This page is part of the Clinical Guidelines (v2.0.0-ballot: STU2 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

Common Care Pathway

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NOTE: This is a proposed common pathway for ambulatory care processes. —

Establish Patient Identity

Identifying and recording the subject of care.

Retrieve Patient Health Summary

Retrieving a summary of the patient’s health.

Triage

Performing basic triage to identify any signs that emergency care is required

Emergency: Escalate Care

Providing emergency care in trauma cases or as part of guideline-based care escalation.

Invoke Applicable CCGs

Invoking the CCGs (Clinical Commissioning Groups) that are applicable to the situation.

Provide Counseling

Informing the subject of care about their treatment options and about how their ongoing care should be managed between visits. This is also where treatment consents are obtained and where health education is provided.

Record Observations

Gathering clinical history and performing and recording observations regarding the patient’s health (e.g. blood pressure, temperature, etc.).

Order Tests

Ordering and conducting diagnostic tests, including lab tests, collection of samples, and other diagnostic tests. Lab testing may be done locally (e.g. HIV quick test) or the samples may require lab order fulfillment workflow.

Evaluate Test Results

Using available information from the patient’s history, current examinations, tests, and assessments to assist in developing a diagnosis.

Record Diagnosis

Recording the diagnosis that was reached in the evaluation process.

Order Interventions

Ordering the necessary interventions.

Provide Interventions

Providing the interventions to the patient.

Order Medications

Clinicians ordering medications to be dispensed by a pharmacy. Pharmacies may be local to the care facility or community-based, and involves supply chain transactions to support medication management.

Dispense Medications

Administering medications to the patient.

Establish Monitoring and Follow-up

Monitoring and tracking progress for each patient based on guideline recommendations.

Discharge/Refer Patient

Discharging or referring a patient, including the movement of patients through levels of care delivery (e.g. acute to primary, primary to community, etc.) or the enrollment of patients in guideline-based care programs (e.g. HIV, maternal, diabetes, injury rehabilitation, etc.).

Update Digital Client Record

Updating the Digital Client Record with the appropriate information

Generate Reportable Indicators

Recording and reporting patient-specific care management information which may be aggregated to develop reportable system management indicators at the provider, facility, district, national, and international levels.