StructureDefinition-OPConsultRecord

Sourcendhm.in#current:FHIR Implementation Guide for ABDM (v4.0.1)
resourceTypeStructureDefinition
idOPConsultRecord
canonicalhttps://nrces.in/ndhm/fhir/r4/StructureDefinition/OPConsultRecord
version3.0.0
statusdraft
publisherNational Resource Center for EHR Standards
nameOPConsultRecord
date2020-09-17T13:51:22.1820133Z
descriptionThe Clinical Artifact represents the outpatient visit consultation note which may include clinical information on any OP examinations, procedures along with medication administered, and advice that can be shared across the health ecosystem.
jurisdictionsin
fhirVersion4.0.1
kindresource
abstractfalse
sdTtypeComposition
derivationconstraint
basehttp://hl7.org/fhir/StructureDefinition/Composition
Usages(none)
Name Flags Card. Type Description & Constraints doco
. . Composition Composition
. . . status S
. . . type S Kind of composition (SNOMED CT if possible)
. . . . coding 1..1
. . . . . system Fixed Value: http://snomed.info/sct
. . . . . code 1.. Fixed Value: 371530004
. . . . . display 1.. Fixed Value: Clinical consultation report
. . . . text S
. . . subject S 1.. Reference (Patient)
. . . . reference 1..
. . . encounter S 1.. Reference (Encounter)
. . . date S
. . . author S Reference ( Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization)
. . . . reference 1..
. . . title S
. . . attester S
. . . . party Reference ( RelatedPerson | Patient | Practitioner | PractitionerRole | Organization)
. . . custodian Reference (Organization)
. . . Slices for section S 1 .. Slice: Unordered, Open At End by value:code.coding.code
. . . . section:ChiefComplaints ..1
. . . . . code
. . . . . . coding S ..1
. . . . . . . system Fixed Value: http://snomed.info/sct
. . . . . . . code 1.. Fixed Value: 422843007
. . . . . . . display 1.. Fixed Value: Chief complaint section
. . . . . . text S
. . . . . entry S Reference (Condition)
. . . . . . reference 1..
. . . . section:PhysicalExamination ..1
. . . . . code
. . . . . . coding S ..1
. . . . . . . system Fixed Value: http://snomed.info/sct
. . . . . . . code 1.. Fixed Value: 425044008
. . . . . . . display 1.. Fixed Value: Physical exam section
. . . . . . text S
. . . . . entry S Reference (Observation)
. . . . . . reference 1..
. . . . section:Allergies ..1
. . . . . code
. . . . . . coding S ..1
. . . . . . . system Fixed Value: http://snomed.info/sct
. . . . . . . code 1.. Fixed Value: 722446000
. . . . . . . display 1.. Fixed Value: Allergy record
. . . . . . text S
. . . . . entry S Reference (AllergyIntolerance)
. . . . . . reference 1..
. . . . section:MedicalHistory ..1
. . . . . code
. . . . . . coding S ..1
. . . . . . . system Fixed Value: http://snomed.info/sct
. . . . . . . code 1.. Fixed Value: 371529009
. . . . . . . display 1.. Fixed Value: History and physical report
. . . . . . text S
. . . . . entry S Reference (Condition | Procedure)
. . . . . . reference 1..
. . . . section:FamilyHistory ..1
. . . . . code
. . . . . . coding S ..1
. . . . . . . system Fixed Value: http://snomed.info/sct
. . . . . . . code 1.. Fixed Value: 422432008
. . . . . . . display 1.. Fixed Value: Family history section
. . . . . . text S
. . . . . entry S Reference (FamilyMemberHistory)
. . . . . . reference 1..
. . . . section:InvestigationAdvice ..1
. . . . . code
. . . . . . coding S ..1
. . . . . . . system Fixed Value: http://snomed.info/sct
. . . . . . . code 1.. Fixed Value: 721963009
. . . . . . . display 1.. Fixed Value: Order document
. . . . . . text S
. . . . . entry S Reference (ServiceRequest)
. . . . . . reference 1..
. . . . section:Medications ..1
. . . . . code
. . . . . . coding S ..1
. . . . . . . system Fixed Value: http://snomed.info/sct
. . . . . . . code 1.. Fixed Value: 721912009
. . . . . . . display 1.. Fixed Value: Medication summary document
. . . . . . text S
. . . . . entry S Reference (MedicationStatement | MedicationRequest)
. . . . . . reference 1..
. . . . section:FollowUp ..1
. . . . . code
. . . . . . coding S ..1
. . . . . . . system Fixed Value: http://snomed.info/sct
. . . . . . . code 1.. Fixed Value: 736271009
. . . . . . . display 1.. Fixed Value: Outpatient care plan
. . . . . . text S
. . . . . entry S Reference (Appointment)
. . . . . . reference 1..
. . . . section:Procedure ..1
. . . . . code
. . . . . . coding S ..1
. . . . . . . system Fixed Value: http://snomed.info/sct
. . . . . . . code 1.. Fixed Value: 371525003
. . . . . . . display 1.. Fixed Value: Clinical procedure report
. . . . . . text S
. . . . . entry S Reference (Procedure)
. . . . . . reference 1..
. . . . section:OtherObservations ..1
. . . . . code
. . . . . . coding S
. . . . . . . system Fixed Value: http://snomed.info/sct
. . . . . . . code 1.. Fixed Value: 404684003
. . . . . . . display 1.. Fixed Value: Clinical finding
. . . . . . text S
. . . . . entry S Reference (Observation)
. . . . . . reference 1..
. . . . section:DocumentReference ..1
. . . . . code
. . . . . . coding S ..1
. . . . . . . system Fixed Value: http://snomed.info/sct
. . . . . . . code 1.. Fixed Value: 371530004
. . . . . . . display 1.. Fixed Value: Clinical consultation report
. . . . . . text S
. . . . . entry S Reference (DocumentReference)
. . . . . . reference 1..

doco Documentation for this format

Produced 08 Sep 2023