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
| Active as of 2026-09-15 |
{
"resourceType" : "CodeSystem",
"id" : "clinical-form-category-codesystem",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: CodeSystem clinical-form-category-codesystem</b></p><a name=\"clinical-form-category-codesystem\"> </a><a name=\"hcclinical-form-category-codesystem\"> </a><p>This case-sensitive code system <code>https://fhir.slade360.co.ke/fhir/CodeSystem/clinical-form-category-codesystem</code> defines the following codes:</p><table class=\"codes\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style=\"white-space:nowrap\">admission-record<a name=\"clinical-form-category-codesystem-admission-record\"> </a></td><td>Admission record</td><td>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.</td></tr><tr><td style=\"white-space:nowrap\">triage-record<a name=\"clinical-form-category-codesystem-triage-record\"> </a></td><td>Triage record</td><td>The sheet a patient is sorted on at the front door — how urgently they need to be seen, and the signs that decided it.</td></tr><tr><td style=\"white-space:nowrap\">clinical-assessment<a name=\"clinical-form-category-codesystem-clinical-assessment\"> </a></td><td>Clinical assessment</td><td>A structured assessment by one service, completed once per episode: palliative, nutrition, psychological, rehabilitation intake and the like.</td></tr><tr><td style=\"white-space:nowrap\">scored-instrument<a name=\"clinical-form-category-codesystem-scored-instrument\"> </a></td><td>Scored instrument</td><td>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.</td></tr><tr><td style=\"white-space:nowrap\">observation-chart<a name=\"clinical-form-category-codesystem-observation-chart\"> </a></td><td>Observation chart</td><td>Vital signs and physiological observations charted round by round through an admission.</td></tr><tr><td style=\"white-space:nowrap\">monitoring-chart<a name=\"clinical-form-category-codesystem-monitoring-chart\"> </a></td><td>Monitoring chart</td><td>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.</td></tr><tr><td style=\"white-space:nowrap\">fluid-balance-chart<a name=\"clinical-form-category-codesystem-fluid-balance-chart\"> </a></td><td>Fluid balance chart</td><td>Intake and output charted over a shift or a day, with the totals that decide the next fluid order.</td></tr><tr><td style=\"white-space:nowrap\">feeding-chart<a name=\"clinical-form-category-codesystem-feeding-chart\"> </a></td><td>Feeding chart</td><td>What a patient — usually a baby — was fed, when, how much and by what route.</td></tr><tr><td style=\"white-space:nowrap\">nursing-care-plan<a name=\"clinical-form-category-codesystem-nursing-care-plan\"> </a></td><td>Nursing care plan</td><td>The nursing problem list with the care planned against each problem and the evaluation of it.</td></tr><tr><td style=\"white-space:nowrap\">medication-chart<a name=\"clinical-form-category-codesystem-medication-chart\"> </a></td><td>Medication chart</td><td>A prescription or an administration record: what was ordered or given, at what dose, by what route.</td></tr><tr><td style=\"white-space:nowrap\">wound-care-record<a name=\"clinical-form-category-codesystem-wound-care-record\"> </a></td><td>Wound care record</td><td>Dressing changes, irrigation and the state of a wound or a surgical site over time.</td></tr><tr><td style=\"white-space:nowrap\">rehabilitation-record<a name=\"clinical-form-category-codesystem-rehabilitation-record\"> </a></td><td>Rehabilitation record</td><td>Therapy given and progress against it, session by session — physiotherapy, occupational therapy, speech therapy.</td></tr><tr><td style=\"white-space:nowrap\">progress-note<a name=\"clinical-form-category-codesystem-progress-note\"> </a></td><td>Progress note</td><td>A dated clinical entry continuing the record of a stay: doctors' notes, ward round entries, review notes.</td></tr><tr><td style=\"white-space:nowrap\">procedure-record<a name=\"clinical-form-category-codesystem-procedure-record\"> </a></td><td>Procedure record</td><td>The record of a procedure actually performed — the operation note, the anaesthetic chart, the endoscopy record.</td></tr><tr><td style=\"white-space:nowrap\">recovery-record<a name=\"clinical-form-category-codesystem-recovery-record\"> </a></td><td>Recovery record</td><td>Observations and care in the recovery period immediately after a procedure, before the patient goes back to a ward.</td></tr><tr><td style=\"white-space:nowrap\">safety-checklist<a name=\"clinical-form-category-codesystem-safety-checklist\"> </a></td><td>Safety checklist</td><td>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.</td></tr><tr><td style=\"white-space:nowrap\">handover-record<a name=\"clinical-form-category-codesystem-handover-record\"> </a></td><td>Handover record</td><td>What one team tells the next about a patient at a shift change or a transfer between units.</td></tr><tr><td style=\"white-space:nowrap\">referral<a name=\"clinical-form-category-codesystem-referral\"> </a></td><td>Referral</td><td>A patient sent on to another unit or facility, with the history and the reason for sending them.</td></tr><tr><td style=\"white-space:nowrap\">discharge-summary<a name=\"clinical-form-category-codesystem-discharge-summary\"> </a></td><td>Discharge summary</td><td>The account of a completed admission that the patient leaves with and the next clinician reads.</td></tr><tr><td style=\"white-space:nowrap\">requisition<a name=\"clinical-form-category-codesystem-requisition\"> </a></td><td>Requisition</td><td>A request to another department for a test, an image, a blood product or a supply.</td></tr><tr><td style=\"white-space:nowrap\">consent<a name=\"clinical-form-category-codesystem-consent\"> </a></td><td>Consent</td><td>A record of permission given or refused for a procedure, a treatment, a disclosure or a disposal.</td></tr><tr><td style=\"white-space:nowrap\">clinical-report<a name=\"clinical-form-category-codesystem-clinical-report\"> </a></td><td>Clinical report</td><td>A report on a patient written for someone outside the treating team — an insurer, a court, another hospital, a mortality review.</td></tr><tr><td style=\"white-space:nowrap\">mortuary-record<a name=\"clinical-form-category-codesystem-mortuary-record\"> </a></td><td>Mortuary record</td><td>Admission to, release from, or a consent connected with the mortuary.</td></tr><tr><td style=\"white-space:nowrap\">survey<a name=\"clinical-form-category-codesystem-survey\"> </a></td><td>Survey</td><td>A questionnaire whose answers are about the service rather than about the patient's health, and which produces no clinical resource.</td></tr></table></div>"
},
"url" : "https://fhir.slade360.co.ke/fhir/CodeSystem/clinical-form-category-codesystem",
"version" : "0.1.0",
"name" : "SGHIClinicalFormCategoryCodeSystem",
"title" : "SGHI Clinical Form Category Code System",
"status" : "active",
"experimental" : false,
"date" : "2026-09-15T11:40:24+00:00",
"publisher" : "Kathurima Kimathi",
"contact" : [
{
"name" : "Kathurima Kimathi",
"telecom" : [
{
"system" : "url",
"value" : "https://www.linkedin.com/in/kathurima-kimathi/"
},
{
"system" : "email",
"value" : "kathurimakimathi415@gmail.com"
}
]
},
{
"name" : "Oscar John",
"telecom" : [
{
"system" : "email",
"value" : "oscarjohnotieno@gmail.com",
"use" : "work"
}
]
},
{
"name" : "Kennedy Omondi",
"telecom" : [
{
"system" : "email",
"value" : "kennankole@gmail.com",
"use" : "work"
}
]
}
],
"description" : "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.",
"caseSensitive" : true,
"content" : "complete",
"count" : 24,
"concept" : [
{
"code" : "admission-record",
"display" : "Admission record",
"definition" : "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."
},
{
"code" : "triage-record",
"display" : "Triage record",
"definition" : "The sheet a patient is sorted on at the front door — how urgently they need to be seen, and the signs that decided it."
},
{
"code" : "clinical-assessment",
"display" : "Clinical assessment",
"definition" : "A structured assessment by one service, completed once per episode: palliative, nutrition, psychological, rehabilitation intake and the like."
},
{
"code" : "scored-instrument",
"display" : "Scored instrument",
"definition" : "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."
},
{
"code" : "observation-chart",
"display" : "Observation chart",
"definition" : "Vital signs and physiological observations charted round by round through an admission."
},
{
"code" : "monitoring-chart",
"display" : "Monitoring chart",
"definition" : "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."
},
{
"code" : "fluid-balance-chart",
"display" : "Fluid balance chart",
"definition" : "Intake and output charted over a shift or a day, with the totals that decide the next fluid order."
},
{
"code" : "feeding-chart",
"display" : "Feeding chart",
"definition" : "What a patient — usually a baby — was fed, when, how much and by what route."
},
{
"code" : "nursing-care-plan",
"display" : "Nursing care plan",
"definition" : "The nursing problem list with the care planned against each problem and the evaluation of it."
},
{
"code" : "medication-chart",
"display" : "Medication chart",
"definition" : "A prescription or an administration record: what was ordered or given, at what dose, by what route."
},
{
"code" : "wound-care-record",
"display" : "Wound care record",
"definition" : "Dressing changes, irrigation and the state of a wound or a surgical site over time."
},
{
"code" : "rehabilitation-record",
"display" : "Rehabilitation record",
"definition" : "Therapy given and progress against it, session by session — physiotherapy, occupational therapy, speech therapy."
},
{
"code" : "progress-note",
"display" : "Progress note",
"definition" : "A dated clinical entry continuing the record of a stay: doctors' notes, ward round entries, review notes."
},
{
"code" : "procedure-record",
"display" : "Procedure record",
"definition" : "The record of a procedure actually performed — the operation note, the anaesthetic chart, the endoscopy record."
},
{
"code" : "recovery-record",
"display" : "Recovery record",
"definition" : "Observations and care in the recovery period immediately after a procedure, before the patient goes back to a ward."
},
{
"code" : "safety-checklist",
"display" : "Safety checklist",
"definition" : "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."
},
{
"code" : "handover-record",
"display" : "Handover record",
"definition" : "What one team tells the next about a patient at a shift change or a transfer between units."
},
{
"code" : "referral",
"display" : "Referral",
"definition" : "A patient sent on to another unit or facility, with the history and the reason for sending them."
},
{
"code" : "discharge-summary",
"display" : "Discharge summary",
"definition" : "The account of a completed admission that the patient leaves with and the next clinician reads."
},
{
"code" : "requisition",
"display" : "Requisition",
"definition" : "A request to another department for a test, an image, a blood product or a supply."
},
{
"code" : "consent",
"display" : "Consent",
"definition" : "A record of permission given or refused for a procedure, a treatment, a disclosure or a disposal."
},
{
"code" : "clinical-report",
"display" : "Clinical report",
"definition" : "A report on a patient written for someone outside the treating team — an insurer, a court, another hospital, a mortality review."
},
{
"code" : "mortuary-record",
"display" : "Mortuary record",
"definition" : "Admission to, release from, or a consent connected with the mortuary."
},
{
"code" : "survey",
"display" : "Survey",
"definition" : "A questionnaire whose answers are about the service rather than about the patient's health, and which produces no clinical resource."
}
]
}