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Outpatient Letter Headings

Overview of the Outpatient Letter headings


This section provides a list of the PRSB headings used for text sections in the ITK3 FHIR Outpatient Letter based on the “Standards for the clinical structure and content of patient records” documentation.

This section lists the following

  • The headings used
  • An overview of the type of information carried within the text section
  • An example of a text section instance
  • A list of the coded resources which may be used to give the text carried in the section in a coded format.

Typical Text Section Content

This diagram shows the elements of a typical text section which is found in the FHIR Composition Resource. Note: the examples of section HTML in this specification show only example HTML format such as tables. This is an exemplar format. There is no mandated format for the section HTML.

Must Support Property

Some elements in the the Composition Resource used within ITK3 Transfer of Care documents have the must support property set to “true” These are :

  • Composition.extension(careSettingTypeExtension)
  • Composition.identifier
  • Composition.status
  • Composition.type
  • Composition.subject
  • Composition.encounter
  • Composition.title
  • Composition.custodian
  • Composition.relatesTo
  • Composition.section(slice) Where slice=The PRSB headings for the ITK3 Transfer of Care document type.

The “must support” property has been added to all the elements that must be supported regardless of cardinality. Whether the conformance of the element is mandatory or optional has no relevance for the “must support” property. This means that for sending or receiving systems to claim conformance to any ITK3 Transfer of Care Composition Profile the following MUST be true:

  • The sending system MUST support the creation and sending of all the elements in the list above.
  • The sending system MUST support the creation and sending of all Composition.section slices with the specified sub-elements and narrative.* See Note 1.
  • The receiving system MUST support the processing of all the elements in the list above.
  • The receiving system MUST support the display of all Composition.section slices with the specified sub-elements and narrative.

Note 1 - There are rules around when sections are sent or not sent in a document. These are specified in the document headings sections.

Headings Used By Outpatient Letter

Section Name SNOMED Concept Cardinality Conformance Associated Coded Profiles
Allergies and adverse reactions 886921000000105 1..1 Mandatory 2
Assessment scales 887141000000103 0..1 Optional 0
Attendance details 1077881000000105 1..1 Mandatory 0
Clinical review of systems 1077901000000108 0..1 Optional 0
Clinical summary 887181000000106 1..1 Mandatory 0
Diagnoses 887161000000102 0..1 Required 2
Distribution list 887261000000109 0..1 Required 4
Examination findings 715851000000102 0..1 Optional 2
Family history 887111000000104 0..1 Optional 0
GP practice 886711000000101 1..1 Mandatory 2
History 717121000000105 0..1 Required 0
Individual requirements 1078911000000106 0..1 Required 0
Information and advice given 1052951000000105 0..1 Required 0
Investigation results 1082101000000102 0..1 Optional 0
Legal information 886961000000102 0..1 Required 0
Medications and medical devices 933361000000108 0..1 Optional 2
Participation in research 886751000000102 0..1 Required 0
Patient and carer concerns,expectations and wishes 1052941000000107 0..1 Optional 0
Patient demographics 886731000000109 1..1 Mandatory 1
Person completing record 887231000000104 1..1 Mandatory 0
Plan and requested actions 887201000000105 0..1 Required 0
Problems and issues 887151000000100 0..1 Required 2
Procedures 887171000000109 0..1 Required 2
Referrer details 1052891000000108 0..1 Required 0
Relevant clinical risk factors 886821000000100 0..1 Optional 0
Safety alerts 886931000000107 0..1 Required 0
Social context 887051000000101 0..1 Optional 0

Overview of Outpatient Letter Sections and Coded profiles

This diagram illustrates the sections used in Outpatient Letter and which sections allow coded representation of the section text.

Click to open in new window

The text sections are carried in the FHIR Composition Resource. This is profiled as the ITK-OPL-Compostion

Tags: fhir

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