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 - phlebotomist - XML Representation

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<AdverseEvent xmlns="http://hl7.org/fhir">
  <id value="clinicalcareexample2phlebotomist"/>
  <meta>
    <versionId value="2"/>
    <lastUpdated value="2021-12-15T21:05:01.812+00:00"/>
    <profile
             value="http://hl7.org/fhir/uv/adverseeventclinicalcare/StructureDefinition/AdverseEvent-clinical-care"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: AdverseEvent</b><a name="clinicalcareexample2phlebotomist"> </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;clinicalcareexample2phlebotomist&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: 001</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>: phlebotomist</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, 3.5 cm laceration on left forearm</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>
  </text>
  <!--  an identifier used for this allergic propensity (adverse reaction risk)  -->
  <identifier>
    <system value="http://acme.com/ids/patients/risks"/>
    <value value="001"/>
  </identifier>
  <status value="completed"/>
  <!--  this was an actual adverse event, not just a potential one  -->
  <actuality value="actual"/>
  <!--  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 -->
  <category>
    <coding>
      <system
              value="http://terminology.hl7.org/CodeSystem/adverse-event-category"/>
      <code value="unsafe-physical-environment"/>
      <display value="Unsafe Physical Environment"/>
    </coding>
  </category>
  <!--  more precise details of the event  -->
  <code>
    <coding>
      <!--  example uses SNOMED CT. Other likely possibilities include MedDRA  -->
      <system value="http://snomed.info/sct"/>
      <code value="370927008"/>
      <display
               value="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)"/>
    </coding>
  </code>
  <!--  the patient that actually had the adverse event  -->
  <!-- subject>
    <reference value="Patient/example"/>
  </subject>
  <subject> 
    <reference value="AdverseEvent/patientSAE1example"/> 
  </subject -->
  <subject>
    <type value="Practitioner"/>
    <display value="phlebotomist"/>
  </subject>
  <encounter>
    <display
             value="Inpatient encounter of event that was initiated with ER visit"/>
  </encounter>
  <!--  when the event happened  -->
  <detected value="2021-12-10T13:28:17-05:00"/>
  <recordedDate value="2021-12-15T13:28:17-05:00"/>
  <resultingEffect>
    <display
             value="Condition with Diagnosis category, 3.5 cm laceration on left forearm"/>
  </resultingEffect>
  <location>
    <display value="Hospital, Inpatient"/>
  </location>
  <outcome>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="398056004"/>
      <display value="Transient abnormality with full recovery (finding)"/>
    </coding>
  </outcome>
  <!--  who made the record / last updated it  -->
  <recorder>
    <display value="The person entering in the information"/>
  </recorder>
  <!--  may have been for cream to treat sunburn on that arm, reference to that medication  -->
  <suspectEntity>
    <instanceReference>
      <type value="MedicationAdministration"/>
      <display value="14 year-old patient had increase in Levetiracetam"/>
    </instanceReference>
    <causality>
      <entityRelatedness>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/adverse-event-causality-assess"/>
          <code value="probably-likely"/>
          <display value="Probably/Likely"/>
        </coding>
      </entityRelatedness>
    </causality>
  </suspectEntity>
  <mitigatingAction>
    <itemReference>
      <type value="MedicationRequest"/>
      <display
               value="for 14 year-old patient dose reduced to pre-admission dose for the remainder of his hospital stay."/>
    </itemReference>
  </mitigatingAction>
  <note>
    <authorString value="Practitioner"/>
    <text
          value="There was no clinical or electrographic seizure episode or recurrence of fever since admission in the 14 year-old patient."/>
  </note>
</AdverseEvent>