Primary Care Practice-to-Practice
0.0.3 - CI Build

Primary Care Practice-to-Practice, published by . This is not an authorized publication; it is the continuous build for version 0.0.3). This version is based on the current content of https://github.com/aehrc/primary-care-data-technical/ and changes regularly. See the Directory of published versions

Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

Structures: Resource Profiles

These define constraints on FHIR resources for systems conforming to this implementation guide

AU Primary Care Alcohol Consumption Summary

Narrative description about all forms of alcohol consumption.

Usage

It is possible to incorporate the narrative descriptions of alcohol consumption within existing or legacy clinical systems into this data element.

AU Primary Care Absolute CVD Risk

Calculatd risk score using an assessment tool used to calculate the absolute cardiovascular disease risk (CVD) in the next 5 years.

Usage

Use to record the results for each component parameter and the CVD risk assessment total score.

Record as a single instance per observation in a health record.

AU Primary Care Alcohol Consumption Date Ceased

The date when the individual last ceased consuming alcohol of any type.

Usage

The definition of alcohol cessation is not universally clear, obviously involving abstinence from alcohol consumption for a period of time. At any time, especially within the first 12 months, there is a possibility of relapse and the quit date will need to be removed and the item updated.

Partial dates are permitted.

AU Primary Care Alcohol Pattern Of Use

Details about a discrete period of time with a consistent pattern of typical consumption.

Usage This includes:

  • Episode Label - Identification of an episode of alcohol consumption.
  • Episode Period - Date when this episode ocurred.
  • Pattern - The typical pattern of consumption of alcohol.
  • Typical Consumption - Estimate of number of standard alcohol units consumed in the specified time period
  • Alcohol Free Days - The number of days where no alcohol was consumed during the specified interval.
  • Binge Drinking Frequency - The individual’s typical frequency of heavy drinking over a short period of time with the intent of becoming intoxicated.
  • Binge Drinking Description - Narrative description about the individual’s typical pattern of binge drinking.
  • Number Quit Attempts - Total number of times the individual has attempted to stop consuming alcohol within this episode.
AU Primary Care Alcohol Status

Statement about current consumption habits for all types of alcohol.

AU Primary Care Allergy Intolerance

Risk of harmful or undesirable physiological response which is unique to the individual and associated with exposure to a known substance.

Usage

Use to provide a single place within the health record to document a range of clinical statements about adverse reactions, including:

  • record a clinical assessment of the individual’s propensity for a potential future reaction upon re-exposure; and
  • record cumulative information about the reaction to each exposure.

Use to record information about the positive presence of the risk of an adverse reaction:

  • to support direct clinical care of an individual;
  • as part of a managed adverse reaction or allergy/intolerance list;
  • to support exchange of information about the propensity and events related to adverse reactions;
  • to inform adverse reaction reporting; and
  • to assist computerised knowledge-based activities such as clinical decision support and alerts.

Use to record information about the risk of adverse reactions to a broad range of substances, including: incipients and excipients in medicinal preparations; biological products; metal salts; and organic chemical compounds.

Adverse reaction may be:

  • an immune mediated reaction - Types I-IV (including allergic reactions and hypersensitivities); or
  • a non-immune mediated reaction - including pseudo-allergic reactions, side effects, intolerances, drug toxicities (eg to Gentamicin). In clinical practice distinguishing between immune-mediated and non-immune mediated reactions is difficult and often not practical. Identification of the type of reaction is not a proxy for seriousness or risk of harm to the patient, which is better expressed by the manifestation in clinical practice.

The risk of an adverse reaction event or manifestation should not be recorded without identifying a proposed causative substance or class of substance. If there is uncertainty that a specific substance is the cause, this uncertainty can be recorded using the ‘Verification status’ data element. If there are multiple possible substances that may have caused a reaction/manifestation, each substance should be recorded using a separate instance of this adverse reaction archetype with the ‘Status’ set to an initial state of ‘Unconfirmed’ so that adverse reaction checking can be activated in clinical systems. Once the substance, agent or class is later proven not to be the cause for a given reaction then the ‘Status’ can be modified to ‘Refuted’.

This item has been designed to allow recording of information about a specific substance (amoxycillin, oysters, or bee sting venom) or, alternatively, a class of substance (eg Penicillins). If a class of substance is recorded then identification of the exact substance can be recorded on a per exposure basis.

AU Primary Care Allergy Intolerance List

This profile defines an allergy intolerance list structure that includes core localisation concepts for use in an Australian primary care practice-to-practice record transfer context.

AU Primary Care Attachment

Document content as an attachment. This includes the binary content of the document as part of the entry.

Usage

Used to attach any relevant documents to the summary including their full content.

AU Primary Care Blood Pressure

Blood pressure observation

AU Primary Care Body Mass Index

The measurement of the circumference of the waist.

AU Primary Care Breastfeeding Status

Summary or persistent information about current or past breastfeeding activity by an individual.

Usage

Use to record details about the current breastfeeding status and current and/or past breastfeeding activity. Record as a single instance in a health record; updated and revised over time as a new version.

AU Primary Care Composition

This profile defines a composition structure that includes core localisation concepts for use in an Australian primary care practice-to-practice record transfer context.

AU Primary Care Condition

Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual.

Usage

  • Use to record details about a single, identified health problem or diagnosis.
  • Clear delineation between the scope of a problem versus a diagnosis is often not easy to achieve in practice. For the purposes of clinical documentation using this item, problem and diagnosis are regarded as a continuum, with increasing information and reaching or exceeding diagnostic criteria supporting formalisation of the label of ‘diagnosis’. It is not necessary to classify the condition as a ‘problem’ or ‘diagnosis’, especially as a problem may evolve into a formal diagnosis as evidence is gathered. The data requirements to support documentation of either are identical, with additional data structure required to support inclusion of the evidence if and when it becomes available. In practice, most problems or diagnoses do not sit at either end of the problem-diagnosis spectrum, but somewhere in between.

Misuse

  • Not to be used to describe reasons for encounter - use the ‘Reason for encounter’ item.
  • Not to be used to describe procedures - use the ‘Procedure’ item.
  • Not to be used to describe adverse reactions - use the ‘Adverse reaction’ item.
  • Not to be used to describe symptoms, examination findings, diagnostic test results or health risk assessments.
  • Not to be used to describe differential diagnoses.
Primary Care Diagnostic Report

Basic diagnostic report

AU Primary Care Estimated Date of Delivery

” Estimated date of delivery for a pregnancy, calculated or estimated by a variety of methods.

AU Primary Care Encounter

Record of a patient encounter including timing, reason, type and participating practitoner.

Usage

Reason for Encounter - Use to record the reason, or reasons, for initiation of any type of healthcare encounter or contact between a healthcare provider and an individual who is the subject of care. The reason may be for clinical, social or administrative purposes.

AU Primary Care Encounter List

This profile defines a encounter list structure that includes core localisation concepts for use in an Australian primary care practice-to-practice record transfer context.

AU Primary Care Family Member History

Summary or persistent information about significant health and related issues in family members.

Usage

Use to record a summary of information about problems or diagnoses found in family members. This information may be used to contribute to the identification of a current health problem, assessment of future risk from familial problems or conditions, or to initiate preventive health activities.

Traditionally the scope of family history has been focused on genetic factors or biomarkers as indicators of risk or potential risk. The scope of this item includes both recording of problems or diagnoses that have an inheritable origin as well as those that are not directly inheritable but influenced by the domestic setting, including psycho-social or environmental factors. Examples include exposure to toxins in the family environment, domestic violence, sexual abuse, alcoholism and other addictions.

Non-genetic family members can include adopted or long term fostered children, those related by marriage, or other unrelated individuals who participate in the regular life and influence of the family.

It may be necessary to identify each family member specifically and not just by the relationship to the individual. For example, while there will be only one maternal grandmother, there may be many female maternal cousins. This may be required to ensure that a pedigree chart is accurate. It will also enable accurate amendments to the record for each identified family member. If the record is private and will not be shared, for reasons of clarity it may be preferable to record the relative’s actual name. If the record, or part of the record, is to be shared, it may be more appropriate for the family member to be identified by a unique label or alias.

Record as a single instance in a health record; updated and revised over time as a new version.

AU Primary Care Family Member History List

This profile defines a family member history list structure that includes core localisation concepts for use in an Australian primary care practice-to-practice record transfer context.

AU Primary Care Follow up

Health-related service or activity to be delivered by a clinician, organisation or agency at a future time.

Usage

Use to record a request for a health-related service or activity to be delivered by a clinician, organisation or agency.

This item has been designed as a framework that can be used as the basis for:

  • a request from one clinician, organisation or agency to another clinician, organisation or agency for a health-related service. For example: a referral to a specialist clinician for treatment or a second clinical opinion; transfer of care to an emergency department; four hourly vital signs monitoring; and provision of home services from a municipal council; or
  • a request for a follow up service to be scheduled for the same clinician, organisation or agency. For example: a review appointment in outpatients in 6 weeks.
AU Primary Care Follow Up List

This profile defines a follow up list structure that includes core localisation concepts for use in an Australian primary care practice-to-practice record transfer context.

AU Primary Care Food Nutrition Summary

Summary or persistent record of the dietary habits, nutritional intake and eating patterns of the individual.

Usage

Summary or persistent record of the dietary habits, nutritional intake and eating patterns of the individual.

Misuse

Not to be used to record a food diary.

AU Primary Care Gestational Age

Estimated gestational age by variable methods.

AU Primary Care Goal

Data group for the recording of goals

AU Primary Care Goal List

This profile defines an goal list structure that includes core localisation concepts for use in an Australian primary care practice-to-practice record transfer context.

AU Primary Care Gravidity

Number of times a woman has been pregnant, current and past, regardless of the pregnancy outcome.

AU Primary Care Heart Rate

Heart Rate observation

AU Primary Care Height

Height observation

AU Primary Care Immunisation

A vaccine that has been administered to an individual.

Usage

Use to record details about a vaccination that had been administered to an individual.

AU Primary Care Immunisation List

This profile defines an immunisation list structure that includes core localisation concepts for use in an Australian primary care practice-to-practice record transfer context.

AU Primary Care Last Menstrual Period

First day of menstrual bleeding in the most recent typical menstrual cycle experienced by the individual.

AU Primary Care Medical History List

This profile defines a medical history list structure that includes core localisation concepts for use in an Australian primary care practice-to-practice record transfer context.

AU Primary Care Medication

A single medication, ingredient, or substance.

Usage

Use to record specific details about a single medication:

  • when details about the medication are not part of an authoritative knowledge base or pharmacopoeia;
  • to represent a custom compounded medication and/or it’s components; and
  • to identify medications which are included in a multi-component pack.

Designed to be nested within a clinically appropriate, standalone item which requires a consistent model for recording details about a single medication - for example, to extend the ‘Medication statement item’ by inserting within the [Medication item] data element.

AU Primary Care Medication Statement

A snapshot view about the use of a specified medication by an individual.

Usage

Use to store or exchange a snapshot view about the use of a specified medication, including current use, past use or planned use. A Medication statement can only be considered correct and accurate at the time it was asserted.

Misuse

Not to be used to record specific details about a medication order. Not to be used to record details about specific medication-related activities, such as administration or dispense.

AU Primary Care Medicine List

This profile defines a medicine list structure that includes core localisation concepts for use in an Australian primary care practice-to-practice record transfer context.

AU Primary Tobacco Smoking Overall Pack Years

Total number of times the individual has attempted to stop smoking the specified type of tobacco.

AU Primary Care Parity

Number of times a woman has given birth to a viable baby, regardless of the pregnancy outcome.

AU Primary Care Patient

Details of a patient including identity, demographic and contacts.

Extensions

  • Indigenous Status : Aboriginal or Torres Strait Islander origin status for the individual, usually self-identified.
  • Birth Place : Record of place of birth.
  • Date of Arrival : Record of date of arrival in australia.
  • Ethnicity : Use to record information about one or more cultural and ethnic identities, self described by the individual.
  • Gender Identity : Record of personal identity with respect to gender.
AU Primary Care Physical Activity Summary

Summary or persistent record of the typical level of physical activity undertaken by the individual.

Usage

Use to record a summary of the typical exercise habits of an individual.

Record as a single instance in a health record; updated and revised over time as a new version.

Misuse

Not to be used to record a physical activity diary of specific activities.

AU Primary Care Procedure

A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes.

Usage

Use to record information about procedures that have been carried out for an individual.

The scope of this item encompasses activities for a broad range of clinical procedures performed for evaluative, investigative, screening, diagnostic, curative, therapeutic or palliative purposes. Examples range from the relatively simple activities, such as insertion of an intravenous cannula, through to complex surgical operations.

AU Primary Care Smoking Status

Statement about current behaviour for all types of tobacco smoking.

AU Primary Care Social Summary

Narrative description about social circumstances or experiences that may have a potential impact on an individual’s health.

Usage

It is possible to incorporate the narrative descriptions about social history-related information within existing or legacy clinical systems into this data element.

AU Primary Care Substance Use Summary

Summary or persistent information about the typical use of a non-prescribed substance or misuse of a prescribed substance by an individual.

Usage

Use to record summary information about the individual’s typical pattern of substance use.

The scope of a substance in the context of this model is includes the administration or consumption of any psychoactive or biologically active substance (with the exception of tobacco and alcohol) used without a prescription or beyond its medical scope, intended purpose or dosage other than prescribed. The scope of this model does not differentiate between legal and illegal substances.

Record a single instance per substance, or class of substance, in a health record; updated over time as a new version.

Misuse

Not to be used to represent tobacco smoking or alcohol consumption - use specific Tobacco smoking and Alcohol consumption models for this purpose.

Not to be used to record event- or period-based information about substance use, such as actual daily use or the average use over a specified period of time, as required for a diary or questionnaire.

Not to be used to record prescribed substances such as medical marijuana. This should be recorded using Medication-related models.

For example: Recreational drugs, Solvents, Anabolic steroids, Opioid abuse, Benzodiazepine abuse

AU Primary Tobacco Smoking Pattern Of Use

Details about smoking activity for a specified type of smoked tobacco.

Usage

Record a single instance per type of tobacco smoked in a health record; updated over time as a new version of the entire summary Includes:

  • Type - Record a single instance per type of tobacco smoked in a health record; updated over time as a new version of the entire summary
  • Typical Use (Units) - Estimate of number of units of the specified type of tobacco smoked.
  • Typical Use (Mass) - Estimate of the weight of loose leaf tobacco smoked.
  • Pattern - The typical pattern of smoking for the specified type of tobacco.
  • Number of Quit Attempts - Total number of times the individual has attempted to stop smoking the specified type of tobacco.
AU Primary Care Tobacco Smoking Date Ceased

The date when the individual last ceased smoking tobacco of any type.

Usage

The definition of smoking cessation is not universally clear, obviously involving abstinence from tobacco smoking for various periods of time, often varying between 28 days and 12 months. At any time, especially within the first 12 months, there is a possibility of relapse and the quit date will need to be removed and the item updated.

Partial dates are permitted.

AU Primary Tobacco Smoking Date Started

The date when the individual first started regular, but usually non-daily, smoking of tobacco of any type.

Usage

Use to record when the individual started smoking on a regular basis, such as every Friday night or at parties.

Record as a single instance in a health record.

Partial dates are permitted

AU Primary Tobacco Smoking Summary

Narrative description about all forms of tobacco smoking.

Usage

It is possible to incorporate the narrative descriptions of tobacco smoking within existing or legacy clinical systems into this data element.

AU Primary Care Ultrasound Scan Obstetric

A record ultrasound scan for obstetric purposes. Including the date scan performed.

AU Primary Care Waist Circumference

The measurement of the circumference of the waist.

AU Primary Care Weight

Weight observation

Structures: Extension Definitions

These define constraints on FHIR data types for systems conforming to this implementation guide

AU Primary Care Review Date

Date when this goal is planned to be reviewed

Terminology: Value Sets

These define sets of codes used by systems conforming to this implementation guide

Alcohol Fee Days Use Units
Alcohol Intake Code Valueset

Procedure coding including absence and exclusion; references relevant NCTS Assertion of Absence codes.

Alcohol Use Units
Alcohol Pattern
Allergy Code Valueset

Allergy coding including absence and exclusion; references relevant NCTS Assertion of Absence codes.

Breastfeeding Code Valueset

Breastfeeding status record

Clinical Indication For Medication ValueSet

Clinical Indication For Medication ValueSet

Condition Code Valueset

Condition coding including absence and exclusion; references relevant NCTS Assertion of Absence codes.

Course ValueSet

The valueset of options to represent clincial course of a condition

Expected Date Of Delivery Types

Expected Date of Delivery observables, e.g. calculated from either scan date or last normal menstrual period and cycle length.

Family History Absent Code Valueset

Family History coding for absence and exclusion; references relevant NCTS Assertion of Absence codes.

Gender Type
Genetic Family Member ValueSet

Members of a family from a genetic perspective

Medication Code Valueset

Medication coding including absence and exclusion; references relevant NCTS Assertion of Absence codes.

Procedure Code Valueset

Procedure coding including absence and exclusion; references relevant NCTS Assertion of Absence codes.

Smoking Pattern
Smoking Type
Smoking Use Units
Substance Use Status
Vaccination Code Valueset

Vaccination coding including absence and exclusion; references relevant NCTS Assertion of Absence codes.

Terminology: Code Systems

These define new code systems used by systems conforming to this implementation guide

Observation Code

Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like

No significant history
Allergy List
Oesophagitis caused by dairy food

Oesophagitis caused by dairy food

Peanut allergy

Urticaria as a result of a Peanut allergy

Penicillin anaphylaxis

Penicillin anaphylaxis

Alpha blocker rash

A rash as a consequence to Alpha adrenergic blockers

Example composition with all sections populated

The composition for a patient with all sections completed

Example composition with no data

The composition for a patient with no relevant history. Required sections are present with no data. This shows ONLY required elements. List resources are contained.

Confirmed diagnosis of Polio

Polio

Confirmed diagnosis of Asthma

Asthma

Estimated Date of Delivery

Estimated Date of Delivery

Father with diabetes

Father with diabetes

Family History List
Followup list
Blood Pressure review

Review to check Blood Pressure

Gestation on scan

Gestation on scan

Gravidity

Gravidity

MMR Vaccination

MMR

MMR Vaccination

MMR

Hepatitis

Hepatitis

No significant history
Immunizations list
Last Menstrual Period

Last Menstrual Period

Mary Fictitious example

Rendering a supplied clincial example into a bundle

No significant history
Medical History List
Simvastatin

Simvastatin

No significant history
No significant history
Parity

Parity

Patient

Supporting patient for examples

Practitioner

Supporting practitioner for examples

Stent, coronary artery

Stent, coronary artery

Plantar wart excision

Plantar wart excision

Obstetric Ultrasound

Obstetric Ultrasound

Cigarette smoker

is a cigarette smoker

Mary Fictitious

Supporting patient for examples

Simvastatin

Simvastatin

Cigarette smoker

Alcohol intake

Allergy List
Hypertension

Hypertension

Rheumatoid Arthritis

Rheumatoid Arthritis

Bipolar disorder

Bipolar disorder

Cigarette smoker

is a ex cigarette smoker

Mother hypothyroid

Mother hypothyroid

Sister hypothyroid

Sister hypothyroid

Family History List
Followup list
Blood Pressure review

Review to check Blood Pressure

Medical History List
Sevikar HCT 40/10/25

Sevikar HCT 40/10/25

SMethotrexate

Methotrexate

lithium carbonate

lithium carbonate

Medication List
No allergies reported

Urticaria as a result of a Peanut allergy

Occupation

Occupation

UteroVaginal prolapse repair

UteroVaginal prolapse repair

Widowed May 2019

Widowed May 2019