FHIR Clinical Guidelines (v1.0.0) (STU1)

Clinical Practice Guidelines, published by Clinical Decision Support WG. This is not an authorized publication; it is the continuous build for version 1.0.0). This version is based on the current content of https://github.com/HL7/cqf-recommendations/ and changes regularly. See the Directory of published versions

CPG_Common_Process

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<CodeSystem xmlns="http://hl7.org/fhir">
  <id value="cpg-common-process"/>
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    <div xmlns="http://www.w3.org/1999/xhtml"><p>This code system http://hl7.org/fhir/uv/cpg/CodeSystem/cpg-common-process defines the following codes:</p><table class="codes"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style="white-space:nowrap">registration<a name="cpg-common-process-registration"> </a></td><td>Registration</td><td>Identifying and recording the subject of care.</td></tr><tr><td style="white-space:nowrap">triage<a name="cpg-common-process-triage"> </a></td><td>Triage</td><td>Performing basic triage to identify any signs that emergency care is required.</td></tr><tr><td style="white-space:nowrap">local-urgent-care<a name="cpg-common-process-local-urgent-care"> </a></td><td>Local Urgent Care</td><td>Providing local urgent care based on the outcome of a triage process.</td></tr><tr><td style="white-space:nowrap">history-and-physical<a name="cpg-common-process-history-and-physical"> </a></td><td>History and Physical</td><td>Gathering clinical history and performing and recording observations regarding the patient's health (e.g. blood pressure, temperature, etc.)</td></tr><tr><td style="white-space:nowrap">provide-counseling<a name="cpg-common-process-provide-counseling"> </a></td><td>Provide Counseling</td><td>Informing the subject of care about their treatment options and about how their ongoing care should be managed between visits. This is also where treatment constents are obtained and where health education is provided.</td></tr><tr><td style="white-space:nowrap">diagnostic-testing<a name="cpg-common-process-diagnostic-testing"> </a></td><td>Conduct Diagnostic Tests</td><td>Conducting diagnostic tests, including lab tests, collection of samples, and other diagnostic tests. Lab testing may be done locally (e.g. HIV quick test) or the samples may require lab order fulfillment workflow.</td></tr><tr><td style="white-space:nowrap">determine-diagnosis<a name="cpg-common-process-determine-diagnosis"> </a></td><td>Determine Diagnosis</td><td>Using available information from the patient's history, current examinations, tests, and assessments to assist in developing a diagnosis.</td></tr><tr><td style="white-space:nowrap">guideline-based-care<a name="cpg-common-process-guideline-based-care"> </a></td><td>Guideline-based Care</td><td>Performing and recording observations, interventions, and treatment plans recommended by specific guidelines.</td></tr><tr><td style="white-space:nowrap">dispense-medications<a name="cpg-common-process-dispense-medications"> </a></td><td>Dispense Medications</td><td>Administering medications, ordered by clinicians and dispensed by a pharmacy. Pharmacies may be local to the care facility or community-based, and involves supply chain transactions to support medication management.</td></tr><tr><td style="white-space:nowrap">emergency-care<a name="cpg-common-process-emergency-care"> </a></td><td>Emergency Care</td><td>Providing emergency care in trauma cases or as part of guildeline-based care escalation.</td></tr><tr><td style="white-space:nowrap">actue-tertiary-care<a name="cpg-common-process-actue-tertiary-care"> </a></td><td>Acute/Tertiary Care</td><td>Providing acute or tertiary care, either as an escalation from emergency care, or from primary care due to guideline-based referral patterns.</td></tr><tr><td style="white-space:nowrap">charge-for-service<a name="cpg-common-process-charge-for-service"> </a></td><td>Charge for Service</td><td>Charging for services rendered, regardless of the mechanism of coverage.</td></tr><tr><td style="white-space:nowrap">discharge-referral-of-patient<a name="cpg-common-process-discharge-referral-of-patient"> </a></td><td>Discharge/Referral of Patient</td><td>Discharging or referring a patient, including the movement of patients through levels of care delivery (e.g. acute to primary, primary to community, etc.) or the enrollment of patients in guideline-based care programs (e.g. HIV, maternal, diabetes, injury rehabilitiation, etc.).</td></tr><tr><td style="white-space:nowrap">record-and-report<a name="cpg-common-process-record-and-report"> </a></td><td>Record and Report</td><td>Recording and reporting patient-specific care management information which may be aggregated to develop reportable system management indicators at the priovider, facility, district, national, and international levels.</td></tr><tr><td style="white-space:nowrap">monitor-and-follow-up-of-patient<a name="cpg-common-process-monitor-and-follow-up-of-patient"> </a></td><td>Monitor and Follow-up of Patient</td><td>Monitoring and tracking progress for each patient based on guideline recommendations.</td></tr><tr><td style="white-space:nowrap">alerts-reminders-education<a name="cpg-common-process-alerts-reminders-education"> </a></td><td>Alerts Reminders Education</td><td>Providing alerts, reminders, and education to patients, providers, and health system managers.</td></tr></table></div>
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  <url value="http://hl7.org/fhir/uv/cpg/CodeSystem/cpg-common-process"/>
  <version value="1.0.0"/>
  <name value="CPG_Common_Process"/>
  <title value="CPG Common Process"/>
  <status value="draft"/>
  <experimental value="false"/>
  <date value="2019-05-08"/>
  <publisher value="Health Level 7 International - Clinical Decision Support WG"/>
  <contact>
    <telecom>
      <system value="url"/>
      <value value="http://www.hl7.org/Special/committees/dss/index.cfm"/>
    </telecom>
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  <description
               value="Common processes performed in providing guideline-based care, regardless of the specific guideline."/>
  <jurisdiction>
    <coding>
      <system value="http://unstats.un.org/unsd/methods/m49/m49.htm"/>
      <code value="001"/>
      <display value="World"/>
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  <caseSensitive value="true"/>
  <valueSet value="http://hl7.org/fhir/uv/cpg/ValueSet/cpg-common-process"/>
  <content value="complete"/>
  <concept>
    <code value="registration"/>
    <display value="Registration"/>
    <definition value="Identifying and recording the subject of care."/>
  </concept>
  <concept>
    <code value="triage"/>
    <display value="Triage"/>
    <definition
                value="Performing basic triage to identify any signs that emergency care is required."/>
  </concept>
  <concept>
    <code value="local-urgent-care"/>
    <display value="Local Urgent Care"/>
    <definition
                value="Providing local urgent care based on the outcome of a triage process."/>
  </concept>
  <concept>
    <code value="history-and-physical"/>
    <display value="History and Physical"/>
    <definition
                value="Gathering clinical history and performing and recording observations regarding the patient&#39;s health (e.g. blood pressure, temperature, etc.)"/>
  </concept>
  <concept>
    <code value="provide-counseling"/>
    <display value="Provide Counseling"/>
    <definition
                value="Informing the subject of care about their treatment options and about how their ongoing care should be managed between visits. This is also where treatment constents are obtained and where health education is provided."/>
  </concept>
  <concept>
    <code value="diagnostic-testing"/>
    <display value="Conduct Diagnostic Tests"/>
    <definition
                value="Conducting diagnostic tests, including lab tests, collection of samples, and other diagnostic tests. Lab testing may be done locally (e.g. HIV quick test) or the samples may require lab order fulfillment workflow."/>
  </concept>
  <concept>
    <code value="determine-diagnosis"/>
    <display value="Determine Diagnosis"/>
    <definition
                value="Using available information from the patient&#39;s history, current examinations, tests, and assessments to assist in developing a diagnosis."/>
  </concept>
  <concept>
    <code value="guideline-based-care"/>
    <display value="Guideline-based Care"/>
    <definition
                value="Performing and recording observations, interventions, and treatment plans recommended by specific guidelines."/>
  </concept>
  <concept>
    <code value="dispense-medications"/>
    <display value="Dispense Medications"/>
    <definition
                value="Administering medications, ordered by clinicians and dispensed by a pharmacy. Pharmacies may be local to the care facility or community-based, and involves supply chain transactions to support medication management."/>
  </concept>
  <concept>
    <code value="emergency-care"/>
    <display value="Emergency Care"/>
    <definition
                value="Providing emergency care in trauma cases or as part of guildeline-based care escalation."/>
  </concept>
  <concept>
    <code value="actue-tertiary-care"/>
    <display value="Acute/Tertiary Care"/>
    <definition
                value="Providing acute or tertiary care, either as an escalation from emergency care, or from primary care due to guideline-based referral patterns."/>
  </concept>
  <concept>
    <code value="charge-for-service"/>
    <display value="Charge for Service"/>
    <definition
                value="Charging for services rendered, regardless of the mechanism of coverage."/>
  </concept>
  <concept>
    <code value="discharge-referral-of-patient"/>
    <display value="Discharge/Referral of Patient"/>
    <definition
                value="Discharging or referring a patient, including the movement of patients through levels of care delivery (e.g. acute to primary, primary to community, etc.) or the enrollment of patients in guideline-based care programs (e.g. HIV, maternal, diabetes, injury rehabilitiation, etc.)."/>
  </concept>
  <concept>
    <code value="record-and-report"/>
    <display value="Record and Report"/>
    <definition
                value="Recording and reporting patient-specific care management information which may be aggregated to develop reportable system management indicators at the priovider, facility, district, national, and international levels."/>
  </concept>
  <concept>
    <code value="monitor-and-follow-up-of-patient"/>
    <display value="Monitor and Follow-up of Patient"/>
    <definition
                value="Monitoring and tracking progress for each patient based on guideline recommendations."/>
  </concept>
  <concept>
    <code value="alerts-reminders-education"/>
    <display value="Alerts Reminders Education"/>
    <definition
                value="Providing alerts, reminders, and education to patients, providers, and health system managers."/>
  </concept>
</CodeSystem>