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) |
|||
|---|---|---|---|---|
| Series # | Claim.identifier | Identifier | 0..* | — |
| Part I - Health Care Institution (HCI) Information | ||||
| Name of HCI | Claim.provider | Reference(PH_Organization) | 1..1 | — |
| Organization.name | string | — | — | |
| Accreditation Number | Claim.provider | Reference(PH_Organization) | 1..1 | — |
| Organization.identifier | Identifier | — | — | |
| Address of HCI (Bldg. No. and Name/Lot/Block/Street) | Claim.provider | Reference(PH_Organization) | 1..1 | — |
| Organization.address.line | string | — | — | |
| Address of HCI (Subdivision/Village) | Claim.provider | Reference(PH_Organization) | 1..1 | — |
| Organization.address.line | string | — | — | |
| Address of HCI (Barangay/City/Municipality) | Claim.provider | Reference(PH_Organization) | 1..1 | — |
| Organization.address.extension:barangay | Coding | — | Barangay | |
| Address of HCI (Barangay/City/Municipality) | Claim.provider | Reference(PH_Organization) | 1..1 | — |
| Organization.address.extension:cityMunicipality | Coding | — | CityMunicipality | |
| Address of HCI (Province) | Claim.provider | Reference(PH_Organization) | 1..1 | — |
| Organization.address.extension:province | Coding | — | Province | |
| Address of HCI (Zip Code) | Claim.provider | Reference(PH_Organization) | 1..1 | — |
| Organization.address.postalCode | Coding | — | ||
| Part II - Patient's Data | ||||
| Name of Patient (Last Name) | Claim.patient | Reference(PH_Patient) | 1..1 | — |
| Patient.name.family | string | — | — | |
| Name of Patient (First Name) | Claim.patient | Reference(PH_Patient) | 1..1 | — |
| Patient.name.given[0] | string | — | — | |
| Name of Patient (Middle Name) | Claim.patient | Reference(PH_Patient) | 1..1 | — |
| Patient.name.given[1] | string | — | — | |
| PhilHealth Identification Number (PIN) | Claim.patient | Reference(PH_Patient) | 1..1 | — |
| Patient.identifier | Identifier | — | — | |
| Age | Claim.extension:claimEncounter | Reference(PH_Encounter) | — | — |
| Encounter.extension:ageYears | integer | — | — | |
| Sex | Claim.patient | Reference(PH_Patient) | 1..1 | — |
| Patient.extension:sex | CodeableConcept | — | — | |
| Chief Complaint | Claim.extension:claimEncounter | Reference(PH_Encounter) | — | — |
| Encounter.reasonReference | Reference(PH_Observation) | — | — | |
| Observation.valueString | string | — | — | |
| Admitting Diagnosis | Claim.diagnosis.diagnosisReference | Reference(PH_Condition) | — | — |
| Condition.code | CodeableConcept | — | — | |
| Discharge Diagnosis | Claim.diagnosis.diagnosisReference | Reference(PH_Condition) | — | — |
| Condition.code | CodeableConcept | — | — | |
| 1st Case Rate Code | Claim.item.productOrService | CodeableConcept | 1..1 | — |
| 2nd Case Rate Code | Claim.item.productOrService | CodeableConcept | 1..1 | — |
| Date Admitted (MM-DD-YYYY)(Time Admitted HH:MM)(AM/PM) | Claim.extension:claimEncounter | Reference(PH_Encounter) | — | — |
| Encounter.period.start | dateTime | — | — | |
| Date Discharged (MM-DD-YYYY)(Time Discharged HH:MM)(AM/PM) | Claim.extension:claimEncounter | Reference(PH_Encounter) | — | — |
| Encounter.period.end | dateTime | — | — | |
| Part III - Reason for Admission | ||||
| 1. History of Present Illness | Claim.supportingInfo.valueReference | Reference(PH_Condition) | 0..1 | — |
| Condition.note | Annotation | — | — | |
| 2. Pertinent Past Medical History | Claim.supportingInfo.valueReference | Reference(PH_Condition) | 0..1 | — |
| Condition.note | Annotation | — | — | |
| 2. OB/GYN History (G) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueInteger | integer | — | — | |
| 2. OB/GYN History (P) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueInteger | integer | — | — | |
| 2. OB/GYN History (P)(T) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueInteger | integer | — | — | |
| 2. OB/GYN History (P)(P) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueInteger | integer | — | — | |
| 2. OB/GYN History (P)(A) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueInteger | integer | — | — | |
| 2. OB/GYN History (P)(L) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueInteger | integer | — | — | |
| 2. OB/GYN History LMP (MM-DD-YYYY) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueDateTime | dateTime | — | — | |
| 2. OB/GYN History (Checkbox NA) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueBoolean | boolean | — | — | |
| 3. Pertinent Signs and Symptoms on Admission (tick applicable boxes) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueCodeableConcept | CodeableConcept | — | — | |
| 4. Referred from another health care institution (HCI) [Yes/No] | Claim.referral | Reference(PH_ServiceRequest) | 0..1 | — |
| ServiceRequest.status | code | — | — | |
| 4. if Yes, Specify Reason | Claim.referral | Reference(PH_ServiceRequest) | 0..1 | — |
| ServiceRequest.reasonReference | Reference(PH_Observation) | — | — | |
| Observation.valueString | string | — | — | |
| 4. Name of Originating HCI | Claim.referral | Reference(PH_ServiceRequest) | 0..1 | — |
| ServiceRequest.requester | Reference(PH_Organization) | — | — | |
| Organization.name | string | — | — | |
| 5. Height (cm) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueString | string | — | — | |
| 5. Weight (kg) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueString | string | — | — | |
| 5. General Survey | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueCodeableConcept | CodeableConcept | — | — | |
| 5. Vital Signs (BP) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueString | string | — | — | |
| 5. Vital Signs (HR) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueString | string | — | — | |
| 5. Vital Signs (RR) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueString | string | — | — | |
| 5. Vital Signs (Temp) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueString | string | — | — | |
| 5. HEENT (Check notes for options) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueCodeableConcept | CodeableConcept | — | — | |
| 5. CHEST/LUNGS (Check notes for options) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueCodeableConcept | CodeableConcept | — | — | |
| 5. CVS (Check notes for options) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueCodeableConcept | CodeableConcept | — | — | |
| 5. ABDOMEN (Check notes for options) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueCodeableConcept | CodeableConcept | — | — | |
| 5. GU (IE) (Check notes for options) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueCodeableConcept | CodeableConcept | — | — | |
| 5. SKIN/EXTREMITIES (Check notes for options) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueCodeableConcept | CodeableConcept | — | — | |
| 5. NEURO-EXAM (Check notes for options) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | — |
| Observation.valueCodeableConcept | CodeableConcept | — | — | |
| IV. COURSE IN THE WARD | ||||
| Date (MM-DD-YYYY) | Claim.supportingInfo.valueReference | Reference(PH_ClinicalImpression) | 0..1 | — |
| ClinicalImpression.effectiveDateTime | dateTime | — | — | |
| DOCTOR'S ORDER/ACTION | Claim.supportingInfo.valueReference | Reference(PH_ClinicalImpression) | 0..1 | — |
| ClinicalImpression.description | string | — | — | |
| SURGICAL PROCEDURE / RVS CODE (Attach photocopy of OR technique) | Claim.procedure.procedureCodeableConcept | 0..1 | — | |
| V. DRUGS / MEDICINES | ||||
| Generic Name | Claim.item.productOrService | CodeableConcept | 1..1 | — |
| Quantity | Claim.prescription | Reference(PH_MedicationRequest) | 0..1 | — |
| MedicationRequest.dispenseRequest.quantity | SimpleQuantity | — | — | |
| Dosage | Claim.prescription | Reference(PH_MedicationRequest) | 0..1 | — |
| MedicationRequest.dosageInstruction | — | — | ||
| Route | Claim.prescription | Reference(PH_MedicationRequest) | 0..1 | — |
| MedicationRequest.dosageInstruction.route | CodeableConcept | — | — | |
| Frequency | Claim.prescription | Reference(PH_MedicationRequest) | 0..1 | — |
| MedicatioNRequest.dosageInstruction.doseAndRate.rateQuantity | SimpleQuantity | — | — | |
| Total Cost | Claim.item.net | Money | 0..1 | — |
| Part VI - OUTCOME OF TREATMENT | ||||
| OUTCOME OF TREATMENT (Check notes for options) | Claim.extension:claimEncounter | Reference(PH_Encounter) | — | — |
| Encounter.hospitalization.dischargeDisposition | CodeableConcept | — | — | |
| Part VII - CERTIFICATION OF HEALTH CARE PROFESSIONAL | ||||
| Signature Type | Provenance.signature.type | Coding | 1..* | — |
| Signature over Printed Name of Attending Health Care Professional | Provenance.signature.who | Reference(PH_Practitioner) | — | — |
| Practitioner.name | HumanName | — | — | |
| Signature over Printed Name of Attending Health Care Professional | Provenance.signature.data | base64Binary | 0..1 | — |
| Date Signed | Provenance.signature.when | instant | 1..1 | — |