (If known) Binding (required): Identifies the purpose for this identifier, if known. IdentifierUse |
| - - type | 0..1 | Not Used | CodeableConcept | Description of identifier Binding (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes |
| - - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - - system | 1..1 | Required | Uri | The namespace for the identifier value The system from which the identifier came from |
| - - value | 1..1 | Mandatory | String | The value that is unique Business identifier An identifier for this Assessment scales list |
| - - period | 0..1 | Not Used | Period | Time period when id is/was valid for use |
| - - - start | 0..1 | Not Used | dateTime | Starting time with inclusive boundary |
| - - - end | 0..1 | Not Used | dateTime | End time with inclusive boundary, if not ongoing |
| - - assigner | 0..1 | Not Used | Reference | Organization that issued id (may be just text) Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | CareConnect-Organization-1 | |||
| - - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - - display | 0..1 | Required | String | Text alternative for the resource The organization that allocated the identifier |
| - status | 1..1 | Mandatory | Code | current : retired : entered-in-error Binding (required): The current state of the list ListStatus The status of the list MUST contain the value 'current' |
| - mode | 1..1 | Mandatory | Code | working : snapshot : changes Binding (required): The processing mode that applies to this list ListMode The mode of the list MUST contain the value 'snapshot' |
| - title | 0..1 | Mandatory | String | Descriptive name for the list This MUST contain the value 'Assessment scales' Mapping to Maternity data item = 'PSRB Heading Assessment scales' |
| - code | 0..1 | Mandatory | CodeableConcept | What the purpose of this list is Binding (preferred): What the purpose of a list is CareConnect-ListCode-1 The PRSB heading for this list. Note: for Maternity the value stated below is used which is not from the preferred value set |
| - - coding | 0..* | Mandatory | Coding | Code defined by a terminology system The SNOMED CT concept for the PRSB heading type |
| - - - system | 0..1 | Mandatory | Uri | Identity of the terminology system This MUST contain the value 'http://snomed.info/sct' |
| - - - version | 0..1 | Not Used | String | Version of the system - if relevant Mapping to Maternity Data item = 'Not applicable' |
| - - - code | 0..1 | Mandatory | Code | Symbol in syntax defined by the system This MUST contain the value '887141000000103' |
| - - - display | 0..1 | Mandatory | String | Representation defined by the system This MUST contain the value 'Assessment scales' Mapping to Maternity data item = 'PSRB Heading Assessment scales' |
| - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - subject | 0..1 | Mandatory | Reference | If all resources have the same subject Constraint (ref-1): SHALL have a contained resource if a local reference is provided This is a reference to the Patient who is the subject of the list. |
| Not Used | Group | |||
| Not Used | Device | |||
| Mandatory | CareConnect-Patient-1 | This is the subject of the Assessment scales List. This MUST use the CareConnect patient profile. See patient resource reference for information on how to populate the resource. |
||
| Not Used | CareConnect-Location-1 | |||
| - - reference | 0..1 | Mandatory | String | Literal reference, Relative, internal or absolute URL A reference to the patient resource included in the Patient demographics list within the FHIR Bundle. Note the Patient demographics list is mandatory in the FHIR bundle |
| - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - encounter | 0..1 | Not Used | Reference | Context in which list created Constraint (ref-1): SHALL have a contained resource if a local reference is provided A reference to the encounter resource within the Admission details list. |
| Not Used | CareConnect-Encounter-1 | This is the context of the Admission details List. This MUST use the CareConnect encounter profile. See encounter resource for information on how to populate the resource. |
||
| - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - date | 0..1 | Mandatory | dateTime | When the list was prepared This MUST contain a system date to indicate when the list was created or updated |
| - source | 0..1 | Not Used | Reference | Who and/or what defined the list contents (aka Author) Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | Device | |||
| Not Used | CareConnect-Patient-1 | |||
| Not Used | CareConnect-Practitioner-1 | |||
| - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - orderedBy | 0..1 | Not Used | CodeableConcept | What order the list has Binding (preferred): What order applies to the items in a list List Order Codes |
| - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - note | 0..* | Optional | Annotation | Comments about the list |
| - - author[x] | 0..1 | Not Used | Reference | Individual responsible for the annotation Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | RelatedPerson | |||
| Not Used | CareConnect-Patient-1 | |||
| Not Used | CareConnect-Practitioner-1 | |||
| Required | String | Who authored the comment on the list. | ||
| - - time | 0..1 | Required | dateTime | When the annotation was made |
| - - text | 1..1 | Required | String | The annotation - text content |
| - entry | 0..* | Mandatory | BackboneElement | Entries in the list The entries MUST be as per the diagram for this PRSB headings list with the Observation resource being the focal resource. Multiple resources MAY be present |
| - - modifierExtension | 0..* | Not Used | Extension | Extensions that cannot be ignored Constraint (ext-1): Must have either extensions or value[x], not both |
| - - flag | 0..1 | Not Used | CodeableConcept | Status/Workflow information about this item Binding (example): Codes that provide further information about the reason and meaning of the item in the list Patient Medicine Change Types |
| - - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - - deleted | 0..1 | Not Used | Boolean | If this item is actually marked as deleted Default Value: false |
| - - date | 0..1 | Required | dateTime | When item added to list The SHOULD contain a system time of when the item was added to the list. |
| - - item | 1..1 | Required | Reference | Actual entry Constraint (ref-1): SHALL have a contained resource if a local reference is provided A reference to an Observation resource included in the list This MUST use the CareConnect Observation profile. See Observation resource for information on how to populate the resource. |
| Not Used | Resource | |||
| - - - reference | 0..1 | Mandatory | String | Literal reference, Relative, internal or absolute URL The reference to the included Observation resource. |
| - - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - emptyReason | 0..1 | Not Used | CodeableConcept | Why list is empty Binding (preferred): If a list is empty, why it is empty CareConnect-ListEmptyReasonCode-1 |
| - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - text | 0..1 | Not Used | String | Plain text representation of the concept |
Mapping for Assessment Scales Observation
| > | Level 1 | Observation Resource | > | Level 2 | CareConnect-Observation-1 | > | Level 3 | None |
| View Used FHIR Elements | View All FHIR Elements |
| Name | Card. | Conformance | Type | Description, Constraints and mapping for Implementation |
|---|---|---|---|---|
| Observation | | Measurements and simple assertions Constraint (dom-2): If the resource is contained in another resource, it SHALL NOT contain nested Resources Constraint (dom-1): If the resource is contained in another resource, it SHALL NOT contain any narrative Constraint (dom-4): If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated Constraint (dom-3): If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource Constraint (obs-7): If code is the same as a component code then the value element associated with the code SHALL NOT be present Constraint (obs-6): dataAbsentReason SHALL only be present if Observation.value[x] is not present |
||
| - id | 0..1 | Optional | Id | Logical id of this artifact |
| - meta | 0..1 | Mandatory | Meta | Metadata about the resource The value attribute of the profile element MUST contain the value 'https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Observation-1' |
| - implicitRules | 0..1 | Not Used | Uri | A set of rules under which this content was created |
| - language | 0..1 | Not Used | Code | Language of the resource content Binding (extensible): A human language. Common Languages |
| - text | 0..1 | Not Used | Narrative | Text summary of the resource, for human interpretation |
| - contained | 0..* | Not Used | Resource | Contained, inline Resources |
| - modifierExtension | 0..* | Not Used | Extension | Extensions that cannot be ignored Constraint (ext-1): Must have either extensions or value[x], not both Slicing: Description: Extensions are always sliced by (at least) url, Discriminator: url, Ordering: false, Rules: Open |
| - identifier | 0..* | Required | Identifier | Business Identifier for observation An identifier for this Assessment scales observation |
| - - use | 0..1 | Not Used | Code | usual : official : temp : secondary (If known) Binding (required): Identifies the purpose for this identifier, if known. IdentifierUse |
| - - type | 0..1 | Not Used | CodeableConcept | Description of identifier Binding (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes |
| - - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - - text | 0..1 | Required | String | Plain text representation of the concept |
| - - system | 1..1 | Mandatory | Uri | The namespace for the identifier value |
| - - value | 1..1 | Mandatory | String | The value that is unique |
| - - period | 0..1 | Not Used | Period | Time period when id is/was valid for use Constraint (per-1): If present, start SHALL have a lower value than end |
| - - - start | 0..1 | Not Used | dateTime | Starting time with inclusive boundary |
| - - - end | 0..1 | Not Used | dateTime | End time with inclusive boundary, if not ongoing |
| - - assigner | 0..1 | Required | Reference | Organization that issued id (may be just text) Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | CareConnect-Organization-1 | |||
| - - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - - display | 0..1 | Required | String | Text alternative for the resource |
| - basedOn | 0..* | Not Used | Reference | Fulfills plan, proposal or order. Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | CarePlan | |||
| Not Used | DeviceRequest | |||
| Not Used | ImmunizationRecommendation | |||
| Not Used | NutritionOrder | |||
| Not Used | ProcedureRequest | |||
| Not Used | ReferralRequest | |||
| Not Used | CareConnect-MedicationRequest-1 | |||
| - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - status | 1..1 | Mandatory | Code | registered : preliminary : final : amended + Binding (required): Codes providing the status of an observation. ObservationStatus MUST contain the value 'final'. |
| - category | 0..* | Not Used | CodeableConcept | Classification of type of observation Binding (preferred): Codes for high level observation categories. Observation Category Codes |
| - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - code | 1..1 | Mandatory | CodeableConcept | Type of observation (code / type) Binding (example): Codes identifying names of simple observations. LOINC Codes This example ValueSet is not used by Maternity record. The following SNOMED reference is used Assessment scale observables simple reference set |
| - - coding | 0..* | Required | Coding | Code defined by a terminology system Slicing: Discriminator: code, Ordering: false, Rules: Open |
| - - coding (snomedCT) | 0..1 | Required | Coding | Code defined by a terminology system Binding (extensible): A code from the SNOMED Clinical Terminology UK coding system describing a type of observation CareConnect-ObservationType-1 This SNOMED ValueSet SHOULD be constrained to the ValueSet as indicated in the code element above. |
| - - - extension (snomedCTDescriptionID) | 0..1 | Not Used | Extension-coding-sctdescid | The SNOMED CT Description ID for the display. Constraint (ext-1): Must have either extensions or value[x], not both |
| - - - system | 1..1 | Mandatory | Uri | Identity of the terminology system The element MUST contain the value 'http://snomed.info/sct' |
| - - - code | 1..1 | Mandatory | Code | Symbol in syntax defined by the system A SNOMED concept from the ValueSet indicated. |
| - - - display | 1..1 | Mandatory | String | Representation defined by the system The display associated with the SNOMED CT concept. This SHOULD be the preferred term |
| - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - subject | 0..1 | Not Used | Reference | Who and/or what this is about Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | Group | |||
| Not Used | Device | |||
| Not Used | CareConnect-Patient-1 | |||
| Not Used | CareConnect-Location-1 | |||
| - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - context | 0..1 | Required | Reference | Healthcare event during which this observation is made Constraint (ref-1): SHALL have a contained resource if a local reference is provided This MUST be a reference to the Encounter resource |
| Not Used | EpisodeOfCare | |||
| Required | CareConnect-Encounter-1 | The Encounter where the assesment was carried out. This MUST use the Encounter resource. See Encounter resource for information on how to populate the resource. |
||
| - - reference | 0..1 | Required | String | Literal reference, Relative, internal or absolute URL A reference to the Encounter resource included in the Assessment scales list |
| - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - effective[x] | 0..1 | Required | dateTime | Clinically relevant time/time-period for observation The date on which the assessment scale was recorded. |
| Not Used | Period | |||
| - issued | 0..1 | Not Used | Instant | Date/Time this was made available |
| - performer | 0..* | Required | Reference | Who is responsible for the observation Constraint (ref-1): SHALL have a contained resource if a local reference is provided The professional performing the assessment scale. |
| Not Used | RelatedPerson | |||
| Not Used | CareConnect-Patient-1 | |||
| Not Used | CareConnect-Organization-1 | |||
| Mandatory | CareConnect-Practitioner-1 | The professional performing the Assessment. This MUST use the Practitioner resource.See Practitioner resource for information on how to populate the resource.” | ||
| - - reference | 0..1 | Required | String | Literal reference, Relative, internal or absolute URL A reference to the Practitioner resource included in the Assessment scales list |
| - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - value[x] | 0..1 | Required | Quantity | Actual result Constraint (qty-3): If a code for the unit is present, the system SHALL also be present The value of the assessment scales where one is required to be recorded. |
| Required | CodeableConcept | |||
| Required | String | |||
| Required | Boolean | |||
| Required | Range | |||
| Not Used | Ratio | |||
| Not Used | SampledData | |||
| Not Used | Attachment | |||
| Not Used | Time | |||
| Not Used | dateTime | |||
| Not Used | Period | |||
| - dataAbsentReason | 0..1 | Not Used | CodeableConcept | Why the result is missing Binding (extensible): Codes specifying why the result (Observation.value[x]) is missing. Observation Value Absent Reason |
| - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - interpretation | 0..1 | Not Used | CodeableConcept | High, low, normal, etc. Binding (extensible): Codes identifying interpretations of observations. Observation Interpretation Codes |
| - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - comment | 0..1 | Required | String | Comments about result Supporting text may be given regarding the assessment scale as a whole or a subscale. code.text and component.code.text SHOULD be used when the scale cannot be coded using SNOMED, value.string and component.value.string should be used for the values where no suitable data type is available or applicable. |
| - bodySite | 0..1 | Not Used | CodeableConcept | Observed body part Binding (example): Codes describing anatomical locations. May include laterality. SNOMED CT Body Structures |
| - - coding | 0..* | Not Used | Coding | Code defined by a terminology system Slicing: Discriminator: code, Ordering: false, Rules: Open |
| - - coding (snomedCT) | 0..1 | Not Used | Coding | Code defined by a terminology system |
| - - - extension (snomedCTDescriptionID) | 0..1 | Not Used | Extension-coding-sctdescid | The SNOMED CT Description ID for the display. Constraint (ext-1): Must have either extensions or value[x], not both |
| - - - system | 1..1 | Not Used | Uri | Identity of the terminology system The element MUST contain the value 'http://snomed.info/sct' |
| - - - code | 1..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - display | 1..1 | Not Used | String | Representation defined by the system |
| - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - method | 0..1 | Not Used | CodeableConcept | How it was done Binding (example): Methods for simple observations. Observation Methods |
| - - coding | 0..* | Not Used | Coding | Code defined by a terminology system Slicing: Discriminator: code, Ordering: false, Rules: Open |
| - - coding (snomedCT) | 0..1 | Not Used | Coding | Code defined by a terminology system Binding (preferred): A code from SNOMED Clinical Terminology UK CareConnect-ObservationMethod-1 |
| - - - extension (snomedCTDescriptionID) | 0..1 | Not Used | Extension-coding-sctdescid | The SNOMED CT Description ID for the display. Constraint (ext-1): Must have either extensions or value[x], not both |
| - - - system | 1..1 | Not Used | Uri | Identity of the terminology system The element MUST contain the value 'http://snomed.info/sct' |
| - - - code | 1..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - display | 1..1 | Not Used | String | Representation defined by the system |
| - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - specimen | 0..1 | Not Used | Reference | Specimen used for this observation Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | Specimen | |||
| - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - device | 0..1 | Not Used | Reference | (Measurement) Device Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | Device | |||
| Not Used | DeviceMetric | |||
| - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - referenceRange | 0..* | Not Used | BackboneElement | Provides guide for interpretation Constraint (obs-3): Must have at least a low or a high or text |
| - - modifierExtension | 0..* | Not Used | Extension | Extensions that cannot be ignored Constraint (ext-1): Must have either extensions or value[x], not both |
| - - low | 0..1 | Not Used | Quantity ( SimpleQuantity ) | Low Range, if relevant Constraint (qty-3): If a code for the unit is present, the system SHALL also be present Constraint (sqty-1): The comparator is not used on a SimpleQuantity |
| - - - value | 0..1 | Not Used | Decimal | Numerical value (with implicit precision) |
| - - - unit | 0..1 | Not Used | String | Unit representation |
| - - - system | 0..1 | Not Used | Uri | System that defines coded unit form |
| - - - code | 0..1 | Not Used | Code | Coded form of the unit |
| - - high | 0..1 | Not Used | Quantity ( SimpleQuantity ) | High Range, if relevant Constraint (qty-3): If a code for the unit is present, the system SHALL also be present Constraint (sqty-1): The comparator is not used on a SimpleQuantity |
| - - - value | 0..1 | Not Used | Decimal | Numerical value (with implicit precision) |
| - - - unit | 0..1 | Not Used | String | Unit representation |
| - - - system | 0..1 | Not Used | Uri | System that defines coded unit form |
| - - - code | 0..1 | Not Used | Code | Coded form of the unit |
| - - type | 0..1 | Not Used | CodeableConcept | Reference range qualifier Binding (extensible): Code for the meaning of a reference range. Observation Reference Range Meaning Codes |
| - - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - - appliesTo | 0..* | Not Used | CodeableConcept | Reference range population Binding (example): Codes identifying the population the reference range applies to. Observation Reference Range Applies To Codes |
| - - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - - age | 0..1 | Not Used | Range | Applicable age range, if relevant Constraint (rng-2): If present, low SHALL have a lower value than high |
| - - - low | 0..1 | Not Used | Quantity ( SimpleQuantity ) | Low limit Constraint (qty-3): If a code for the unit is present, the system SHALL also be present Constraint (sqty-1): The comparator is not used on a SimpleQuantity |
| - - - - value | 0..1 | Not Used | Decimal | Numerical value (with implicit precision) |
| - - - - unit | 0..1 | Not Used | String | Unit representation |
| - - - - system | 0..1 | Not Used | Uri | System that defines coded unit form |
| - - - - code | 0..1 | Not Used | Code | Coded form of the unit |
| - - - high | 0..1 | Not Used | Quantity ( SimpleQuantity ) | High limit Constraint (qty-3): If a code for the unit is present, the system SHALL also be present Constraint (sqty-1): The comparator is not used on a SimpleQuantity |
| - - - - value | 0..1 | Not Used | Decimal | Numerical value (with implicit precision) |
| - - - - unit | 0..1 | Not Used | String | Unit representation |
| - - - - system | 0..1 | Not Used | Uri | System that defines coded unit form |
| - - - - code | 0..1 | Not Used | Code | Coded form of the unit |
| - - text | 0..1 | Not Used | String | Text based reference range in an observation |
| - related | 0..* | Not Used | BackboneElement | Resource related to this observation |
| - - modifierExtension | 0..* | Not Used | Extension | Extensions that cannot be ignored Constraint (ext-1): Must have either extensions or value[x], not both |
| - - type | 0..1 | Not Used | Code | has-member : derived-from : sequel-to : replaces : qualified-by : interfered-by Binding (required): Codes specifying how two observations are related. ObservationRelationshipType |
| - - target | 1..1 | Not Used | Reference | Resource that is related to this one Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | QuestionnaireResponse | |||
| Not Used | Sequence | |||
| Not Used | CareConnect-Observation-1 | |||
| - - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - component | 0..* | Required | BackboneElement | Component results. Component Assessment scales |
| - - modifierExtension | 0..* | Not Used | Extension | Extensions that cannot be ignored Constraint (ext-1): Must have either extensions or value[x], not both |
| - - code | 1..1 | Required | CodeableConcept | Type of component observation (code / type) Binding (example): Codes identifying names of simple observations. LOINC Codes This example ValueSet is not used by Maternity record. The following SNOMED reference is used Assessment scale observables simple reference set |
| - - coding | 0..* | Required | Coding | Code defined by a terminology system Slicing: Discriminator: code, Ordering: false, Rules: Open |
| - - coding (snomedCT) | 0..1 | Required | Coding | Code defined by a terminology system Binding (extensible): A code from the SNOMED Clinical Terminology UK coding system describing a type of observation CareConnect-ObservationType-1 This SNOMED ValueSet SHOULD be constrained to the ValueSet as indicated in the code element above. |
| - - - extension (snomedCTDescriptionID) | 0..1 | Not Used | Extension-coding-sctdescid | The SNOMED CT Description ID for the display. Constraint (ext-1): Must have either extensions or value[x], not both |
| - - - system | 1..1 | Required | Uri | Identity of the terminology system The element MUST contain the value 'http://snomed.info/sct' |
| - - - code | 1..1 | Required | Code | Symbol in syntax defined by the system A SNOMED concept from the ValueSet indicated. |
| - - - display | 1..1 | Required | String | Representation defined by the system The display associated with the SNOMED CT concept. This SHOULD be the preferred term |
| - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - value[x] | 0..1 | Required | Quantity | Actual component result Constraint (qty-3): If a code for the unit is present, the system SHALL also be present The value of the assessment scales where one is required to recorded. |
| Required | CodeableConcept | |||
| Required | String | |||
| Required | Range | |||
| Not Used | Ratio | |||
| Not Used | SampledData | |||
| Not Used | Attachment | |||
| Not Used | Time | |||
| Not Used | dateTime | |||
| Not Used | Period | |||
| - dataAbsentReason | 0..1 | Not Used | CodeableConcept | Why the component result is missing Binding (extensible): Codes specifying why the result (Observation.value[x]) is missing. Observation Value Absent Reason |
| - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - interpretation | 0..1 | Not Used | CodeableConcept | High, low, normal, etc. Binding (extensible): Codes identifying interpretations of observations. Observation Interpretation Codes |
| - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - referenceRange | 0..* | Not Used | see Observation.referenceRange | Provides guide for interpretation of component result |
Mapping for Assessment Scales Encounter
| > | Level 1 | Encounter Resource | > | Level 2 | CareConnect-Encounter-1 | > | Level 3 | None |
| View Used FHIR Elements | View All FHIR Elements |
| Name | Card. | Conformance | Type | Description, Constraints and mapping for Implementation |
|---|---|---|---|---|
| Encounter | | An interaction during which services are provided to the patient Constraint (dom-2): If the resource is contained in another resource, it SHALL NOT contain nested Resources Constraint (dom-1): If the resource is contained in another resource, it SHALL NOT contain any narrative Constraint (dom-4): If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated Constraint (dom-3): If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource |
||
| - id | 0..1 | Optional | Id | Logical id of this artifact |
| - meta | 0..1 | Mandatory | Meta | Metadata about the resource The value attribute of the profile element MUST contain the value 'https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Encounter-1' |
| - implicitRules | 0..1 | Not Used | Uri | A set of rules under which this content was created |
| - language | 0..1 | Not Used | Code | Language of the resource content Binding (extensible): A human language. Common Languages |
| - text | 0..1 | Not Used | Narrative | Text summary of the resource, for human interpretation |
| - contained | 0..* | Not Used | Resource | Contained, inline Resources |
| - extension (encounterTransport) | 0..1 | Not Used | Extension-CareConnect-EncounterTransport-1 | Encounter transport Constraint (ext-1): Must have either extensions or value[x], not both |
| - extension (outcomeOfAttendance) | 0..1 | Not Used | Extension-CareConnect-OutcomeOfAttendance-1 | An extension to the Encounter resource to record the outcome of an Out-Patient attendance. Constraint (ext-1): Must have either extensions or value[x], not both |
| - extension (emergencyCareDischargeStatus) | 0..1 | Not Used | Extension-CareConnect-EmergencyCareDischargeStatus-1 | An extension to the Encounter resource which is used indicate the status of the Patient on discharge from an Emergency Care Department. Constraint (ext-1): Must have either extensions or value[x], not both |
| - modifierExtension | 0..* | Not Used | Extension | Extensions that cannot be ignored Constraint (ext-1): Must have either extensions or value[x], not both Slicing: Description: Extensions are always sliced by (at least) url, Discriminator: url, Ordering: false, Rules: Open |
| - identifier | 0..* | Required | Identifier | Identifier(s) by which this encounter is known An identifier for this Encounter |
| - - use | 0..1 | Not Used | Code | usual : official : temp : secondary (If known) Binding (required): Identifies the purpose for this identifier, if known. IdentifierUse |
| - - type | 0..1 | Not Used | CodeableConcept | Description of identifier Binding (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes |
| - - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - - system | 1..1 | Required | Uri | The namespace for the identifier value The system from which the identifier came from |
| - - value | 1..1 | Required | String | The value that is unique An identifier for this Assessment scales encounter |
| - - period | 0..1 | Not Used | Period | Time period when id is/was valid for use Constraint (per-1): If present, start SHALL have a lower value than end |
| - - - start | 0..1 | Not Used | dateTime | Starting time with inclusive boundary |
| - - - end | 0..1 | Not Used | dateTime | End time with inclusive boundary, if not ongoing |
| - - assigner | 0..1 | Not Used | Reference | Organization that issued id (may be just text) Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | CareConnect-Organization-1 | |||
| - - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - status | 1..1 | Mandatory | Code | planned : arrived : triaged : in-progress : onleave : finished : cancelled + Binding (required): Current state of the encounter EncounterStatus The status of the Encounter MUST contain the value 'finished' |
| - statusHistory | 0..* | Not Used | BackboneElement | List of past encounter statuses |
| - - modifierExtension | 0..* | Not Used | Extension | Extensions that cannot be ignored Constraint (ext-1): Must have either extensions or value[x], not both |
| - - status | 1..1 | Not Used | Code | planned : arrived : triaged : in-progress : onleave : finished : cancelled + Binding (required): Current state of the encounter EncounterStatus |
| - - period | 1..1 | Not Used | Period | The time that the episode was in the specified status Constraint (per-1): If present, start SHALL have a lower value than end |
| - - - start | 0..1 | Not Used | dateTime | Starting time with inclusive boundary |
| - - - end | 0..1 | Not Used | dateTime | End time with inclusive boundary, if not ongoing |
| - class | 0..1 | Not Used | Coding | Classification of the encounter Binding (extensible): Classification of the encounter ActEncounterCode |
| - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - classHistory | 0..* | Not Used | BackboneElement | List of past encounter classes |
| - - modifierExtension | 0..* | Not Used | Extension | Extensions that cannot be ignored Constraint (ext-1): Must have either extensions or value[x], not both |
| - - class | 1..1 | Not Used | Coding | Classification of the encounter Binding (extensible): Classification of the encounter ActEncounterCode |
| - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - period | 1..1 | Not Used | Period | The time that the episode was in the specified class Constraint (per-1): If present, start SHALL have a lower value than end |
| - - - start | 0..1 | Not Used | dateTime | Starting time with inclusive boundary |
| - - - end | 0..1 | Not Used | dateTime | End time with inclusive boundary, if not ongoing |
| - type | 0..* | Not Used | CodeableConcept | Specific type of encounter Binding (example): The type of encounter EncounterType |
| - - coding | 0..1 | Not Used | Coding | Code defined by a terminology system Slicing: Discriminator: system, Ordering: false, Rules: Open |
| - - coding (snomedCT) | 0..* | Not Used | Coding | Code defined by a terminology system Binding (extensible): A code from the SNOMED Clinical Terminology UK coding system that describes an encounter between a care professional and the patient (or patient’s record). CareConnect-EncounterType-1 |
| - - - extension (snomedCTDescriptionID) | 0..1 | Not Used | Extension-coding-sctdescid | The SNOMED CT Description ID for the display Constraint (ext-1): Must have either extensions or value[x], not both |
| - - - system | 1..1 | Not Used | Uri | Identity of the terminology system |
| - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - code | 1..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - display | 1..1 | Not Used | String | Representation defined by the system |
| - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - priority | 0..1 | Not Used | CodeableConcept | Indicates the urgency of the encounter Binding (example): Indicates the urgency of the encounter. v3 Code System ActPriority |
| - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - subject | 0..1 | Not Used | Reference | The patient or group present at the encounter Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | Group | |||
| Not Used | CareConnect-Patient-1 | |||
| - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - episodeOfCare | 0..* | Not Used | Reference | Episode(s) of care that this encounter should be recorded against Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | EpisodeOfCare | |||
| - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - incomingReferral | 0..* | Not Used | Reference | The ReferralRequest that initiated this encounter Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | ReferralRequest | |||
| - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - participant | 0..* | Not Used | BackboneElement | List of participants involved in the encounter |
| - - modifierExtension | 0..* | Not Used | Extension | Extensions that cannot be ignored Constraint (ext-1): Must have either extensions or value[x], not both |
| - - type | 0..2 | Not Used | CodeableConcept | Role of participant in encounter Binding (extensible): Role of participant in encounter ParticipantType There will be up to two instances of this element, the first carries a reference to the responsible clinical using the Practitioner resource and the second a reference to the person accompanying the patient using the relatedPerson resource |
| - - - coding | 1..1 | Not Used | Coding | Code defined by a terminology system There will be one instance of the coding for each instance of type |
| - - - - system | 1..1 | Not Used | Uri | Identity of the terminology system This MUST contain the value 'http://hl7.org/fhir/ValueSet/encounter-participant-type' |
| - - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - - code | 1..1 | Not Used | Code | Symbol in syntax defined by the system The Responsible Clinician will use a code of 'CON' The Person accompanying patient will use a code of 'ESC' |
| - - - - display | 1..1 | Not Used | String | The Responsible Clinician will use a display of 'consultant' The Person accompanying patient will use a code of 'escort' |
| - - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - - period | 0..1 | Not Used | Period | Period of time during the encounter that the participant participated Constraint (per-1): If present, start SHALL have a lower value than end |
| - - - start | 0..1 | Not Used | dateTime | Starting time with inclusive boundary |
| - - - end | 0..1 | Not Used | dateTime | End time with inclusive boundary, if not ongoing |
| - - individual | 1..1 | Not Used | Reference | Persons involved in the encounter other than the patient Constraint (ref-1): SHALL have a contained resource if a local reference is provided This MUST be a reference to either the Practitioner or RelatedPerson resource |
| Not Used | RelatedPerson | The person accompanying the patient. This MUST use the RelatedPerson resource. See RelatedPerson resource for information on how to populate the resource. |
||
| Not Used | CareConnect-Practitioner-1 | The responsible clinician for the encounter. This MUST use the CareConnect Practitioner profile. See Practitioner resource for information on how to populate the resource. |
||
| - - - reference | 1..1 | Not Used | String | Literal reference, Relative, internal or absolute URL A reference to the RelatedPerson resource or the Practitioner resource included in the Assessment scales list |
| - - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - appointment | 0..1 | Not Used | Reference | The appointment that scheduled this encounter Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | Appointment | |||
| - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - period | 0..1 | Not Used | Period | The start and end time of the encounter Constraint (per-1): If present, start SHALL have a lower value than end |
| - - start | 0..1 | Not Used | dateTime | Starting time with inclusive boundary The date and time of admission Mapping to Maternity data item = 'Date and Time of admission'. |
| - - end | 0..1 | Not Used | dateTime | End time with inclusive boundary, if not ongoing |
| - length | 0..1 | Not Used | Duration | Quantity of time the encounter lasted (less time absent) Constraint (qty-3): If a code for the unit is present, the system SHALL also be present Constraint (drt-1): There SHALL be a code if there is a value and it SHALL be an expression of time. If system is present, it SHALL be UCUM. |
| - - value | 0..1 | Not Used | Decimal | Numerical value (with implicit precision) |
| - - comparator | 0..1 | Not Used | Code | < : <= : >= : > - how to understand the value Binding (required): How the Quantity should be understood and represented. QuantityComparator |
| - - unit | 0..1 | Not Used | String | Unit representation |
| - - system | 0..1 | Not Used | Uri | System that defines coded unit form |
| - - code | 0..1 | Not Used | Code | Coded form of the unit |
| - reason | 0..1 | Not Used | CodeableConcept | Reason the encounter takes place (code) Binding (preferred): Reason why the encounter takes place. Encounter Reason Codes The Assessment scales encounter does not use the preferred value set but uses SNOMED CT concepts instead |
| - - coding | 0..* | Not Used | Coding | Code defined by a terminology system Slicing: Discriminator: system, Ordering: false, Rules: Open |
| - - coding (snomedCT) | 0..1 | Not Used | Coding | Code defined by a terminology system A concept from the Care planning health issues simple reference set See here for further information Note this reference set MAY be extended as required by the sending system |
| - - - extension (snomedCTDescriptionID) | 0..1 | Not Used | Extension-coding-sctdescid | The SNOMED CT Description ID for the display Constraint (ext-1): Must have either extensions or value[x], not both |
| - - - system | 1..1 | Not Used | Uri | Identity of the terminology system The element MUST contain the value 'http://snomed.info/sct' |
| - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - code | 1..1 | Not Used | Code | Symbol in syntax defined by the system A SNOMED CT from the Care planning health issues simple reference set as defined above |
| - - - display | 1..1 | Not Used | String | Representation defined by the system The display associated with the SNOMED CT concept. This SHOULD be the preferred term |
| - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - text | 0..1 | Not Used | String | Plain text representation of the concept This MAY be used where a suitable coded concept is not available to the sending system |
| - diagnosis | 0..* | Not Used | BackboneElement | The list of diagnosis relevant to this encounter |
| - - modifierExtension | 0..* | Not Used | Extension | Extensions that cannot be ignored Constraint (ext-1): Must have either extensions or value[x], not both |
| - - condition | 1..1 | Not Used | Reference | Reason the encounter takes place (resource) Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | CareConnect-Procedure-1 | |||
| Not Used | CareConnect-Condition-1 | |||
| - - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - - role | 0..1 | Not Used | CodeableConcept | Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …) Binding (preferred): The type of diagnosis this condition represents DiagnosisRole |
| - - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - - rank | 0..1 | Not Used | positiveInt | Ranking of the diagnosis (for each role type) |
| - account | 0..* | Not Used | Reference | The set of accounts that may be used for billing for this Encounter Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | Account | |||
| - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - hospitalization | 0..1 | Not Used | BackboneElement | Details about the admission to a healthcare service |
| - - extension (admissionMethod) | 0..1 | Not Used | Extension-CareConnect-AdmissionMethod-1 | An extension to the Encounter resource to record how a Patient was admitted to hospital. Constraint (ext-1): Must have either extensions or value[x], not both An extension to the Encounter resource See Admission method extension for information on how to populate this extension to the resource. Mapping to Maternity data item = 'Reason for Admission'. |
| - - extension (dischargeMethod) | 0..1 | Not Used | Extension-CareConnect-DischargeMethod-1 | An extension to the Encounter resource to record the method of discharge from hospital. Constraint (ext-1): Must have either extensions or value[x], not both |
| - - modifierExtension | 0..* | Not Used | Extension | Extensions that cannot be ignored Constraint (ext-1): Must have either extensions or value[x], not both |
| - - preAdmissionIdentifier | 0..1 | Not Used | Identifier | Pre-admission identifier |
| - - - use | 0..1 | Not Used | Code | usual : official : temp : secondary (If known) Binding (required): Identifies the purpose for this identifier, if known . IdentifierUse |
| - - - type | 0..1 | Not Used | CodeableConcept | Description of identifier Binding (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes |
| - - - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - - - system | 1..1 | Not Used | Uri | The namespace for the identifier value |
| - - - value | 1..1 | Not Used | String | The value that is unique |
| - - - period | 0..1 | Not Used | Period | Time period when id is/was valid for use Constraint (per-1): If present, start SHALL have a lower value than end |
| - - - - start | 0..1 | Not Used | dateTime | Starting time with inclusive boundary |
| - - - - end | 0..1 | Not Used | dateTime | End time with inclusive boundary, if not ongoing |
| - - - assigner | 0..1 | Not Used | Reference | Organization that issued id (may be just text) Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | CareConnect-Organization-1 | |||
| - - - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - - origin | 0..1 | Not Used | Reference | The location from which the patient came before admission Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | CareConnect-Location-1 | |||
| - - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - - admitSource | 0..1 | Not Used | CodeableConcept | From where patient was admitted (physician referral, transfer) Binding (preferred): The source of admission to a Hospital Provider Spell or a Nursing Episode when the Patient is in a Hospital Site or a Care Home. CareConnect-SourceOfAdmission-1 Mapping to Maternity data item = 'Source of Admission' |
| - - - coding | 0..1 | Not Used | Coding | Code defined by a terminology system |
| - - - - system | 1..1 | Not Used | Uri | Identity of the terminology system |
| - - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - - code | 1..1 | Not Used | Code | Symbol in syntax defined by the system This MUST contain the value 'https://fhir.hl7.org.uk/STU3/ValueSet/CareConnect-SourceOfAdmission-1' |
| - - - - display | 1..1 | Not Used | String | Representation defined by the system This MUST contain a code from the stated ValueSet |
| - - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - - reAdmission | 0..1 | Not Used | CodeableConcept | The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission Binding (example): The reason for re-admission of this hospitalization encounter. v2 Re-Admission Indicator |
| - - - coding | 0..* | Not Used | Coding | Code defined by a terminology system Slicing: Discriminator: system, Ordering: false, Rules: Open |
| - - - coding (snomedCT) | 0..1 | Not Used | Coding | Code defined by a terminology system |
| - - - - extension (snomedCTDescriptionID) | 0..1 | Not Used | Extension-coding-sctdescid | The SNOMED CT Description ID for the display Constraint (ext-1): Must have either extensions or value[x], not both |
| - - - - system | 1..1 | Not Used | Uri | Identity of the terminology system The element MUST contain the value 'http://snomed.info/sct' |
| - - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - - code | 1..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - - display | 1..1 | Not Used | String | Representation defined by the system |
| - - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - - dietPreference | 0..* | Not Used | CodeableConcept | Diet preferences reported by the patient Binding (extensible): Medical, cultural or ethical food preferences to help with catering requirements. Diet |
| - - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - - specialCourtesy | 0..* | Not Used | CodeableConcept | Special courtesies (VIP, board member) Binding (preferred): Special courtesies SpecialCourtesy |
| - - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - - specialArrangement | 0..* | Not Used | CodeableConcept | Wheelchair, translator, stretcher, etc. Binding (preferred): Special arrangements SpecialArrangements |
| - - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - - destination | 0..1 | Not Used | Reference | Location to which the patient is discharged Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | CareConnect-Location-1 | |||
| - - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - - dischargeDisposition | 0..1 | Not Used | CodeableConcept | Category or kind of location after discharge Binding (example): The destination of a Patient on completion of a Hospital Provider Spell, or a note that the Patient died or was a still birth. CareConnect-DischargeDestination-1 |
| - - - coding | 0..* | Not Used | Coding | Code defined by a terminology system |
| - - - - system | 0..1 | Not Used | Uri | Identity of the terminology system |
| - - - - version | 0..1 | Not Used | String | Version of the system - if relevant |
| - - - - code | 0..1 | Not Used | Code | Symbol in syntax defined by the system |
| - - - - display | 0..1 | Not Used | String | Representation defined by the system |
| - - - - userSelected | 0..1 | Not Used | Boolean | If this coding was chosen directly by the user |
| - - - text | 0..1 | Not Used | String | Plain text representation of the concept |
| - location | 0..1 | Required | BackboneElement | List of locations where the patient has been |
| - - modifierExtension | 0..* | Not Used | Extension | Extensions that cannot be ignored Constraint (ext-1): Must have either extensions or value[x], not both |
| - - location | 1..1 | Mandatory | Reference | Location the encounter takes place Constraint (ref-1): SHALL have a contained resource if a local reference is provided The site code of the unit to which the person was admitted |
| Mandatory | CareConnect-Location-1 | The location This MUST use the CareConnect Location profile. See Location resource for information on how to populate the resource.” |
||
| - - - reference | 1..1 | Mandatory | String | Literal reference, Relative, internal or absolute URL A reference to the Location resource included in the Assessment scales list |
| - - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - - status | 0..1 | Not Used | Code | planned : active : reserved : completed Binding (required): The status of the location. EncounterLocationStatus |
| - - period | 0..1 | Not Used | Period | Time period during which the patient was present at the location Constraint (per-1): If present, start SHALL have a lower value than end |
| - - - start | 0..1 | Not Used | dateTime | Starting time with inclusive boundary |
| - - - end | 0..1 | Not Used | dateTime | End time with inclusive boundary, if not ongoing |
| - serviceProvider | 0..1 | Not Used | Reference | The custodian organization of this Encounter record Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | CareConnect-Organization-1 | |||
| - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - display | 0..1 | Not Used | String | Text alternative for the resource |
| - partOf | 0..1 | Not Used | Reference | Another Encounter this encounter is part of Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Not Used | CareConnect-Encounter-1 | |||
| - - reference | 0..1 | Not Used | String | Literal reference, Relative, internal or absolute URL |
| - - identifier | 0..1 | Not Used | Identifier | Logical reference, when literal reference is not known |
| - - display | 0..1 | Not Used | String | Text alternative for the resource |
Patient Reference
The assessment scales details list has a mandated subject reference to the Patient resource. This means that any exchange of the assessment scales details heading data must also include the Patient demographics List.
Mapping for Assessment Scales Location
The assessment scales details has reference(s) to the Location resource. This means that any exchange of the assessment scales details heading data must also include the Location Details.
Mapping for Assessment Scales Practitioner
The assessment scales details has reference(s) to the Practitioner resource. This means that any exchange of the assessment scales details heading data must also include the Practitioner Details.
Mapping for Assessment Scales PractitionerRole
The assessment scales details has reference(s) to the Practitioner Role resource. This means that any exchange of the assessment scales details heading data must also include the Practitioner Role Details.
