Inbound Data Transform Specifications: Difference between revisions

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{{TOC right}}
== Introduction ==
== Introduction ==
This article forms the basis of the technical implementation of any new inbound transform of data into the Discovery Data Service (DDS), specifically for non-transactional flat file formats.  
This article forms the basis of the technical implementation of any new inbound transform of data into the Discovery Data Service (DDS), specifically for non-transactional flat file formats.  
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The aim is to ask potential publishers to consider and answer the following questions:
The aim is to ask potential publishers to consider and answer the following questions:


* How will the source data be sent to DDS? Will it be an SFTP push or pull? Will the files be encrypted?
* How will the source data be sent to DDS? Will it be an SFTP push or pull? Will the files be encrypted? See [[Secure publication to the DDS]] for currently supported options.
* How often will the source data be sent to DDS? Will it be sent in a daily extract?
* How often will the source data be sent to DDS? Will it be sent in a daily extract? See [[Latency of extract data feeds]] to see how often and when data is currently received, and how that relates to the data available in the DDS.
* How should the source data be mapped to the FHIR-based DDS data format? What file contains patient demographics? What column contains first name? What column contains middle names?
* How should the source data be mapped to the FHIR-based DDS data format? What file contains patient demographics? What column contains first name? What column contains middle names? See [[Publishers and mapping to the common model]] for more information.
* How should any value sets should be mapped to equivalent DDS value sets? What values are used for different genders and what FHIR gender does each map to?
* How should any value sets should be mapped to equivalent DDS value sets? What values are used for different genders and what FHIR gender does each map to?
* What clinical coding systems are used? Are clinical observations recorded using SNOMED CT, CTV3, Read2, ICD-10, OPCS-4 or some other nationally or locally defined system?
* What clinical coding systems are used? Are clinical observations recorded using SNOMED CT, CTV3, Read2, ICD-10, OPCS-4 or some other nationally or locally defined system?
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* What files require bulk dumps for the first extract and which will start from a point in time? Will a full dump of organisational data be possible? Will a full dump of master patient list be possible?
* What files require bulk dumps for the first extract and which will start from a point in time? Will a full dump of organisational data be possible? Will a full dump of master patient list be possible?
* Is there any overlap with an existing transform supported by DDS? Does the feed include any national standard file that DDS already supports?
* Is there any overlap with an existing transform supported by DDS? Does the feed include any national standard file that DDS already supports?
Questions that need to be answered are highlighted throughout this article: 
{{Question| This is a question that needs to be answered.}}


The understanding of the answers provided can then be used by the DDS technical team to implement the technical transformation for the source data.  
The understanding of the answers provided can then be used by the DDS technical team to implement the technical transformation for the source data.  
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Completion and sign off of the specifications is a collaborative process, involving the data publisher (or their representatives) and the DDS technical team; the data publisher has a greater understanding of their own data, and the DDS technical team have experience of multiple and differing transformations.
Completion and sign off of the specifications is a collaborative process, involving the data publisher (or their representatives) and the DDS technical team; the data publisher has a greater understanding of their own data, and the DDS technical team have experience of multiple and differing transformations.


<br />
== DDS inbound overview ==
[[File:Inbound view.png|640x640px|alt=|DDS inbound overview|thumb|none]]
This diagram provides an overview of the way the DDS processes a sample of existing inbound data feeds. Each data publisher has their own transport mechanism for getting data into the DDS estate (SFTP push, SFTP pull, bespoke software) which is then sent through a common pipeline that performs a number of checks (most importantly validating that DDS has a data processing agreement to accept the data). Once the checks are passed, the data is handed over to the DDS transformation application, that then invokes the relevant transform code for the published data format. The result of the transformation code is standardised FHIR that is saved to the DDS database; this may be further transformed for any subscribers to that publisher’s data.
 
Unless there are exceptional circumstances that preclude it, all DDS software is written in Java, running on Ubuntu.
 
{{Note| the image represents the logical flow of data into the DDS, rather than the distinct software components themselves.}}
 
== Publishing process ==
The end to end process for publishing new data into the DDS generally follows the below steps. This isn’t necessarily a fixed-order list, as many of the steps can be performed out of order or in parallel to other steps, but it covers all the actions that need to happen.
 
# Agree extract transport mechanism and frequency.
#Define project phases based on data types and dependencies.
#Set up transport mechanism and test (this can be done at any point before live data is sent).
#For the first phase:
## Provide file extract format specification.
##Provide sample data.
##Validate and assure the published data.
##Define how inserts, updates and deletes are represented.
##Define transformation mapping.
##List any known special cases.
##Sign off transform specification document.
##Implement transform code to specification.
##Validate and assure new code using sample data (if possible).
##Start live feed of data, bulk followed by deltas (data will be securely stored but won’t flow into production DDS yet).
##Validate and assure code using subset of live data (in secure pre-production environment).
##Deploy new code to production DDS and start processing data.
##At this point, this phase is now considered live.
# If required, repeat step 4 for the subsequent phases.
 
== Assurance and sign-off ==
Assurance and sign-off is required at three distinct stages of the publishing process:
 
=== Extract assurance ===
The data publisher must assure that their data extract accurately represents the data in the source clinical software.
 
How this assurance is done will vary from publisher to publisher, although the DDS team may be able to provide some guidance on how to conduct this.
 
=== Transform specification sign-off ===
Both the publisher and DDS team must agree that the completed transform specification document is accurate and sufficient to implement the transformation code.
 
This will be done when both parties agree that the document has been sufficiently completed.
 
=== Transform assurance ===
Once the transformation implementation is complete, it must be assured that it can accurately transform the source data into the DDS format.
 
This will generally be done in two passes, once on sample data and a second time on live data. This will involve comparing the data in the pre-production DDS against the source software.
 
== Transport mechanism & frequency ==
The goal of the transport mechanism is to securely send the extract files into the DDS estate (hosted in AWS with HSCN connectivity). The frequency defines how often files are sent.
 
For context, these are examples of existing publisher scenarios:
 
* A daily extract of 100+ files but staggered throughout the day. As each file is produced it is uploaded to a DDS SFTP server over HSCN (secured with an SSH key). As the SFTP server receives new files, these are moved into the secure file store. At midnight, the files received that day are sent for transformation.
* A daily extract of 20 files. The files are PGP compressed and encrypted and made available on an SFTP server the publisher hosts on HSCN (secured with an SSH key). Each hour, a DDS SFTP client polls the SFTP server for new files. When new files are detected, they are downloaded and decrypted, then stored in the DDS secure file store. Once DDS has received the full set of 20 daily files, the new files are sent for transformation.
* A single daily zip file using their own client software to a Windows PC workstation hosted within a CCG building. A small DDS-written application runs on the workstation and detects each new extract file, which is then uploaded via HTTPS over HSCN to a DDS API. The DDS API unzips the file and stores the decompressed files in the secure file store, which are then sent for transformation.
 
{{Question| How many files will be produced in your extract and how often, and how you see them being transported to the DDS?}}
 
{{Info| It is recommended that any transport be done using SFTP, secure using an SSH key and over HSCN. For further security, it is also recommended that extract files be encrypted themselves before transport.}}
 
==Scheduling and dependencies==
Depending on the complexity of the published data it may be necessary to split the implementation into several phases, each phase introducing new data to the DDS. For example, if a secondary care publisher extract contains data on organisational metadata, patient demographics, procedures, diagnoses, and clinical observations, it may be more efficient to break the implementation into several discrete phases for implementation; For example, doing the full procedures implementation before doing conditions, and then finally moving on to observations.
 
However, because some data naturally depends on other data, the dependencies must be understood to know what data items must be done before others. For example:
 
# Organisational metadata is always required first, since everything depends on organisations, locations and clinicians.
# Patient demographics are always required next, since all other clinical data depends on matching to patient records.
# A&E attendances, inpatient stays and outpatient appointments are generally required next.
# Finally, procedures, conditions and observations can be interpreted.
 
{{Question|  Is scheduling necessary? What are the dependencies within the data?}}
{{Info| The scope of the first phase should now be agreed.}}
 
== Extract file specification ==
{{Question| Can you supply technical extract documentation such as file specifications?}}
 
== Sample data ==
{{Question| Can you provide sample data?}}
{{Info| Sample data should include fictitious patients only but be as realistic as possible. It should also be in the exact same format as the planned extract.}}
 
== Inserts, updates, and deletes ==
The ideal scenario is that each file within the extract is sent initially as a bulk extract followed by regular deltas (differences only), with clear indication of which records are new, which are updates, and which are deleted.
 
{{Question| Can you explain how the extract represents updates and deletes to data and whether it will be possible to follow the bulk, then deltas pattern?}}
 
== Transformation mapping ==
All inbound DDS transformations, for different source formats, output FHIR using a DDS-specific profile. Approximately 20 different FHIR resources are used in DDS to date. Each FHIR resource has many fields of different types, some mandatory, some not.
 
The sections in [[Inbound Data Transform Specifications#Resource mapping|Resource mapping]] list all the fields for each resource type that the DDS uses.
 
{{Note| Each field requires you to describe where that field can be found in the source data and what, if any, mapping or formatting is required.}}
 
Links to the original FHIR definitions on the HL7 website are also provided, to give more detailed explanations on what each resource is for.
 
{{Info| Field names may not be the same as on the HL7 website and/or may not even be on the HL7 website at all; the DDS uses a number of FHIR extensions to add additional fields to each resource.}}
 
=== Guidance ===
The cell for each resource field asks for the source location and mapping. Not every field will require any mapping, so leave this blank if the value should be taken as is.
{| class="wikitable"
|Field name:
|Date of birth
|-
|Type:
|Date
|-
|Cardinality:
|1..1
|-
|Required:
|Yes
|-
|Description:
|Patient’s date of birth
|-
|Source location:
|“DoB” column, Patient_demographics.csv
|-
|Mapping:
|Date format YYYYMMDD
|}
''Example resource field''
 
The following sub-sections provide additional guidance on more complex scenarios that should be considered when completing these cells.
 
==== Other resource fields and types ====
The 20+ resource types in [[Inbound Data Transform Specifications#Resource mapping|Resource mapping]] are the ones used by the DDS to date out of a possible 150+. If you have data that cannot be mapped to any of them, then raise this issue with the DDS team and additional resource types will be added if necessary.
 
Similarly, the fields used in each resource type are only the ones that have been necessary to use to date. If the data has key information that has no obvious place in a resource, then raise this issue with the DDS team, so new fields can be made available if necessary.
 
==== Dates and times ====
For date and datetime fields, please specify the format the source data is provided in, For example, YYYYMMDD or DD-MM-YYYY HHMM.
 
==== Multiple files ====
If multiple extract files supply data for a single resource, then describe how the two files relate to each other, such as what the primary and foreign keys are.
 
For example, if patient addresses are supplied in a separate file to the other patient demographics, then the primary key for both files needs to be understood, as does how the address file refers to the main file.
 
==== De-duplication ====
If the same data is present in multiple files, then explain how the data can be processed to avoid de-duplication.
 
For example, one DDS publisher feed supplies procedure (such as an operation) data in four files derived from a data warehouse and two files in a national CDS standard. Each logical procedure may be present in one or more of these files, and there is no common unique ID to identify the same procedure throughout. To avoid duplicate procedures in DDS, analysis of the source data to create a de-duplication strategy was required.
 
==== Reference data ====
If understanding of the data requires reference data that is not part of the extract feed itself, then consider how this reference data can be supplied to DDS. For small and static reference data set, an ad hoc arrangement can be made where the reference data is manually loaded into the DDS for later look up. For large or frequently changing reference data sets, the reference data itself should be made part of the extract.
 
For example, one DDS publisher feed has all clinical observations (such as height and weight) coded using SNOMED CT, but the extract file containing the observations is coded using an internal integer which refers to a semi-static reference table which in turn provides the SNOMED CT concept ID. To ensure that the DDS can always look up a SNOMED CT concept ID for every observation, the coding table itself is part of the extract.
 
==== Supported file formats ====
The DDS already supports a number of transformations from national file CDS formats, such as the SUS Inpatient and Outpatient files. If any of these files are to be used, the existing transform can most likely be reused and the transformation mapping won’t need to be re-defined for them.
 
== Special cases ==
 
=== Requirement ===
In all data extracts that the DDS receives there are special cases that aren’t evident from the extract specification or mapping process; these need to be fully understood to safely and accurately transform the data.
 
Examples of previously encountered special cases:
 
* A publisher sent BST times and datetimes in UTC in some, but not all, of their extract files. This meant that in some files, an event that took place at 16:00 was shown as taking place at 15:00, and more noticeably an event that took place at midnight showed as having happened at 23:00 on the previous day. This inconsistency in times is a special case that was mitigated for, so any affected file has timed adjusted by an hour, so that events in DDS show with the correct time (and date).
* A publisher sent extracts instructing the DDS to delete all patient data (a '''delete''' for every patient) if an exception was thrown during the extract generation. The publisher’s software error handling detected the exception and rather than simply not produce an extract for that date, sent a valid extract but with a delete statement for every record. If DDS processed this mass delete, the only way to restore the data was to take a fresh bulk extract of all the data and process it. This special case was mitigated for by detecting the mass delete and raising an alert with the DDS technical team rather than automatically processing it.
 
{{Question| Can you provide details of any known special cases that do or can occur with the extract?}}
 
{{Info| It is expected that special cases won’t necessarily be known until the transform has been implemented and the data transform is going through testing and assurance, but that knowledge must be recorded as and when it is found.}}
== Resource mapping ==
 
=== Resource: Organisation ===
Represents an organisation, such as a GP practice, hospital department, CCG, or trust.
 
Defined at http://hl7.org/fhir/organization.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique identifier within the extract (primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Name'''
{| class="wikitable"
!Field name:
|Name
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Organisation’s name
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Identifier'''
{| class="wikitable"
!Field name:
|Identifier
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|National identifier for the organisation (ODS code)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Main location'''
{| class="wikitable"
!Field name:
|Main location
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Unique ID of a Location resource that represents the primary location this organisation operates from (main surgery site for a GP practice)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Parent organisation'''
{| class="wikitable"
!Field name:
|Parent organisation
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of an organisation resource that this organisation belongs to (CCG organisation for a GP practice) to allow organisational hierarchies be represented
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Type'''
{| class="wikitable"
!Field name:
|Type
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Organisation type.
If not possible to map to the value set, a free-text type can be supported.
 
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/schema/OrganisationType.java
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Open date'''
{| class="wikitable"
!Field name:
|Open date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Date the organisation opened
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Close date'''
{| class="wikitable"
!Field name:
|Close date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Date the organisation closed
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Address'''
{| class="wikitable"
!Field name:
|Address
|-
!Type:
|Address sub-structure
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|The organisation’s address
|}
{| class="wikitable"
!Field name:
|Line
|-
!Type:
|Text
|-
!Cardinality:
|0..n
|-
!Required:
|Recommended
|-
!Description:
|Number, house name, road and locality
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|City
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|City or town
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|County
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|County
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Postcode
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Postcode
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Use
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|The use of the address (work).
For organisations, it may be possible to just infer that all addresses are work addresses.
 
See http://hl7.org/fhir/valueset-address-use.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Telecom'''
{| class="wikitable"
!Field name:
|Telecom
|-
!Type:
|Telecom sub-structure
|-
!Cardinality:
|0..n
|-
!Required:
|Recommended
|-
!Description:
|The organisation’s list of contact methods (phones, faxes and emails)
|}
{| class="wikitable"
!Field name:
|Value
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Contact value (phone number, email address)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Use
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|What this contact method is used for (work).
For organisations, we may simply infer that all contacts are for work purposes.
See http://hl7.org/fhir/valueset-contact-point-use.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|System
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|The type of contact method this is (phone, fax, email).
See http://hl7.org/fhir/valueset-contact-point-system.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Location ===
Represents a physical location.
 
Defined at: http://hl7.org/fhir/location.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique identifier within the extract (primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Name'''
{| class="wikitable"
!Field name:
|Name
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Location’s name
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Identifier'''
{| class="wikitable"
!Field name:
|Identifier
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|National or local identifier for the location
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Main contact name'''
{| class="wikitable"
!Field name:
|Main contact name
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|No
|-
!Description:
|Name of main person responsible for this location (manager)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Part of'''
{| class="wikitable"
!Field name:
|Part of
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Unique ID of a parent Location if this location is part of a hierarchy
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Managing organisation'''
{| class="wikitable"
!Field name:
|Managing organisation
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of an Organisation that this Location belongs to
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Physical type'''
{| class="wikitable"
!Field name:
|Physical type
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|What type of location this is (room, wing, building).
 
See http://hl7.org/fhir/valueset-location-physical-type.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Open date'''
{| class="wikitable"
!Field name:
|Open date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Date the location opened
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Close date'''
{| class="wikitable"
!Field name:
|Close date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Date the location closed
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Address'''
{| class="wikitable"
!Field name:
|Address
|-
!Type:
|Address sub-structure
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|The location’s address
|}
{| class="wikitable"
!Field name:
|Line
|-
!Type:
|Text
|-
!Cardinality:
|0..n
|-
!Required:
|Recommended
|-
!Description:
|Number, house name, road and locality
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|City
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|City or town
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|County
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|County
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Postcode
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Postcode
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Use
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|The use of the address (work).
For locations, it may be possible to just infer that all addresses are work addresses.
 
See http://hl7.org/fhir/valueset-address-use.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Telecom'''
{| class="wikitable"
!Field name:
|Telecom
|-
!Type:
|Telecom sub-structure
|-
!Cardinality:
|0..n
|-
!Required:
|Recommended
|-
!Description:
|The organisation’s list of contact methods (phones, faxes and emails)
|}
{| class="wikitable"
!Field name:
|Value
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Contact value (phone number, email address)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Use
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|What this contact method is used for (such as work).
For organisations, we may simply infer that all contacts are for work purposes.
 
See http://hl7.org/fhir/valueset-contact-point-use.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|System
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|The type of contact method this is (phone, fax, email).
See http://hl7.org/fhir/valueset-contact-point-system.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Practitioner ===
Represents an individual working at an organisation, such as a clinician or administrator.
 
Defined at http://hl7.org/fhir/practitioner.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique identifier within the extract (primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Managing organisation'''
{| class="wikitable"
!Field name:
|Managing organisation
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the Organisation that this Practitioner belongs to
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Role start date'''
{| class="wikitable"
!Field name:
|Role start date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Start date of this practitioner in this role
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Role end date'''
{| class="wikitable"
!Field name:
|Role end date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|End date of this practitioner in this role
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Active'''
{| class="wikitable"
!Field name:
|Active
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Boolean flag to define if this practitioner is active or not. Can be used if explicit start and end dates are not available, but if they are available then this should not be used.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Job role code'''
{| class="wikitable"
!Field name:
|Job role code
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Code to define the job role.
 
See https://fhir.hl7.org.uk/STU3/CodeSystem/CareConnect-SDSJobRoleName-1#
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Speciality'''
{| class="wikitable"
!Field name:
|Specialty
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Secondary care specialty this Practitioner works in
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Name'''
{| class="wikitable"
!Field name:
|Name
|-
!Type:
|Name sub-structure
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Practitioners current name
|}
{| class="wikitable"
!Field name:
|Prefix
|-
!Type:
|Text
|-
!Cardinality:
|0..n
|-
!Required:
|Recommended
|-
!Description:
|Title or anything that would proceed the name
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Given
|-
!Type:
|Text
|-
!Cardinality:
|1..n
|-
!Required:
|Yes
|-
!Description:
|First and middle names
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Family
|-
!Type:
|Text
|-
!Cardinality:
|1..n
|-
!Required:
|Yes
|-
!Description:
|Surname(s) / last name(s).
 
'''Note:''' Hyphenated surnames are not split into separate elements, but other double surnames are.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Suffix
|-
!Type:
|Text
|-
!Cardinality:
|0..n
|-
!Required:
|No
|-
!Description:
|Any title or honorific that would appear after the name (such as OBE)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Identifier'''
{| class="wikitable"
!Field name:
|Identifier
|-
!Type:
|Identifier sub-structure
|-
!Cardinality:
|0..n
|-
!Required:
|No
|-
!Description:
|Any identifiers for the practitioner (such as GMC number)
|}
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Yes, if multiple identifiers of the same type are provided.
No, if only a single identifier of each type is provided.
|-
!Description:
|Unique ID for this identifier record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Value
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|The actual value of the identifier
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|System
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|What kind of identifier this is (GMC number).
 
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirIdentifierUri.java
 
'''Note:''' This value set isn’t fixed, new options can be added.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Start date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Start date of the identifier
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|End date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|End date of the identifier
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Address'''
{| class="wikitable"
!Field name:
|Address
|-
!Type:
|Address sub-structure
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|The practitioner's address
|}
{| class="wikitable"
!Field name:
|Line
|-
!Type:
|Text
|-
!Cardinality:
|0..n
|-
!Required:
|Recommended
|-
!Description:
|Number, house name, road and locality
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|City
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|City or town
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|County
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|County
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Postcode
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Postcode
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Use
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|The use of the address (work).
See http://hl7.org/fhir/valueset-address-use.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Telecom'''
{| class="wikitable"
!Field name:
|Telecom
|-
!Type:
|Telecom sub-structure
|-
!Cardinality:
|0..n
|-
!Required:
|Recommended
|-
!Description:
|The practitioners’s list of contact methods (phones, faxes and emails)
|}
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Yes, if multiple telecoms are supplied per practitioner.
 
No if only a single telecoms is supplied.
|-
!Description:
|Unique ID for this telecom record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Value
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Telecom value (phone number, email address)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Start date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Start date of the telecom
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|End date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|End date of the telecom
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Use
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|What this telecom method is used for (work).
 
See http://hl7.org/fhir/valueset-contact-point-use.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|System
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|The type of telecom method this is (phone, fax, email).
 
See http://hl7.org/fhir/valueset-contact-point-system.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Patient ===
Represents the top-level of the patient record, containing name and other demographics.
 
See http://hl7.org/fhir/patient.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique key for the patient in the source data (primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Managing organisation'''
{| class="wikitable"
!Field name:
|Managing organisation
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique identifier of the Organisation resource that represents the publisher of the data.
For example, if data is published from a Out of Hours Call Centre, this field will refer to the Organisation representing the call centre itself.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''NHS number'''
{| class="wikitable"
!Field name:
|NHS number
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Patient’s NHS number
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''NHS number verification status'''
{| class="wikitable"
!Field name:
|NHS number verification status
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Status of how the NHS number has been validated against the PDS.
 
See https://www.datadictionary.nhs.uk/version2/data_dictionary/data_field_notes/n/nhs_number_status_indicator_de.asp?shownav=1
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Date of birth'''
{| class="wikitable"
!Field name:
|Date of birth
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Patient’s date of birth
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Deceased'''
{| class="wikitable"
!Field name:
|Deceased
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Boolean flag to indicate if the patient is deceased
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Date of death'''
{| class="wikitable"
!Field name:
|Date of death
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Date of patient’s death
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Gender'''
{| class="wikitable"
!Field name:
|Gender
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Patient’s gender
 
See http://hl7.org/fhir/valueset-administrative-gender.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Residential institute code'''
{| class="wikitable"
!Field name:
|Residential institute code
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|'''Note:''' This field is only present in GP software so no attempt to populate it should be made from non-GP data.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Spine sensitive'''
{| class="wikitable"
!Field name:
|Spine sensitive
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Whether this patient record is known to be flagged as sensitive on the PDS or not.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Confidential'''
{| class="wikitable"
!Field name:
|Confidential
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Patient record confidentiality flag
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Care provider'''
{| class="wikitable"
!Field name:
|Care provider
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Reference to an Organisation representing the patient’s known registered GP practice.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Marital status'''
{| class="wikitable"
!Field name:
|Marital status
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Patient’s current marital status.
 
See http://hl7.org/fhir/valueset-marital-status.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Ethnicity'''
{| class="wikitable"
!Field name:
|Ethnicity
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Patient’s ethnicity.
 
See https://www.datadictionary.nhs.uk/data_dictionary/attributes/e/end/ethnic_category_code_de.asp
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Religion'''
{| class="wikitable"
!Field name:
|Religion
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Patient’s religion.
 
See https://www.datadictionary.nhs.uk/data_dictionary/attributes/r/red/religious_or_other_belief_system_affiliation_code_de.asp?shownav=1  
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Language'''
{| class="wikitable"
!Field name:
|Language
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Patient’s main spoken language  
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Speaks English'''
{| class="wikitable"
!Field name:
|Speaks English
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Whether the patient speaks English or not
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Test patient'''
{| class="wikitable"
!Field name:
|Test patient
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Flag to indicate that the patient record is a dummy or test record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Name'''
{| class="wikitable"
!Field name:
|Name
|-
!Type:
|Name sub-structure
|-
!Cardinality:
|1..n
|-
!Required:
|Yes
|-
!Description:
|Patient’s current name, any aliases and name history
|}
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Yes, if multiple names of the same type are provided.
 
No, if only a single name of each type is provided.
|-
!Description:
|Unique ID for this name record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Prefix
|-
!Type:
|Text
|-
!Cardinality:
|0..n
|-
!Required:
|Recommended
|-
!Description:
|Patient’s title or anything that would proceed the name
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Given'''
{| class="wikitable"
!Field name:
|Given
|-
!Type:
|Text
|-
!Cardinality:
|1..n
|-
!Required:
|Yes
|-
!Description:
|First and middle names
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Family'''
{| class="wikitable"
!Field name:
|Family
|-
!Type:
|Text
|-
!Cardinality:
|1..n
|-
!Required:
|Yes
|-
!Description:
|Surname(s) / last name(s).
'''Note:''' Hyphenated surnames are not split into separate elements, but other double surnames are.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Suffix'''
{| class="wikitable"
!Field name:
|Suffix
|-
!Type:
|Text
|-
!Cardinality:
|0..n
|-
!Required:
|No
|-
!Description:
|Any title or honorific that would appear after the name (OBE)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Start date'''
{| class="wikitable"
!Field name:
|Start date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Start date of the identifier
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''End date'''
{| class="wikitable"
!Field name:
|End date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|End date of the identifier
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Identifier'''
{| class="wikitable"
!Field name:
|Identifier
|-
!Type:
|Identifier sub-structure
|-
!Cardinality:
|0..n
|-
!Required:
|No
|-
!Description:
|Any locally used identifiers for the patient record (medical record number, patient number, client number)
|}
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Yes, if multiple identifiers of the same type are provided.
 
No, if only a single identifier of each type is provided.
|-
!Description:
|Unique ID for this identifier record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Value
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|The actual value of the identifier
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|System
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|What kind of identifier this is (MRN, patient number, client number).
 
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirIdentifierUri.java
 
'''Note:''' This value set isn’t fixed, and new options can be added.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Start date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Start date of the identifier
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|End date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|End date of the identifier
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Address'''
{| class="wikitable"
!Field name:
|Address
|-
!Type:
|Address sub-structure
|-
!Cardinality:
|0..n
|-
!Required:
|Recommended
|-
!Description:
|The patient’s addresses
|}
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Yes, if multiple addresses are supplied per patient.
 
No if only a single address is supplied.
|-
!Description:
|Unique ID for this address record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Line
|-
!Type:
|Text
|-
!Cardinality:
|0..n
|-
!Required:
|Recommended
|-
!Description:
|Number, house name, road and locality of the address
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|City
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|City or town
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|County
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|County
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Postcode
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Postcode
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Start date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Start date of the address
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|End date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|End date of the address
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Use
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|The use of the address (home, temporary).
 
See http://hl7.org/fhir/valueset-address-use.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Telecom'''
{| class="wikitable"
!Field name:
|Telecom
|-
!Type:
|Telecom sub-structure
|-
!Cardinality:
|0..n
|-
!Required:
|Recommended
|-
!Description:
|The patient’s list of contact methods (phones, faxes and emails)
|}
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Yes, if multiple telecoms are supplied per patient.
 
No if only a single telecoms is supplied.
|-
!Description:
|Unique ID for this contact record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Value
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Telecom value (phone number, email address)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Start date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Start date of the telecom
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|End date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|End date of the telecom
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Use
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|What this telecom method is used for (home, work).
 
See http://hl7.org/fhir/valueset-contact-point-use.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|System
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|The type of telecom method this is (phone, fax, email).
 
See http://hl7.org/fhir/valueset-contact-point-system.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Contact'''
{| class="wikitable"
!Field name:
|Contact
|-
!Type:
|Family member / carer / relationship sub-structure
|-
!Cardinality:
|0..n
|-
!Required:
|No
|-
!Description:
|The patient’s list of family members, carers and relationships
|}
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Yes, if multiple contacts are supplied per patient.
 
No if only a single contact is supplied.
|-
!Description:
|Unique ID for this contact record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Relationship
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Relationship of this person to the patient
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Language
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Main spoken language of this person
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Date of birth
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Birth date of this person
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Gender
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Gender of this person.
 
See http://hl7.org/fhir/valueset-administrative-gender.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Start date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Start date of the contact
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|End date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|End date of the contact
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Name'''
{| class="wikitable"
!Field name:
|Name
|-
!Type:
|Name sub-structure
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Person’s current name
|}
{| class="wikitable"
!Field name:
|Prefix
|-
!Type:
|Text
|-
!Cardinality:
|0..n
|-
!Required:
|Recommended
|-
!Description:
|Patient’s title or anything that would proceed the name
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Given
|-
!Type:
|Text
|-
!Cardinality:
|1..n
|-
!Required:
|Yes
|-
!Description:
|First and middle names
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Family
|-
!Type:
|Text
|-
!Cardinality:
|1..n
|-
!Required:
|Yes
|-
!Description:
|Surname(s) / last name(s).
 
'''Note:''' Hyphenated surnames are not split into separate elements, but other double surnames are.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Address'''
{| class="wikitable"
!Field name:
|Address
|-
!Type:
|Address sub-structure
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|The person’s addresses
|}
{| class="wikitable"
!Field name:
|Line
|-
!Type:
|Text
|-
!Cardinality:
|0..n
|-
!Required:
|Recommended
|-
!Description:
|Number, house name, road and locality of the address
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|City
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|City or town
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|County
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|County
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Postcode
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Postcode
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Use
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|The use of the address (home, temporary).
 
See http://hl7.org/fhir/valueset-address-use.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Telecom'''
{| class="wikitable"
!Field name:
|Telecom
|-
!Type:
|Telecom sub-structure
|-
!Cardinality:
|0..n
|-
!Required:
|No
|-
!Description:
|The person’s list of contact methods (phones, faxes and emails)
|}
{| class="wikitable"
!Field name:
|Value
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Contact value (phone number, email address)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Use
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|What this contact method is used for (home, work).
 
See http://hl7.org/fhir/valueset-contact-point-use.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|System
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|The type of contact method this is (phone, fax, email).
 
See http://hl7.org/fhir/valueset-contact-point-system.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Episode of Care ===
Represents the duration a patient was under the care of a care provider.
 
For primary care, this would be the period of registration. For secondary care, this would be the period from referral or A&E attendance to clinical discharge.
 
See http://hl7.org/fhir/episodeofcare.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique key for the episode in the source data (primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Patient'''
{| class="wikitable"
!Field name:
|Patient
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the patient record this episode belongs to
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Managing organisation'''
{| class="wikitable"
!Field name:
|Managing organisation
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the organisation this episode belongs to.
Should be the same as the same field on the Patient resource.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Care manager'''
{| class="wikitable"
!Field name:
|Care manager
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Unique ID of the Practitioner responsible for this episode, such as their consultant or usual GP.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Start date'''
{| class="wikitable"
!Field name:
|Start date
|-
!Type:
|Date
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Date this episode started.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''End date'''
{| class="wikitable"
!Field name:
|End date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Date this episode ended, if it has ended.
A future-dated end date is permitted if it is known.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Registration type'''
{| class="wikitable"
!Field name:
|Registration type
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|GP registration type. Only for use in GP practice care settings.
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/schema/RegistrationType.java
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Registration status'''
{| class="wikitable"
!Field name:
|Registration status
|-
!Type:
|Sub-element
|-
!Cardinality:
|0..n
|-
!Required:
|No
|-
!Description:
|GP registration status. Only for use in GP practice care settings.
|}
{| class="wikitable"
!Field name:
|Status code
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Registration status code.
 
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/schema/RegistrationStatus.java
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Status date
|-
!Type:
|Date
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Date this registration status was recorded
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Outcome'''
{| class="wikitable"
!Field name:
|Outcome
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Outcome of this episode. Used in non-scheduled care and secondary care (discharged).
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Priority'''
{| class="wikitable"
!Field name:
|Priority
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Priority of this episode. Used in non-scheduled care (urgent, less urgent).
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Encounter ===
Represents a patient’s contact with a care provider (GP consultation, A&E attendance, inpatient stay).
 
Encounters may also be nested and link to a wider, parent encounter, such as a consultant performing a bedside examination may be recorded as an encounter that is linked to the encounter representing the inpatient stay.
 
See http://hl7.org/fhir/encounter.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique key for the condition in the source data (primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Patient'''
{| class="wikitable"
!Field name:
|Patient
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the patient record this Condition belongs to
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Episode of care'''
{| class="wikitable"
!Field name:
|Episode of Care
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the episode of care that this encounter belongs to
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Service Provider'''
{| class="wikitable"
!Field name:
|Service Provider
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the Organisation that performed this encounter
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective Clinician'''
{| class="wikitable"
!Field name:
|Effective Clinician
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the practitioner that performed (or was responsible for) this encounter (not necessarily the person who input it into the software)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective date'''
{| class="wikitable"
!Field name:
|Effective date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this encounter was began
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded by'''
{| class="wikitable"
!Field name:
|Recorded by
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that entered this encounter into the publishing software
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded date'''
{| class="wikitable"
!Field name:
|Recorded date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this encounter was entered into the publishing software
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''End date'''
{| class="wikitable"
!Field name:
|End date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Datetime this encounter ended
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Status'''
{| class="wikitable"
!Field name:
|Status
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Current status of this encounter (planned, arrived, finished).
 
See http://hl7.org/fhir/valueset-encounter-status.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Appointment'''
{| class="wikitable"
!Field name:
|Appointment
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Unique ID of an appointment resource that this Eecounter is related to.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Confidential'''
{| class="wikitable"
!Field name:
|Confidential
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Confidentiality flag.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Class'''
{| class="wikitable"
!Field name:
|Class
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|The top-level classification of this encounter (inpatient, outpatient, emergency).
 
See http://hl7.org/fhir/v3/ActEncounterCode/vs.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Reason'''
{| class="wikitable"
!Field name:
|Reason
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|The main reason for this encounter.
 
See http://hl7.org/fhir/valueset-encounter-reason.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Type'''
{| class="wikitable"
!Field name:
|Type
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|The free-text type of encounter (telephone appointment, outpatient appointment, diabetic review)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Location'''
{| class="wikitable"
!Field name:
|Location
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|The unique ID of the current location of the patient, (a specific bed, room or ward)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Location type'''
{| class="wikitable"
!Field name:
|Location type
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Free-text description of the location of the patient if a specific named location (see above) is not available, (emergency department).
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Status'''
{| class="wikitable"
!Field name:
|Status
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|The current status of this encounter (planned, arrived, finished).
 
See http://hl7.org/fhir/valueset-encounter-status.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Specialty'''
{| class="wikitable"
!Field name:
|Specialty
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Hospital specialty that this encounter is under.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Allergy Intolerance ===
Represents a patient’s allergy or drug sensitivity.
 
See http://hl7.org/fhir/allergyintolerance.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique key for the Allergy in the source data (primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Patient'''
{| class="wikitable"
!Field name:
|Patient
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the patient record this Allergy belongs to
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective Clinician'''
{| class="wikitable"
!Field name:
|Effective Clinician
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that captured this Allergy (not necessarily the person who input it into the software)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective date'''
{| class="wikitable"
!Field name:
|Effective date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Allergy was captured (not necessarily the datetime it was input into the software)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded by'''
{| class="wikitable"
!Field name:
|Recorded by
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that entered this Allergy into the publishing software
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded date'''
{| class="wikitable"
!Field name:
|Recorded date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Allergy was entered into the publishing software
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Encounter'''
{| class="wikitable"
!Field name:
|Encounter
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Unique ID of the Encounter resource this Allergy belongs to (if recorded during a consultation, this would link to the Encounter representing the consultation)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''End date'''
{| class="wikitable"
!Field name:
|End date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Datetime this Allergy ceased
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Status'''
{| class="wikitable"
!Field name:
|Status
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Current status of this Allergy (active, inactive, resolved).
 
See http://hl7.org/fhir/valueset-allergyintolerance-clinical.html
 
'''Note:''' This can be inferred from the End Date field (if end date present, status is inactive)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Severity'''
{| class="wikitable"
!Field name:
|Severity
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Severity of this Allergy (mild, moderate).
 
See http://hl7.org/fhir/valueset-reaction-event-severity.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Category'''
{| class="wikitable"
!Field name:
|Category
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|What kind of Allergy is this (food, environment, medication).
 
See http://hl7.org/fhir/valueset-allergy-intolerance-category.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Note'''
{| class="wikitable"
!Field name:
|Note
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Free-text narrative associated with this Allergy
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Confidential'''
{| class="wikitable"
!Field name:
|Confidential
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Confidentiality flag
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Code'''
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Code sub-element
|-
!Cardinality:
|1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
|-
!Required:
|Yes
|-
!Description:
|Clinical code for this Allergy
|}
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Clinical code for the (G00.1 for ICD-10 meningitis)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Term
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Associated term to go with the above code.
 
'''Note:''' If the code is from a standard coding system (ICD-10, OPCS-4, Read2, CTV3, SNOMED CT), this can be looked up from reference data already held in the DDS.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|System
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Coding scheme that this code uses.
 
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java
 
'''Note:''' This list of supported codes can be added to if necessary
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Condition ===
Represents a clinical condition or complaint within a patient record.
 
See http://hl7.org/fhir/condition.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique key for the Condition in the source data (primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Patient'''
{| class="wikitable"
!Field name:
|Patient
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the patient record this Condition belongs to
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Code'''
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Code sub-element
|-
!Cardinality:
|1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
|-
!Required:
|Yes
|-
!Description:
|Clinical code for this Condition
|}
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Clinical code for the (G00.1 for ICD-10 meningitis)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Term
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Associated term to go with the above code.
 
'''Note:''' if the code is from a standard coding system (ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) then this can be looked up from reference data already held in DDS.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|System
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Coding scheme that this code uses.
 
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java
 
'''Note:''' This list of supported codes can be added to if necessary
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Is problem'''
{| class="wikitable"
!Field name:
|Is problem
|-
!Type:
|Boolean
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Flag to indicate if this condition is regarded as a problem or not
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective Clinician'''
{| class="wikitable"
!Field name:
|Effective Clinician
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that diagnosed or captured this complaint (not necessarily the person who input it into the software)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective Date'''
{| class="wikitable"
!Field name:
|Effective date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Condition was diagnosed or complaint captured (not necessarily the datetime it was input into the software)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded by'''
{| class="wikitable"
!Field name:
|Recorded by
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that entered this Condition or complaint into the publishing software
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded date'''
{| class="wikitable"
!Field name:
|Recorded date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Condition was entered into the publishing software
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Encounter'''
{| class="wikitable"
!Field name:
|Encounter
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Unique ID of the Encounter resource this Condition belongs to (if recorded during a consultation, this would link to the Encounter representing the consultation)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Notes'''
{| class="wikitable"
!Field name:
|Notes
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Any free-text narrative associated with this Condition
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Confidential'''
{| class="wikitable"
!Field name:
|Confidential
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Confidentiality flag
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Is review'''
{| class="wikitable"
|Field name:
|Is review
|-
|Type:
|Boolean
|-
|Cardinality:
|0..1
|-
|Required:
|No
|-
|Description:
|Flag to indicate that this Condition is a review of an existing one, rather than a new diagnosis.
 
Some publishing systems record reviews (annual asthma review) using the same clinical code as the initial diagnosis but qualified with an '''is review''' flag.
|-
|Source location:
|What file and field contains this?
|-
|Mapping:
|Is any mapping or formatting required?
|}
'''Is primary'''
{| class="wikitable"
!Field name:
|Is primary
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Flag to indicate if this Condition is a primary diagnosis.
 
For example, in secondary care settings, a patient may have many diagnoses during a single in patient stay, but only one is flagged as the primary diagnosis that the patient was admitted for.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Sequence number'''
{| class="wikitable"
!Field name:
|Sequence number
|-
!Type:
|Integer
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Ordinal to maintain the order of diagnoses within an Encounter.
 
For example, in the secondary care example mentioned above, the primary diagnosis is given sequence number 1, and all the secondary diagnoses are numbered accordingly to preserve the order they were entered into the source software.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Parent resource'''
{| class="wikitable"
!Field name:
|Parent resource
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Unique ID of a parent Condition resource that this is logically related.
 
For example, in the secondary care example mentioned above, the secondary diagnoses are linked to the primary one using this field.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Parent problem'''
{| class="wikitable"
!Field name:
|Parent problem
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Unique ID of a parent Condition resource (that has “is problem” = true) that this Condition has been grouped under.
 
For example, a patient may have a symptomatic Condition of “Nausea” and a diagnostic Condition of “Angina”. If the angina Condition is flagged as a problem,
 
then the nausea Condition may be linked to the problem to indicate that the nausea complaint is related to the angina diagnosis.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Problem end date'''
{| class="wikitable"
!Field name:
|Problem end date
|-
!Type:
|Date
|-
!Cardinality:
|0..1 (only applicable if Condition has “is problem” = true)
|-
!Required:
|No
|-
!Description:
|Date the problem was ended
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Problem expected duration'''
{| class="wikitable"
!Field name:
|Problem expected duration
|-
!Type:
|Integer
|-
!Cardinality:
|0..1 (only applicable if Condition has “is problem” = true)
|-
!Required:
|No
|-
!Description:
|Estimated number of days the problem is expected to last for
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Problem last reviewed by'''
{| class="wikitable"
!Field name:
|Problem last reviewed by
|-
!Type:
|Test
|-
!Cardinality:
|0..1 (only applicable if Condition has “is problem” = true)
|-
!Required:
|No
|-
!Description:
|Unique ID of the Practitioner who last reviewed this problem (performed an asthma review for an asthma problem)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Problem last reviewed date'''
{| class="wikitable"
!Field name:
|Problem last reviewed date
|-
!Type:
|Date
|-
!Cardinality:
|0..1 (only applicable if Condition has “is problem” = true)
|-
!Required:
|No
|-
!Description:
|Date that this problem was last reviewed
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Problem significance'''
{| class="wikitable"
!Field name:
|Problem significance
|-
!Type:
|Value set
|-
!Cardinality:
|0..1 (only applicable if Condition has “is problem” = true)
|-
!Required:
|No
|-
!Description:
|Significance of this problem.
 
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/schema/ProblemSignificance.java
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Service Request ===
Represents: an order for diagnostics. For example, a blood or urine test, a planned review, (an asthma review) or a referral (referral for investigation).
 
See http://hl7.org/fhir/servicerequest.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique key for this request in the source data (primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Patient'''
{| class="wikitable"
!Field name:
|Patient
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the Patient this request is for
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Ordered by'''
{| class="wikitable"
!Field name:
|Ordered by
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner or Organisation making this request.
 
'''Note:''' In the case of referrals received by the publisher, this may be someone outside of this organisation.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Ordered date'''
{| class="wikitable"
!Field name:
|Ordered date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this request was made
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded by'''
{| class="wikitable"
!Field name:
|Recorded by
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner who recorded this request in the publishing software
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded date'''
{| class="wikitable"
!Field name:
|Recorded date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this request was recorded in the publishing software
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Encounter'''
{| class="wikitable"
!Field name:
|Encounter
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Encounter this request was made in
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Notes'''
{| class="wikitable"
!Field name:
|Notes
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Free text narrative associated with this request
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Status'''
{| class="wikitable"
!Field name:
|Status
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|The current status of this request (such as completed).
See http://hl7.org/fhir/valueset-request-status.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Confidential'''
{| class="wikitable"
!Field name:
|Confidential
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Confidentiality flag
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Code'''
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Code sub-element
|-
!Cardinality:
|1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
|-
!Required:
|Yes
|-
!Description:
|Clinical code for this request
|}
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Clinical code for the (such as G00.1 for ICD-10 meningitis)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Term
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Associated term to go with the above code.
 
'''Note:''' If the code is from a standard coding system (such as ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) then this can be looked up from reference data already held in DDS.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|System
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Coding scheme that this code uses.
 
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java
 
'''Note:''' This list of supported codes can be added to if necessary
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recipient'''
{| class="wikitable"
!Field name:
|Recipient
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Yes, if a referral
|-
!Description:
|Unique ID of the recipient Organisation or Practitioner of this request (such as who a referral is to)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Priority'''
{| class="wikitable"
!Field name:
|Priority
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|Yes, if a referral
|-
!Description:
|Priority of this request e.g. routine, urgent.
 
See http://hl7.org/fhir/valueset-request-priority.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Referral Type'''
{| class="wikitable"
!Field name:
|Referral Type
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|Yes, if a referral
|-
!Description:
|Type of referral,(investigation, treatment).
 
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/schema/ReferralType.java  
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Referral Mode'''
{| class="wikitable"
!Field name:
|Referral Mode
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|Yes, if a referral
|-
!Description:
|How a referral was sent, (written, e-Referral).
 
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/schema/ReferralRequestSendMode.java
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Diagnostic Report ===
Represents a test request report; the individual test results within the report are represented as Observation resources that link back to this report.
 
See http://hl7.org/fhir/diagnosticreport.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique key for this report in the source data (such as primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Patient'''
{| class="wikitable"
!Field name:
|Patient
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the Patient that this report belongs to
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Encounter'''
{| class="wikitable"
!Field name:
|Encounter
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Encounter during which this report was filed into the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Filed by'''
{| class="wikitable"
!Field name:
|Filed by
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that processed/assessed this report on receipt
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Filed date'''
{| class="wikitable"
!Field name:
|Filed date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this report was processed/assessed
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded by'''
{| class="wikitable"
!Field name:
|Recorded by
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that saved the report into the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded date'''
{| class="wikitable"
!Field name:
|Recorded date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this report was saved into the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Status'''
{| class="wikitable"
!Field name:
|Status
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Status of this report (final, partial).
 
See http://hl7.org/fhir/valueset-diagnostic-report-status.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Conclusion'''
{| class="wikitable"
!Field name:
|Conclusion
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Free-text narrative conclusion about this report (not the results of the tests themselves, but the conclusion made by the clinician when filing the report into the patient record)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Confidential'''
{| class="wikitable"
!Field name:
|Confidential
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Confidentiality flag
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Results'''
{| class="wikitable"
!Field name:
|Results
|-
!Type:
|Results sub-type
|-
!Cardinality:
|0..n
|-
!Required:
|Recommended
|-
!Description:
|References to the individual results within this report, which are held as separate Observation resources
|}
{| class="wikitable"
!Field name:
|Result
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of an Observation that is one of the investigation results within this report
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Code'''
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Code sub-element
|-
!Cardinality:
|1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
|-
!Required:
|Yes
|-
!Description:
|Clinical code for this report (generally the code representing the test battery performed, such as Full blood count)
|}
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Clinical code for the (such as G00.1 for ICD-10 meningitis)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Term
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Associated term to go with the above code. Note, if the code is from a standard coding system (such as ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) then this can be looked up from reference data already held in DDS.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|System
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Coding scheme that this code uses.
 
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java
 
'''Note:''' This list of supported codes can be added to if necessary
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Family Member History ===
Records any known medical conditions in family members.
 
See http://hl7.org/fhir/familymemberhistory.html<br />'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique key for this History in the source data (such as primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Patient'''
{| class="wikitable"
!Field name:
|Patient
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the Patient that this History belongs to
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Encounter'''
{| class="wikitable"
!Field name:
|Encounter
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Encounter during which this History was added to the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective clinician'''
{| class="wikitable"
!Field name:
|Effective clinician
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that captured this History
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective date'''
{| class="wikitable"
!Field name:
|Effective date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this History was captured
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded by'''
{| class="wikitable"
!Field name:
|Recorded by
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that saved the History into the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded date'''
{| class="wikitable"
!Field name:
|Recorded date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this History was saved into the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Code'''
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Code sub-element
|-
!Cardinality:
|1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
|-
!Required:
|Yes
|-
!Description:
|Clinical code for this History (note that codes should be specific '''family history of''' codes, such as '''family history of diabetes''', and not just the unqualified disease code such as diabetes).
|}
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Clinical code for the (such as G00.1 for ICD-10 meningitis)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Term
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Associated term to go with the above code.
 
'''Note:''' If the code is from a standard coding system (ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) then this can be looked up from reference data already held in DDS.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|System
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Coding scheme that this code uses.
 
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java
 
'''Note:''' This list of supported codes can be added to if necessary
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Relationship'''
{| class="wikitable"
!Field name:
|Relationship
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|The relationship of the family member to the patient.
 
See http://hl7.org/fhir/v3/FamilyMember/vs.html
 
'''Note:''' If it isn’t possible to map to this value set, a free-text relationship can be accepted.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Confidential'''
{| class="wikitable"
!Field name:
|Confidential
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Confidentiality flag
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Notes'''
{| class="wikitable"
!Field name:
|Notes
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Free-text narrative associated with this History
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Flag ===
Represents an alert or warning on a Patient record (such as a Protection Plan).
 
See http://hl7.org/fhir/flag.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique key for this Flag in the source data (such as primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Patient'''
{| class="wikitable"
!Field name:
|Patient
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the Patient that this Flag belongs to
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Encounter'''
{| class="wikitable"
!Field name:
|Encounter
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Encounter during which this Flag was added to the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective clinician'''
{| class="wikitable"
!Field name:
|Effective clinician
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that captured this Flag
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective date'''
{| class="wikitable"
!Field name:
|Effective date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Flag was captured
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded by'''
{| class="wikitable"
!Field name:
|Recorded by
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that saved the Flag into the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded date'''
{| class="wikitable"
!Field name:
|Recorded date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Flag was saved into the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Status'''
{| class="wikitable"
!Field name:
|Status
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Active status of this Flag.
 
See http://hl7.org/fhir/valueset-flag-status.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Category'''
{| class="wikitable"
!Field name:
|Category
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Description of the type of Flag (clinical, administrative).
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Code'''
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Textual message for this Flag
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Immunization ===
Represents the patient having received a vaccination or immunization.
 
See http://hl7.org/fhir/immunization.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique key for this Immunization in the source data (primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Patient'''
{| class="wikitable"
!Field name:
|Patient
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the Patient that this Immunization belongs to
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Encounter'''
{| class="wikitable"
!Field name:
|Encounter
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Encounter during which this Immunization was added to the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective clinician'''
{| class="wikitable"
!Field name:
|Effective clinician
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that captured this Immunization
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective date'''
{| class="wikitable"
!Field name:
|Effective date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Immunization was captured
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded by'''
{| class="wikitable"
!Field name:
|Recorded by
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that saved the Immunization into the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded date'''
{| class="wikitable"
!Field name:
|Recorded date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Immunization was saved into the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Code'''
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Code sub-element
|-
!Cardinality:
|1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
|-
!Required:
|Yes
|-
!Description:
|Clinical code for this Immunization
|}
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Clinical code for the (such as G00.1 for ICD-10 meningitis)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Term
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Associated term to go with the above code. Note, if the code is from a standard coding system (ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) then this can be looked up from reference data already held in DDS.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|System
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Coding scheme that this code uses.
 
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java
 
'''Note:''' This list of supported codes can be added to if necessary
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Site'''
{| class="wikitable"
!Field name:
|Site
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Physical body location the Immunization was administered (such as arm)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Route'''
{| class="wikitable"
!Field name:
|Route
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Method by which this Immunization was given (such as intramuscularly)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Dose'''
{| class="wikitable"
!Field name:
|Dose
|-
!Type:
|Sub-element
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Amount of the Immunization administered
|}
{| class="wikitable"
!Field name:
|Value
|-
!Type:
|Number
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Quantity administered
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Unit
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Units of measure qualifying the above (such as ml)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Expiration date'''
{| class="wikitable"
!Field name:
|Expiration date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Date the Immunization was due to expire
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Note'''
{| class="wikitable"
!Field name:
|Note
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Any free-text narrative associated with this Immunization
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Batch number'''
{| class="wikitable"
!Field name:
|Batch number
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|The batch number of the Immunization given
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Reason'''
{| class="wikitable"
!Field name:
|Reason
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|The reason the Patient was administered this Immunization (such as Routine measure, traveller)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Confidential'''
{| class="wikitable"
!Field name:
|Confidential
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Confidentiality flag
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Medication Statement ===
Represents the prescribing of medication to a patient.
 
See http://hl7.org/fhir/medicationstatement.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique key for this Medication Statement in the source data (primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Patient'''
{| class="wikitable"
!Field name:
|Patient
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the Patient that this Medication Statement belongs to
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Encounter'''
{| class="wikitable"
!Field name:
|Encounter
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Encounter during which this Medication Statement was added to the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective clinician'''
{| class="wikitable"
!Field name:
|Effective clinician
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that prescribed this Medication Statement
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective date'''
{| class="wikitable"
!Field name:
|Effective date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Medication Statement was prescribed
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded by'''
{| class="wikitable"
!Field name:
|Recorded by
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that saved the Medication Statement into the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded date'''
{| class="wikitable"
!Field name:
|Recorded date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Medication Statement was saved into the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Code'''
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Code sub-element
|-
!Cardinality:
|1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
|-
!Required:
|Yes
|-
!Description:
|Clinical code for this Medication Statement. Ideally DM+D.
|}
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Clinical code for the (such as G00.1 for ICD-10 meningitis)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Term
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Associated term to go with the above code.
'''Note:''' If the code is from a standard coding system (such as ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) it can be looked up from reference data already held in DDS.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|System
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Coding scheme that this code uses.
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java
 
'''Note:''' This list of supported codes can be added to if necessary.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Dose'''
{| class="wikitable"
!Field name:
|Dose
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Prescribed medication dose
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Number of issues authorised'''
{| class="wikitable"
!Field name:
|Number of issues authorised
|-
!Type:
|Integer
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|If a primary care repeat prescription, this gives the number of authorised issues the patient is allowed
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Number of issues'''
{| class="wikitable"
!Field name:
|Number of issues
|-
!Type:
|Integer
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|If a primary care repeat prescription, this gives the number of issues the patient has had
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Reasons for use'''
{| class="wikitable"
!Field name:
|Reason for use
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Unique ID of a Condition resource that is the reason this medication was prescribed
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''End date'''
{| class="wikitable"
!Field name:
|End date
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|Yes, for ended medication
|-
!Description:
|Date the prescription ended or is due to end.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Authorisation type'''
{| class="wikitable"
!Field name:
|Authorisation type
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Type of prescription (such as acute, repeat).
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/schema/MedicationAuthorisationType.java
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Confidential'''
{| class="wikitable"
!Field name:
|Confidential
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Confidentiality flag
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Quantity'''
{| class="wikitable"
!Field name:
|Quantity
|-
!Type:
|Sub-element
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Quantity of prescribed drug to be dispensed. For repeat medications, this is the quantity per issue.
|}
{| class="wikitable"
!Field name:
|Value
|-
!Type:
|Number
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Numeric quantity component
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Units
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Quantity units of measure (such as tablets)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Medication Dispense ===
Represents the dispensing of medication, links to a Medication Statement.
 
See http://hl7.org/fhir/medicationdispense.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique key for this Medication Dispense in the source data (e.g. primary key)
|-
!Source location:
|TODO: What file and field contains this?
|-
!Mapping:
|TODO: Is any mapping or formatting required?
|}
'''Patient'''
{| class="wikitable"
!Field name:
|Patient
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the Patient that this Medication Dispense belongs to
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Encounter'''
{| class="wikitable"
!Field name:
|Encounter
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Encounter during which this Medication Dispense was added to the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective clinician'''
{| class="wikitable"
!Field name:
|Effective clinician
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that issued this Medication Dispense
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective date'''
{| class="wikitable"
!Field name:
|Effective date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Medication Dispense was dispensed
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded by'''
{| class="wikitable"
!Field name:
|Recorded by
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that saved the Medication Dispense into the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded date'''
{| class="wikitable"
!Field name:
|Recorded date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Medication Dispense was saved into the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Code'''
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Code sub-element
|-
!Cardinality:
|1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
|-
!Required:
|Yes
|-
!Description:
|Clinical code for this Medication Dispense. Ideally DM+D.
|}
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Clinical code for the (such as G00.1 for ICD-10 meningitis)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Term
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Associated term to go with the above code.
'''Note:''' If the code is from a standard coding system (ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) this can be looked up from reference data already held in DDS.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|System
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Coding scheme that this code uses.
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java
 
'''Note:''' This list of supported codes can be added to if necessary
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Medication statement'''
{| class="wikitable"
!Field name:
|Medication statement
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the Medication Statement this is for
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Dose'''
{| class="wikitable"
!Field name:
|Dose
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Dispensed medication dose
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Confidential'''
{| class="wikitable"
!Field name:
|Confidential
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Confidentiality flag
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Reason for use'''
{| class="wikitable"
!Field name:
|Reason for use
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Unique ID of a Condition resource that is the reason this medication was prescribed
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Quantity'''
{| class="wikitable"
!Field name:
|Quantity
|-
!Type:
|Sub-element
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Quantity of drug dispensed
|}
{| class="wikitable"
!Field name:
|Value
|-
!Type:
|Number
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Numeric quantity component
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Units
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Quantity units of measure e.g. tablets
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Duration'''
{| class="wikitable"
|Field name:
|Duration
|-
|Type:
|Integer
|-
|Cardinality:
|0..1
|-
|Required:
|Recommended
|-
|Description:
|Days duration that this dispensed medication is intended to last
|-
|Source location:
|TODO: What file and field contains this?
|-
|Mapping:
|TODO: Is any mapping or formatting required?
|}
 
=== Resource: Observation ===
Represents a clinical observation about the patient with an optional numeric value.
 
See http://hl7.org/fhir/observation.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique key for this Observation in the source data (primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Patient'''
{| class="wikitable"
!Field name:
|Patient
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the Patient that this Observation belongs to
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Encounter'''
{| class="wikitable"
!Field name:
|Encounter
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Encounter during which this Observation was added to the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective clinician'''
{| class="wikitable"
!Field name:
|Effective clinician
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that captured this Observation
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective date'''
{| class="wikitable"
!Field name:
|Effective date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Observation was captured
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded by'''
{| class="wikitable"
!Field name:
|Recorded by
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that saved the Observation into the patient record
|-
!Source location:
|TODO: What file and field contains this?
|-
!Mapping:
|TODO: Is any mapping or formatting required?
|}
'''Recorded date'''
{| class="wikitable"
!Field name:
|Recorded date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Observation was saved into the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Code'''
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Code sub-element
|-
!Cardinality:
|1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
|-
!Required:
|Yes
|-
!Description:
|Clinical code for this Observation
|}
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Clinical code for the (such as G00.1 for ICD-10 meningitis)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Term
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Associated term to go with the above code.
 
'''Note:''' If the code is from a standard coding system (ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) then this can be looked up from reference data already held in DDS.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|System
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Coding scheme that this code uses.
 
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java
 
'''Note:''' This list of supported codes can be added to if necessary.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Numeric value'''
{| class="wikitable"
!Field name:
|Numeric value
|-
!Type:
|Sub-element
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Numeric value associated with this Observation such the reading when recording weight.
 
Mutually exclusive with the other value properties of Observation.
|}
{| class="wikitable"
!Field name:
|Value
|-
!Type:
|Number
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Numeric value for this Observation
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Units
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Units of measure for this numeric value
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Comparator
|-
!Type:
|Value set
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Qualifies the value to indicate if it is greater than or less than the true value.
 
See http://hl7.org/fhir/valueset-quantity-comparator.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Date value'''
{| class="wikitable"
!Field name:
|Date value
|-
!Type:
|Date
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Date value associated with this Observation, e.g. the date in an Observation recording an expected date of delivery. Mutually exclusive with the other value properties of Observation.
|-
!Source location:
|TODO: What file and field contains this?
|-
!Mapping:
|TODO: Is any mapping or formatting required?
|}
'''Text value'''
{| class="wikitable"
!Field name:
|Text value
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Text value associated with this Observation. For example 'negative' when recording an HIV status.
 
Mutually exclusive with the other value properties of Observation.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Notes'''
{| class="wikitable"
!Field name:
|Notes
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Free-text narrative associated with this Observation
|-
!Source location:
|TODO: What file and field contains this?
|-
!Mapping:
|TODO: Is any mapping or formatting required?
|}
'''Confidential'''
{| class="wikitable"
!Field name:
|Confidential
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Confidentiality flag
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Lower normal value range'''
{| class="wikitable"
!Field name:
|Lower normal value range
|-
!Type:
|Number
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Lower bound of normal range, only applies to Observations with a numeric value.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Upper normal value range'''
{| class="wikitable"
!Field name:
|Upper normal value range
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Lower bound of normal range, only applies to Observations with a numeric value.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Parent resource'''
{| class="wikitable"
!Field name:
|Parent resource
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Unique ID of a parent Resource (either another Observation or Diagnostic Report) that this Observation relates to.
 
For example, if an Observation is a systolic or diastolic blood pressure reading, they will link to a parent Observation representing the blood pressure reading as a whole;
 
if an Observation is a investigation result in a test (such as FBC, urine) then it will link to a parent Diagnostic Report.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Child observations'''
{| class="wikitable"
!Field name:
|Child observations
|-
!Type:
|Sub-element
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|The reverse of the above child-parent relationship, this field represents the parent-child link, linking the parent Observation to its children
|}
{| class="wikitable"
!Field name:
|Child resource
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of a child Observation
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Procedure ===
Represents a procedure or operation performed on a patient. Only procedures that have actually been performed are desired – planned or cancelled procedures are not required.
 
See http://hl7.org/fhir/procedure.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique key for the Procedure in the source data (primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Patient'''
{| class="wikitable"
!Field name:
|Patient
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the patient record this Procedure belongs to
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Code'''
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Code sub-element
|-
!Cardinality:
|1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
|-
!Required:
|Yes
|-
!Description:
|Clinical code for this Procedure
|}
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Clinical code for the (such as G00.1 for ICD-10 meningitis)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Term
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Associated term to go with the above code.
 
'''Note:''' If the code is from a standard coding system (ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) then this can be looked up from reference data already held in DDS.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|System
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Coding scheme that this code uses.
 
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java
 
'''Note:''' This list of supported codes can be added to if necessary
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective Clinician'''
{| class="wikitable"
!Field name:
|Effective Clinician
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that performed this Procedure
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective date'''
{| class="wikitable"
!Field name:
|Effective date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Procedure was performed
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded by'''
{| class="wikitable"
!Field name:
|Recorded by
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that entered this Procedure into the publishing software
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded date'''
{| class="wikitable"
!Field name:
|Recorded date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Procedure was entered into the publishing software
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Encounter'''
{| class="wikitable"
!Field name:
|Encounter
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Unique ID of the Encounter resource this Procedure belongs to (if performed during an inpatient stay, this would link to the Encounter representing the stay)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Notes'''
{| class="wikitable"
!Field name:
|Notes
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Any free-text narrative associated with this Procedure
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Confidential'''
{| class="wikitable"
!Field name:
|Confidential
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Confidentiality flag
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Is primary'''
{| class="wikitable"
!Field name:
|Is primary
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Flag to indicate if this Procedure is a primary procedure.
 
For example, in secondary care settings, a patient may have many procedures during a single operation, but only one is flagged as the “primary” procedure that the patient was admitted for.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Sequence number'''
{| class="wikitable"
!Field name:
|Sequence number
|-
!Type:
|Integer
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Ordinal to maintain the order of procedures within an Encounter.
 
For example, in the secondary care example mentioned above, the primary Procedure is given sequence number 1, and all the secondary Procedures are numbered accordingly to preserve the order they were entered into the source software.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Parent resource'''
{| class="wikitable"
!Field name:
|Parent resource
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Unique ID of a parent Procedure resource that this is logically related to.
 
For example, in the secondary care example mentioned above, the secondary Procedures are linked to the primary one using this field.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''End date'''
{| class="wikitable"
!Field name:
|End date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|When the procedure was completed, if known
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Specialty'''
{| class="wikitable"
!Field name:
|Specialty
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Specialty performing this procedure
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Location'''
{| class="wikitable"
!Field name:
|Location
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Unique ID of a Location resource when this Procedure was performed, for example the theatre.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Questionnaire Response ===
Represents a series of questions and answers, such as the output of 111 triage pathway.
 
See http://hl7.org/fhir/questionnaireresponse.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique key for the Questionnaire Response in the source data (primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Patient'''
{| class="wikitable"
!Field name:
|Patient
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the patient record this Questionnaire Response belongs to
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective Clinician'''
{| class="wikitable"
!Field name:
|Effective Clinician
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that performed this Questionnaire
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective date'''
{| class="wikitable"
!Field name:
|Effective date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Questionnaire was performed
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded by'''
{| class="wikitable"
!Field name:
|Recorded by
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that entered this Questionnaire into the publishing software
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded date'''
{| class="wikitable"
!Field name:
|Recorded date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Questionnaire was entered into the publishing software
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Encounter'''
{| class="wikitable"
!Field name:
|Encounter
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Unique ID of the Encounter resource this Procedure belongs to (if performed during an inpatient stay, this would link to the Encounter representing the stay)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Items'''
{| class="wikitable"
!Field name:
|Items
|-
!Type:
|Sub-element
|-
!Cardinality:
|0..n
|-
!Required:
|Yes
|-
!Description:
|Questions and answers
|}
{| class="wikitable"
!Field name:
|Question
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Question text
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Answer
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Answer text
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Specimen ===
Represents a biological specimen taken for a test.
 
See http://hl7.org/fhir/specimen.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique key for this Specimen in the source data (primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Patient'''
{| class="wikitable"
!Field name:
|Patient
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the Patient that this Specimen belongs to
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Encounter'''
{| class="wikitable"
!Field name:
|Encounter
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Encounter during which this Specimen was added to the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective clinician'''
{| class="wikitable"
!Field name:
|Effective clinician
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that took this Specimen
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Effective date'''
{| class="wikitable"
!Field name:
|Effective date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Specimen was taken
|-
!Source location:
|TODO: What file and field contains this?
|-
!Mapping:
|TODO: Is any mapping or formatting required?
|}
'''Recorded by'''
{| class="wikitable"
!Field name:
|Recorded by
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Practitioner that saved the Specimen into the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Recorded date'''
{| class="wikitable"
!Field name:
|Recorded date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Datetime this Specimen was saved into the patient record
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Code'''
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Code sub-element
|-
!Cardinality:
|1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
|-
!Required:
|Yes
|-
!Description:
|Clinical code for this Specimen
|}
{| class="wikitable"
!Field name:
|Code
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Clinical code for the (such as G00.1 for ICD-10 meningitis)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|Term
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Associated term to go with the above code.
 
'''Note:''' If the code is from a standard coding system (ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) then this can be looked up from reference data already held in DDS.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
{| class="wikitable"
!Field name:
|System
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Coding scheme that this code uses.
 
See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java
 
'''Note:''' This list of supported codes can be added to if necessary.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Notes'''
{| class="wikitable"
!Field name:
|Notes
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Free-text narrative about this Specimen
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Confidential'''
{| class="wikitable"
!Field name:
|Confidential
|-
!Type:
|Boolean
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Confidentiality flag
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Schedule ===
Represents an appointment session.
 
See http://hl7.org/fhir/schedule.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique key for this Schedule in the source data (primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Location'''
{| class="wikitable"
!Field name:
|Location
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|Recommended
|-
!Description:
|Unique ID of the Location where this Schedule took/will take place
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Location type'''
{| class="wikitable"
!Field name:
|Location type
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Free-text description of the type of location this Schedule is at (the above Location is preferred, but this can be used if no actual named Location is possible)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Schedule name'''
{| class="wikitable"
!Field name:
|Schedule name
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Free-text name for this Schedule such as Dr X AM Appts
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Schedule type'''
{| class="wikitable"
!Field name:
|Schedule type
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Type of Schedule this is such as general appointments, outpatient clinic
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Notes'''
{| class="wikitable"
!Field name:
|Notes
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Free-text comments about this Schedule
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Start date'''
{| class="wikitable"
!Field name:
|Start date
|-
!Type:
|Datetime
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Datetime this Schedule started or is due to start
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''End date'''
{| class="wikitable"
!Field name:
|End date
|-
!Type:
|Datetime
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Datetime this Schedule ended or is due to end
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Created by'''
{| class="wikitable"
!Field name:
|Created by
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Unique ID of the Practitioner that created this Schedule
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Created date'''
{| class="wikitable"
!Field name:
|Created date
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Datetime this Schedule was created
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Clinician'''
{| class="wikitable"
!Field name:
|Clinician
|-
!Type:
|Sub-element
|-
!Cardinality:
|1..n
|-
!Required:
|Yes
|-
!Description:
|Clinician(s) hosting this Schedule
|}
{| class="wikitable"
!Field name:
|Clinician
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of a Practitioner (the first instance of this is considered to be the 'main' Practitioner)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Slot ===
Represents a slot within a Schedule resource. Forms the link between the Schedule and the Appointment resources.
 
See http://hl7.org/fhir/slot.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique key for this Slot in the source data (primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Schedule'''
{| class="wikitable"
!Field name:
|Schedule
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the Schedule this Slot belongs to
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Start date'''
{| class="wikitable"
!Field name:
|Start date
|-
!Type:
|Datetime
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Start datetime of the Slot
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''End date'''
{| class="wikitable"
!Field name:
|End date
|-
!Type:
|Datetime
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|End datetime of the Slot
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
 
=== Resource: Appointment ===
Represents a booked appointment (such as GP appointment, outpatient appointment) in a Schedule resource.
 
Links to a Slot, which in turn links to the Schedule.
 
See http://hl7.org/fhir/appointment.html
 
'''ID'''
{| class="wikitable"
!Field name:
|ID
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique key for this Appointment in the source data (primary key)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Start date'''
{| class="wikitable"
!Field name:
|Start date
|-
!Type:
|Datetime
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Start datetime of the Appointment
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''End date'''
{| class="wikitable"
!Field name:
|End date
|-
!Type:
|Datetime
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|End datetime of the Appointment
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Notes'''
{| class="wikitable"
!Field name:
|Notes
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Free-text comments associated with this Appointment
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Slot'''
{| class="wikitable"
!Field name:
|Slot
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of the Slot that this Appointment is in
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Clinician'''
{| class="wikitable"
!Field name:
|Clinician
|-
!Type:
|Sub-element
|-
!Cardinality:
|1..n
|-
!Required:
|Yes
|-
!Description:
|Clinician(s) attending this Appointment
|}
{| class="wikitable"
!Field name:
|Clinician
|-
!Type:
|Text
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Unique ID of a Practitioner (the first instance of this is considered to be the 'main' Practitioner)
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Patient wait'''
{| class="wikitable"
!Field name:
|Patient wait
|-
!Type:
|Integer
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Minutes wait that the patient experienced between arrival and the Appointment starting
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Patient delay'''
{| class="wikitable"
!Field name:
|Patient delay
|-
!Type:
|Integer
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Minutes wait that the patient experienced between the scheduled Appointment start and the actual Appointment start
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Sent in'''
{| class="wikitable"
!Field name:
|Sent in
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Datetime that the Appointment actually started. May or may not be the same as the scheduled start date.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Left'''
{| class="wikitable"
!Field name:
|Left
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Datetime that the Appointment actually ended.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Cancelled'''
{| class="wikitable"
!Field name:
|Cancelled
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Datetime that the Appointment was cancelled.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Booked'''
{| class="wikitable"
!Field name:
|Booked
|-
!Type:
|Datetime
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Datetime that the Appointment was booked.
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Did not attend reason'''
{| class="wikitable"
!Field name:
|Did not attend reason
|-
!Type:
|Text
|-
!Cardinality:
|0..1
|-
!Required:
|No
|-
!Description:
|Reason for Appointment being DNA
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}
'''Status'''
{| class="wikitable"
!Field name:
|Status
|-
!Type:
|Value set
|-
!Cardinality:
|1..1
|-
!Required:
|Yes
|-
!Description:
|Current status of this Appointment such as booked, in progress, finished.
 
See http://hl7.org/fhir/valueset-appointmentstatus.html
|-
!Source location:
|What file and field contains this?
|-
!Mapping:
|Is any mapping or formatting required?
|}

Latest revision as of 11:29, 4 May 2021

Introduction

This article forms the basis of the technical implementation of any new inbound transform of data into the Discovery Data Service (DDS), specifically for non-transactional flat file formats.

The aim is to ask potential publishers to consider and answer the following questions:

  • How will the source data be sent to DDS? Will it be an SFTP push or pull? Will the files be encrypted? See Secure publication to the DDS for currently supported options.
  • How often will the source data be sent to DDS? Will it be sent in a daily extract? See Latency of extract data feeds to see how often and when data is currently received, and how that relates to the data available in the DDS.
  • How should the source data be mapped to the FHIR-based DDS data format? What file contains patient demographics? What column contains first name? What column contains middle names? See Publishers and mapping to the common model for more information.
  • How should any value sets should be mapped to equivalent DDS value sets? What values are used for different genders and what FHIR gender does each map to?
  • What clinical coding systems are used? Are clinical observations recorded using SNOMED CT, CTV3, Read2, ICD-10, OPCS-4 or some other nationally or locally defined system?
  • How are source data records uniquely identified within the files? What is the primary identifier/key in each file and how do files reference each other?
  • How are inserts, updates and deletes represented in the source data? Is there a 'deleted' column?
  • Is there any special knowledge required to accurately process the data?
  • Will the publishing of data be done in a phased approach? Will the demographics feed be turned on first, with more complex clinical structures at a later date?
  • What files require bulk dumps for the first extract and which will start from a point in time? Will a full dump of organisational data be possible? Will a full dump of master patient list be possible?
  • Is there any overlap with an existing transform supported by DDS? Does the feed include any national standard file that DDS already supports?

Questions that need to be answered are highlighted throughout this article:

This is a question that needs to be answered.

The understanding of the answers provided can then be used by the DDS technical team to implement the technical transformation for the source data.

Completion and sign off of the specifications is a collaborative process, involving the data publisher (or their representatives) and the DDS technical team; the data publisher has a greater understanding of their own data, and the DDS technical team have experience of multiple and differing transformations.

DDS inbound overview

DDS inbound overview

This diagram provides an overview of the way the DDS processes a sample of existing inbound data feeds. Each data publisher has their own transport mechanism for getting data into the DDS estate (SFTP push, SFTP pull, bespoke software) which is then sent through a common pipeline that performs a number of checks (most importantly validating that DDS has a data processing agreement to accept the data). Once the checks are passed, the data is handed over to the DDS transformation application, that then invokes the relevant transform code for the published data format. The result of the transformation code is standardised FHIR that is saved to the DDS database; this may be further transformed for any subscribers to that publisher’s data.

Unless there are exceptional circumstances that preclude it, all DDS software is written in Java, running on Ubuntu.

the image represents the logical flow of data into the DDS, rather than the distinct software components themselves.

Publishing process

The end to end process for publishing new data into the DDS generally follows the below steps. This isn’t necessarily a fixed-order list, as many of the steps can be performed out of order or in parallel to other steps, but it covers all the actions that need to happen.

  1. Agree extract transport mechanism and frequency.
  2. Define project phases based on data types and dependencies.
  3. Set up transport mechanism and test (this can be done at any point before live data is sent).
  4. For the first phase:
    1. Provide file extract format specification.
    2. Provide sample data.
    3. Validate and assure the published data.
    4. Define how inserts, updates and deletes are represented.
    5. Define transformation mapping.
    6. List any known special cases.
    7. Sign off transform specification document.
    8. Implement transform code to specification.
    9. Validate and assure new code using sample data (if possible).
    10. Start live feed of data, bulk followed by deltas (data will be securely stored but won’t flow into production DDS yet).
    11. Validate and assure code using subset of live data (in secure pre-production environment).
    12. Deploy new code to production DDS and start processing data.
    13. At this point, this phase is now considered live.
  5. If required, repeat step 4 for the subsequent phases.

Assurance and sign-off

Assurance and sign-off is required at three distinct stages of the publishing process:

Extract assurance

The data publisher must assure that their data extract accurately represents the data in the source clinical software.

How this assurance is done will vary from publisher to publisher, although the DDS team may be able to provide some guidance on how to conduct this.

Transform specification sign-off

Both the publisher and DDS team must agree that the completed transform specification document is accurate and sufficient to implement the transformation code.

This will be done when both parties agree that the document has been sufficiently completed.

Transform assurance

Once the transformation implementation is complete, it must be assured that it can accurately transform the source data into the DDS format.

This will generally be done in two passes, once on sample data and a second time on live data. This will involve comparing the data in the pre-production DDS against the source software.

Transport mechanism & frequency

The goal of the transport mechanism is to securely send the extract files into the DDS estate (hosted in AWS with HSCN connectivity). The frequency defines how often files are sent.

For context, these are examples of existing publisher scenarios:

  • A daily extract of 100+ files but staggered throughout the day. As each file is produced it is uploaded to a DDS SFTP server over HSCN (secured with an SSH key). As the SFTP server receives new files, these are moved into the secure file store. At midnight, the files received that day are sent for transformation.
  • A daily extract of 20 files. The files are PGP compressed and encrypted and made available on an SFTP server the publisher hosts on HSCN (secured with an SSH key). Each hour, a DDS SFTP client polls the SFTP server for new files. When new files are detected, they are downloaded and decrypted, then stored in the DDS secure file store. Once DDS has received the full set of 20 daily files, the new files are sent for transformation.
  • A single daily zip file using their own client software to a Windows PC workstation hosted within a CCG building. A small DDS-written application runs on the workstation and detects each new extract file, which is then uploaded via HTTPS over HSCN to a DDS API. The DDS API unzips the file and stores the decompressed files in the secure file store, which are then sent for transformation.
How many files will be produced in your extract and how often, and how you see them being transported to the DDS?
It is recommended that any transport be done using SFTP, secure using an SSH key and over HSCN. For further security, it is also recommended that extract files be encrypted themselves before transport.

Scheduling and dependencies

Depending on the complexity of the published data it may be necessary to split the implementation into several phases, each phase introducing new data to the DDS. For example, if a secondary care publisher extract contains data on organisational metadata, patient demographics, procedures, diagnoses, and clinical observations, it may be more efficient to break the implementation into several discrete phases for implementation; For example, doing the full procedures implementation before doing conditions, and then finally moving on to observations.

However, because some data naturally depends on other data, the dependencies must be understood to know what data items must be done before others. For example:

  1. Organisational metadata is always required first, since everything depends on organisations, locations and clinicians.
  2. Patient demographics are always required next, since all other clinical data depends on matching to patient records.
  3. A&E attendances, inpatient stays and outpatient appointments are generally required next.
  4. Finally, procedures, conditions and observations can be interpreted.
Is scheduling necessary? What are the dependencies within the data?
The scope of the first phase should now be agreed.

Extract file specification

Can you supply technical extract documentation such as file specifications?

Sample data

Can you provide sample data?
Sample data should include fictitious patients only but be as realistic as possible. It should also be in the exact same format as the planned extract.

Inserts, updates, and deletes

The ideal scenario is that each file within the extract is sent initially as a bulk extract followed by regular deltas (differences only), with clear indication of which records are new, which are updates, and which are deleted.

Can you explain how the extract represents updates and deletes to data and whether it will be possible to follow the bulk, then deltas pattern?

Transformation mapping

All inbound DDS transformations, for different source formats, output FHIR using a DDS-specific profile. Approximately 20 different FHIR resources are used in DDS to date. Each FHIR resource has many fields of different types, some mandatory, some not.

The sections in Resource mapping list all the fields for each resource type that the DDS uses.

Each field requires you to describe where that field can be found in the source data and what, if any, mapping or formatting is required.

Links to the original FHIR definitions on the HL7 website are also provided, to give more detailed explanations on what each resource is for.

Field names may not be the same as on the HL7 website and/or may not even be on the HL7 website at all; the DDS uses a number of FHIR extensions to add additional fields to each resource.

Guidance

The cell for each resource field asks for the source location and mapping. Not every field will require any mapping, so leave this blank if the value should be taken as is.

Field name: Date of birth
Type: Date
Cardinality: 1..1
Required: Yes
Description: Patient’s date of birth
Source location: “DoB” column, Patient_demographics.csv
Mapping: Date format YYYYMMDD

Example resource field

The following sub-sections provide additional guidance on more complex scenarios that should be considered when completing these cells.

Other resource fields and types

The 20+ resource types in Resource mapping are the ones used by the DDS to date out of a possible 150+. If you have data that cannot be mapped to any of them, then raise this issue with the DDS team and additional resource types will be added if necessary.

Similarly, the fields used in each resource type are only the ones that have been necessary to use to date. If the data has key information that has no obvious place in a resource, then raise this issue with the DDS team, so new fields can be made available if necessary.

Dates and times

For date and datetime fields, please specify the format the source data is provided in, For example, YYYYMMDD or DD-MM-YYYY HHMM.

Multiple files

If multiple extract files supply data for a single resource, then describe how the two files relate to each other, such as what the primary and foreign keys are.

For example, if patient addresses are supplied in a separate file to the other patient demographics, then the primary key for both files needs to be understood, as does how the address file refers to the main file.

De-duplication

If the same data is present in multiple files, then explain how the data can be processed to avoid de-duplication.

For example, one DDS publisher feed supplies procedure (such as an operation) data in four files derived from a data warehouse and two files in a national CDS standard. Each logical procedure may be present in one or more of these files, and there is no common unique ID to identify the same procedure throughout. To avoid duplicate procedures in DDS, analysis of the source data to create a de-duplication strategy was required.

Reference data

If understanding of the data requires reference data that is not part of the extract feed itself, then consider how this reference data can be supplied to DDS. For small and static reference data set, an ad hoc arrangement can be made where the reference data is manually loaded into the DDS for later look up. For large or frequently changing reference data sets, the reference data itself should be made part of the extract.

For example, one DDS publisher feed has all clinical observations (such as height and weight) coded using SNOMED CT, but the extract file containing the observations is coded using an internal integer which refers to a semi-static reference table which in turn provides the SNOMED CT concept ID. To ensure that the DDS can always look up a SNOMED CT concept ID for every observation, the coding table itself is part of the extract.

Supported file formats

The DDS already supports a number of transformations from national file CDS formats, such as the SUS Inpatient and Outpatient files. If any of these files are to be used, the existing transform can most likely be reused and the transformation mapping won’t need to be re-defined for them.

Special cases

Requirement

In all data extracts that the DDS receives there are special cases that aren’t evident from the extract specification or mapping process; these need to be fully understood to safely and accurately transform the data.

Examples of previously encountered special cases:

  • A publisher sent BST times and datetimes in UTC in some, but not all, of their extract files. This meant that in some files, an event that took place at 16:00 was shown as taking place at 15:00, and more noticeably an event that took place at midnight showed as having happened at 23:00 on the previous day. This inconsistency in times is a special case that was mitigated for, so any affected file has timed adjusted by an hour, so that events in DDS show with the correct time (and date).
  • A publisher sent extracts instructing the DDS to delete all patient data (a delete for every patient) if an exception was thrown during the extract generation. The publisher’s software error handling detected the exception and rather than simply not produce an extract for that date, sent a valid extract but with a delete statement for every record. If DDS processed this mass delete, the only way to restore the data was to take a fresh bulk extract of all the data and process it. This special case was mitigated for by detecting the mass delete and raising an alert with the DDS technical team rather than automatically processing it.
Can you provide details of any known special cases that do or can occur with the extract?
It is expected that special cases won’t necessarily be known until the transform has been implemented and the data transform is going through testing and assurance, but that knowledge must be recorded as and when it is found.

Resource mapping

Resource: Organisation

Represents an organisation, such as a GP practice, hospital department, CCG, or trust.

Defined at http://hl7.org/fhir/organization.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique identifier within the extract (primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Name

Field name: Name
Type: Text
Cardinality: 1..1
Required: Yes
Description: Organisation’s name
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Identifier

Field name: Identifier
Type: Text
Cardinality: 0..1
Required: Recommended
Description: National identifier for the organisation (ODS code)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Main location

Field name: Main location
Type: Text
Cardinality: 0..1
Required: No
Description: Unique ID of a Location resource that represents the primary location this organisation operates from (main surgery site for a GP practice)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Parent organisation

Field name: Parent organisation
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of an organisation resource that this organisation belongs to (CCG organisation for a GP practice) to allow organisational hierarchies be represented
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Type

Field name: Type
Type: Value set
Cardinality: 0..1
Required: Recommended
Description: Organisation type.

If not possible to map to the value set, a free-text type can be supported.

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/schema/OrganisationType.java

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Open date

Field name: Open date
Type: Date
Cardinality: 0..1
Required: No
Description: Date the organisation opened
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Close date

Field name: Close date
Type: Date
Cardinality: 0..1
Required: No
Description: Date the organisation closed
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Address

Field name: Address
Type: Address sub-structure
Cardinality: 0..1
Required: Recommended
Description: The organisation’s address
Field name: Line
Type: Text
Cardinality: 0..n
Required: Recommended
Description: Number, house name, road and locality
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: City
Type: Text
Cardinality: 0..1
Required: Recommended
Description: City or town
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: County
Type: Text
Cardinality: 0..1
Required: No
Description: County
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Postcode
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Postcode
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Use
Type: Value set
Cardinality: 1..1
Required: Yes
Description: The use of the address (work).

For organisations, it may be possible to just infer that all addresses are work addresses.

See http://hl7.org/fhir/valueset-address-use.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Telecom

Field name: Telecom
Type: Telecom sub-structure
Cardinality: 0..n
Required: Recommended
Description: The organisation’s list of contact methods (phones, faxes and emails)
Field name: Value
Type: Text
Cardinality: 1..1
Required: Yes
Description: Contact value (phone number, email address)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Use
Type: Value set
Cardinality: 1..1
Required: Yes
Description: What this contact method is used for (work).

For organisations, we may simply infer that all contacts are for work purposes. See http://hl7.org/fhir/valueset-contact-point-use.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: System
Type: Text
Cardinality: 1..1
Required: Yes
Description: The type of contact method this is (phone, fax, email).

See http://hl7.org/fhir/valueset-contact-point-system.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Location

Represents a physical location.

Defined at: http://hl7.org/fhir/location.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique identifier within the extract (primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Name

Field name: Name
Type: Text
Cardinality: 1..1
Required: Yes
Description: Location’s name
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Identifier

Field name: Identifier
Type: Text
Cardinality: 0..1
Required: Recommended
Description: National or local identifier for the location
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Main contact name

Field name: Main contact name
Type: Text
Cardinality: 1..1
Required: No
Description: Name of main person responsible for this location (manager)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Part of

Field name: Part of
Type: Text
Cardinality: 0..1
Required: No
Description: Unique ID of a parent Location if this location is part of a hierarchy
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Managing organisation

Field name: Managing organisation
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of an Organisation that this Location belongs to
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Physical type

Field name: Physical type
Type: Value set
Cardinality: 0..1
Required: Recommended
Description: What type of location this is (room, wing, building).

See http://hl7.org/fhir/valueset-location-physical-type.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Open date

Field name: Open date
Type: Date
Cardinality: 0..1
Required: No
Description: Date the location opened
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Close date

Field name: Close date
Type: Date
Cardinality: 0..1
Required: No
Description: Date the location closed
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Address

Field name: Address
Type: Address sub-structure
Cardinality: 0..1
Required: Recommended
Description: The location’s address
Field name: Line
Type: Text
Cardinality: 0..n
Required: Recommended
Description: Number, house name, road and locality
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: City
Type: Text
Cardinality: 0..1
Required: Recommended
Description: City or town
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: County
Type: Text
Cardinality: 0..1
Required: No
Description: County
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Postcode
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Postcode
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Use
Type: Value set
Cardinality: 1..1
Required: Yes
Description: The use of the address (work).

For locations, it may be possible to just infer that all addresses are work addresses.

See http://hl7.org/fhir/valueset-address-use.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Telecom

Field name: Telecom
Type: Telecom sub-structure
Cardinality: 0..n
Required: Recommended
Description: The organisation’s list of contact methods (phones, faxes and emails)
Field name: Value
Type: Text
Cardinality: 1..1
Required: Yes
Description: Contact value (phone number, email address)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Use
Type: Value set
Cardinality: 1..1
Required: Yes
Description: What this contact method is used for (such as work).

For organisations, we may simply infer that all contacts are for work purposes.

See http://hl7.org/fhir/valueset-contact-point-use.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: System
Type: Text
Cardinality: 1..1
Required: Yes
Description: The type of contact method this is (phone, fax, email).

See http://hl7.org/fhir/valueset-contact-point-system.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Practitioner

Represents an individual working at an organisation, such as a clinician or administrator.

Defined at http://hl7.org/fhir/practitioner.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique identifier within the extract (primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Managing organisation

Field name: Managing organisation
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the Organisation that this Practitioner belongs to
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Role start date

Field name: Role start date
Type: Date
Cardinality: 0..1
Required: No
Description: Start date of this practitioner in this role
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Role end date

Field name: Role end date
Type: Date
Cardinality: 0..1
Required: No
Description: End date of this practitioner in this role
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Active

Field name: Active
Type: Boolean
Cardinality: 0..1
Required: No
Description: Boolean flag to define if this practitioner is active or not. Can be used if explicit start and end dates are not available, but if they are available then this should not be used.
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Job role code

Field name: Job role code
Type: Value set
Cardinality: 0..1
Required: Recommended
Description: Code to define the job role.

See https://fhir.hl7.org.uk/STU3/CodeSystem/CareConnect-SDSJobRoleName-1#

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Speciality

Field name: Specialty
Type: Text
Cardinality: 0..1
Required: No
Description: Secondary care specialty this Practitioner works in
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Name

Field name: Name
Type: Name sub-structure
Cardinality: 1..1
Required: Yes
Description: Practitioners current name
Field name: Prefix
Type: Text
Cardinality: 0..n
Required: Recommended
Description: Title or anything that would proceed the name
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Given
Type: Text
Cardinality: 1..n
Required: Yes
Description: First and middle names
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Family
Type: Text
Cardinality: 1..n
Required: Yes
Description: Surname(s) / last name(s).

Note: Hyphenated surnames are not split into separate elements, but other double surnames are.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Suffix
Type: Text
Cardinality: 0..n
Required: No
Description: Any title or honorific that would appear after the name (such as OBE)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Identifier

Field name: Identifier
Type: Identifier sub-structure
Cardinality: 0..n
Required: No
Description: Any identifiers for the practitioner (such as GMC number)
Field name: ID
Type: Text
Cardinality: 0..1
Required: Yes, if multiple identifiers of the same type are provided.

No, if only a single identifier of each type is provided.

Description: Unique ID for this identifier record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Value
Type: Text
Cardinality: 1..1
Required: Yes
Description: The actual value of the identifier
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: System
Type: Value set
Cardinality: 1..1
Required: Yes
Description: What kind of identifier this is (GMC number).

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirIdentifierUri.java

Note: This value set isn’t fixed, new options can be added.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Start date
Type: Date
Cardinality: 0..1
Required: No
Description: Start date of the identifier
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: End date
Type: Date
Cardinality: 0..1
Required: Recommended
Description: End date of the identifier
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Address

Field name: Address
Type: Address sub-structure
Cardinality: 0..1
Required: Recommended
Description: The practitioner's address
Field name: Line
Type: Text
Cardinality: 0..n
Required: Recommended
Description: Number, house name, road and locality
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: City
Type: Text
Cardinality: 0..1
Required: Recommended
Description: City or town
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: County
Type: Text
Cardinality: 0..1
Required: No
Description: County
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Postcode
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Postcode
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Use
Type: Value set
Cardinality: 1..1
Required: Yes
Description: The use of the address (work).

See http://hl7.org/fhir/valueset-address-use.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Telecom

Field name: Telecom
Type: Telecom sub-structure
Cardinality: 0..n
Required: Recommended
Description: The practitioners’s list of contact methods (phones, faxes and emails)
Field name: ID
Type: Text
Cardinality: 0..1
Required: Yes, if multiple telecoms are supplied per practitioner.

No if only a single telecoms is supplied.

Description: Unique ID for this telecom record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Value
Type: Text
Cardinality: 1..1
Required: Yes
Description: Telecom value (phone number, email address)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Start date
Type: Date
Cardinality: 0..1
Required: No
Description: Start date of the telecom
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: End date
Type: Date
Cardinality: 0..1
Required: Recommended
Description: End date of the telecom
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Use
Type: Value set
Cardinality: 1..1
Required: Yes
Description: What this telecom method is used for (work).

See http://hl7.org/fhir/valueset-contact-point-use.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: System
Type: Text
Cardinality: 1..1
Required: Yes
Description: The type of telecom method this is (phone, fax, email).

See http://hl7.org/fhir/valueset-contact-point-system.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Patient

Represents the top-level of the patient record, containing name and other demographics.

See http://hl7.org/fhir/patient.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique key for the patient in the source data (primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Managing organisation

Field name: Managing organisation
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique identifier of the Organisation resource that represents the publisher of the data.

For example, if data is published from a Out of Hours Call Centre, this field will refer to the Organisation representing the call centre itself.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

NHS number

Field name: NHS number
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Patient’s NHS number
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

NHS number verification status

Field name: NHS number verification status
Type: Value set
Cardinality: 0..1
Required: Recommended
Description: Status of how the NHS number has been validated against the PDS.

See https://www.datadictionary.nhs.uk/version2/data_dictionary/data_field_notes/n/nhs_number_status_indicator_de.asp?shownav=1

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Date of birth

Field name: Date of birth
Type: Date
Cardinality: 0..1
Required: Recommended
Description: Patient’s date of birth
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Deceased

Field name: Deceased
Type: Boolean
Cardinality: 0..1
Required: No
Description: Boolean flag to indicate if the patient is deceased
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Date of death

Field name: Date of death
Type: Date
Cardinality: 0..1
Required: No
Description: Date of patient’s death
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Gender

Field name: Gender
Type: Value set
Cardinality: 0..1
Required: Recommended
Description: Patient’s gender

See http://hl7.org/fhir/valueset-administrative-gender.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Residential institute code

Field name: Residential institute code
Type: Text
Cardinality: 0..1
Required: No
Description: Note: This field is only present in GP software so no attempt to populate it should be made from non-GP data.
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Spine sensitive

Field name: Spine sensitive
Type: Boolean
Cardinality: 0..1
Required: No
Description: Whether this patient record is known to be flagged as sensitive on the PDS or not.
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Confidential

Field name: Confidential
Type: Boolean
Cardinality: 0..1
Required: No
Description: Patient record confidentiality flag
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Care provider

Field name: Care provider
Type: Text
Cardinality: 0..1
Required: No
Description: Reference to an Organisation representing the patient’s known registered GP practice.
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Marital status

Field name: Marital status
Type: Value set
Cardinality: 0..1
Required: No
Description: Patient’s current marital status.

See http://hl7.org/fhir/valueset-marital-status.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Ethnicity

Field name: Ethnicity
Type: Value set
Cardinality: 0..1
Required: No
Description: Patient’s ethnicity.

See https://www.datadictionary.nhs.uk/data_dictionary/attributes/e/end/ethnic_category_code_de.asp

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Religion

Field name: Religion
Type: Value set
Cardinality: 0..1
Required: No
Description: Patient’s religion.

See https://www.datadictionary.nhs.uk/data_dictionary/attributes/r/red/religious_or_other_belief_system_affiliation_code_de.asp?shownav=1  

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Language

Field name: Language
Type: Text
Cardinality: 0..1
Required: No
Description: Patient’s main spoken language  
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Speaks English

Field name: Speaks English
Type: Boolean
Cardinality: 0..1
Required: No
Description: Whether the patient speaks English or not
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Test patient

Field name: Test patient
Type: Boolean
Cardinality: 0..1
Required: No
Description: Flag to indicate that the patient record is a dummy or test record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Name

Field name: Name
Type: Name sub-structure
Cardinality: 1..n
Required: Yes
Description: Patient’s current name, any aliases and name history
Field name: ID
Type: Text
Cardinality: 0..1
Required: Yes, if multiple names of the same type are provided.

No, if only a single name of each type is provided.

Description: Unique ID for this name record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Prefix
Type: Text
Cardinality: 0..n
Required: Recommended
Description: Patient’s title or anything that would proceed the name
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Given

Field name: Given
Type: Text
Cardinality: 1..n
Required: Yes
Description: First and middle names
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Family

Field name: Family
Type: Text
Cardinality: 1..n
Required: Yes
Description: Surname(s) / last name(s).

Note: Hyphenated surnames are not split into separate elements, but other double surnames are.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Suffix

Field name: Suffix
Type: Text
Cardinality: 0..n
Required: No
Description: Any title or honorific that would appear after the name (OBE)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Start date

Field name: Start date
Type: Date
Cardinality: 0..1
Required: No
Description: Start date of the identifier
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

End date

Field name: End date
Type: Date
Cardinality: 0..1
Required: Recommended
Description: End date of the identifier
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Identifier

Field name: Identifier
Type: Identifier sub-structure
Cardinality: 0..n
Required: No
Description: Any locally used identifiers for the patient record (medical record number, patient number, client number)
Field name: ID
Type: Text
Cardinality: 0..1
Required: Yes, if multiple identifiers of the same type are provided.

No, if only a single identifier of each type is provided.

Description: Unique ID for this identifier record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Value
Type: Text
Cardinality: 1..1
Required: Yes
Description: The actual value of the identifier
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: System
Type: Value set
Cardinality: 1..1
Required: Yes
Description: What kind of identifier this is (MRN, patient number, client number).

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirIdentifierUri.java

Note: This value set isn’t fixed, and new options can be added.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Start date
Type: Date
Cardinality: 0..1
Required: No
Description: Start date of the identifier
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: End date
Type: Date
Cardinality: 0..1
Required: Recommended
Description: End date of the identifier
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Address

Field name: Address
Type: Address sub-structure
Cardinality: 0..n
Required: Recommended
Description: The patient’s addresses
Field name: ID
Type: Text
Cardinality: 0..1
Required: Yes, if multiple addresses are supplied per patient.

No if only a single address is supplied.

Description: Unique ID for this address record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Line
Type: Text
Cardinality: 0..n
Required: Recommended
Description: Number, house name, road and locality of the address
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: City
Type: Text
Cardinality: 0..1
Required: Recommended
Description: City or town
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: County
Type: Text
Cardinality: 0..1
Required: No
Description: County
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Postcode
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Postcode
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Start date
Type: Date
Cardinality: 0..1
Required: No
Description: Start date of the address
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: End date
Type: Date
Cardinality: 0..1
Required: Recommended
Description: End date of the address
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Use
Type: Value set
Cardinality: 1..1
Required: Yes
Description: The use of the address (home, temporary).

See http://hl7.org/fhir/valueset-address-use.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Telecom

Field name: Telecom
Type: Telecom sub-structure
Cardinality: 0..n
Required: Recommended
Description: The patient’s list of contact methods (phones, faxes and emails)
Field name: ID
Type: Text
Cardinality: 0..1
Required: Yes, if multiple telecoms are supplied per patient.

No if only a single telecoms is supplied.

Description: Unique ID for this contact record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Value
Type: Text
Cardinality: 1..1
Required: Yes
Description: Telecom value (phone number, email address)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Start date
Type: Date
Cardinality: 0..1
Required: No
Description: Start date of the telecom
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: End date
Type: Date
Cardinality: 0..1
Required: Recommended
Description: End date of the telecom
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Use
Type: Value set
Cardinality: 1..1
Required: Yes
Description: What this telecom method is used for (home, work).

See http://hl7.org/fhir/valueset-contact-point-use.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: System
Type: Text
Cardinality: 1..1
Required: Yes
Description: The type of telecom method this is (phone, fax, email).

See http://hl7.org/fhir/valueset-contact-point-system.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Contact

Field name: Contact
Type: Family member / carer / relationship sub-structure
Cardinality: 0..n
Required: No
Description: The patient’s list of family members, carers and relationships
Field name: ID
Type: Text
Cardinality: 0..1
Required: Yes, if multiple contacts are supplied per patient.

No if only a single contact is supplied.

Description: Unique ID for this contact record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Relationship
Type: Text
Cardinality: 1..1
Required: Yes
Description: Relationship of this person to the patient
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Language
Type: Text
Cardinality: 0..1
Required: No
Description: Main spoken language of this person
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Date of birth
Type: Date
Cardinality: 0..1
Required: No
Description: Birth date of this person
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Gender
Type: Value set
Cardinality: 0..1
Required: No
Description: Gender of this person.

See http://hl7.org/fhir/valueset-administrative-gender.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Start date
Type: Date
Cardinality: 0..1
Required: No
Description: Start date of the contact
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: End date
Type: Date
Cardinality: 0..1
Required: Recommended
Description: End date of the contact
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Name

Field name: Name
Type: Name sub-structure
Cardinality: 0..1
Required: Recommended
Description: Person’s current name
Field name: Prefix
Type: Text
Cardinality: 0..n
Required: Recommended
Description: Patient’s title or anything that would proceed the name
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Given
Type: Text
Cardinality: 1..n
Required: Yes
Description: First and middle names
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Family
Type: Text
Cardinality: 1..n
Required: Yes
Description: Surname(s) / last name(s).

Note: Hyphenated surnames are not split into separate elements, but other double surnames are.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Address

Field name: Address
Type: Address sub-structure
Cardinality: 0..1
Required: No
Description: The person’s addresses
Field name: Line
Type: Text
Cardinality: 0..n
Required: Recommended
Description: Number, house name, road and locality of the address
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: City
Type: Text
Cardinality: 0..1
Required: Recommended
Description: City or town
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: County
Type: Text
Cardinality: 0..1
Required: No
Description: County
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Postcode
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Postcode
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Use
Type: Value set
Cardinality: 1..1
Required: Yes
Description: The use of the address (home, temporary).

See http://hl7.org/fhir/valueset-address-use.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Telecom

Field name: Telecom
Type: Telecom sub-structure
Cardinality: 0..n
Required: No
Description: The person’s list of contact methods (phones, faxes and emails)
Field name: Value
Type: Text
Cardinality: 1..1
Required: Yes
Description: Contact value (phone number, email address)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Use
Type: Value set
Cardinality: 1..1
Required: Yes
Description: What this contact method is used for (home, work).

See http://hl7.org/fhir/valueset-contact-point-use.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: System
Type: Text
Cardinality: 1..1
Required: Yes
Description: The type of contact method this is (phone, fax, email).

See http://hl7.org/fhir/valueset-contact-point-system.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Episode of Care

Represents the duration a patient was under the care of a care provider.

For primary care, this would be the period of registration. For secondary care, this would be the period from referral or A&E attendance to clinical discharge.

See http://hl7.org/fhir/episodeofcare.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique key for the episode in the source data (primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Patient

Field name: Patient
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the patient record this episode belongs to
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Managing organisation

Field name: Managing organisation
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the organisation this episode belongs to.

Should be the same as the same field on the Patient resource.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Care manager

Field name: Care manager
Type: Text
Cardinality: 0..1
Required: No
Description: Unique ID of the Practitioner responsible for this episode, such as their consultant or usual GP.
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Start date

Field name: Start date
Type: Date
Cardinality: 1..1
Required: Yes
Description: Date this episode started.
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

End date

Field name: End date
Type: Date
Cardinality: 0..1
Required: No
Description: Date this episode ended, if it has ended.

A future-dated end date is permitted if it is known.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Registration type

Field name: Registration type
Type: Value set
Cardinality: 0..1
Required: No
Description: GP registration type. Only for use in GP practice care settings.

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/schema/RegistrationType.java

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Registration status

Field name: Registration status
Type: Sub-element
Cardinality: 0..n
Required: No
Description: GP registration status. Only for use in GP practice care settings.
Field name: Status code
Type: Value set
Cardinality: 1..1
Required: Yes
Description: Registration status code.

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/schema/RegistrationStatus.java

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Status date
Type: Date
Cardinality: 1..1
Required: Yes
Description: Date this registration status was recorded
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Outcome

Field name: Outcome
Type: Text
Cardinality: 0..1
Required: No
Description: Outcome of this episode. Used in non-scheduled care and secondary care (discharged).
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Priority

Field name: Priority
Type: Text
Cardinality: 0..1
Required: No
Description: Priority of this episode. Used in non-scheduled care (urgent, less urgent).
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Encounter

Represents a patient’s contact with a care provider (GP consultation, A&E attendance, inpatient stay).

Encounters may also be nested and link to a wider, parent encounter, such as a consultant performing a bedside examination may be recorded as an encounter that is linked to the encounter representing the inpatient stay.

See http://hl7.org/fhir/encounter.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique key for the condition in the source data (primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Patient

Field name: Patient
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the patient record this Condition belongs to
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Episode of care

Field name: Episode of Care
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the episode of care that this encounter belongs to
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Service Provider

Field name: Service Provider
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the Organisation that performed this encounter
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective Clinician

Field name: Effective Clinician
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the practitioner that performed (or was responsible for) this encounter (not necessarily the person who input it into the software)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective date

Field name: Effective date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this encounter was began
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded by

Field name: Recorded by
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that entered this encounter into the publishing software
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded date

Field name: Recorded date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this encounter was entered into the publishing software
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

End date

Field name: End date
Type: Datetime
Cardinality: 0..1
Required: No
Description: Datetime this encounter ended
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Status

Field name: Status
Type: Value set
Cardinality: 1..1
Required: Yes
Description: Current status of this encounter (planned, arrived, finished).

See http://hl7.org/fhir/valueset-encounter-status.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Appointment

Field name: Appointment
Type: Text
Cardinality: 0..1
Required: No
Description: Unique ID of an appointment resource that this Eecounter is related to.
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Confidential

Field name: Confidential
Type: Boolean
Cardinality: 0..1
Required: No
Description: Confidentiality flag.
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Class

Field name: Class
Type: Value set
Cardinality: 1..1
Required: Yes
Description: The top-level classification of this encounter (inpatient, outpatient, emergency).

See http://hl7.org/fhir/v3/ActEncounterCode/vs.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Reason

Field name: Reason
Type: Value set
Cardinality: 0..1
Required: Recommended
Description: The main reason for this encounter.

See http://hl7.org/fhir/valueset-encounter-reason.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Type

Field name: Type
Type: Text
Cardinality: 0..1
Required: Recommended
Description: The free-text type of encounter (telephone appointment, outpatient appointment, diabetic review)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Location

Field name: Location
Type: Text
Cardinality: 0..1
Required: No
Description: The unique ID of the current location of the patient, (a specific bed, room or ward)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Location type

Field name: Location type
Type: Text
Cardinality: 0..1
Required: No
Description: Free-text description of the location of the patient if a specific named location (see above) is not available, (emergency department).
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Status

Field name: Status
Type: Value set
Cardinality: 1..1
Required: Yes
Description: The current status of this encounter (planned, arrived, finished).

See http://hl7.org/fhir/valueset-encounter-status.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Specialty

Field name: Specialty
Type: Text
Cardinality: 0..1
Required: No
Description: Hospital specialty that this encounter is under.
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Allergy Intolerance

Represents a patient’s allergy or drug sensitivity.

See http://hl7.org/fhir/allergyintolerance.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique key for the Allergy in the source data (primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Patient

Field name: Patient
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the patient record this Allergy belongs to
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective Clinician

Field name: Effective Clinician
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that captured this Allergy (not necessarily the person who input it into the software)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective date

Field name: Effective date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Allergy was captured (not necessarily the datetime it was input into the software)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded by

Field name: Recorded by
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that entered this Allergy into the publishing software
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded date

Field name: Recorded date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Allergy was entered into the publishing software
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Encounter

Field name: Encounter
Type: Text
Cardinality: 0..1
Required: No
Description: Unique ID of the Encounter resource this Allergy belongs to (if recorded during a consultation, this would link to the Encounter representing the consultation)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

End date

Field name: End date
Type: Datetime
Cardinality: 0..1
Required: No
Description: Datetime this Allergy ceased
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Status

Field name: Status
Type: Value set
Cardinality: 0..1
Required: No
Description: Current status of this Allergy (active, inactive, resolved).

See http://hl7.org/fhir/valueset-allergyintolerance-clinical.html

Note: This can be inferred from the End Date field (if end date present, status is inactive)

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Severity

Field name: Severity
Type: Value set
Cardinality: 0..1
Required: No
Description: Severity of this Allergy (mild, moderate).

See http://hl7.org/fhir/valueset-reaction-event-severity.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Category

Field name: Category
Type: Value set
Cardinality: 0..1
Required: No
Description: What kind of Allergy is this (food, environment, medication).

See http://hl7.org/fhir/valueset-allergy-intolerance-category.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Note

Field name: Note
Type: Text
Cardinality: 0..1
Required: No
Description: Free-text narrative associated with this Allergy
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Confidential

Field name: Confidential
Type: Boolean
Cardinality: 0..1
Required: No
Description: Confidentiality flag
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Code

Field name: Code
Type: Code sub-element
Cardinality: 1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
Required: Yes
Description: Clinical code for this Allergy
Field name: Code
Type: Text
Cardinality: 1..1
Required: Yes
Description: Clinical code for the (G00.1 for ICD-10 meningitis)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Term
Type: Text
Cardinality: 1..1
Required: Yes
Description: Associated term to go with the above code.

Note: If the code is from a standard coding system (ICD-10, OPCS-4, Read2, CTV3, SNOMED CT), this can be looked up from reference data already held in the DDS.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: System
Type: Value set
Cardinality: 1..1
Required: Yes
Description: Coding scheme that this code uses.

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java

Note: This list of supported codes can be added to if necessary

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Condition

Represents a clinical condition or complaint within a patient record.

See http://hl7.org/fhir/condition.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique key for the Condition in the source data (primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Patient

Field name: Patient
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the patient record this Condition belongs to
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Code

Field name: Code
Type: Code sub-element
Cardinality: 1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
Required: Yes
Description: Clinical code for this Condition
Field name: Code
Type: Text
Cardinality: 1..1
Required: Yes
Description: Clinical code for the (G00.1 for ICD-10 meningitis)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Term
Type: Text
Cardinality: 1..1
Required: Yes
Description: Associated term to go with the above code.

Note: if the code is from a standard coding system (ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) then this can be looked up from reference data already held in DDS.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: System
Type: Value set
Cardinality: 1..1
Required: Yes
Description: Coding scheme that this code uses.

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java

Note: This list of supported codes can be added to if necessary

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Is problem

Field name: Is problem
Type: Boolean
Cardinality: 1..1
Required: Yes
Description: Flag to indicate if this condition is regarded as a problem or not
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective Clinician

Field name: Effective Clinician
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that diagnosed or captured this complaint (not necessarily the person who input it into the software)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective Date

Field name: Effective date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Condition was diagnosed or complaint captured (not necessarily the datetime it was input into the software)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded by

Field name: Recorded by
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that entered this Condition or complaint into the publishing software
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded date

Field name: Recorded date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Condition was entered into the publishing software
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Encounter

Field name: Encounter
Type: Text
Cardinality: 0..1
Required: No
Description: Unique ID of the Encounter resource this Condition belongs to (if recorded during a consultation, this would link to the Encounter representing the consultation)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Notes

Field name: Notes
Type: Text
Cardinality: 0..1
Required: No
Description: Any free-text narrative associated with this Condition
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Confidential

Field name: Confidential
Type: Boolean
Cardinality: 0..1
Required: No
Description: Confidentiality flag
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Is review

Field name: Is review
Type: Boolean
Cardinality: 0..1
Required: No
Description: Flag to indicate that this Condition is a review of an existing one, rather than a new diagnosis.

Some publishing systems record reviews (annual asthma review) using the same clinical code as the initial diagnosis but qualified with an is review flag.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Is primary

Field name: Is primary
Type: Boolean
Cardinality: 0..1
Required: No
Description: Flag to indicate if this Condition is a primary diagnosis.

For example, in secondary care settings, a patient may have many diagnoses during a single in patient stay, but only one is flagged as the primary diagnosis that the patient was admitted for.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Sequence number

Field name: Sequence number
Type: Integer
Cardinality: 0..1
Required: No
Description: Ordinal to maintain the order of diagnoses within an Encounter.

For example, in the secondary care example mentioned above, the primary diagnosis is given sequence number 1, and all the secondary diagnoses are numbered accordingly to preserve the order they were entered into the source software.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Parent resource

Field name: Parent resource
Type: Boolean
Cardinality: 0..1
Required: No
Description: Unique ID of a parent Condition resource that this is logically related.

For example, in the secondary care example mentioned above, the secondary diagnoses are linked to the primary one using this field.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Parent problem

Field name: Parent problem
Type: Text
Cardinality: 0..1
Required: No
Description: Unique ID of a parent Condition resource (that has “is problem” = true) that this Condition has been grouped under.

For example, a patient may have a symptomatic Condition of “Nausea” and a diagnostic Condition of “Angina”. If the angina Condition is flagged as a problem,

then the nausea Condition may be linked to the problem to indicate that the nausea complaint is related to the angina diagnosis.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Problem end date

Field name: Problem end date
Type: Date
Cardinality: 0..1 (only applicable if Condition has “is problem” = true)
Required: No
Description: Date the problem was ended
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Problem expected duration

Field name: Problem expected duration
Type: Integer
Cardinality: 0..1 (only applicable if Condition has “is problem” = true)
Required: No
Description: Estimated number of days the problem is expected to last for
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Problem last reviewed by

Field name: Problem last reviewed by
Type: Test
Cardinality: 0..1 (only applicable if Condition has “is problem” = true)
Required: No
Description: Unique ID of the Practitioner who last reviewed this problem (performed an asthma review for an asthma problem)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Problem last reviewed date

Field name: Problem last reviewed date
Type: Date
Cardinality: 0..1 (only applicable if Condition has “is problem” = true)
Required: No
Description: Date that this problem was last reviewed
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Problem significance

Field name: Problem significance
Type: Value set
Cardinality: 0..1 (only applicable if Condition has “is problem” = true)
Required: No
Description: Significance of this problem.

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/schema/ProblemSignificance.java

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Service Request

Represents: an order for diagnostics. For example, a blood or urine test, a planned review, (an asthma review) or a referral (referral for investigation).

See http://hl7.org/fhir/servicerequest.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique key for this request in the source data (primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Patient

Field name: Patient
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the Patient this request is for
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Ordered by

Field name: Ordered by
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner or Organisation making this request.

Note: In the case of referrals received by the publisher, this may be someone outside of this organisation.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Ordered date

Field name: Ordered date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this request was made
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded by

Field name: Recorded by
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner who recorded this request in the publishing software
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded date

Field name: Recorded date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this request was recorded in the publishing software
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Encounter

Field name: Encounter
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Encounter this request was made in
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Notes

Field name: Notes
Type: Text
Cardinality: 0..1
Required: No
Description: Free text narrative associated with this request
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Status

Field name: Status
Type: Value set
Cardinality: 0..1
Required: Recommended
Description: The current status of this request (such as completed).

See http://hl7.org/fhir/valueset-request-status.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Confidential

Field name: Confidential
Type: Value set
Cardinality: 0..1
Required: No
Description: Confidentiality flag
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Code

Field name: Code
Type: Code sub-element
Cardinality: 1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
Required: Yes
Description: Clinical code for this request
Field name: Code
Type: Text
Cardinality: 1..1
Required: Yes
Description: Clinical code for the (such as G00.1 for ICD-10 meningitis)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Term
Type: Text
Cardinality: 1..1
Required: Yes
Description: Associated term to go with the above code.

Note: If the code is from a standard coding system (such as ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) then this can be looked up from reference data already held in DDS.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: System
Type: Value set
Cardinality: 1..1
Required: Yes
Description: Coding scheme that this code uses.

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java

Note: This list of supported codes can be added to if necessary

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recipient

Field name: Recipient
Type: Text
Cardinality: 0..1
Required: Yes, if a referral
Description: Unique ID of the recipient Organisation or Practitioner of this request (such as who a referral is to)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Priority

Field name: Priority
Type: Value set
Cardinality: 0..1
Required: Yes, if a referral
Description: Priority of this request e.g. routine, urgent.

See http://hl7.org/fhir/valueset-request-priority.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Referral Type

Field name: Referral Type
Type: Value set
Cardinality: 0..1
Required: Yes, if a referral
Description: Type of referral,(investigation, treatment).

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/schema/ReferralType.java  

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Referral Mode

Field name: Referral Mode
Type: Value set
Cardinality: 0..1
Required: Yes, if a referral
Description: How a referral was sent, (written, e-Referral).

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/schema/ReferralRequestSendMode.java

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Diagnostic Report

Represents a test request report; the individual test results within the report are represented as Observation resources that link back to this report.

See http://hl7.org/fhir/diagnosticreport.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique key for this report in the source data (such as primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Patient

Field name: Patient
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the Patient that this report belongs to
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Encounter

Field name: Encounter
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Encounter during which this report was filed into the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Filed by

Field name: Filed by
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that processed/assessed this report on receipt
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Filed date

Field name: Filed date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this report was processed/assessed
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded by

Field name: Recorded by
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that saved the report into the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded date

Field name: Recorded date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this report was saved into the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Status

Field name: Status
Type: Value set
Cardinality: 0..1
Required: Recommended
Description: Status of this report (final, partial).

See http://hl7.org/fhir/valueset-diagnostic-report-status.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Conclusion

Field name: Conclusion
Type: Text
Cardinality: 0..1
Required: No
Description: Free-text narrative conclusion about this report (not the results of the tests themselves, but the conclusion made by the clinician when filing the report into the patient record)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Confidential

Field name: Confidential
Type: Boolean
Cardinality: 0..1
Required: No
Description: Confidentiality flag
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Results

Field name: Results
Type: Results sub-type
Cardinality: 0..n
Required: Recommended
Description: References to the individual results within this report, which are held as separate Observation resources
Field name: Result
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of an Observation that is one of the investigation results within this report
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Code

Field name: Code
Type: Code sub-element
Cardinality: 1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
Required: Yes
Description: Clinical code for this report (generally the code representing the test battery performed, such as Full blood count)
Field name: Code
Type: Text
Cardinality: 1..1
Required: Yes
Description: Clinical code for the (such as G00.1 for ICD-10 meningitis)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Term
Type: Text
Cardinality: 1..1
Required: Yes
Description: Associated term to go with the above code. Note, if the code is from a standard coding system (such as ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) then this can be looked up from reference data already held in DDS.
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: System
Type: Value set
Cardinality: 1..1
Required: Yes
Description: Coding scheme that this code uses.

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java

Note: This list of supported codes can be added to if necessary

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Family Member History

Records any known medical conditions in family members.

See http://hl7.org/fhir/familymemberhistory.html
ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique key for this History in the source data (such as primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Patient

Field name: Patient
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the Patient that this History belongs to
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Encounter

Field name: Encounter
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Encounter during which this History was added to the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective clinician

Field name: Effective clinician
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that captured this History
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective date

Field name: Effective date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this History was captured
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded by

Field name: Recorded by
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that saved the History into the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded date

Field name: Recorded date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this History was saved into the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Code

Field name: Code
Type: Code sub-element
Cardinality: 1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
Required: Yes
Description: Clinical code for this History (note that codes should be specific family history of codes, such as family history of diabetes, and not just the unqualified disease code such as diabetes).
Field name: Code
Type: Text
Cardinality: 1..1
Required: Yes
Description: Clinical code for the (such as G00.1 for ICD-10 meningitis)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Term
Type: Text
Cardinality: 1..1
Required: Yes
Description: Associated term to go with the above code.

Note: If the code is from a standard coding system (ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) then this can be looked up from reference data already held in DDS.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: System
Type: Value set
Cardinality: 1..1
Required: Yes
Description: Coding scheme that this code uses.

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java

Note: This list of supported codes can be added to if necessary

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Relationship

Field name: Relationship
Type: Value set
Cardinality: 0..1
Required: Recommended
Description: The relationship of the family member to the patient.

See http://hl7.org/fhir/v3/FamilyMember/vs.html

Note: If it isn’t possible to map to this value set, a free-text relationship can be accepted.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Confidential

Field name: Confidential
Type: Boolean
Cardinality: 0..1
Required: No
Description: Confidentiality flag
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Notes

Field name: Notes
Type: Text
Cardinality: 0..1
Required: No
Description: Free-text narrative associated with this History
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Flag

Represents an alert or warning on a Patient record (such as a Protection Plan).

See http://hl7.org/fhir/flag.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique key for this Flag in the source data (such as primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Patient

Field name: Patient
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the Patient that this Flag belongs to
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Encounter

Field name: Encounter
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Encounter during which this Flag was added to the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective clinician

Field name: Effective clinician
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that captured this Flag
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective date

Field name: Effective date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Flag was captured
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded by

Field name: Recorded by
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that saved the Flag into the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded date

Field name: Recorded date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Flag was saved into the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Status

Field name: Status
Type: Value set
Cardinality: 1..1
Required: Yes
Description: Active status of this Flag.

See http://hl7.org/fhir/valueset-flag-status.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Category

Field name: Category
Type: Text
Cardinality: 1..1
Required: Yes
Description: Description of the type of Flag (clinical, administrative).
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Code

Field name: Code
Type: Text
Cardinality: 1..1
Required: Yes
Description: Textual message for this Flag
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Immunization

Represents the patient having received a vaccination or immunization.

See http://hl7.org/fhir/immunization.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique key for this Immunization in the source data (primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Patient

Field name: Patient
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the Patient that this Immunization belongs to
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Encounter

Field name: Encounter
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Encounter during which this Immunization was added to the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective clinician

Field name: Effective clinician
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that captured this Immunization
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective date

Field name: Effective date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Immunization was captured
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded by

Field name: Recorded by
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that saved the Immunization into the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded date

Field name: Recorded date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Immunization was saved into the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Code

Field name: Code
Type: Code sub-element
Cardinality: 1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
Required: Yes
Description: Clinical code for this Immunization
Field name: Code
Type: Text
Cardinality: 1..1
Required: Yes
Description: Clinical code for the (such as G00.1 for ICD-10 meningitis)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Term
Type: Text
Cardinality: 1..1
Required: Yes
Description: Associated term to go with the above code. Note, if the code is from a standard coding system (ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) then this can be looked up from reference data already held in DDS.
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: System
Type: Value set
Cardinality: 1..1
Required: Yes
Description: Coding scheme that this code uses.

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java

Note: This list of supported codes can be added to if necessary

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Site

Field name: Site
Type: Text
Cardinality: 0..1
Required: No
Description: Physical body location the Immunization was administered (such as arm)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Route

Field name: Route
Type: Text
Cardinality: 0..1
Required: No
Description: Method by which this Immunization was given (such as intramuscularly)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Dose

Field name: Dose
Type: Sub-element
Cardinality: 0..1
Required: No
Description: Amount of the Immunization administered
Field name: Value
Type: Number
Cardinality: 0..1
Required: No
Description: Quantity administered
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Unit
Type: Text
Cardinality: 0..1
Required: No
Description: Units of measure qualifying the above (such as ml)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Expiration date

Field name: Expiration date
Type: Date
Cardinality: 0..1
Required: No
Description: Date the Immunization was due to expire
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Note

Field name: Note
Type: Text
Cardinality: 0..1
Required: No
Description: Any free-text narrative associated with this Immunization
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Batch number

Field name: Batch number
Type: Text
Cardinality: 0..1
Required: No
Description: The batch number of the Immunization given
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Reason

Field name: Reason
Type: Text
Cardinality: 0..1
Required: No
Description: The reason the Patient was administered this Immunization (such as Routine measure, traveller)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Confidential

Field name: Confidential
Type: Text
Cardinality: 0..1
Required: No
Description: Confidentiality flag
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Medication Statement

Represents the prescribing of medication to a patient.

See http://hl7.org/fhir/medicationstatement.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique key for this Medication Statement in the source data (primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Patient

Field name: Patient
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the Patient that this Medication Statement belongs to
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Encounter

Field name: Encounter
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Encounter during which this Medication Statement was added to the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective clinician

Field name: Effective clinician
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that prescribed this Medication Statement
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective date

Field name: Effective date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Medication Statement was prescribed
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded by

Field name: Recorded by
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that saved the Medication Statement into the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded date

Field name: Recorded date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Medication Statement was saved into the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Code

Field name: Code
Type: Code sub-element
Cardinality: 1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
Required: Yes
Description: Clinical code for this Medication Statement. Ideally DM+D.
Field name: Code
Type: Text
Cardinality: 1..1
Required: Yes
Description: Clinical code for the (such as G00.1 for ICD-10 meningitis)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Term
Type: Text
Cardinality: 1..1
Required: Yes
Description: Associated term to go with the above code.

Note: If the code is from a standard coding system (such as ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) it can be looked up from reference data already held in DDS.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: System
Type: Value set
Cardinality: 1..1
Required: Yes
Description: Coding scheme that this code uses.

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java

Note: This list of supported codes can be added to if necessary.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Dose

Field name: Dose
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Prescribed medication dose
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Number of issues authorised

Field name: Number of issues authorised
Type: Integer
Cardinality: 0..1
Required: No
Description: If a primary care repeat prescription, this gives the number of authorised issues the patient is allowed
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Number of issues

Field name: Number of issues
Type: Integer
Cardinality: 0..1
Required: No
Description: If a primary care repeat prescription, this gives the number of issues the patient has had
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Reasons for use

Field name: Reason for use
Type: Text
Cardinality: 0..1
Required: No
Description: Unique ID of a Condition resource that is the reason this medication was prescribed
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

End date

Field name: End date
Type: Date
Cardinality: 0..1
Required: Yes, for ended medication
Description: Date the prescription ended or is due to end.
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Authorisation type

Field name: Authorisation type
Type: Value set
Cardinality: 1..1
Required: Yes
Description: Type of prescription (such as acute, repeat).

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/schema/MedicationAuthorisationType.java

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Confidential

Field name: Confidential
Type: Boolean
Cardinality: 0..1
Required: No
Description: Confidentiality flag
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Quantity

Field name: Quantity
Type: Sub-element
Cardinality: 1..1
Required: Yes
Description: Quantity of prescribed drug to be dispensed. For repeat medications, this is the quantity per issue.
Field name: Value
Type: Number
Cardinality: 1..1
Required: Yes
Description: Numeric quantity component
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Units
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Quantity units of measure (such as tablets)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Medication Dispense

Represents the dispensing of medication, links to a Medication Statement.

See http://hl7.org/fhir/medicationdispense.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique key for this Medication Dispense in the source data (e.g. primary key)
Source location: TODO: What file and field contains this?
Mapping: TODO: Is any mapping or formatting required?

Patient

Field name: Patient
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the Patient that this Medication Dispense belongs to
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Encounter

Field name: Encounter
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Encounter during which this Medication Dispense was added to the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective clinician

Field name: Effective clinician
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that issued this Medication Dispense
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective date

Field name: Effective date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Medication Dispense was dispensed
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded by

Field name: Recorded by
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that saved the Medication Dispense into the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded date

Field name: Recorded date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Medication Dispense was saved into the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Code

Field name: Code
Type: Code sub-element
Cardinality: 1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
Required: Yes
Description: Clinical code for this Medication Dispense. Ideally DM+D.
Field name: Code
Type: Text
Cardinality: 1..1
Required: Yes
Description: Clinical code for the (such as G00.1 for ICD-10 meningitis)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Term
Type: Text
Cardinality: 1..1
Required: Yes
Description: Associated term to go with the above code.

Note: If the code is from a standard coding system (ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) this can be looked up from reference data already held in DDS.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: System
Type: Value set
Cardinality: 1..1
Required: Yes
Description: Coding scheme that this code uses.

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java

Note: This list of supported codes can be added to if necessary

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Medication statement

Field name: Medication statement
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the Medication Statement this is for
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Dose

Field name: Dose
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Dispensed medication dose
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Confidential

Field name: Confidential
Type: Boolean
Cardinality: 0..1
Required: No
Description: Confidentiality flag
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Reason for use

Field name: Reason for use
Type: Text
Cardinality: 0..1
Required: No
Description: Unique ID of a Condition resource that is the reason this medication was prescribed
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Quantity

Field name: Quantity
Type: Sub-element
Cardinality: 1..1
Required: Yes
Description: Quantity of drug dispensed
Field name: Value
Type: Number
Cardinality: 1..1
Required: Yes
Description: Numeric quantity component
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Units
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Quantity units of measure e.g. tablets
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Duration

Field name: Duration
Type: Integer
Cardinality: 0..1
Required: Recommended
Description: Days duration that this dispensed medication is intended to last
Source location: TODO: What file and field contains this?
Mapping: TODO: Is any mapping or formatting required?

Resource: Observation

Represents a clinical observation about the patient with an optional numeric value.

See http://hl7.org/fhir/observation.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique key for this Observation in the source data (primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Patient

Field name: Patient
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the Patient that this Observation belongs to
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Encounter

Field name: Encounter
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Encounter during which this Observation was added to the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective clinician

Field name: Effective clinician
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that captured this Observation
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective date

Field name: Effective date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Observation was captured
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded by

Field name: Recorded by
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that saved the Observation into the patient record
Source location: TODO: What file and field contains this?
Mapping: TODO: Is any mapping or formatting required?

Recorded date

Field name: Recorded date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Observation was saved into the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Code

Field name: Code
Type: Code sub-element
Cardinality: 1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
Required: Yes
Description: Clinical code for this Observation
Field name: Code
Type: Text
Cardinality: 1..1
Required: Yes
Description: Clinical code for the (such as G00.1 for ICD-10 meningitis)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Term
Type: Text
Cardinality: 1..1
Required: Yes
Description: Associated term to go with the above code.

Note: If the code is from a standard coding system (ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) then this can be looked up from reference data already held in DDS.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: System
Type: Value set
Cardinality: 1..1
Required: Yes
Description: Coding scheme that this code uses.

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java

Note: This list of supported codes can be added to if necessary.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Numeric value

Field name: Numeric value
Type: Sub-element
Cardinality: 0..1
Required: No
Description: Numeric value associated with this Observation such the reading when recording weight.

Mutually exclusive with the other value properties of Observation.

Field name: Value
Type: Number
Cardinality: 1..1
Required: Yes
Description: Numeric value for this Observation
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Units
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Units of measure for this numeric value
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Comparator
Type: Value set
Cardinality: 0..1
Required: No
Description: Qualifies the value to indicate if it is greater than or less than the true value.

See http://hl7.org/fhir/valueset-quantity-comparator.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Date value

Field name: Date value
Type: Date
Cardinality: 0..1
Required: No
Description: Date value associated with this Observation, e.g. the date in an Observation recording an expected date of delivery. Mutually exclusive with the other value properties of Observation.
Source location: TODO: What file and field contains this?
Mapping: TODO: Is any mapping or formatting required?

Text value

Field name: Text value
Type: Text
Cardinality: 0..1
Required: No
Description: Text value associated with this Observation. For example 'negative' when recording an HIV status.

Mutually exclusive with the other value properties of Observation.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Notes

Field name: Notes
Type: Text
Cardinality: 0..1
Required: No
Description: Free-text narrative associated with this Observation
Source location: TODO: What file and field contains this?
Mapping: TODO: Is any mapping or formatting required?

Confidential

Field name: Confidential
Type: Boolean
Cardinality: 0..1
Required: No
Description: Confidentiality flag
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Lower normal value range

Field name: Lower normal value range
Type: Number
Cardinality: 0..1
Required: No
Description: Lower bound of normal range, only applies to Observations with a numeric value.
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Upper normal value range

Field name: Upper normal value range
Type: Boolean
Cardinality: 0..1
Required: No
Description: Lower bound of normal range, only applies to Observations with a numeric value.
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Parent resource

Field name: Parent resource
Type: Text
Cardinality: 0..1
Required: No
Description: Unique ID of a parent Resource (either another Observation or Diagnostic Report) that this Observation relates to.

For example, if an Observation is a systolic or diastolic blood pressure reading, they will link to a parent Observation representing the blood pressure reading as a whole;

if an Observation is a investigation result in a test (such as FBC, urine) then it will link to a parent Diagnostic Report.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Child observations

Field name: Child observations
Type: Sub-element
Cardinality: 0..1
Required: No
Description: The reverse of the above child-parent relationship, this field represents the parent-child link, linking the parent Observation to its children
Field name: Child resource
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of a child Observation
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Procedure

Represents a procedure or operation performed on a patient. Only procedures that have actually been performed are desired – planned or cancelled procedures are not required.

See http://hl7.org/fhir/procedure.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique key for the Procedure in the source data (primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Patient

Field name: Patient
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the patient record this Procedure belongs to
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Code

Field name: Code
Type: Code sub-element
Cardinality: 1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
Required: Yes
Description: Clinical code for this Procedure
Field name: Code
Type: Text
Cardinality: 1..1
Required: Yes
Description: Clinical code for the (such as G00.1 for ICD-10 meningitis)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Term
Type: Text
Cardinality: 1..1
Required: Yes
Description: Associated term to go with the above code.

Note: If the code is from a standard coding system (ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) then this can be looked up from reference data already held in DDS.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: System
Type: Value set
Cardinality: 1..1
Required: Yes
Description: Coding scheme that this code uses.

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java

Note: This list of supported codes can be added to if necessary

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective Clinician

Field name: Effective Clinician
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that performed this Procedure
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective date

Field name: Effective date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Procedure was performed
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded by

Field name: Recorded by
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that entered this Procedure into the publishing software
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded date

Field name: Recorded date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Procedure was entered into the publishing software
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Encounter

Field name: Encounter
Type: Text
Cardinality: 0..1
Required: No
Description: Unique ID of the Encounter resource this Procedure belongs to (if performed during an inpatient stay, this would link to the Encounter representing the stay)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Notes

Field name: Notes
Type: Text
Cardinality: 0..1
Required: No
Description: Any free-text narrative associated with this Procedure
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Confidential

Field name: Confidential
Type: Boolean
Cardinality: 0..1
Required: No
Description: Confidentiality flag
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Is primary

Field name: Is primary
Type: Boolean
Cardinality: 0..1
Required: No
Description: Flag to indicate if this Procedure is a primary procedure.

For example, in secondary care settings, a patient may have many procedures during a single operation, but only one is flagged as the “primary” procedure that the patient was admitted for.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Sequence number

Field name: Sequence number
Type: Integer
Cardinality: 0..1
Required: No
Description: Ordinal to maintain the order of procedures within an Encounter.

For example, in the secondary care example mentioned above, the primary Procedure is given sequence number 1, and all the secondary Procedures are numbered accordingly to preserve the order they were entered into the source software.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Parent resource

Field name: Parent resource
Type: Boolean
Cardinality: 0..1
Required: No
Description: Unique ID of a parent Procedure resource that this is logically related to.

For example, in the secondary care example mentioned above, the secondary Procedures are linked to the primary one using this field.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

End date

Field name: End date
Type: Datetime
Cardinality: 0..1
Required: No
Description: When the procedure was completed, if known
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Specialty

Field name: Specialty
Type: Text
Cardinality: 0..1
Required: No
Description: Specialty performing this procedure
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Location

Field name: Location
Type: Text
Cardinality: 0..1
Required: No
Description: Unique ID of a Location resource when this Procedure was performed, for example the theatre.
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Questionnaire Response

Represents a series of questions and answers, such as the output of 111 triage pathway.

See http://hl7.org/fhir/questionnaireresponse.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique key for the Questionnaire Response in the source data (primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Patient

Field name: Patient
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the patient record this Questionnaire Response belongs to
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective Clinician

Field name: Effective Clinician
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that performed this Questionnaire
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective date

Field name: Effective date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Questionnaire was performed
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded by

Field name: Recorded by
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that entered this Questionnaire into the publishing software
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded date

Field name: Recorded date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Questionnaire was entered into the publishing software
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Encounter

Field name: Encounter
Type: Text
Cardinality: 0..1
Required: No
Description: Unique ID of the Encounter resource this Procedure belongs to (if performed during an inpatient stay, this would link to the Encounter representing the stay)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Items

Field name: Items
Type: Sub-element
Cardinality: 0..n
Required: Yes
Description: Questions and answers
Field name: Question
Type: Text
Cardinality: 1..1
Required: Yes
Description: Question text
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Answer
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Answer text
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Specimen

Represents a biological specimen taken for a test.

See http://hl7.org/fhir/specimen.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique key for this Specimen in the source data (primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Patient

Field name: Patient
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the Patient that this Specimen belongs to
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Encounter

Field name: Encounter
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Encounter during which this Specimen was added to the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective clinician

Field name: Effective clinician
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that took this Specimen
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Effective date

Field name: Effective date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Specimen was taken
Source location: TODO: What file and field contains this?
Mapping: TODO: Is any mapping or formatting required?

Recorded by

Field name: Recorded by
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Practitioner that saved the Specimen into the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Recorded date

Field name: Recorded date
Type: Datetime
Cardinality: 0..1
Required: Recommended
Description: Datetime this Specimen was saved into the patient record
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Code

Field name: Code
Type: Code sub-element
Cardinality: 1..n (may be repeated multiple times if the same code is provided in multiple code systems, but all codes must be semantically the same)
Required: Yes
Description: Clinical code for this Specimen
Field name: Code
Type: Text
Cardinality: 1..1
Required: Yes
Description: Clinical code for the (such as G00.1 for ICD-10 meningitis)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: Term
Type: Text
Cardinality: 1..1
Required: Yes
Description: Associated term to go with the above code.

Note: If the code is from a standard coding system (ICD-10, OPCS-4, Read2, CTV3, SNOMED CT) then this can be looked up from reference data already held in DDS.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?
Field name: System
Type: Value set
Cardinality: 1..1
Required: Yes
Description: Coding scheme that this code uses.

See https://github.com/endeavourhealth/Fhir/blob/master/src/main/java/org/endeavourhealth/common/fhir/FhirCodeUri.java

Note: This list of supported codes can be added to if necessary.

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Notes

Field name: Notes
Type: Text
Cardinality: 0..1
Required: No
Description: Free-text narrative about this Specimen
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Confidential

Field name: Confidential
Type: Boolean
Cardinality: 0..1
Required: No
Description: Confidentiality flag
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Schedule

Represents an appointment session.

See http://hl7.org/fhir/schedule.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique key for this Schedule in the source data (primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Location

Field name: Location
Type: Text
Cardinality: 0..1
Required: Recommended
Description: Unique ID of the Location where this Schedule took/will take place
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Location type

Field name: Location type
Type: Text
Cardinality: 0..1
Required: No
Description: Free-text description of the type of location this Schedule is at (the above Location is preferred, but this can be used if no actual named Location is possible)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Schedule name

Field name: Schedule name
Type: Text
Cardinality: 0..1
Required: No
Description: Free-text name for this Schedule such as Dr X AM Appts
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Schedule type

Field name: Schedule type
Type: Text
Cardinality: 0..1
Required: No
Description: Type of Schedule this is such as general appointments, outpatient clinic
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Notes

Field name: Notes
Type: Text
Cardinality: 0..1
Required: No
Description: Free-text comments about this Schedule
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Start date

Field name: Start date
Type: Datetime
Cardinality: 1..1
Required: Yes
Description: Datetime this Schedule started or is due to start
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

End date

Field name: End date
Type: Datetime
Cardinality: 1..1
Required: Yes
Description: Datetime this Schedule ended or is due to end
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Created by

Field name: Created by
Type: Text
Cardinality: 0..1
Required: No
Description: Unique ID of the Practitioner that created this Schedule
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Created date

Field name: Created date
Type: Datetime
Cardinality: 0..1
Required: No
Description: Datetime this Schedule was created
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Clinician

Field name: Clinician
Type: Sub-element
Cardinality: 1..n
Required: Yes
Description: Clinician(s) hosting this Schedule
Field name: Clinician
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of a Practitioner (the first instance of this is considered to be the 'main' Practitioner)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Slot

Represents a slot within a Schedule resource. Forms the link between the Schedule and the Appointment resources.

See http://hl7.org/fhir/slot.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique key for this Slot in the source data (primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Schedule

Field name: Schedule
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the Schedule this Slot belongs to
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Start date

Field name: Start date
Type: Datetime
Cardinality: 1..1
Required: Yes
Description: Start datetime of the Slot
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

End date

Field name: End date
Type: Datetime
Cardinality: 1..1
Required: Yes
Description: End datetime of the Slot
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Resource: Appointment

Represents a booked appointment (such as GP appointment, outpatient appointment) in a Schedule resource.

Links to a Slot, which in turn links to the Schedule.

See http://hl7.org/fhir/appointment.html

ID

Field name: ID
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique key for this Appointment in the source data (primary key)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Start date

Field name: Start date
Type: Datetime
Cardinality: 1..1
Required: Yes
Description: Start datetime of the Appointment
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

End date

Field name: End date
Type: Datetime
Cardinality: 1..1
Required: Yes
Description: End datetime of the Appointment
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Notes

Field name: Notes
Type: Text
Cardinality: 0..1
Required: No
Description: Free-text comments associated with this Appointment
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Slot

Field name: Slot
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of the Slot that this Appointment is in
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Clinician

Field name: Clinician
Type: Sub-element
Cardinality: 1..n
Required: Yes
Description: Clinician(s) attending this Appointment
Field name: Clinician
Type: Text
Cardinality: 1..1
Required: Yes
Description: Unique ID of a Practitioner (the first instance of this is considered to be the 'main' Practitioner)
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Patient wait

Field name: Patient wait
Type: Integer
Cardinality: 0..1
Required: No
Description: Minutes wait that the patient experienced between arrival and the Appointment starting
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Patient delay

Field name: Patient delay
Type: Integer
Cardinality: 0..1
Required: No
Description: Minutes wait that the patient experienced between the scheduled Appointment start and the actual Appointment start
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Sent in

Field name: Sent in
Type: Datetime
Cardinality: 0..1
Required: No
Description: Datetime that the Appointment actually started. May or may not be the same as the scheduled start date.
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Left

Field name: Left
Type: Datetime
Cardinality: 0..1
Required: No
Description: Datetime that the Appointment actually ended.
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Cancelled

Field name: Cancelled
Type: Datetime
Cardinality: 0..1
Required: No
Description: Datetime that the Appointment was cancelled.
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Booked

Field name: Booked
Type: Datetime
Cardinality: 0..1
Required: No
Description: Datetime that the Appointment was booked.
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Did not attend reason

Field name: Did not attend reason
Type: Text
Cardinality: 0..1
Required: No
Description: Reason for Appointment being DNA
Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?

Status

Field name: Status
Type: Value set
Cardinality: 1..1
Required: Yes
Description: Current status of this Appointment such as booked, in progress, finished.

See http://hl7.org/fhir/valueset-appointmentstatus.html

Source location: What file and field contains this?
Mapping: Is any mapping or formatting required?