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 - mom - XML Representation

Page standards status: Informative

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    <AdverseEvent xmlns="http://hl7.org/fhir">
      <id value="clinicalcareexample2mom"/>
      <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="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: 002</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>
      </text>
      <!--  an identifier used for this allergic propensity (adverse reaction risk)  -->
      <identifier>
        <system value="http://acme.com/ids/patients/risks"/>
        <value value="002"/>
      </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="RelatedPerson"/>
        <display value="mother"/>
      </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, bruises to forehead, neck and both forearms"/>
      </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>