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

## : AE Clinical Care example 2 - phlebotomist - JSON Representation

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    {
      "resourceType" : "AdverseEvent",
      "id" : "clinicalcareexample2phlebotomist",
      "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=\"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:\u00a0001</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>"
      },
      "identifier" : [
        //  an identifier used for this allergic propensity (adverse reaction risk)
        {
          "system" : "http://acme.com/ids/patients/risks",
          "value" : "001"
        }
      ],
      "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" : "Practitioner",
        "display" : "phlebotomist"
      },
      "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, 3.5 cm laceration on left forearm"
        }
      ],
      "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."
        }
      ]
    }