Adverse Event Clinical Care
0.2.0 - ci-build
Adverse Event Clinical Care
0.2.0 - ci-build
Adverse Event Clinical Care, published by HL7 International - Patient Care Work Group, Vulcan AdverseEvent groups. This is not an authorized publication; it is the continuous build for version 0.2.0). This version is based on the current content of https://github.com/HL7/fhir-ae-care-ig/ and changes regularly. See the Directory of published versions
| Page standards status: Informative |
{
"resourceType" : "AdverseEvent",
"id" : "clinicalcareexample2mom",
"meta" : {
"versionId" : "2",
"lastUpdated" : "2021-12-15T21:05:01.812+00:00",
"profile" : [
"http://hl7.org/fhir/uv/adverseeventclinicalcare/StructureDefinition/AdverseEvent-clinical-care"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: AdverseEvent</b><a name=\"clinicalcareexample2mom\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource AdverseEvent "clinicalcareexample2mom" Version "2" Updated "2021-12-15 21:05:01+0000" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-AdverseEvent-clinical-care.html\">Adverse Event Clinical Care</a></p></div><p><b>identifier</b>: id:\u00a0002</p><p><b>status</b>: completed</p><p><b>actuality</b>: actual</p><p><b>category</b>: Unsafe Physical Environment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-adverse-event-category.html\">AdverseEventCategory</a>#unsafe-physical-environment)</span></p><p><b>code</b>: Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the healthcare facility (event) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#370927008)</span></p><p><b>subject</b>: <span>: mother</span></p><p><b>encounter</b>: <span>: Inpatient encounter of event that was initiated with ER visit</span></p><p><b>detected</b>: 2021-12-10 13:28:17-0500</p><p><b>recordedDate</b>: 2021-12-15 13:28:17-0500</p><p><b>resultingEffect</b>: <span>: Condition with Diagnosis category, bruises to forehead, neck and both forearms</span></p><p><b>location</b>: <span>: Hospital, Inpatient</span></p><p><b>outcome</b>: Transient abnormality with full recovery (finding) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#398056004)</span></p><p><b>recorder</b>: <span>: The person entering in the information</span></p><blockquote><p><b>suspectEntity</b></p><p><b>instance</b>: <span>: 14 year-old patient had increase in Levetiracetam</span></p><h3>Causalities</h3><table class=\"grid\"><tr><td>-</td><td><b>EntityRelatedness</b></td></tr><tr><td>*</td><td>Probably/Likely <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-adverse-event-causality-assess.html\">AdverseEventCausalityAssessment</a>#probably-likely)</span></td></tr></table></blockquote><h3>MitigatingActions</h3><table class=\"grid\"><tr><td>-</td><td><b>Item[x]</b></td></tr><tr><td>*</td><td><span>: for 14 year-old patient dose reduced to pre-admission dose for the remainder of his hospital stay.</span></td></tr></table><p><b>note</b>: There was no clinical or electrographic seizure episode or recurrence of fever since admission in the 14 year-old patient. (By Practitioner)</p></div>"
},
"identifier" : [
// an identifier used for this allergic propensity (adverse reaction risk)
{
"system" : "http://acme.com/ids/patients/risks",
"value" : "002"
}
],
"status" : "completed",
"actuality" : "actual",
"category" : [
// this was an actual adverse event, not just a potential one
// high level categorizion. The "event" below will say more
// category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adverse-event-category"/>
<code value="medication-mishap"/>
<display value="Medication Mishap"/>
</coding>
</category
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adverse-event-category",
"code" : "unsafe-physical-environment",
"display" : "Unsafe Physical Environment"
}
]
}
],
"code" : // more precise details of the event
{
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "370927008",
"display" : "Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the healthcare facility (event)"
}
]
},
"subject" : // example uses SNOMED CT. Other likely possibilities include MedDRA
// the patient that actually had the adverse event
// subject>
<reference value="Patient/example"/>
</subject>
<subject>
<reference value="AdverseEvent/patientSAE1example"/>
</subject
{
"type" : "RelatedPerson",
"display" : "mother"
},
"encounter" : {
"display" : "Inpatient encounter of event that was initiated with ER visit"
},
"detected" : "2021-12-10T13:28:17-05:00",
"recordedDate" : "2021-12-15T13:28:17-05:00",
"resultingEffect" : [
// when the event happened
{
"display" : "Condition with Diagnosis category, bruises to forehead, neck and both forearms"
}
],
"location" : {
"display" : "Hospital, Inpatient"
},
"outcome" : [
{
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "398056004",
"display" : "Transient abnormality with full recovery (finding)"
}
]
}
],
"recorder" : // who made the record / last updated it
{
"display" : "The person entering in the information"
},
"suspectEntity" : [
// may have been for cream to treat sunburn on that arm, reference to that medication
{
"instanceReference" : {
"type" : "MedicationAdministration",
"display" : "14 year-old patient had increase in Levetiracetam"
},
"causality" : {
"entityRelatedness" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adverse-event-causality-assess",
"code" : "probably-likely",
"display" : "Probably/Likely"
}
]
}
}
}
],
"mitigatingAction" : [
{
"itemReference" : {
"type" : "MedicationRequest",
"display" : "for 14 year-old patient dose reduced to pre-admission dose for the remainder of his hospital stay."
}
}
],
"note" : [
{
"authorString" : "Practitioner",
"text" : "There was no clinical or electrographic seizure episode or recurrence of fever since admission in the 14 year-old patient."
}
]
}
IG © 2019+ HL7 International - Patient Care Work Group, Vulcan AdverseEvent groups. Package hl7.fhir.uv.adverseeventclinicalcare#0.2.0 based on FHIR 5.0.0. Generated 2023-05-25
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