NHDR Implementation Guide Release 1.0
0.1.0 - ci-build
NHDR Implementation Guide Release 1.0, published by NHDR. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/UP-Manila-SILab/PhilHealth-NHDR-IG-Review/ and changes regularly. See the Directory of published versions
/ Target Element |
(if any) |
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|---|---|---|---|---|
| Part I - Patient's Clinical Record | ||||
| PhilHealth Accreditation No. (PAN) - Institutional Health Care Provider | Claim.provider | Reference(PH_Organization) | 1..1 | |
| Organization.identifier | Identifier | |||
| Name of Patient (Last Name) | Claim.patient | Reference(PH_Patient) | 1..1 | |
| Patient.name.family | string | 0..1 | ||
| Name of Patient (First Name) | Claim.patient | Reference(PH_Patient) | 1..1 | |
| Patient.name.given[0] | string | 0..* | Use first instance of name.given |
|
| Name of Patient (Middle Name) | Claim.patient | Reference(PH_Patient) | 1..1 | |
| Patient.name.given[1] | string | 0..* | Use second instance of name.given |
|
| Chief Complaint / Reason for Admission | Claim.extension:encounter | Reference(PH_Encounter) | ||
| Encounter.reasonReference | Reference(PH_Observation) | 0..* | ||
| Observation.valueString | string | 0..1 | ||
| Date Admitted (MM-DD-YYYY)(Time Admitted HH:MM(AM/PM)) | Claim.extension:encounter | Reference(PH_Encounter) | ||
| Encounter.period.start | dateTime | 0..1 | ||
| Date Discharged (MM-DD-YYYY)(Time Discharge HH:MM)(AM/PM) | Claim.extension:encounter | Reference(PH_Encounter) | ||
| Encounter.period.end | dateTime | 0..1 | ||
| Brief History of Present Illness / OB History | Claim.diagnosis.diagnosisReference | Reference(PH_Condition) | 1..1 | |
| Condition.note | Annotation | 0..* | ||
| General Survey | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.valueString | string | 0..1 | ||
| Vital Signs (BP) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.valueString | string | 0..1 | ||
| Vital Signs (CR) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.valueString | string | 0..1 | ||
| Vital Signs (RR) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.valueString | string | 0..1 | ||
| Vital Signs (Temperature) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.valueString | string | 0..1 | ||
| Abdomen | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.valueString | string | 0..1 | ||
| HEENT | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.valueString | string | 0..1 | ||
| GU (IE) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.valueString | string | 0..1 | ||
| Chest / Lungs | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.valueString | string | 0..1 | ||
| Skin / Extremities | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.valueString | string | 0..1 | ||
| CVS | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.valueString | string | 0..1 | ||
| Neuro Examination | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.valueString | string | 0..1 | ||
| Course in the Wards (attach additional sheets if necessary) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| ClinicalImpression.description | string | 0..1 | ||
| Pertinent Laboratory and Diagnostic Findings: (CBC, Urinalysis, Fecalysis, X-ray, Biopsy, etc.) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.code | CodeableConcept | 0..1 | ||
| Pertinent Laboratory and Diagnostic Findings: (CBC, Urinalysis, Fecalysis, X-ray, Biopsy, etc.) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.valueString | string | 0..1 | ||
| Pertinent Laboratory and Diagnostic Findings: (CBC Urinalysis, Fecalysis, X-ray, Biopsy, etc.) | Claim.supportingInfo.valueReference | Reference(PH_DiagnosticReport) | 0..1 | |
| DiagnosticReport.conclusion | string | |||
| Disposition on Discharge (Check notes for options) | Claim.extension:encounter | Reference(PH_Encounter) | ||
| Encounter.hospitalization.dischargeDisposition | CodeableConcept | 0..1 | ||
| Part II - Maternity Care Package | ||||
| 1. Initial Prenatal Consultation (MM-DD-YYYY) | Claim.item.servicedDate | date | 0..1 | |
| 2. Clinical History and Physical Examination: a. Vital signs are normal | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.interpretation | CodeableConcept | 0..* | ||
| 2. Clinical History and Physical Examination: b. Ascertain the present Pregnancy is low-Risk | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueBoolean | boolean | 0..1 | ||
| 2. Clinical History and Physical Examination: c. Menstrual History LMP (MM-DD-YYYY) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 2. Clinical History and Physical Examination: c. Menstrual History LMP (MM-DD-YYYY) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueDateTime | dateTime | 0..1 | ||
| 2. Clinical History and Physical Examination: d. Menstrual History (Age of Menarche) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 2. Clinical History and Physical Examination: d. Menstrual History (Age of Menarche) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueInteger | integer | 0..1 | ||
| 2. Obstetric History (G) | ClaimsupportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 2. Obstetric History (G) (value) | ClaimsupportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueInteger | integer | 0..1 | ||
| 2. Obstetric History (P) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 2. Obstetric History (P) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueInteger | integer | 0..1 | ||
| 2. Obstetric History (P)[T] | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 2. Obstetric History (P)[T] (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueInteger | integer | 0..1 | ||
| 2. Obstetric History (P)[P] | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 2. Obstetric History (P)[P] (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueInteger | integer | 0..1 | ||
| 2. Obstetric History (P)[A] | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 2. Obstetric History (P)[A] (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueInteger | integer | 0..1 | ||
| 2. Obstetric History (P)[L] | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 2. Obstetric History (P)[L] (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueInteger | integer | 0..1 | ||
| 3. Obstetric risk factors (Check notes for options) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.code | CodeableConcept | 1..1 | ||
| 4. Medical / Surgical risk factors (Check notes for options) | Claim.diagnosis.diagnosisCodeableConcept | CodeableConcept | 1..1 | |
| 5. Admitting Diagnosis | Claim.diagnosis.diagnosisReference | Reference(PH_Condition) | 1..1 | |
| 6. Orientation to MCP / Availment of Benefits (Yes / No) | Questionnaire.item.text | string | 0..1 | |
| 6. Expected date of delivery (MM-DD-YYYY) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.effectiveDateTime | dateTime | 0..1 | ||
| 7a. Prenatal Consultation No. | Claim.item.sequence | positiveInt | 1..1 | |
| 7b. Date of visit (MM-DD-YYYY) | Claim.item.servicedDate | date | 0..1 | |
| 7c. AOG in weeks | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.valueInteger | integer | 0..1 | ||
| 7d. Weight and Vital Signs | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.valcodeueInteger | CodeableConcept | 1..1 | ||
| 7d.1 Weight | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 7d.1 Weight (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueQuantity | Quantity | 0..1 | ||
| 7d.2 Cardiac Rate | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 7d.2 Cardiac Rate (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueString | string | 0..1 | ||
| 7d.3 Respiratory Rate | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 7d.3 Respiratory Rate (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueString | string | 0..1 | ||
| 7d.4 Blood Pressure | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 7d.4 Blood Pressure (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueString | string | 0..1 | ||
| 7d.5 Temperature | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 7d.5 Temperature (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueQuantity | Quantity | 0..1 | ||
| Part II - Maternity Care Package (Delivery Outcome) | ||||
| 8. Date of Delivery (MM-DD-YYYY)(AM/PM)[HH:MM] | Claim.item.servicedDate | date | 0..1 | |
| 9. Maternal Outcome (Obstetric Index) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 9. Maternal Outcome (Obstetric Index) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueString | string | 0..1 | ||
| 9. Pregnancy Uterine (AOG by LMP) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 9. Pregnancy Uterine (AOG by LMP) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueString | string | 0..1 | ||
| 9. Pregnancy Uterine (Manner of Delivery) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 9. Pregnancy Uterine (Manner of Delivery) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueString | string | 0..1 | ||
| 9. Pregnancy Uterine (Presentation) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 9. Pregnancy Uterine (Presentation) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueString | string | 0..1 | ||
| 10. Birth Outcome | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.code | CodeableConcept | 1..1 | ||
| 10. Birth Outcome (Fetal Outcome) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 10. Birth Outcome (Fetal Outcome) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueString | string | 0..1 | ||
| 10. Birth Outcome (Sex) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 10. Birth Outcome (Sex) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueString | string | 0..1 | ||
| 10. Birth Outcome (Birth Weight (grm)) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 10. Birth Outcome (Birth Weight (grm)) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueString | string | 0..1 | ||
| 10. Birth Outcome (APGAR Score) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 10. Birth Outcome (APGAR Score) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueString | string | 0..1 | ||
| 11. Scheduled Postpartum follow-up consultation 1 week after delivery | Claim.extension:encounter | Reference(PH_Encounter) | ||
| Encounter.period.start | dateTime | |||
| 12. Date of Discharge | Claim.extension:encounter | Reference(PH_Encounter) | ||
| Encounter.period.end | dateTime | |||
| Part II - Maternity Care Package (Postpartum Care) | ||||
| 13. Perineal wound care (checkbox) | Questionnaire.item.text | string | 0..1 | |
| 13. Perineal wound care (Remarks) | Questionnaire.item.text | string | 0..1 | |
| 14. Signs of Maternal Postpartum Complications (checkbox) | Questionnaire.item.text | string | 0..1 | |
| 14. Signs of Maternal Postpartum Complications (Remarks) | Questionnaire.item.text | string | 0..1 | |
| 15a. Counselling and Education (Breastfeeding and Nutrition) (checkbox) | Questionnaire.item.text | string | 0..1 | |
| 15a. Counselling and Education (Breastfeeding and Nutrition) (Remarks) | Questionnaire.item.text | string | 0..1 | |
| 15b. Counselling and Education (Family Planning) (checkbox) | Questionnaire.item.text | string | 0..1 | |
| 15b. Counselling and Education (Family Planning) (Remarks) | Questionnaire.item.text | string | 0..1 | |
| 16. Provided family planning service to patient (as requested by patient) (checkbox) | Questionnaire.item.text | string | 0..1 | |
| 16. Provided family planning service to patient (as requested by patient) (Remarks) | Questionnaire.item.text | string | 0..1 | |
| 17. Referred to partner physician for Voluntary Surgical Sterilization (as requested by pt.) (checkbox) | Questionnaire.item.text | string | 0..1 | |
| 17. Refereed to partner physician for Voluntary Surgical Sterilization (as requested by pt.) (Remarks) | Questionnaire.item.text | string | 0..1 | |
| 18. Schedule the next postpartum follow-up (checkbox) | Questionnaire.item.text | string | 0..1 | |
| 18. Schedule the next postpartum follow-up (Remarks) | Questionnaire.item.text | string | 0..1 | |
| 19. Signature Type | Provenance.signature.type | 1..* | Coding | |
| 19. Signature Over Printed Name of Attending Physician / Midwife | Provenance.signature.who | Reference(PH_Practitioner) | 1..1 | |
| Practitioner.name | HumanName | |||
| 19. Signature Over Printed Name of Attending Physician / Midwife | Provenance.signature.data | base64Binary | 0..1 | |
| 19. Date Signed | Provenance.signature.when | instant | 1..1 |
| Provenance.target | Reference(PH_Claim) | Reference the intact Claim resource |
| Provenance.recorded | instant | Must be system-generated timestamp |
| Provenance.agent.who | Reference(PH_Organization) | Reference the intact Organization (Health Facility) resource |
| Organization.name | string | Derive from the referenced Organization resource |
| Claim.status | code | Use expected value 'submitted' |
| Claim.type | CodeableConcept | Use expected value '( |
| Claim.use | code | Use expected value 'claim' |
| Claim.created | dateTime | "Resource creation date", should be the instant that the resource was created. |
| Claim.priority | CodeableConcept | Use expected value 'normal' |
| Claim.supportingInfo.sequence | positiveInt | Expected incrementing value per object |
| Claim.supportingInfo.category | CodeableConcept | TBD |
| Claim.diagnosis.sequence | positiveInt | Expected incrementing value per object |
| Claim.procedure.sequence | positiveInt | Expected incrementing value per object |
| Claim.insurance.sequence | positiveInt | Expected incrementing value per object |
| Claim.insurance.focal | boolean | Flag that determines the coverage to be used for the adjudication of this claim. |
| Claim.insurance.coverage | Reference(PH_Coverage) | To be resolved |
| Claim.item.sequence | positiveInt | Expected incrementing value per object |
| Questionnaire.status | code | Use expected value 'active' |
| Questionnaire.item.linkId | string | Expected incrementing value per questionnaire item. |
| Questionnaire.item.type | code | Indicates expected data type for the questionnaire item. |