HL7 Czech Outpatient Encounter Report Implementation Guide
0.1.0 - ci-build
HL7 Czech Outpatient Encounter Report Implementation Guide
0.1.0 - ci-build
HL7 Czech Outpatient Encounter Report Implementation Guide, published by HL7 Czech Republic. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7-cz/amb/ and changes regularly. See the Directory of published versions
Contents:
This page provides a list of the FHIR artifacts defined as part of this implementation guide.
Actors and Obligations used to describe the Outpatient Encounter Report functional requirements for the specified data elements. Informative for this version of the guide.
| Encounter Obligations (AMB CZ) |
This profile defines the obligations for the CZ_EncounterAmb profile used in the Amb CZ project. |
| Flag Obligations (AMB CZ) |
This profile defines the obligations for the CZ_FlagAmb profile used in the Amb CZ project. |
Logical model in czech language. Informative for this version of the guide.
| A - Ambulantní zpráva |
Ambulantní zpráva |
| A.1 - Hlavička dokumentu |
Záhlaví dokumentu s administrativními údaji |
| A.2.1 - Dříve vyslovená přání |
Ambulantní zpráva - Dříve vyslovená přání |
| A.2.2 - Urgentní informace |
Urgentní informace |
| A.2.3 - Údaje o ambulantním kontaktu |
Záznam o ambulantním kontaktu v rámci ambulantní zprávy. |
| A.2.4 - Stav při přijetí |
Stav při přijetí (Nepovinná sekce uvádět pouze v případě významu pro zajištění kontinuity péče.) |
| A.2.6 - Anamnéza pacienta |
Anamnéza pacienta |
| A.2.7 - Průběh ambulantního kontaktu |
Popis průběhu ambulantního kontaktu zahrnující diagnostické souhrny, výkony, léčbu, vyšetření i klinické shrnutí. |
| A.2.8 - Souhrn medikace |
Souhrnná informace o medikaci, doporučené na období po propuštění, s vyznačením, zda se jedná o medikaci pokračující, změněnou či nově zahájenou. |
| A.2.9.1 - Plán péče |
Plán péče po ambulantním kontaktu |
| A.3 - Prezentační forma |
Ambulantní zpráva - čitelná lidským okem, je požadován PDF formát. Obsahuje informace o průběhu hospitalizace v rozsahu vydané zprávy. |
| A.4 - Ostatní přílohy |
Ostatní přílohy |
These define data models that represent the domain covered by this implementation guide in more business-friendly terms than the underlying FHIR resources.
| A - Outpatient Encounter Report |
Outpatient Encounter Report |
| A.1 - Header |
Header with administrative data |
| A.1.1 - Identification and A.1.2 - related contact information of the Patient/subject |
Outpatient Report - Outpatient Report subject data element - A.1.1 and A.1.2 eHN |
| A.1.1 - Identifikace a A.1.2 - informace o pacientovi |
Ambulantní zpráva - Informace o pacientovi. |
| A.1.9 - Digital signature |
Digital signature - Electronic signature or seal of a document according to Act 327/2011 §54a |
| A.1.9 - Digitální podpis |
Nemocniční propouštěcí zpráva - Elektronický podpis dle zákona 327/2011 §54a |
| A.2.1 - Advance Directives |
Advance Directives |
| A.2.2 - Alerts |
Alerts |
| A.2.3 - Encounter |
Encounter information |
| A.2.4 - Admission Evaluation |
Admission Evaluation |
| A.2.6 - Patient History |
Patient History |
| A.2.7 - Encounter Summary |
Encounter Summary |
| A.2.8 - Medication Summary |
Medication Summary |
| A.2.9.1 - Plan of Care |
Plan of Care |
| A.3 - Presented Form |
Presented form - Entire report as issued. Various formats could be provided, pdf format is recommended. |
| A.4 - Attachments |
Attachments |
These define constraints on FHIR resources for systems conforming to this implementation guide.
| AllergyIntolerance: Outpatient Encounter Report (CZ) |
AllergyIntolerance resource to represent information about allergies or intolerances relevant to ambulatory care in the scope of this guide. |
| Bundle Outpatient Encounter Report (CZ) |
Clinical document used to represent a Outpatient Encounter Report for the scope of this guide. |
| Composition: Outpatient Encounter Report (CZ) |
Clinical document used to represent an Outpatient Encounter Report for the scope of this guide. |
| Consent (Advance Directives) (AMB CZ) |
This profile constrains the Consent resource for the purpose of representing Advance Directives in this project. |
| Encounter - Ambulatory (CZ) |
Ambulatory encounter specialization of the Czech national Encounter profile (CZ_Encounter) for outpatient/ambulatory reports. |
| Flag: Outpatient Encounter Report (CZ) |
Flag resource to represent important clinical or administrative information about the patient relevant to ambulatory care in the scope of this guide. |
These define constraints on FHIR data types for systems conforming to this implementation guide.
| Encounter note (CZ) |
Free-text note related to the encounter. |
These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like.
| Ambulantní zpráva - L1 composition |
Example Composition for Outpatient Report for patient Mrakomorová Mračena |
| Ambulantní zpráva - L1 composition |
Example Composition for Outpatient Report for patient Novák Jan |
| Ambulantní zpráva - L3 composition |
Example Composition for Outpatient Report for patient Mrakomorová Mračena - L3 |
| Ambulantní zpráva - L3 composition |
Example Composition for Outpatient Report for patient Novák Jan - L3 |
| AttachmentExampleDocumentReferencePdf | |
| Infekční kontakt – spalničky |
Pacient byl v kontaktu s osobou nakaženou spalničkami |
| OutpatientBundle-Mracena-L1 |
Example Bundle for Outpatient Report for patient Mrakomorová Mračena |
| OutpatientBundle-Mracena-L3 |
Example Bundle for Outpatient Report for patient Mrakomorová Mračena - L3 |
| OutpatientBundle-Novak-L1 |
Example Bundle for Outpatient Report for patient Novák Jan |
| OutpatientBundle-Novak-L3 |
Example Bundle for Outpatient Report for patient Novák Jan - L3 |
| Patient-Novak |
Patient, contact information and practitioner |
| Practitioner-987654321 |
Practitioner id(KRZP)=987654321 |