Gives information about the Clinical Narrative section

Important: This specification is based on the Professional Records Standards Body's Pharmacy information flows standard which provides further information on document headings and content: https://theprsb.org/standards/pharmacyinformationflows1and2/

Clinical Narrative Section Content

The Clinical Narrative section carries information about the Clinical Narrative details used. PRSB Elements should be formatted as subheadings in any HTML sent.

CLINICAL NARRATIVE
Data Item	Description	Cardinality	Values	Mandatory/required/ optional	FHIR Target
Clinical narrative	A description detailing a patient’s reason for attendance, any red flags, results from the diagnostic and treatment process.	1 ONLY	Free text	Mandatory	Composition.section.text
CKS Checked	Confirmation Yes/No whether the Clinical Knowledge Summaries were checked as part of the referral		Options - “Yes”, “No”	Mandatory	Composition.section.text
Red Flags	Confirmation Yes/No whether the presence of clinical Red Flags were checked as part of the referral		Options - “Yes”, “No”	Mandatory	Composition.section.text
Red Flag Details	Details captured as to the Clinical Red Flags identified if the Red Flags were identified as “Yes”		Free text data entry	Mandatory	Composition.section.text
Consultation Pharmacist Notes	Consultation notes from the pharmacist consultation, in addition to that captured from the referring organisation referral discussion with the patient		Free text data entry	Mandatory	Composition.section.text
Consultation Outcome	The Patient outcome of the referral to Community Pharmacy			Mandatory	Composition.section.text
Consent For Onward Referral	Confirmation of consent for onward referral to Pharmacy		Options - “Yes”, “No”	Mandatory	Composition.section.text
GP Notification Form - Referrals for low acuity/minor illness: notification status	Confirmation audit trail that the Post Event Message (PEM) has been sent to the patient’s GP Practice once the referral is recorded as “Completed”			Mandatory	Composition.section.text
Incident	Record of whether the pharmacy is logging feedback on the referral which relates to an incident (or potential incident)		Options - “Yes”, “No”	Mandatory	Composition.section.text
Incident Pharmacist Feedback	Details captured of the incident feedback reported as “Yes”		Free text data entry	Mandatory	Composition.section.text
Survey Consent	Capturing of consent to participate in a patient survey on the Service		Options - “Yes”, “No”	Mandatory	Composition.section.text
Patient Survey information: notification status	Confirmation audit trail that the Patient Survey has been sent to the patient			Mandatory	Composition.section.text

Example Clinical Narrative Section

Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.

<!--<xml>-->
<!--Clinical Narrative-->
	<section>
		<title value="Clinical Narrative"/>
		<code>
			<coding>
				<system value="http://snomed.info/sct"/>
				<code value="1077901000000108"/>
				<display value="Clinical narrative"/>
			</coding>
		</code>
		<text>
			<status value="additional"/>
			<div xmlns="http://www.w3.org/1999/xhtml">
			<table width="100%">
				<tbody>
				<tr>
					<th>Clinical Narrative</th>
					<td>A description detailing a patient’s reason for attendance, any red flags, results from the diagnostic and treatment process.</td>
				</tr>
				</tbody>
			</table>
			</div>
		</text>
	</section>
<!--</xml>-->

Tags: fhir