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 | 0..1 | ||
| 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 | 0..* | ||
| Address of HCI (Subdivision/Village) | Claim.provider | Reference(PH_Organization) | 1..1 | |
| Organization.address.line | string | 0..* | ||
| Address of HCI (Barangay/City/Municipality) | Claim.provider | Reference(PH_Organization) | 1..1 | |
| Organization.address.extension:barangay | Coding | 0..1 | Barangay | |
| Address of HCI (Barangay/City/Municipality) | Claim.provider | Reference(PH_Organization) | 1..1 | |
| Organization.address.extension:cityMunicipality | Coding | 0..1 | CityMunicipality | |
| Address of HCI (Province) | Claim.provider | Reference(PH_Organization) | 1..1 | |
| Organization.address.extension:province | Coding | 0..1 | Province | |
| Address of HCI (Zip Code) | Claim.provider | Reference(PH_Organization) | 1..1 | |
| Organization.address.postalCode | Coding | 0..1 | ||
| Part II - Patient's Data | ||||
| 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 |
|
| PhilHealth Identification Number (PIN) | Claim.patient | Reference(PH_Patient) | 1..1 | |
| Patient.identifier | Identifier | 0..* | ||
| Age | Claim.extension:encounter | Reference(PH_Encounter) | ||
| Encounter.extension:ageYears | integer | 0..1 | ||
| Sex | Claim.patient | Reference(PH_Patient) | 1..1 | |
| Patient.extension:sex | CodeableConcept | 0..1 | ||
| Chief Complaint | Claim.extension:encounter | Reference(PH_Encounter) | ||
| Encounter.reasonReference | Reference(PH_Observation) | 0..* | ||
| Observation.valueString | string | 0..1 | ||
| Admitting Diagnosis | Claim.diagnosis.diagnosisReference | Reference(PH_Condition) | 1..1 | Set Claim.diagnosis.type value as 'admitting' |
| Condition.code | CodeableConcept | 0..1 | ||
| Discharge Diagnosis | Claim.diagnosis.diagnosisReference | Reference(PH_Condition) | 1..1 | Set Claim.diagnosis.type value as 'discharge' |
| Condition.code | CodeableConcept | 0..1 | ||
| 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:encounter | Reference(PH_Encounter) | ||
| Encounter.period.start | dateTime | 0..1 | ||
| Date Discharged (MM-DD-YYYY)(Time Discharged HH:MM)(AM/PM) | Claim.extension:encounter | Reference(PH_Encounter) | ||
| Encounter.period.end | dateTime | 0..1 | ||
| Part III - Reason for Admission | ||||
| 1. History of Present Illness | Claim.supportingInfo.valueReference | Reference(PH_Condition) | 0..1 | |
| Condition.note | Annotation | 0..* | ||
| 2. Pertinent Past Medical History | Claim.supportingInfo.valueReference | Reference(PH_Condition) | 0..1 | |
| Condition.note | Annotation | 0..* | ||
| 2. OB/GYN History (G) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 2. OB/GYN History (G) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueInteger | integer | 0..1 | ||
| 2. OB/GYN History (P) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 2. OB/GYN History (P) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueInteger | integer | 0..1 | ||
| 2. OB/GYN History (P)(T) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 2. OB/GYN History (P)(T) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueInteger | integer | 0..1 | ||
| 2. OB/GYN History (P)(P) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 2. OB/GYN History (P)(P) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueInteger | integer | 0..1 | ||
| 2. OB/GYN History (P)(A) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 2. OB/GYN History (P)(A) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueInteger | integer | 0..1 | ||
| 2. OB/GYN History (P)(L) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 2. OB/GYN History (P)(L) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueInteger | integer | 0..1 | ||
| 2. OB/GYN History LMP (MM-DD-YYYY) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 2. OB/GYN History LMP (MM-DD-YYYY) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueDateTime | dateTime | 0..1 | ||
| 2. OB/GYN History (Checkbox NA) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.dataAbsentReason | CodeableConcept | 0..1 | If checked, expected value not-applicable or not-performed |
|
| 3. Pertinent Signs and Symptoms on Admission (tick applicable boxes) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.code | CodeableConcept | 1..1 | ||
| 4. Referred from another health care institution (HCI) [Yes/No] | Claim.referral | Reference(PH_ServiceRequest) | 0..1 | |
| ServiceRequest.status | code | 1..1 | ||
| 4. if Yes, Specify Reason | Claim.referral | Reference(PH_ServiceRequest) | 0..1 | |
| ServiceRequest.reasonReference | Reference(PH_Observation) | 0..* | ||
| Observation.valueString | string | 0..1 | ||
| 4. Name of Originating HCI | Claim.referral | Reference(PH_ServiceRequest) | 0..1 | |
| ServiceRequest.requester | Reference(PH_Organization) | 0..1 | ||
| Organization.name | string | 0..1 | ||
| 5. Physical Examination on Admission (Pertinent Findings per System) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.code | CodeableConcept | 1..1 | ||
| 5. Height (cm) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 5. Height (cm) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueQuantity | Quantity | 0..1 | ||
| 5. Weight (kg) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 5. Weight (kg) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueQuantity | Quantity | 0..1 | ||
| 5. General Survey | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 5. General Survey (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueCodeableConcept | CodeableConcept | 0..1 | ||
| 5. Vital Signs (BP) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 5. Vital Signs (BP) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueString | string | 0..1 | ||
| 5. Vital Signs (HR) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 5. Vital Signs (HR) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueString | string | 0..1 | ||
| 5. Vital Signs (RR) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 5. Vital Signs (RR) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueString | string | 0..1 | ||
| 5. Vital Signs (Temp) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 5. Vital Signs (Temp) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueString | string | 0..1 | ||
| 5. HEENT | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 5. HEENT (Check notes for options) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueCodeableConcept | CodeableConcept | 0..1 | Options: 1. Essentially normal 2. Icteric sclerae 3. Abnormal pupillary reaction 4. Pale conjunctivae 5. Cervical lymphadenopathy 6. Sunken eyeballs 7. Dry mucous membrane 8. Sunken fontanelle 9. Others |
|
| 5. CHEST/LUNGS | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 5. CHEST/LUNGS (Check notes for options) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueCodeableConcept | CodeableConcept | 0..1 | Options: 1. Essentially normal 2. Lump/s over breast(s) 3. Asymmetrical chest expansion 4. Rales/crackles/rhonchi 5. Decreased breath sounds 6. Intercostal rib/clavicular retraction 7. Wheezes 8. Others |
|
| 5. CVS | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 5. CVS (Check notes for options) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueCodeableConcept | CodeableConcept | 0..1 | Options: 1. Essentially normal 2. Irregular rhythm 3. Displaced apex beat 4. Muffled heart sound 5. Heaves and/or thrills 6. Murmur 7. Pericardial bulge 8. Others |
|
| 5. ABDOMEN | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 5. ABDOMEN (Check notes for options) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueCodeableConcept | CodeableConcept | 0..1 | Options: 1. Essentially normal 2. Palpable mass(es) 3. Abdominal rigidity 4. Tympanitic/dull abdomen 5. Abdomen tenderness 6. Uterine contraction 7. Hyperactive bowel sounds 8. Others |
|
| 5. GU (IE) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 5. GU (IE) (Check notes for options) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueCodeableConcept | CodeableConcept | 0..1 | Options: 1. Essentially normal 2. Blood stained in exam finger 3. Cervical dilatation 4. Presence of abnormal discharge 5. Others |
|
| 5. SKIN/EXTREMITIES | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 5. SKIN/EXTREMITIES (Check notes for options) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueCodeableConcept | CodeableConcept | 0..1 | Options: 1. Essentially normal 2. Edema/swelling 3. Rashes/petechiae 4. Clubbing 5. Decreased mobility 6. Weak pulses 7. Cold clammy skin 8. Pale nailbeds 9. Cyanosis/mottled skin 10. Poor skin tungor 11. Others |
|
| 5. NEURO-EXAM | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.code | CodeableConcept | 1..1 | ||
| 5. NEURO-EXAM (Check notes for options) (value) | Claim.supportingInfo.valueReference | Reference(PH_Observation) | 0..1 | |
| Observation.component.valueCodeableConcept | CodeableConcept | 0..1 | Options: 1. Essentially normal 2. Abnormal reflex(es) 3. Abnormal gait 4. Poor/altered memory 5. Abnormal position sense 6. Poor muscle tone/strength 7. Abnormal/decreased sensation 8. Poor coordination 9. Others |
|
| IV. COURSE IN THE WARD | ||||
| Date (MM-DD-YYYY) | Claim.supportingInfo.valueReference | Reference(PH_ClinicalImpression) | 0..1 | |
| ClinicalImpression.effectiveDateTime | dateTime | 0..1 | ||
| DOCTOR'S ORDER/ACTION | Claim.supportingInfo.valueReference | Reference(PH_ClinicalImpression) | 0..1 | |
| ClinicalImpression.description | string | 0..1 | ||
| SURGICAL PROCEDURE / RVS CODE (Attach photocopy of OR technique) | Claim.procedure.procedureCodeableConcept | CodeableConcept | 0..1 | |
| V. DRUGS / MEDICINES | ||||
| Generic Name | Claim.item.productOrService | CodeableConcept | 1..1 | |
| Quantity | Claim.item.quantity | SimpleQuantity | 0..1 | |
| Dosage | Claim.prescription | Reference(PH_MedicationRequest) | 0..1 | |
| MedicationRequest.dosageInstruction.doseAndRate.dose[x] | Range / SimpleQuantity | 0..1 | ||
| Route | Claim.prescription | Reference(PH_MedicationRequest) | 0..1 | |
| MedicationRequest.dosageInstruction.route | CodeableConcept | 0..1 | ||
| Frequency | Claim.prescription | Reference(PH_MedicationRequest) | 0..1 | |
| MedicatioNRequest.dosageInstruction.timing | Timing | 0..1 | ||
| Total Cost | Claim.item.net | Money | 0..1 | |
| Part VI - OUTCOME OF TREATMENT | ||||
| OUTCOME OF TREATMENT (Check notes for options) | Claim.extension:encounter | Reference(PH_Encounter) | ||
| Encounter.hospitalization.dischargeDisposition | CodeableConcept | 0..1 | ||
| 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) | 0..1 | |
| Practitioner.name | HumanName | 0..1 | ||
| Signature over Printed Name of Attending Health Care Professional | Provenance.signature.data | base64Binary | 0..1 | |
| 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. |