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 Clinical Form Category Code System

Official URL: https://fhir.slade360.co.ke/fhir/CodeSystem/clinical-form-category-codesystem Version: 0.1.0
Active as of 2026-09-15 Computable Name: SGHIClinicalFormCategoryCodeSystem

The kind of clinical form a Questionnaire represents, at the granularity a clinician would use to find one: an admission record, an observation chart, a theatre record, a consent. Facility-independent by design, so the same code means the same thing across every hospital in the deployment and a form can be found by shape rather than by the name one hospital happens to print on it.

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/clinical-form-category-codesystem defines the following codes:

CodeDisplayDefinition
admission-record Admission record The structured record made when a patient is taken onto a ward: presenting illness, the examination on admission, and the plan the admission starts from.
triage-record Triage record The sheet a patient is sorted on at the front door — how urgently they need to be seen, and the signs that decided it.
clinical-assessment Clinical assessment A structured assessment by one service, completed once per episode: palliative, nutrition, psychological, rehabilitation intake and the like.
scored-instrument Scored instrument A form whose output is a score rather than a set of findings — Bishop, Apgar, Glasgow, MUAC-based screens. Scored instruments are kept apart from assessments because the score is comparable over time and a free assessment is not.
observation-chart Observation chart Vital signs and physiological observations charted round by round through an admission.
monitoring-chart Monitoring chart A chart tracking one device or one therapy over time — ventilator, CPAP, dialysis, neurological observations, a chemotherapy cycle. Distinct from an observation chart because the columns are settings and responses to a treatment rather than the patient's own vitals.
fluid-balance-chart Fluid balance chart Intake and output charted over a shift or a day, with the totals that decide the next fluid order.
feeding-chart Feeding chart What a patient — usually a baby — was fed, when, how much and by what route.
nursing-care-plan Nursing care plan The nursing problem list with the care planned against each problem and the evaluation of it.
medication-chart Medication chart A prescription or an administration record: what was ordered or given, at what dose, by what route.
wound-care-record Wound care record Dressing changes, irrigation and the state of a wound or a surgical site over time.
rehabilitation-record Rehabilitation record Therapy given and progress against it, session by session — physiotherapy, occupational therapy, speech therapy.
progress-note Progress note A dated clinical entry continuing the record of a stay: doctors' notes, ward round entries, review notes.
procedure-record Procedure record The record of a procedure actually performed — the operation note, the anaesthetic chart, the endoscopy record.
recovery-record Recovery record Observations and care in the recovery period immediately after a procedure, before the patient goes back to a ward.
safety-checklist Safety checklist A checklist completed to confirm a step was taken before, during or after a procedure. Its value is the record that somebody checked, which is why an unfilled box is a finding rather than a blank.
handover-record Handover record What one team tells the next about a patient at a shift change or a transfer between units.
referral Referral A patient sent on to another unit or facility, with the history and the reason for sending them.
discharge-summary Discharge summary The account of a completed admission that the patient leaves with and the next clinician reads.
requisition Requisition A request to another department for a test, an image, a blood product or a supply.
consent Consent A record of permission given or refused for a procedure, a treatment, a disclosure or a disposal.
clinical-report Clinical report A report on a patient written for someone outside the treating team — an insurer, a court, another hospital, a mortality review.
mortuary-record Mortuary record Admission to, release from, or a consent connected with the mortuary.
survey Survey A questionnaire whose answers are about the service rather than about the patient's health, and which produces no clinical resource.