Clinical - FHIR v1.0.0

DSTU2 QA Preview

This page is part of the FHIR Specification (v1.0.0: DSTU 2 Ballot 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

4.0 Clinical Resources

FHIR Infrastructure

Work Group

Maturity Level: N/A

Ballot Status: DSTU 2

General

Resources that provide core clinical record keeping - focused on the content of the provider/patient encounter
Name	Aliases	Description
AllergyIntolerance	Allergy, Intolerance	Risk of harmful or undesirable, physiological response which is unique to an individual and associated with exposure to a substance.
ClinicalImpression		A record of a clinical assessment performed to determine what problem(s) may affect the patient and before planning the treatments or management strategies that are best to manage a patient's condition. Assessments are often 1:1 with a clinical consultation / encounter, but this varies greatly depending on the clinical workflow. This resource is called "ClinicalImpression" rather than "ClinicalAssessment" to avoid confusion with the recording of assessment tools such as Apgar score.
Condition		Use to record detailed information about conditions, problems or diagnoses recognized by a clinician. There are many uses including: recording a Diagnosis during an Encounter; populating a problem List or a Summary Statement, such as a Discharge Summary.
ProcedureRequest		A request for a procedure to be performed. May be a proposal or an order.
Procedure		An action that is or was performed on a patient. This can be a physical 'thing' like an operation, or less invasive like counseling or hypnotherapy.
ReferralRequest	ReferralRequest TransferOfCare Request	Used to record and send details about a request for referral service or transfer of a patient to the care of another provider or provider organisation.
RiskAssessment	Prognosis	An assessment of the likely outcome(s) for a patient or other subject as well as the likelihood of each outcome.

Care Provision
Care planning, tracking care provided
Name	Aliases	Description
CarePlan	Care Team	Describes the intention of how one or more practitioners intend to deliver care for a particular patient, group or community for a period of time, possibly limited to care for a specific condition or set of conditions.
Goal		Describes the intended objective(s) for a patient, group or organization care, for example, weight loss, restoring an activity of daily living, obtaining herd immunity via immunization, meeting a process improvement objective, etc.;.
DetectedIssue	DDI, drug-drug interaction, Contraindication	Indicates an actual or potential clinical issue with or between one or more active or proposed clinical actions for a patient. E.g. Drug-drug interaction, Ineffective treatment frequency, Procedure-condition conflict, etc.
FamilyMemberHistory		Significant health events and conditions for a person related to the patient relevant in the context of care for the patient.
NutritionOrder	Diet Order, Diet, Nutritional Supplement	A request to supply a diet, formula feeding (enteral) or oral nutritional supplement to a patient/resident.
VisionPrescription		An authorization for the supply of glasses and/or contact lenses to a patient.

Medication, Immunization
Support the medication & immunization processes
Name	Aliases	Description
Medication		This resource is primarily used for the identification and definition of a medication. It covers the ingredients and the packaging for a medication.
MedicationOrder	Prescription	An order for both supply of the medication and the instructions for administration of the medication to a patient. The resource is called "MedicationOrder" rather than "MedicationPrescription" to generalize the use across inpatient and outpatient settings as well as for care plans, etc.
MedicationAdministration		Describes the event of a patient consuming or otherwise being administered a medication. This may be as simple as swallowing a tablet or it may be a long running infusion. Related resources tie this event to the authorizing prescription, and the specific encounter between patient and health care practitioner.
MedicationDispense		Indicates that a medication product is to be or has been dispensed for a named person/patient. This includes a description of the medication product (supply) provided and the instructions for administering the medication. The medication dispense is the result of a Pharmacy system responding to a Medication Order.
MedicationStatement		A record of a medication that is being consumed by a patient. A medication statements may indicate that the patient may be taking the medication now, or has taken the medication in the past or will be taking the medication in the future. The source of this information can be the patient, significant other (such as a family member or spouse), or a clinician. A common scenario where this information is captured is during the history taking process during a patient visit or stay. The medication information may come from e.g. the patients’ memory, from a prescription bottle, or from a list of medications the patient, clinician or other party maintains. The primary difference between a medication statement and a medication administration is that the medication administration has complete administration information and is based on actual administration information from the person who administered the medication. A medication statement is often, if not always less specific. There is no required date/time when the medication was administered, in fact we only know that a source has reported the patient is taking this medication, where details such as time, quantity, or rate or even medication product may be incomplete or missing or less precise. As stated earlier, the Medication Statement information may come from the patient’s memory, from a prescription bottle or from a list of medications the patient, clinician or other party maintains. Medication Administration is more formal and is not missing detailed information.
Immunization		Describes the event of a patient being administered a vaccination or a record of a vaccination as reported by a patient, a clinician or another party and may include vaccine reaction information and what vaccination protocol was followed.
ImmunizationRecommendation		A patient’s point-in-time immunization and recommendation (i.e. forecasting a patient’s immunization eligibility according to a published schedule) with optional supporting justification.

Diagnostics
Provider support for diagnostic services - lab, pathology, imaging, etc
Name	Aliases	Description
Observation	Vital Signs, Measurement, Results	Measurements and simple assertions made about a patient, device or other subject.
DiagnosticReport	Report, Test, Result, Results, Labs	The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretation, and formatted representation of diagnostic reports.
DiagnosticOrder		A record of a request for a diagnostic investigation service to be performed.
ImagingStudy		Representation of the content produced in a DICOM imaging study. A study comprises a set of Series, each of which includes a set of Service-Object Pair Instances (SOP Instances - images or other data) acquired or produced in a common context. A Series is of only one modality (e.g., X-ray, CT, MR, ultrasound), but a Study may have multiple Series of different modalities.
ImagingObjectSelection	Manifest, XDS-I summary, Key Images	A manifest of a set of DICOM Service-Object Pair Instances (SOP Instances). The referenced SOP Instances (images or other content) are for a single patient, and may be from one or more studies. The referenced SOP Instances have been selected for a purpose, such as quality assurance, conference, or consult. Reflecting that range of purposes, typical ImagingObjectSelection resources may include all SOP Instances in a study (perhaps for sharing through a Health Information Exchange); key images from multiple studies (for reference by a referring or treating physician); a multi-frame ultrasound instance ("cine" video clip) and a set of measurements taken from that instance (for inclusion in a teaching file); and so on.
Specimen		Sample for analysis.
BodySite	anatomical location	Record details about the anatomical location of a specimen or body part. This resource may be used when a coded concept does not provide the necessary detail needed for the use case.

Additional Resources will be added in the future. A list of hypothesized resources can be found on the HL7 wiki . Feel free to add any you think are missing or engage with one of the HL7 Work Groups to submit a proposal to define a resource of particular interest.