SGHI FHIR Profile Implementation Guide
0.1.0 - ci-build

SGHI FHIR Profile Implementation Guide, published by Kathurima Kimathi. 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/savannahghi/sil_fhir_profile_ig/ and changes regularly. See the Directory of published versions

CodeSystem: SGHI Answer Code System

Official URL: https://fhir.slade360.co.ke/fhir/CodeSystem/answer-codesystem Version: 0.1.0
Active as of 2026-09-15 Computable Name: SGHIAnswerCodeSystem

The answers the pick lists offer, where the list is local to these forms and carries no ordinal weight. Displays are the wording printed on the paper form and should not be reworded without reprinting the form, because the form is the contract with the ward. Answers that belong to a scored instrument live in SGHIScoreCodeSystem instead, since those also carry a weight.

This Code system is referenced in the content logical definition of the following value sets:

This case-sensitive code system https://fhir.slade360.co.ke/fhir/CodeSystem/answer-codesystem defines the following codes:

CodeDisplayDefinition
triage-emergency Emergency Needs a clinician immediately. An emergency sign is present.
triage-priority Priority Needs a clinician within fifteen minutes. A priority sign is present.
triage-less-urgent Less urgent Can safely wait in the queue.
triage-well-baby Well baby Attending for a routine check, not for illness.
grade-absent 0 — absent The finding is not present.
grade-mild + — mild The finding is present and mild.
grade-severe +++ — severe The finding is present and severe.
avpu-alert A — alert Awake and alert.
avpu-verbal V — responds to voice Responds to voice but is not fully alert.
avpu-pain P — responds to pain Responds only to a painful stimulus.
avpu-unresponsive U — unresponsive Does not respond to a painful stimulus.
oedema-none None No oedema.
oedema-feet Feet Oedema of the feet only.
oedema-knee To the knee Oedema extending to the knees.
oedema-face Face Oedema involving the face, which is the most severe grade.
umbilicus-normal Normal The cord stump is clean and dry.
umbilicus-pus Pus The cord stump is discharging pus.
umbilicus-pus-and-redness Pus and red skin The cord stump is discharging pus and the surrounding skin is red, which is periumbilical cellulitis.
cord-fresh Fresh The cord is still fresh.
cord-dry Dry The cord has dried.
cord-infected Infected The cord is infected.
pmtct-positive Positive The mother is known to be HIV positive and in the PMTCT programme.
pmtct-negative Negative The mother tested HIV negative.
pmtct-unknown Unknown The mother's status could not be established.
delivery-svd SVD Spontaneous vaginal delivery.
delivery-breech Breech Breech vaginal delivery.
delivery-caesarean C/S Caesarean section.
delivery-assisted-vacuum Vacuum Assisted vaginal delivery by vacuum extraction.
delivery-assisted-forceps Forceps Assisted vaginal delivery by forceps.
place-of-birth-home Home Born at home.
place-of-birth-hospital Hospital Born in a health facility.
place-of-birth-other Other Born somewhere other than home or a facility, such as in transit.
lie-longitudinal Longitudinal The fetus lies along the axis of the uterus.
lie-transverse Transverse The fetus lies across the uterus.
lie-oblique Oblique The fetus lies obliquely.
membranes-intact Intact The membranes are intact.
membranes-ruptured Ruptured The membranes have ruptured.
placenta-complete Complete Placenta and membranes delivered complete.
placenta-incomplete Incomplete Placenta or membranes incomplete, so the uterus must be explored.
perineum-intact Intact The perineum is intact.
perineum-tear Tear The perineum tore.
perineum-episiotomy Episiotomy repaired An episiotomy was performed and repaired.
anaesthesia-general General General anaesthesia.
anaesthesia-spinal Spinal Spinal anaesthesia.
anaesthesia-regional-block Regional block A peripheral or plexus block.
anaesthesia-sedation Sedation Conscious sedation.
anaesthesia-local Local infiltration Local infiltration by the operator.
check-confirmed Confirmed The item was checked and confirmed.
check-not-applicable Not applicable The item does not apply to this case.
check-not-done Not done The item was not checked.
phase-sign-in Sign in — before induction of anaesthesia The first phase, with at least the nurse and the anaesthetist present.
phase-time-out Time out — before skin incision The second phase, with the nurse, the anaesthetist and the surgeon present.
phase-sign-out Sign out — before the patient leaves the operating room The third phase, with the nurse, the anaesthetist and the surgeon present.
access-av-fistula Arteriovenous fistula A surgically created arteriovenous fistula.
access-av-graft Arteriovenous graft A prosthetic arteriovenous graft.
access-tunnelled-catheter Tunnelled catheter A cuffed, tunnelled central venous catheter.
access-temporary-catheter Temporary catheter A non-tunnelled temporary central venous catheter.
donor-replacement Replacement Donating to replace blood used for a named patient.
donor-voluntary Voluntary Donating voluntarily, for no named recipient.
donor-autologous Autologous Donating for their own later use.
donation-normal Normal A whole-blood collection.
donation-apheresis Apheresis A component collection by apheresis.
line-first First line First-line therapy.
line-second Second line Second-line therapy, after progression or intolerance on first line.
line-third Third line Third-line therapy.
line-subsequent Fourth line or later Fourth-line therapy or beyond.
yes Yes Yes.
no No No.
not-known Not known The answer could not be established.
abdominal-ultrasound Abdominal ultrasound Ultrasound of the abdomen.
pelvic-ultrasound Pelvic ultrasound Ultrasound of the pelvis.
kub-ultrasound KUB ultrasound Ultrasound of the kidneys, ureters and bladder.
early-obstetric-ultrasound Early obstetric ultrasound First-trimester dating and viability scan.
routine-obstetric-ultrasound Routine obstetric ultrasound Routine growth and anatomy scan.
obstetric-ultrasound-biophysical-profile Obstetric ultrasound with biophysical profile Obstetric scan including the biophysical profile.
thyroid-ultrasound Thyroid ultrasound Ultrasound of the thyroid.
scrotal-ultrasound Scrotal ultrasound Ultrasound of the scrotum.
breast-ultrasound Breast ultrasound Ultrasound of the breast.
musculoskeletal-ultrasound Musculoskeletal or regional ultrasound Ultrasound of a joint, muscle or soft-tissue region.
cranial-ultrasound Cranial ultrasound Ultrasound of the head, through the fontanelle in an infant.
renal-doppler Renal Doppler ultrasound Doppler study of the renal vessels.
carotid-doppler Carotid Doppler ultrasound Doppler study of the carotid arteries.
upper-limb-venous-doppler Upper limb venous Doppler ultrasound Doppler study of the upper limb veins.
upper-limb-arterial-doppler Upper limb arterial Doppler ultrasound Doppler study of the upper limb arteries.
lower-limb-venous-doppler Lower limb venous Doppler ultrasound Doppler study of the lower limb veins, usually for deep vein thrombosis.
lower-limb-arterial-doppler Lower limb arterial Doppler ultrasound Doppler study of the lower limb arteries.
upper-gi-endoscopy Upper gastrointestinal endoscopy Endoscopy of the oesophagus, stomach and duodenum.
colonoscopy Colonoscopy Endoscopy of the whole colon.
flexible-sigmoidoscopy Flexible sigmoidoscopy Endoscopy of the rectum and sigmoid colon.
ercp Endoscopic retrograde cholangiopancreatography Endoscopic cannulation of the biliary and pancreatic ducts, with contrast.
pulse-normal Normal Peripheral pulse of normal volume.
pulse-weak Weak Peripheral pulse weak or thready.
warm-to-hand Hand Skin warm as far as the hand — normal peripheral perfusion.
warm-to-elbow Elbow Skin warm only as far as the elbow — the extremities are cold.
warm-to-shoulder Shoulder Skin warm only as far as the shoulder — the worst grade the sheet records.
malaria-blood-slide Blood slide Malaria microscopy on a blood slide.
malaria-rapid-test Rapid test Malaria rapid diagnostic test.
review-medical-6-hours Medical review within 6 hours The child is to be seen by a clinician within six hours.
review-priority-nursing Priority nursing observations The child is to be kept on priority nursing observations.
capillary-refill-under-2s Under 2 seconds Capillary refill returns in under two seconds.
capillary-refill-2-to-3s 2 to 3 seconds Capillary refill takes two to three seconds.
capillary-refill-over-3s Over 3 seconds Capillary refill takes more than three seconds, which is shock.
colour-pink Pink The baby is pink.
colour-blue Blue The baby is blue.
round-morning Morning The morning round — the chart's M column.
round-evening Evening The evening round — the chart's E column.
round-night Night The night round — the chart's N column.
pain-mild Mild Mild pain, as the triage sheet bands it.
pain-moderate Moderate Moderate pain.
pain-severe Severe Severe pain. A priority sign by ETAT+.
referral-clinic Clinic Referred from a clinic.
referral-ward Ward Referred from a ward.
referral-self-or-private Private, staff or self Came without an internal referral — privately, as a member of staff, or self-referred. The three the palliative care sheet prints separately, which all mean the same thing for the service's own workflow.
consciousness-alert Alert Awake and alert.
consciousness-sedated Sedated Sedated.
consciousness-agitated Agitated Agitated.
modality-x-ray X-ray A plain radiograph.
modality-ultrasound Ultrasound An ultrasound study.
consent-general-operation General operation or treatment The hospital's general consent form for an operation or treatment.
consent-endoscopy Endoscopy The endoscopy-specific consent form.
consent-anti-cancer-therapy Systemic anti-cancer therapy The cancer centre's consent form for chemotherapy, hormonal or targeted therapy.
consenter-patient The patient themselves The patient is giving their own consent.
consenter-next-of-kin Next of kin or guardian Consent is being given by the next of kin or a guardian, because the patient cannot.
arm-power-5 Normal power Arm power: normal.
arm-power-4 Mild weakness Arm power: mild weakness.
arm-power-3 Severe weakness Arm power: severe weakness.
arm-power-2 Spastic flexion Arm power: spastic flexion.
arm-power-1 Extension Arm power: extension only.
arm-power-0 No response Arm power: no response.
leg-power-4 Normal power Leg power: normal.
leg-power-3 Mild weakness Leg power: mild weakness.
leg-power-2 Severe weakness Leg power: severe weakness.
leg-power-1 Extension Leg power: extension only.
leg-power-0 No response Leg power: no response.
pupil-brisk Brisk Pupil reacts briskly to light.
pupil-sluggish Sluggish Pupil reacts sluggishly to light.
pupil-fixed Fixed Pupil does not react to light.
pupil-closed Closed Eye closed — the pupil could not be assessed. Distinct from fixed, which is a finding.
oesophagogastroduodenoscopy Oesophagogastroduodenoscopy Endoscopy of the oesophagus, stomach and duodenum. The form spells it OESOPHAGAGASTRODUODENOSCOPY.
oesophagogastroscopy Oesophagogastroscopy Endoscopy of the oesophagus and stomach.
oesophagoscopy Oesophagoscopy Endoscopy of the oesophagus alone.
rectosigmoidoscopy Rectosigmoidoscopy Endoscopy of the rectum and sigmoid colon.
colonoscopy-investigation Colonoscopy Endoscopy of the whole colon, as recorded on the investigation form.
packed-red-blood-cells Packed red blood cells Red cells with most of the plasma removed.
fresh-frozen-plasma Fresh frozen plasma Plasma frozen within hours of collection.
platelet-concentrate Platelet concentrate Platelets concentrated from whole blood or collected by apheresis.
whole-blood Whole blood Unseparated blood as collected.
urgency-desperate Desperate Needed immediately — the patient is bleeding now.
urgency-urgent Urgent Needed within hours.
urgency-elective Elective Planned, for a scheduled procedure.
abo-a A Blood group A.
abo-b B Blood group B.
abo-ab AB Blood group AB.
abo-o O Blood group O.
rh-positive Positive Rhesus D positive.
rh-negative Negative Rhesus D negative.
xmatch-compatible Compatible Cross-match compatible — the unit may be issued.
xmatch-incompatible Incompatible Cross-match incompatible — the unit must not be issued.
decline-care Care in the ward Refusing ward care — the patient is leaving.
decline-procedure A procedure Refusing a specific procedure.
decline-assessment An assessment or investigation Refusing an assessment or investigation.
decline-destination-home Home Going home.
decline-destination-other-hospital Hospital of choice Transferring to a hospital of their own choosing.
vent-mode-cmv CMV Controlled mandatory ventilation, as printed on the ICU observation chart.
vent-mode-simv SIMV Synchronised intermittent mandatory ventilation.
vent-mode-cpap CPAP Continuous positive airway pressure.
vent-mode-psv PSV Pressure support ventilation.
vent-mode-spontaneous Spontaneous Breathing spontaneously, off mandatory ventilation.
position-supine Supine Patient positioned on the back.
position-left-lateral Left lateral Patient turned onto the left side.
position-right-lateral Right lateral Patient turned onto the right side.
position-prone Prone Patient positioned face down.
position-semi-fowler Semi-Fowler Head of bed raised between 30 and 45 degrees.
conscious-fully Fully conscious Answers questions intelligently, as the head injury chart words it.
conscious-confused Conscious but confused Answers simple questions only.
conscious-semi Semi conscious Responds to pain only.
conscious-coma Coma No response to pain.
finding-present Present The finding was observed.
finding-absent Absent The finding was looked for and not observed.
injury-chest Chest Chest injury, from the other-injuries tick list on the head injury chart.
injury-abdomen Abdomen Abdominal injury.
injury-arm Arm Arm injury.
injury-leg Leg Leg injury.
injury-neck Neck Neck injury.
injury-spine Spine Spinal injury.
feed-breast Breast feeding Fed at the breast.
feed-ebm Expressed breast milk Fed the mother’s own expressed milk.
feed-term-formula Term formula Fed a term infant formula.
feed-preterm-formula Pre-term formula Fed a preterm infant formula.
route-cup Cup Fed by cup.
route-ngt Nasogastric tube Fed through a nasogastric tube.
route-ogt Orogastric tube Fed through an orogastric tube.
newborn-category-a Category A Acutely ill on ventilator, CPAP or oxygen, as graded at the foot of the newborn comprehensive chart.
newborn-category-b Category B Stabilising on intensive phototherapy, IV fluids and assisted feeds.
newborn-category-c Category C A stable baby.
oxygen-prongs Nasal prongs Oxygen given through nasal prongs.
oxygen-non-rebreather Non-rebreather mask Oxygen given through a non-rebreather mask.
oxygen-bub Bubble CPAP Oxygen given through bubble CPAP.
art-azt AZT Zidovudine prophylaxis, as printed on the newborn handover form.
art-nvp NVP Nevirapine prophylaxis.
lab-urgency-desperate Desperate The most urgent of the three degrees the lab requisition prints.
lab-urgency-urgent Urgent The middle degree of urgency.
lab-urgency-routine Routine The routine degree of urgency, as the lab forms word it — the blood requisition says "elective" instead.
rating-poor Poor The lowest of the four ratings on the satisfaction questionnaire.
rating-fair Fair The second of four.
rating-good Good The third of four.
rating-excellent Excellent The highest of the four.
resus-dnr Do not resuscitate A recorded decision not to attempt resuscitation.
resus-full Full resuscitation A recorded decision that resuscitation is to be attempted.
body-part-home Taken home The removed body part is released to the family.
body-part-hospital Disposed by the hospital The removed body part is disposed of by the hospital.
mortuary-from-ward From a ward of this hospital The body came from a ward here, so the deceased was a patient.
mortuary-from-casualty From casualty The body came from casualty.
mortuary-from-home From home The body was brought from home; the deceased may never have been a patient here.
mortuary-from-other-facility From another facility The body was transferred from another facility, with a permit.
mortuary-police-case Police case The body was brought by the police, under an OB number.
dressing-grade-b B The first of the three grading letters printed on the surgical dressing sheet. The sheet does not expand the letters anywhere on it.
dressing-grade-m M The second of the three grading letters printed on the surgical dressing sheet.
dressing-grade-s S The third of the three grading letters printed on the surgical dressing sheet.
admitted-from-opd Out-patient department Admitted from the out-patient department.
admitted-from-casualty Casualty Admitted from casualty.
arrival-walked Walked Arrived on foot.
arrival-ambulance Ambulance Arrived by ambulance.
arrival-wheelchair Wheelchair Arrived by wheelchair.
arrival-cart Cart Arrived on a cart or trolley, as the admission form words it.
chronic-tb Tuberculosis From the chronic illness tick list on the admission form.
chronic-hiv HIV The admission form prints this column as CD4.
chronic-arthritis Arthritis From the chronic illness tick list.
chronic-hypertension Hypertension The admission form prints this as HPN.
chronic-pneumonia Pneumonia From the chronic illness tick list.
chronic-malaria Malaria From the chronic illness tick list.
chronic-diabetes Diabetes From the chronic illness tick list.
chronic-skin Skin disease From the chronic illness tick list.
chronic-cardiac Cardiac disease From the chronic illness tick list.
chronic-renal Renal disease From the chronic illness tick list.
chronic-psychiatric Psychiatric illness The admission form prints this as Psych.
chronic-carcinoma Carcinoma From the chronic illness tick list.
presentation-cephalic Cephalic Head presenting.
presentation-breech Breech Buttocks or feet presenting.
presentation-shoulder Shoulder Shoulder presenting, with the fetus lying transversely.
presentation-face Face Face presenting.
presentation-brow Brow Brow presenting.
bowels-opened Opened Bowels opened.
bowels-not-opened Not opened Bowels not opened.
milk-breast Breast milk Expressed or direct breast milk, as the milk feeding chart prints it.
milk-nan NAN formula The formula the milk feeding chart names by its brand column.
urine-clear Clear Clear irrigation return.
urine-straw Straw Straw-coloured return.
urine-rose Rose Rose or lightly blood-tinged return.
urine-blood-stained Blood stained Frankly blood-stained return.
urine-clots With clots Return carrying clots -- the finding that stops an irrigation and calls a surgeon.