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 |
<CodeSystem xmlns="http://hl7.org/fhir">
<id value="clinical-form-category-codesystem"/>
<text>
<status value="generated"/>
<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>
</text>
<url
value="https://fhir.slade360.co.ke/fhir/CodeSystem/clinical-form-category-codesystem"/>
<version value="0.1.0"/>
<name value="SGHIClinicalFormCategoryCodeSystem"/>
<title value="SGHI Clinical Form Category Code System"/>
<status value="active"/>
<experimental value="false"/>
<date value="2026-09-15T11:40:24+00:00"/>
<publisher value="Kathurima Kimathi"/>
<contact>
<name value="Kathurima Kimathi"/>
<telecom>
<system value="url"/>
<value value="https://www.linkedin.com/in/kathurima-kimathi/"/>
</telecom>
<telecom>
<system value="email"/>
<value value="kathurimakimathi415@gmail.com"/>
</telecom>
</contact>
<contact>
<name value="Oscar John"/>
<telecom>
<system value="email"/>
<value value="oscarjohnotieno@gmail.com"/>
<use value="work"/>
</telecom>
</contact>
<contact>
<name value="Kennedy Omondi"/>
<telecom>
<system value="email"/>
<value value="kennankole@gmail.com"/>
<use value="work"/>
</telecom>
</contact>
<description
value="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 value="true"/>
<content value="complete"/>
<count value="24"/>
<concept>
<code value="admission-record"/>
<display value="Admission record"/>
<definition
value="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."/>
</concept>
<concept>
<code value="triage-record"/>
<display value="Triage record"/>
<definition
value="The sheet a patient is sorted on at the front door — how urgently they need to be seen, and the signs that decided it."/>
</concept>
<concept>
<code value="clinical-assessment"/>
<display value="Clinical assessment"/>
<definition
value="A structured assessment by one service, completed once per episode: palliative, nutrition, psychological, rehabilitation intake and the like."/>
</concept>
<concept>
<code value="scored-instrument"/>
<display value="Scored instrument"/>
<definition
value="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."/>
</concept>
<concept>
<code value="observation-chart"/>
<display value="Observation chart"/>
<definition
value="Vital signs and physiological observations charted round by round through an admission."/>
</concept>
<concept>
<code value="monitoring-chart"/>
<display value="Monitoring chart"/>
<definition
value="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."/>
</concept>
<concept>
<code value="fluid-balance-chart"/>
<display value="Fluid balance chart"/>
<definition
value="Intake and output charted over a shift or a day, with the totals that decide the next fluid order."/>
</concept>
<concept>
<code value="feeding-chart"/>
<display value="Feeding chart"/>
<definition
value="What a patient — usually a baby — was fed, when, how much and by what route."/>
</concept>
<concept>
<code value="nursing-care-plan"/>
<display value="Nursing care plan"/>
<definition
value="The nursing problem list with the care planned against each problem and the evaluation of it."/>
</concept>
<concept>
<code value="medication-chart"/>
<display value="Medication chart"/>
<definition
value="A prescription or an administration record: what was ordered or given, at what dose, by what route."/>
</concept>
<concept>
<code value="wound-care-record"/>
<display value="Wound care record"/>
<definition
value="Dressing changes, irrigation and the state of a wound or a surgical site over time."/>
</concept>
<concept>
<code value="rehabilitation-record"/>
<display value="Rehabilitation record"/>
<definition
value="Therapy given and progress against it, session by session — physiotherapy, occupational therapy, speech therapy."/>
</concept>
<concept>
<code value="progress-note"/>
<display value="Progress note"/>
<definition
value="A dated clinical entry continuing the record of a stay: doctors' notes, ward round entries, review notes."/>
</concept>
<concept>
<code value="procedure-record"/>
<display value="Procedure record"/>
<definition
value="The record of a procedure actually performed — the operation note, the anaesthetic chart, the endoscopy record."/>
</concept>
<concept>
<code value="recovery-record"/>
<display value="Recovery record"/>
<definition
value="Observations and care in the recovery period immediately after a procedure, before the patient goes back to a ward."/>
</concept>
<concept>
<code value="safety-checklist"/>
<display value="Safety checklist"/>
<definition
value="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."/>
</concept>
<concept>
<code value="handover-record"/>
<display value="Handover record"/>
<definition
value="What one team tells the next about a patient at a shift change or a transfer between units."/>
</concept>
<concept>
<code value="referral"/>
<display value="Referral"/>
<definition
value="A patient sent on to another unit or facility, with the history and the reason for sending them."/>
</concept>
<concept>
<code value="discharge-summary"/>
<display value="Discharge summary"/>
<definition
value="The account of a completed admission that the patient leaves with and the next clinician reads."/>
</concept>
<concept>
<code value="requisition"/>
<display value="Requisition"/>
<definition
value="A request to another department for a test, an image, a blood product or a supply."/>
</concept>
<concept>
<code value="consent"/>
<display value="Consent"/>
<definition
value="A record of permission given or refused for a procedure, a treatment, a disclosure or a disposal."/>
</concept>
<concept>
<code value="clinical-report"/>
<display value="Clinical report"/>
<definition
value="A report on a patient written for someone outside the treating team — an insurer, a court, another hospital, a mortality review."/>
</concept>
<concept>
<code value="mortuary-record"/>
<display value="Mortuary record"/>
<definition
value="Admission to, release from, or a consent connected with the mortuary."/>
</concept>
<concept>
<code value="survey"/>
<display value="Survey"/>
<definition
value="A questionnaire whose answers are about the service rather than about the patient's health, and which produces no clinical resource."/>
</concept>
</CodeSystem>