Overview
A two or three level List structure is used to represent structured consultations.
- List (Consultation)
- List (Topic)
- List (Heading)
List (Consultation) SHALL be coded as 325851000000107 |Consultation|. This top-level profile represents the structured consultation as a whole.
List (Topic) SHALL be coded as 25851000000105 |Topic (EHR)|. This level represents the Topic/Problem groupings within consultations.
List (Heading) SHALL be coded as 24781000000107 |Category (EHR)|. This level represents the headings (SOAP heading) levels of the consultation structure that contain record entries.
In the case of consultation which has a ‘flat’ structure, that is, contains record entries without a surrounding Topic/Heading structure, producer systems generate a List(Topic) level which links directly to record entries without the List(Heading) level.
Empty consultations and empty subsections (topics and headings) are suppressed at source and this is reflected in the cardinalities specified.
Common list attributes
The population of List attributes that are common to all of the consultation list types is described here.
id
Data type: Id |
Optionality: Mandatory | Cardinality: 1..1 |
The logical identifier of the List profile.
meta.profile
Data type: uri |
Optionality: Mandatory | Cardinality: 1..1 |
The List profile URL.
Fixed value https://fhir.nhs.uk/STU3/StructureDefinition/CareConnect-GPC-List-1
status
Data type: Code |
Optionality: Mandatory | Cardinality: 1..1 |
Fixed value of current.
mode
Data type: Code |
Optionality: Mandatory | Cardinality: 1..1 |
Fixed value of snapshot.
subject
Data type: Reference(Patient) |
Optionality: Mandatory | Cardinality: 1..1 |
Reference to the Patient profile for the patient whose patient record contains a consultation represented by this List profile.
The patient reference is provided by all Lists in the structure rather than the top-level List(Consultation) only.
encounter
Data type: Reference(Encounter) |
Optionality: Mandatory | Cardinality: 1..1 |
Mandatory reference to the Encounter profile providing the context for the consultation (Date/Doctor/Place ….)
The Encounter reference is provided by all Lists in the structure rather than the top-level List(Consultation) only.
date
Data type: dateTime |
Optionality: Mandatory | Cardinality: 1..1 |
The system rather than clinical date time for when the consultation was last edited, that is, the date time the consultation was last modified on the source system.
If no separate date time is recorded for consultation sub sections, the overall audit date of the consultation is replicated at all levels.
The clinically significant or effective consultation date is provided by the associated Encounter profile.
orderedBy
Data type: CodeableConcept |
Optionality: Mandatory | Cardinality: 1..1 |
Fixed value of system from vocabulary.
By convention, the order entries should appear is the default order subsections or entries are displayed by the native system at source.
List (consultation)
The following attributes are specific to the List level representing the consultation as a whole.
title
Data type: string |
Optionality: Required | Cardinality: 0..1 |
The type or name of the consultation as it appears to users of the source system.
This duplicates the consultation type/name provided at Encounter.type.
code
Data type: CodeableConcept |
Optionality: Mandatory | Cardinality: 1..1 |
Fixed value of 325851000000107 |Consultation|
entry
Data type: BackboneElement |
Optionality: Mandatory | Cardinality: 1..* |
Will contain at least one reference to a List profile providing the Topic level of the consultation structure. They will be recorded in the same order that the topics appear when viewed in a consultation in the GP system.
List (Topic)
The List level representing the Topic level of the consultation structure.
extension(relatedProblemHeader)
Data type: reference |
Optionality: Required | Cardinality: 0..* |
References to any problems that have been linked to this section of the consultation in the sending clinical system.
These links will have been added by a clinician at the sending practice.
title
Data type: string |
Optionality: Required | Cardinality: 0..1 |
The name of the corresponding Topic section in the source consultation if it is named.
code
Data type: CodeableConcept |
Optionality: Mandatory | Cardinality: 1..1 |
Fixed value of 25851000000105 |Topic (EHR)|
entry
Data type: BackboneElement |
Optionality: Mandatory | Cardinality: 1..* |
Where information within the Topic is organised as sub-headings, entry.list will reference instances of the Category List level. They will be recorded in the same order that the headings appear when viewed in a consultation in the GP system.
For consultations which have a flat structure (for example, clinical record entries made outside of the Topic and heading structure), an artificial Topic List is generated, and entries will reference profiles representing those record entries (such as, Allergies, Medications, Tests, and so on. They will be recorded in the same order that the items appear when viewed in a consultation in the GP system.
The two approaches are never mixed within the same Topic - that is, all entries will either reference List(Category) or profiles representing the source record entries, but not both.
List (Heading)
The level of the consultation that represents the heading sections (SOAP headings) that contain clinical record entries.
title
Data type: string |
Optionality: Required | Cardinality: 0..1 |
The name of the heading section on the source system represented by this List instance.
code
Data type: CodeableConcept |
Optionality: Mandatory | Cardinality: 1..1 |
Fixed value of 24781000000107 |Category (EHR)|
entry
Data type: BackboneElement |
Optionality: Mandatory | Cardinality: 1..* |
Each entry.item is a reference to a profile representing a clinical record entry in the source system - for example, medications, allergies, problems, diagnoses, and so on. They will be recorded in the same order that the items appear when viewed in a consultation in the GP system.
List elements not in use for consultations
The following elements SHALL NOT be populated:
identifier
Data type: identifier |
source
Data type: Reference(Practitioner) |
note
Data type: Annotation |
entry.flag
Data type: CodeableConcept |
entry.deleted
Data type: Boolean |
entry.date
Data type: dateTime |