PACIO Transitions of Care Implementation Guide
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PACIO Transitions of Care Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-transitions-of-care-ig/ and changes regularly. See the Directory of published versions

FHIR Artifacts

Page standards status: Informative

Contents:

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

Behavior: Capability Statements

The following artifacts define the specific capabilities that different types of systems are expected to have in order to comply with this implementation guide. Systems conforming to this implementation guide are expected to declare conformance to one or more of the following capability statements.

TOC CapabilityStatement

This Section describes the expected capabilities of the PACIO Transitions of Care (TOC) Server actor which is responsible for providing responses to the queries submitted by the TOC Requestors.

The TOC information is conveyed via a Bundle.

Structures: Resource Profiles

These define constraints on FHIR resources for systems conforming to this implementation guide.

TOC Document Reference

This profile defines constraints that represent the information needed for a Transition of Care document on a FHIR server.
Transition of Care Bundle

This is a profile for a Transition of Care Bundle, which includes the necessary resources for documenting a patient's transition from one care setting to another.
Transition of Care Composition

This profile defines constraints that represent common administrative and demographic concepts for transitions of care information used in US Realm clinical documents.

Structures: Extension Definitions

These define constraints on FHIR data types for systems conforming to this implementation guide.

Point of Contact

The Point of Contact Extension represents the individual or organization that can be contacted for information about the patient or their care.

Terminology: Value Sets

These define sets of codes used by systems conforming to this implementation guide.

Transitions of Care DEL LOINC Terms Value Set

This value set includes those LOINC terms that are used by the DEL.

Terminology: Code Systems

These define new code systems used by systems conforming to this implementation guide.

Transition of Care Temporary Code System

Codes to be used as placeholders until they have a formal assigned code from a recognized terminology steward.

Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like.

Example-Smith-Johnson-DocRef-Bundle

Example Patient Smith-Johnson DocumentReference Bundle
Example: Allergy List

Allergies for fictional patient Betsy Smith-Johnson.
Example: Discharge Assessment - Lower body dressing

Minimum Data Set (MDS) Discharge Assessment - Lower body dressing for fictional patient Betsy Smith-Johnson.
Example: Discharge Assessment - Sit to stand

Minimum Data Set (MDS) Discharge Assessment - Sit to stand for fictional patient Betsy Smith-Johnson.
Example: Discharge Assessment - Upper body dressing

Minimum Data Set (MDS) Discharge Assessment - Upper body dressing for fictional patient Betsy Smith-Johnson.
Example: Discharge Care Plan

Discharge Care Plan for fictional patient Betsy Smith-Johnson.
Example: Discharge Service Request for OT referral

Discharge Service Request for Occupational Therapy referral for fictional patient Betsy Smith-Johnson.
Example: Discharge Service Request for PT referral

Discharge Service Request for physical therapy referral for fictional patient Betsy Smith-Johnson.
Example: Discharge Service Request for blood chemistry procedure

Discharge Service Request for blood chemistry procedure for fictional patient Betsy Smith-Johnson.
Example: Discharge Service Request for call order

Discharge Service Request for call order for fictional patient Betsy Smith-Johnson.
Example: Discharge Service Request for complete blood count

Discharge Service Request for complete blood count for fictional patient Betsy Smith-Johnson.
Example: Discharge Service Request for discharge SLP referral

Discharge Service Request for Speech Language Pathologist referral for fictional patient Betsy Smith-Johnson.
Example: Discharge Service Request for reduced salt diet

Discharge Service Request for reduced salt diet for fictional patient Betsy Smith-Johnson.
Example: Dr. Anita Chu

Information about fictional practitioner Dr. Anita Chu.
Example: Dr. Gerald Park

Information about fictional practitioner Dr. Gerald Park.
Example: Dr. Jen Cadbury

Information about fictional practitioner Dr. Jen Cadbury.
Example: Dr. Nura Mekel

Information about fictional practitioner Dr. Nura Mekel.
Example: Dr. Tracy Count

Information about fictional practitioner Dr. Tracy Count.
Example: Dressing Concerns

Dressing Concerns for fictional patient Betsy Smith-Johnson.
Example: Encounter

Home Health encounter for Betsy Smith-Johnson
Example: Everyday Community Pharmacy Organization

Information about the Everyday Community Pharmacy Organization.
Example: Happy Nursing Facility Organization

Information about the Happy Nursing Facility Organization.
Example: Heart Disease Diagnosis

Heart Disease Diagnosis for fictional patient Betsy Smith-Johnson.
Example: Hemiparesis Diagnosis

Hemiparesis Diagnosis for fictional patient Betsy Smith-Johnson.
Example: Home Medication List

Home medication list for Betsy Smith-Johnson
Example: Hyperlipidemia Diagnosis

hyperlipidemia Diagnosis for fictional patient Betsy Smith-Johnson.
Example: Hypertension Diagnosis

Hypertension Diagnosis for fictional patient Betsy Smith-Johnson.
Example: Immunization - Influenza, high-dose, quadrivalent, PF (Fluzone)

Influenza, high-dose, quadrivalent, PF (Fluzone) immunization for fictional patient Betsy Smith-Johnson.
Example: Immunization - Pneumococcal Conjugate Vaccine, 20 Valent (PCV20)

Pneumococcal Conjugate Vaccine, 20 Valent (PCV20) immunization for fictional patient Betsy Smith-Johnson.
Example: Location of Michigan Primary Health Care Associates

Location of Michigan Primary Health Care Associates.
Example: Location of the Happy Nursing Facility

Location of the Happy Nursing Facility.
Example: Location of the Motown Home Health Facility

Location of the Motown Home Health Facility.
Example: Location of the Neuro Care Inc. facility

Location of the Neuro Care Inc. facility.
Example: Location of the Not Every Day Contract Pharmacy

Location of the Not Every Day Contract Pharmacy.
Example: Medication request for Atorvastatin 40 MG Oral Tablet

Medication request for Atorvastatin 40 MG Oral Tablet for Betsy Smith-Johnson to treat Hyperlipidemia
Example: Medication request for Losartan 6.25 MG Oral Tablet

Medication request for Losartan 6.25 MG Oral Tablet for Betsy Smith-Johnson to treat Hypertension
Example: Medication request for clopidogrel 75 MG Oral Tablet

Medication request for clopidogrel 75 MG Oral Tablet for Betsy Smith-Johnson to treat Hyperlipidemia
Example: Medication statement for Atorvastatin 40 MG Oral Tablet

Medication statement for Atorvastatin 40 MG Oral Tablet for Betsy Smith-Johnson to treat Hyperlipidemia
Example: Medication statement for clopidogrel 75 MG Oral Tablet

Medication statement for clopidogrel 75 MG Oral Tablet for Betsy Smith-Johnson to treat Hyperlipidemia
Example: Medication statement for losartan potassium 25 MG Oral Tablet

Medication statement for losartan potassium 25 MG Oral Tablet for Betsy Smith-Johnson to treat Hypertension
Example: Michigan Primary Health Care Associates Organization

Information about the Michigan Primary Health Care Associates Organization.
Example: Motown Home Health Organization

Motown Home Health Organization.
Example: Nausea and vomiting

Nausea and vomiting for fictional patient Betsy Smith-Johnson.
Example: Neuro Care Inc. Organization

Information about the Neuro Care Inc. Organization.
Example: Neuropathy Diagnosis

Neuropathy Diagnosis for fictional patient Betsy Smith-Johnson.
Example: Not Every Day Contract Pharmacy Organization

Information about the Not Every Day Contract Pharmacy Organization.
Example: Nursing Home Discharge Assessment Questions - Mobility Part 1

Minimum Data Set (MDS) Nursing Home Discharge Assessment Questions - Mobility Part 1 for fictional patient Betsy Smith-Johnson.
Example: OT Decondition Problem List

Occupational Therapy Decondition problem list for fictional patient Betsy Smith-Johnson.
Example: OT Right Weakness Problem List

Occupational Therapy Right Weakness problem list for fictional patient Betsy Smith-Johnson.
Example: Patient - Betsy Smith-Johnson

Basic information for fictional patient Betsy Smith-Johnson.
Example: Role of Dr. Anita Chu

Dr. Anita Chu is a fictional Internal Medicine Physician at Michigan Primary Health Care Associates.
Example: Role of Dr. Gerald Park

Dr. Gerald Park is a fictional Geriatric Medicine Physician at the Happy Nursing Facility.
Example: Role of Dr. Jen Cadbury

Dr. Jen Cadbury is a fictional Internal Medicine Physician at Neuro Care Inc.
Example: Role of Dr. Nura Mekel

Dr. Nura Mekel is a fictional Internal Medicine Physician at Neuro Care Inc.
Example: Role of Dr. Tracy Count

Dr. Tracy Count is a fictional Pharmacist at Not Every Day Contract Pharmacy.
Example: Service Request to follow up with PCP

Service Request to follow up with PCP for fictional patient Betsy Smith-Johnson.
Example: Stroke Diagnosis

Stroke Diagnosis for fictional patient Betsy Smith-Johnson.
Example: Transition of Care Bundle

Example Transition of Care bundle for fictional patient Betsy Smith-Johnson.
Example: Transitions of Care Clinical Document

Transitions of Care Clinical Document for fictional patient Betsy Smith-Johnson.
Example: Undressing Concern

Undressing Concern for fictional patient Betsy Smith-Johnson.