Adverse Event Clinical Care
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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

: AE Clinical Care example 2 - mom - JSON Representation

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{
  "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 &quot;clinicalcareexample2mom&quot; Version &quot;2&quot; Updated &quot;2021-12-15 21:05:01+0000&quot; </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."
    }
  ]
}