8.13 Resource Flag - Content

8.13.1 Scope and Usage

A flag is a warning or notification of some sort presented to the user - who may be a clinician or some other person involve in patient care. It usually represents something of sufficient significance to warrant a special display of some sort - rather than just a note in the resource. A flag has a subject representing the resource that will trigger its display. This subject can be of different types, as described in the examples below:

• A note that a patient has an overdue account, which the provider may wish to discuss with them - in case of hardship for example (subject = Patient)
• An outbreak of Ebola in a particular region (subject=Location) so that all patients from that region have a higher risk of having that condition
• A particular provider is unavailable for referrals over a given period (subject = Practitioner)
• A patient who is enrolled in a clinical trial (subject=Group)
• Special guidance or caveats to be aware of when following a protocol (subject=PlanDefinition)
• Warnings about using a drug in a formulary requires special approval (subject=Medication)
• etc.

A flag is typically presented as a label in a prominent location in the record to notify the clinician of the potential issues, though it may also appear in other contexts; e.g. notes applicable to a radiology technician, or to a clinician performing a home visit. For patients, the information in the flag will often be derived from the record, and therefore, for a thorough and careful clinician, who has the time to review the notes will be redundant. However, given the volume of information frequently found in patients' records and the potentially serious consequences of losing sight of some facts, this redundancy is deemed appropriate. As well, some flags may reflect information not captured by any other resource in the record. (E.g. "Patient has large dog at home")

In line with its purpose, a flag is concise, highlighting a small set of high-priority issues among the much larger set of data in the chart. Readers who want more detail should consult the chart or other source of information. Caution should be exercised in creating Flag instances. If entries are created for information that could be gleaned in a sufficiently timely fashion by reviewing the patient record, the flag list will itself become overwhelming and will cease to serve its intended purpose.

Flags are expected to persist in a record for some period of time and are, at most, targeted to particular types of practitioners or to practitioners in particular system.

Examples of Patient related issues that might appear in flags:

• Risks to the patient (functional risk of falls, spousal restraining order, latex allergy)
• Patient's needs for special accommodations (hard of hearing, need for easy-open caps)
• Risks to providers (dog in house, patient may bite, infection control precautions)
• Administrative concerns (incomplete information, pre-payment required due to credit risk)

Examples of issues that should not appear only in flags:

• Potential allergy or drug interaction to planned therapy (use DetectedIssue)
• Known adverse reaction to a substance (use AllergyIntolerance)

Note that we include "latex allergy" in the "in scope" list, and "allergy" in the "not in scope" list. The Flag resource is not designed to replace the normal order checking process, and one should not expect to see all allergies in Flags. However, if there is an activity that might occur prior to careful evaluation of the record (e.g. donning of latex gloves) and that activity might pose a risk to the patient, that is the sort of eventuality the Flag is intended to support.

Specific guidelines about what type of information is appropriate to expose using Flag, as well as what categories of individuals should see particular flags, will vary by interoperability community.

8.13.2 Boundaries and Relationships

Flags may highlight a highly condensed view of information found in the AllergyIntolerance, Condition, Observation, Procedure and possibly other resources. A common extension allows the linkage of a Flag to the supporting detail resource. The purpose of these other resources is to provide detailed clinical information. The purpose of a Flag is to alert practitioners to information that is important to influence their interaction with a Patient prior to detailed review of the record.

Flags are not used to convey information to a specific individual or organization (e.g. an abnormal lab result reported to the ordering clinician, reporting of an adverse reaction to a regulatory authority). These are handled using the CommunicationRequest and the Communication resources.

Flags are not raised as a result of a reported or proposed action (e.g. drug-drug interactions, duplicate therapy warnings). These would be handled using DetectedIssue.

• Structure
• UML
• XML
• JSON
• Turtle
• R3 Diff
• All

Structure

Name	Flags	Card.	Type	Description & Constraints
Flag	TU		DomainResource	Key information to flag to healthcare providers Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
identifier	Σ	0..*	Identifier	Business identifier
status	?!Σ	1..1	code	active | inactive | entered-in-error FlagStatus (Required)
category	Σ	0..*	CodeableConcept	Clinical, administrative, etc. Flag Category (Example)
code	Σ	1..1	CodeableConcept	Coded or textual message to display to user Flag Code (Example)
subject	Σ	1..1	Reference(Patient | Location | Group | Organization | Practitioner | PractitionerRole | PlanDefinition | Medication | Procedure)	Who/What is flag about?
period	Σ	0..1	Period	Time period when flag is active
encounter	Σ	0..1	Reference(Encounter)	Alert relevant during encounter
author	Σ	0..1	Reference(Device | Organization | Patient | Practitioner | PractitionerRole)	Flag creator
Documentation for this format

<Flag xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business identifier --></identifier>
 <status value="[code]"/><!-- 1..1 active | inactive | entered-in-error -->
 <category><!-- 0..* CodeableConcept Clinical, administrative, etc. --></category>
 <code><!-- 1..1 CodeableConcept Coded or textual message to display to user --></code>
 <subject><!-- 1..1 Reference(Group|Location|Medication|Organization|Patient|
   PlanDefinition|Practitioner|PractitionerRole|Procedure) Who/What is flag about? --></subject>
 <period><!-- 0..1 Period Time period when flag is active --></period>
 <encounter><!-- 0..1 Reference(Encounter) Alert relevant during encounter --></encounter>
 <author><!-- 0..1 Reference(Device|Organization|Patient|Practitioner|
   PractitionerRole) Flag creator --></author>
</Flag>

{
  "resourceType" : "Flag",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business identifier
  "status" : "<code>", // R!  active | inactive | entered-in-error
  "category" : [{ CodeableConcept }], // Clinical, administrative, etc.
  "code" : { CodeableConcept }, // R!  Coded or textual message to display to user
  "subject" : { Reference(Group|Location|Medication|Organization|Patient|
   PlanDefinition|Practitioner|PractitionerRole|Procedure) }, // R!  Who/What is flag about?
  "period" : { Period }, // Time period when flag is active
  "encounter" : { Reference(Encounter) }, // Alert relevant during encounter
  "author" : { Reference(Device|Organization|Patient|Practitioner|
   PractitionerRole) } // Flag creator
}

@prefix fhir: <http://hl7.org/fhir/> .


[ a fhir:Flag;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:Flag.identifier [ Identifier ], ... ; # 0..* Business identifier
  fhir:Flag.status [ code ]; # 1..1 active | inactive | entered-in-error
  fhir:Flag.category [ CodeableConcept ], ... ; # 0..* Clinical, administrative, etc.
  fhir:Flag.code [ CodeableConcept ]; # 1..1 Coded or textual message to display to user
  fhir:Flag.subject [ Reference(Group|Location|Medication|Organization|Patient|PlanDefinition|Practitioner|
  PractitionerRole|Procedure) ]; # 1..1 Who/What is flag about?
  fhir:Flag.period [ Period ]; # 0..1 Time period when flag is active
  fhir:Flag.encounter [ Reference(Encounter) ]; # 0..1 Alert relevant during encounter
  fhir:Flag.author [ Reference(Device|Organization|Patient|Practitioner|PractitionerRole) ]; # 0..1 Flag creator
]

Structure

Name	Flags	Card.	Type	Description & Constraints
Flag	TU		DomainResource	Key information to flag to healthcare providers Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
identifier	Σ	0..*	Identifier	Business identifier
status	?!Σ	1..1	code	active | inactive | entered-in-error FlagStatus (Required)
category	Σ	0..*	CodeableConcept	Clinical, administrative, etc. Flag Category (Example)
code	Σ	1..1	CodeableConcept	Coded or textual message to display to user Flag Code (Example)
subject	Σ	1..1	Reference(Patient | Location | Group | Organization | Practitioner | PractitionerRole | PlanDefinition | Medication | Procedure)	Who/What is flag about?
period	Σ	0..1	Period	Time period when flag is active
encounter	Σ	0..1	Reference(Encounter)	Alert relevant during encounter
author	Σ	0..1	Reference(Device | Organization | Patient | Practitioner | PractitionerRole)	Flag creator
Documentation for this format

UML Diagram (Legend)

XML Template

<Flag xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business identifier --></identifier>
 <status value="[code]"/><!-- 1..1 active | inactive | entered-in-error -->
 <category><!-- 0..* CodeableConcept Clinical, administrative, etc. --></category>
 <code><!-- 1..1 CodeableConcept Coded or textual message to display to user --></code>
 <subject><!-- 1..1 Reference(Group|Location|Medication|Organization|Patient|
   PlanDefinition|Practitioner|PractitionerRole|Procedure) Who/What is flag about? --></subject>
 <period><!-- 0..1 Period Time period when flag is active --></period>
 <encounter><!-- 0..1 Reference(Encounter) Alert relevant during encounter --></encounter>
 <author><!-- 0..1 Reference(Device|Organization|Patient|Practitioner|
   PractitionerRole) Flag creator --></author>
</Flag>

JSON Template

{
  "resourceType" : "Flag",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business identifier
  "status" : "<code>", // R!  active | inactive | entered-in-error
  "category" : [{ CodeableConcept }], // Clinical, administrative, etc.
  "code" : { CodeableConcept }, // R!  Coded or textual message to display to user
  "subject" : { Reference(Group|Location|Medication|Organization|Patient|
   PlanDefinition|Practitioner|PractitionerRole|Procedure) }, // R!  Who/What is flag about?
  "period" : { Period }, // Time period when flag is active
  "encounter" : { Reference(Encounter) }, // Alert relevant during encounter
  "author" : { Reference(Device|Organization|Patient|Practitioner|
   PractitionerRole) } // Flag creator
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .


[ a fhir:Flag;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:Flag.identifier [ Identifier ], ... ; # 0..* Business identifier
  fhir:Flag.status [ code ]; # 1..1 active | inactive | entered-in-error
  fhir:Flag.category [ CodeableConcept ], ... ; # 0..* Clinical, administrative, etc.
  fhir:Flag.code [ CodeableConcept ]; # 1..1 Coded or textual message to display to user
  fhir:Flag.subject [ Reference(Group|Location|Medication|Organization|Patient|PlanDefinition|Practitioner|
  PractitionerRole|Procedure) ]; # 1..1 Who/What is flag about?
  fhir:Flag.period [ Period ]; # 0..1 Time period when flag is active
  fhir:Flag.encounter [ Reference(Encounter) ]; # 0..1 Alert relevant during encounter
  fhir:Flag.author [ Reference(Device|Organization|Patient|Practitioner|PractitionerRole) ]; # 0..1 Flag creator
]

Changes since Release 3

Flag
Flag.status	Change value set from http://hl7.org/fhir/ValueSet/flag-status|4.0.0 to http://hl7.org/fhir/ValueSet/flag-status|4.2.0
Flag.subject	Type Reference: Added Target Type PractitionerRole

See the Full Difference for further information

This analysis is available as XML or JSON.

See R3 <--> R4 Conversion Maps (status = 2 tests that all execute ok. All tests pass round-trip testing and all r3 resources are valid.)