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 |
@prefix fhir: <http://hl7.org/fhir/> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- <http://hl7.org/fhir/CodeSystem/document-type-codesystem> a fhir:CodeSystem ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "document-type-codesystem"] ; # fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div [ fhir:v "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: CodeSystem document-type-codesystem</b></p><a name=\"document-type-codesystem\"> </a><a name=\"hcdocument-type-codesystem\"> </a><p>This case-sensitive code system <code>https://fhir.slade360.co.ke/fhir/CodeSystem/document-type-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\">paediatric-admission-record<a name=\"document-type-codesystem-paediatric-admission-record\"> </a></td><td>Paediatric admission record</td><td>The three-page structured admission record used on the paediatric ward: presenting illness, immunisation, examination by system, investigations ordered and the coded admission diagnoses.</td></tr><tr><td style=\"white-space:nowrap\">newborn-admission-record<a name=\"document-type-codesystem-newborn-admission-record\"> </a></td><td>Newborn admission record</td><td>The structured admission record for a baby admitted to the newborn unit, including intranatal history and the newborn examination.</td></tr><tr><td style=\"white-space:nowrap\">newborn-observation-chart<a name=\"document-type-codesystem-newborn-observation-chart\"> </a></td><td>Newborn observation chart</td><td>Apgar at one, five and ten minutes, the observations taken during the first two hours of skin-to-skin, and the twice-daily newborn follow-up over the first four days.</td></tr><tr><td style=\"white-space:nowrap\">maternity-record<a name=\"document-type-codesystem-maternity-record\"> </a></td><td>Maternity record</td><td>The maternity admission record: present pregnancy, past obstetric history, examination on admission, the plan, and the report on labour or caesarean section.</td></tr><tr><td style=\"white-space:nowrap\">bishop-score<a name=\"document-type-codesystem-bishop-score\"> </a></td><td>Bishop score</td><td>Cervical assessment before induction of labour, scored across dilation, effacement, consistency, position and station.</td></tr><tr><td style=\"white-space:nowrap\">paediatric-triage-record<a name=\"document-type-codesystem-paediatric-triage-record\"> </a></td><td>Paediatric triage record</td><td>The casualty triage sheet for a child: triage level, vital signs, the SAMPLE history and the emergency and priority signs looked for.</td></tr><tr><td style=\"white-space:nowrap\">surgical-safety-checklist<a name=\"document-type-codesystem-surgical-safety-checklist\"> </a></td><td>Surgical safety checklist</td><td>The hospital's pre-operative and post-operative ward checklist together with the WHO three-phase theatre checklist.</td></tr><tr><td style=\"white-space:nowrap\">anaesthetic-record<a name=\"document-type-codesystem-anaesthetic-record\"> </a></td><td>Anaesthetic record</td><td>The intra-operative anaesthetic chart: technique, agents, the observations recorded through the case, blood loss and the reversal and post-operative instructions.</td></tr><tr><td style=\"white-space:nowrap\">palliative-care-assessment<a name=\"document-type-codesystem-palliative-care-assessment\"> </a></td><td>Palliative care assessment</td><td>The palliative care service's first assessment: the symptom checklist, prior oncological treatment, and the social and spiritual assessment with the problem and action plan.</td></tr><tr><td style=\"white-space:nowrap\">blood-donor-questionnaire<a name=\"document-type-codesystem-blood-donor-questionnaire\"> </a></td><td>Blood donor questionnaire</td><td>The Kenya Tissue and Transplant Authority donor form (FRM CLN 001): donor details, the deferral questionnaire, the declaration and consent, and the donor screening and donation outcome.</td></tr><tr><td style=\"white-space:nowrap\">haemodialysis-session-record<a name=\"document-type-codesystem-haemodialysis-session-record\"> </a></td><td>Haemodialysis session record</td><td>The dialysis flow chart for one session: access and virology screen, the prescription, the machine check and the observations taken through the run.</td></tr><tr><td style=\"white-space:nowrap\">imaging-request<a name=\"document-type-codesystem-imaging-request\"> </a></td><td>Imaging request</td><td>The X-ray and ultrasound request forms, which ask the same four things: what is wanted, why, the clinical summary and how urgently.</td></tr><tr><td style=\"white-space:nowrap\">chemotherapy-prescription<a name=\"document-type-codesystem-chemotherapy-prescription\"> </a></td><td>Chemotherapy prescription</td><td>The oncology prescription sheet: staging and body surface area, the mandatory pre-cycle investigations, pre- and post-hydration, premedication and the cytotoxic drugs by cycle.</td></tr><tr><td style=\"white-space:nowrap\">discharge-summary<a name=\"document-type-codesystem-discharge-summary\"> </a></td><td>Discharge summary</td><td>The sheet the patient leaves with: diagnoses, clinical summary, management given, discharge medication and instructions, plus the ward clearance sign-off.</td></tr><tr><td style=\"white-space:nowrap\">procedure-consent<a name=\"document-type-codesystem-procedure-consent\"> </a></td><td>Consent for a procedure or treatment</td><td>The hospital's general consent form for an operation or treatment, and the two procedure-specific variants for endoscopy and for systemic anti-cancer therapy.</td></tr><tr><td style=\"white-space:nowrap\">icu-neurological-chart<a name=\"document-type-codesystem-icu-neurological-chart\"> </a></td><td>ICU neurological observation chart</td><td>The 24-hour ICU chart: Glasgow Coma Scale, limb power, pupils and vitals, charted round by round rather than once a shift, because a deteriorating conscious level is only visible as a series.</td></tr><tr><td style=\"white-space:nowrap\">decline-form<a name=\"document-type-codesystem-decline-form\"> </a></td><td>Decline form</td><td>The bilingual form on which a patient or their next of kin records a refusal of care, a procedure or an assessment, and where they are going instead.</td></tr><tr><td style=\"white-space:nowrap\">endoscopy-investigation<a name=\"document-type-codesystem-endoscopy-investigation\"> </a></td><td>Endoscopy service investigation form</td><td>The endoscopy unit's single sheet: the request, the procedure, the findings, the conclusion and the treatment suggested.</td></tr><tr><td style=\"white-space:nowrap\">medical-report<a name=\"document-type-codesystem-medical-report\"> </a></td><td>Medical report</td><td>A report on a completed admission written for someone outside the treating team -- an insurer, a court, another hospital.</td></tr><tr><td style=\"white-space:nowrap\">patient-referral<a name=\"document-type-codesystem-patient-referral\"> </a></td><td>Patient referral form</td><td>The form on which a patient is referred on to another unit or facility, carrying the history, the working diagnosis, the treatment already given and the reason for referral.</td></tr><tr><td style=\"white-space:nowrap\">psychological-review<a name=\"document-type-codesystem-psychological-review\"> </a></td><td>Psychological review notes</td><td>A counselling or therapy session recorded as a SOAP note, numbered within the episode of care.</td></tr><tr><td style=\"white-space:nowrap\">blood-requisition<a name=\"document-type-codesystem-blood-requisition\"> </a></td><td>Blood requisition form</td><td>The blood bank requisition: products requested, recipient group, each issued unit with its bag number and cross-match result, and any transfusion reaction.</td></tr><tr><td style=\"white-space:nowrap\">paediatric-nutrition-assessment<a name=\"document-type-codesystem-paediatric-nutrition-assessment\"> </a></td><td>Paediatric nutrition assessment form</td><td>The nutrition unit's assessment of a child: family and feeding history, anthropometry, nutritional diagnosis and prescription.</td></tr><tr><td style=\"white-space:nowrap\">prescription-pad<a name=\"document-type-codesystem-prescription-pad\"> </a></td><td>Prescription</td><td>The out-patient prescription slip: five numbered lines and a doctor's signature, with no dose or frequency column of its own.</td></tr><tr><td style=\"white-space:nowrap\">mortality-committee-findings<a name=\"document-type-codesystem-mortality-committee-findings\"> </a></td><td>Mortality committee findings and recommendations</td><td>The death review: nine numbered questions from the presenting complaint through to the committee's opinion and its recommendation.</td></tr><tr><td style=\"white-space:nowrap\">chemotherapy-protocol-cycles<a name=\"document-type-codesystem-chemotherapy-protocol-cycles\"> </a></td><td>Chemotherapy protocol cycle record</td><td>The 2-, 3- and 4-weekly protocol sheet: one row per cycle carrying the counts and renal function that decide whether the cycle runs.</td></tr><tr><td style=\"white-space:nowrap\">family-conference<a name=\"document-type-codesystem-family-conference\"> </a></td><td>Patient, family and doctors' conference record</td><td>The record of a conference held with a patient and their family, including any resuscitation decision reached.</td></tr><tr><td style=\"white-space:nowrap\">icu-observation-chart<a name=\"document-type-codesystem-icu-observation-chart\"> </a></td><td>ICU observation chart</td><td>The 24-hour intensive care chart: vitals and CVP, the arterial blood gas, and the ventilator settings, round by round.</td></tr><tr><td style=\"white-space:nowrap\">hdu-input-output-chart<a name=\"document-type-codesystem-hdu-input-output-chart\"> </a></td><td>HDU input and output chart</td><td>The high dependency unit's hourly fluid balance: parenteral and oral intake against aspirate, vomit, drain, urine and stool, with the 24-hour balance.</td></tr><tr><td style=\"white-space:nowrap\">lab-requisition-serology<a name=\"document-type-codesystem-lab-requisition-serology\"> </a></td><td>Medical laboratory requisition</td><td>The general laboratory requisition: specimen, urgency, clinical history and the investigations wanted, with the result and dispatch block on the same sheet.</td></tr><tr><td style=\"white-space:nowrap\">newborn-unit-handover<a name=\"document-type-codesystem-newborn-unit-handover\"> </a></td><td>Newborn unit handover form</td><td>The handover taken when a baby arrives in the newborn unit: intranatal history, ANC profile, birth history and the first vital signs.</td></tr><tr><td style=\"white-space:nowrap\">newborn-comprehensive-chart<a name=\"document-type-codesystem-newborn-comprehensive-chart\"> </a></td><td>Newborn comprehensive chart</td><td>The newborn unit's daily sheet: the feed and fluid prescription, the IV nursing plan, the interventions in place, hourly observations, and a shift note with the baby's acuity category.</td></tr><tr><td style=\"white-space:nowrap\">plates-and-screws<a name=\"document-type-codesystem-plates-and-screws\"> </a></td><td>Plates and screws</td><td>The orthopaedic implant tally: forty printed line items with a count against each, signed at the foot.</td></tr><tr><td style=\"white-space:nowrap\">head-injury-chart<a name=\"document-type-codesystem-head-injury-chart\"> </a></td><td>Head injury and craniotomy chart</td><td>The one- or two-hourly neurological chart used after a head injury or a craniotomy: its own four-point conscious level, pupils per side, fits, spontaneous movement and paralysis by limb.</td></tr><tr><td style=\"white-space:nowrap\">theatre-miscellaneous-items<a name=\"document-type-codesystem-theatre-miscellaneous-items\"> </a></td><td>Theatre miscellaneous items</td><td>The tally of consumables issued from theatre stock against one patient.</td></tr><tr><td style=\"white-space:nowrap\">outpatient-summary<a name=\"document-type-codesystem-outpatient-summary\"> </a></td><td>Out-patient summary form</td><td>The out-patient visit summary: complaints, provisional diagnosis and interventions.</td></tr><tr><td style=\"white-space:nowrap\">patient-satisfaction<a name=\"document-type-codesystem-patient-satisfaction\"> </a></td><td>Patient satisfaction questionnaire</td><td>The service-quality survey given to out-patient, casualty, MCH and in-patient users. The only form in this set with no clinical extraction.</td></tr><tr><td style=\"white-space:nowrap\">coagulation-profile-requisition<a name=\"document-type-codesystem-coagulation-profile-requisition\"> </a></td><td>Coagulation profile requisition</td><td>The coagulation requisition, which prints its own reference ranges for PT, INR and APTT -- the INR range applying only to a patient on stabilised oral anticoagulants.</td></tr><tr><td style=\"white-space:nowrap\">mortuary-services-request<a name=\"document-type-codesystem-mortuary-services-request\"> </a></td><td>Mortuary services request form</td><td>The request that accompanies a body into the mortuary, covering both hospital deaths and bodies brought from home or by the police.</td></tr><tr><td style=\"white-space:nowrap\">mortuary-release<a name=\"document-type-codesystem-mortuary-release\"> </a></td><td>Mortuary release form</td><td>The release of a body for transfer to another hospital's morgue.</td></tr><tr><td style=\"white-space:nowrap\">mortuary-baby-disposal-consent<a name=\"document-type-codesystem-mortuary-baby-disposal-consent\"> </a></td><td>Mortuary consent form, disposal of a baby</td><td>The authorisation given by a parent or next of kin for the hospital to dispose of a baby's body.</td></tr><tr><td style=\"white-space:nowrap\">mortuary-admission<a name=\"document-type-codesystem-mortuary-admission\"> </a></td><td>Mortuary admission form</td><td>The admission of a body into the mortuary: registration tag, where the body came from, next of kin and the relatives accompanying it.</td></tr><tr><td style=\"white-space:nowrap\">body-part-disposal-consent<a name=\"document-type-codesystem-body-part-disposal-consent\"> </a></td><td>Body part disposal consent form</td><td>The consent taken before surgery for what happens to a removed body part -- released to the family, or disposed of by the hospital.</td></tr><tr><td style=\"white-space:nowrap\">paediatric-nebulization-chart<a name=\"document-type-codesystem-paediatric-nebulization-chart\"> </a></td><td>Paediatric nebulization chart</td><td>Each nebulisation given: the drug, the amount and the frequency, with the time it was given and who gave it.</td></tr><tr><td style=\"white-space:nowrap\">surgical-irrigation-record<a name=\"document-type-codesystem-surgical-irrigation-record\"> </a></td><td>Surgical continuous irrigation record</td><td>The hourly balance of a continuous bladder irrigation: solution and volume in against volume out, with the colour of the return.</td></tr><tr><td style=\"white-space:nowrap\">milk-feeding-chart<a name=\"document-type-codesystem-milk-feeding-chart\"> </a></td><td>Milk feeding chart</td><td>The three-hourly feed target against what was actually given, what was retained, and whether the baby passed urine and stool.</td></tr><tr><td style=\"white-space:nowrap\">vent-monitoring-chart<a name=\"document-type-codesystem-vent-monitoring-chart\"> </a></td><td>Ventilator monitoring chart</td><td>The ventilator settings charted over time: mode, PEEP, peak inspiratory pressure and FiO2, with the changes made.</td></tr><tr><td style=\"white-space:nowrap\">cpap-monitoring-chart<a name=\"document-type-codesystem-cpap-monitoring-chart\"> </a></td><td>CPAP monitoring chart</td><td>The CPAP settings charted over time: the distending pressure, the gas flow and FiO2, with the change made at each reading and any remark. The ventilator chart's shape with two fewer columns.</td></tr><tr><td style=\"white-space:nowrap\">embalming-authorization<a name=\"document-type-codesystem-embalming-authorization\"> </a></td><td>Embalming authorization form</td><td>The next of kin's authorisation for a body to be embalmed while the burial is arranged.</td></tr><tr><td style=\"white-space:nowrap\">paediatric-vital-sign-chart<a name=\"document-type-codesystem-paediatric-vital-sign-chart\"> </a></td><td>Paediatric vital sign observation chart</td><td>Four observation rounds a day over ten days: temperature and how it was controlled, pulse, respiration, blood pressure, oxygen saturation and any oxygen given.</td></tr><tr><td style=\"white-space:nowrap\">admission-form<a name=\"document-type-codesystem-admission-form\"> </a></td><td>Admission form</td><td>The nursing admission: where the patient came from and how they arrived, the presenting symptoms, a head-to-toe assessment, the chronic illness history, and the investigations and treatment ordered on arrival.</td></tr><tr><td style=\"white-space:nowrap\">rehabilitation-services<a name=\"document-type-codesystem-rehabilitation-services\"> </a></td><td>Rehabilitation services record</td><td>Each rehabilitation contact: the units billed, the devices and materials used, and the progress note.</td></tr><tr><td style=\"white-space:nowrap\">nicu-monitoring-chart<a name=\"document-type-codesystem-nicu-monitoring-chart\"> </a></td><td>NICU monitoring chart</td><td>The neonatal unit's hourly chart: vitals, an assessment including jaundice and apnoea, the ventilator settings and the blood gas.</td></tr><tr><td style=\"white-space:nowrap\">theatre-pacu-observation<a name=\"document-type-codesystem-theatre-pacu-observation\"> </a></td><td>Theatre PACU observation form</td><td>Timed recovery-room observations after anaesthesia, with the drugs given and remarks.</td></tr><tr><td style=\"white-space:nowrap\">pacu-nurses-notes<a name=\"document-type-codesystem-pacu-nurses-notes\"> </a></td><td>PACU nurses notes</td><td>The recovery-room nursing narrative, timestamped and signed per entry.</td></tr><tr><td style=\"white-space:nowrap\">theatre-note<a name=\"document-type-codesystem-theatre-note\"> </a></td><td>Theatre note</td><td>The operation note: diagnosis, procedure, incision, the surgical and anaesthetic team, and the description of what was done.</td></tr><tr><td style=\"white-space:nowrap\">doctors-notes<a name=\"document-type-codesystem-doctors-notes\"> </a></td><td>Doctors notes continuation sheet</td><td>The ward round narrative, timestamped and signed per entry.</td></tr><tr><td style=\"white-space:nowrap\">surgical-dressing-chart<a name=\"document-type-codesystem-surgical-dressing-chart\"> </a></td><td>Surgical dressing chart</td><td>Each dressing change, with the sheet's own three-letter grading and a remark.</td></tr><tr><td style=\"white-space:nowrap\">feeding-and-position-chart<a name=\"document-type-codesystem-feeding-and-position-chart\"> </a></td><td>Feeding and position chart</td><td>How much a patient was fed and how they were positioned, entry by entry -- turning is what prevents pressure injury and this is where it is evidenced.</td></tr><tr><td style=\"white-space:nowrap\">nursing-care-plan<a name=\"document-type-codesystem-nursing-care-plan\"> </a></td><td>Nursing care plan</td><td>The full nursing process per problem: assessment, nursing diagnosis, expected outcome, intervention, the scientific rationale for it, what was implemented and the evaluation.</td></tr><tr><td style=\"white-space:nowrap\">intake-output-record<a name=\"document-type-codesystem-intake-output-record\"> </a></td><td>Intake and output record</td><td>The 24-hour fluid balance: oral, IV and nasogastric intake against urine, stool, vomit, nasogastric suction and drainage, with the totals the sheet asks to be circled.</td></tr><tr><td style=\"white-space:nowrap\">antenatal-vital-signs<a name=\"document-type-codesystem-antenatal-vital-signs\"> </a></td><td>Antenatal vital signs</td><td>Timed antenatal observations: temperature, pulse, respiration and blood pressure with the lie, the presentation, the fetal heart tones and whether the bowels have opened.</td></tr><tr><td style=\"white-space:nowrap\">paediatric-tb-icf-screening<a name=\"document-type-codesystem-paediatric-tb-icf-screening\"> </a></td><td>Paediatric TB intensified case finding screening tool</td><td>The five-question intensified case finding screen asked of every child at every contact -- cough of any duration, fever, failure to thrive or poor weight gain, lethargy, and contact with a TB case -- and the action the answers decide. Table 22.9 of the paediatric TB guideline.</td></tr></table></div>"^^rdf:XMLLiteral ] ] ; # fhir:url [ fhir:v "https://fhir.slade360.co.ke/fhir/CodeSystem/document-type-codesystem"^^xsd:anyURI] ; # fhir:version [ fhir:v "0.1.0"] ; # fhir:name [ fhir:v "SGHIDocumentTypeCodeSystem"] ; # fhir:title [ fhir:v "SGHI Document Type Code System"] ; # fhir:status [ fhir:v "active"] ; # fhir:experimental [ fhir:v false] ; # fhir:date [ fhir:v "2026-09-15T11:40:24+00:00"^^xsd:dateTime] ; # fhir:publisher [ fhir:v "Kathurima Kimathi"] ; # fhir:contact ( [ fhir:name [ fhir:v "Kathurima Kimathi" ] ; fhir:telecom ( [ fhir:system [ fhir:v "url" ] ; fhir:value [ fhir:v "https://www.linkedin.com/in/kathurima-kimathi/" ] ] [ fhir:system [ fhir:v "email" ] ; fhir:value [ fhir:v "kathurimakimathi415@gmail.com" ] ] ) ] [ fhir:name [ fhir:v "Oscar John" ] ; fhir:telecom ( [ fhir:system [ fhir:v "email" ] ; fhir:value [ fhir:v "oscarjohnotieno@gmail.com" ] ; fhir:use [ fhir:v "work" ] ] ) ] [ fhir:name [ fhir:v "Kennedy Omondi" ] ; fhir:telecom ( [ fhir:system [ fhir:v "email" ] ; fhir:value [ fhir:v "kennankole@gmail.com" ] ; fhir:use [ fhir:v "work" ] ] ) ] ) ; # fhir:description [ fhir:v "The hospital paper forms that have been modelled as Questionnaires. Each code names one form, so a QuestionnaireResponse or an extracted Composition can say which sheet of the paper chart it stands in for. LOINC codes are carried alongside where LOINC names the same document — the discharge summary and the operation note — and the rest are local because they are this hospital's own forms."] ; # fhir:caseSensitive [ fhir:v true] ; # fhir:content [ fhir:v "complete"] ; # fhir:count [ fhir:v "63"^^xsd:nonNegativeInteger] ; # fhir:concept ( [ fhir:code [ fhir:v "paediatric-admission-record" ] ; fhir:display [ fhir:v "Paediatric admission record" ] ; fhir:definition [ fhir:v "The three-page structured admission record used on the paediatric ward: presenting illness, immunisation, examination by system, investigations ordered and the coded admission diagnoses." ] ] [ fhir:code [ fhir:v "newborn-admission-record" ] ; fhir:display [ fhir:v "Newborn admission record" ] ; fhir:definition [ fhir:v "The structured admission record for a baby admitted to the newborn unit, including intranatal history and the newborn examination." ] ] [ fhir:code [ fhir:v "newborn-observation-chart" ] ; fhir:display [ fhir:v "Newborn observation chart" ] ; fhir:definition [ fhir:v "Apgar at one, five and ten minutes, the observations taken during the first two hours of skin-to-skin, and the twice-daily newborn follow-up over the first four days." ] ] [ fhir:code [ fhir:v "maternity-record" ] ; fhir:display [ fhir:v "Maternity record" ] ; fhir:definition [ fhir:v "The maternity admission record: present pregnancy, past obstetric history, examination on admission, the plan, and the report on labour or caesarean section." ] ] [ fhir:code [ fhir:v "bishop-score" ] ; fhir:display [ fhir:v "Bishop score" ] ; fhir:definition [ fhir:v "Cervical assessment before induction of labour, scored across dilation, effacement, consistency, position and station." ] ] [ fhir:code [ fhir:v "paediatric-triage-record" ] ; fhir:display [ fhir:v "Paediatric triage record" ] ; fhir:definition [ fhir:v "The casualty triage sheet for a child: triage level, vital signs, the SAMPLE history and the emergency and priority signs looked for." ] ] [ fhir:code [ fhir:v "surgical-safety-checklist" ] ; fhir:display [ fhir:v "Surgical safety checklist" ] ; fhir:definition [ fhir:v "The hospital's pre-operative and post-operative ward checklist together with the WHO three-phase theatre checklist." ] ] [ fhir:code [ fhir:v "anaesthetic-record" ] ; fhir:display [ fhir:v "Anaesthetic record" ] ; fhir:definition [ fhir:v "The intra-operative anaesthetic chart: technique, agents, the observations recorded through the case, blood loss and the reversal and post-operative instructions." ] ] [ fhir:code [ fhir:v "palliative-care-assessment" ] ; fhir:display [ fhir:v "Palliative care assessment" ] ; fhir:definition [ fhir:v "The palliative care service's first assessment: the symptom checklist, prior oncological treatment, and the social and spiritual assessment with the problem and action plan." ] ] [ fhir:code [ fhir:v "blood-donor-questionnaire" ] ; fhir:display [ fhir:v "Blood donor questionnaire" ] ; fhir:definition [ fhir:v "The Kenya Tissue and Transplant Authority donor form (FRM CLN 001): donor details, the deferral questionnaire, the declaration and consent, and the donor screening and donation outcome." ] ] [ fhir:code [ fhir:v "haemodialysis-session-record" ] ; fhir:display [ fhir:v "Haemodialysis session record" ] ; fhir:definition [ fhir:v "The dialysis flow chart for one session: access and virology screen, the prescription, the machine check and the observations taken through the run." ] ] [ fhir:code [ fhir:v "imaging-request" ] ; fhir:display [ fhir:v "Imaging request" ] ; fhir:definition [ fhir:v "The X-ray and ultrasound request forms, which ask the same four things: what is wanted, why, the clinical summary and how urgently." ] ] [ fhir:code [ fhir:v "chemotherapy-prescription" ] ; fhir:display [ fhir:v "Chemotherapy prescription" ] ; fhir:definition [ fhir:v "The oncology prescription sheet: staging and body surface area, the mandatory pre-cycle investigations, pre- and post-hydration, premedication and the cytotoxic drugs by cycle." ] ] [ fhir:code [ fhir:v "discharge-summary" ] ; fhir:display [ fhir:v "Discharge summary" ] ; fhir:definition [ fhir:v "The sheet the patient leaves with: diagnoses, clinical summary, management given, discharge medication and instructions, plus the ward clearance sign-off." ] ] [ fhir:code [ fhir:v "procedure-consent" ] ; fhir:display [ fhir:v "Consent for a procedure or treatment" ] ; fhir:definition [ fhir:v "The hospital's general consent form for an operation or treatment, and the two procedure-specific variants for endoscopy and for systemic anti-cancer therapy." ] ] [ fhir:code [ fhir:v "icu-neurological-chart" ] ; fhir:display [ fhir:v "ICU neurological observation chart" ] ; fhir:definition [ fhir:v "The 24-hour ICU chart: Glasgow Coma Scale, limb power, pupils and vitals, charted round by round rather than once a shift, because a deteriorating conscious level is only visible as a series." ] ] [ fhir:code [ fhir:v "decline-form" ] ; fhir:display [ fhir:v "Decline form" ] ; fhir:definition [ fhir:v "The bilingual form on which a patient or their next of kin records a refusal of care, a procedure or an assessment, and where they are going instead." ] ] [ fhir:code [ fhir:v "endoscopy-investigation" ] ; fhir:display [ fhir:v "Endoscopy service investigation form" ] ; fhir:definition [ fhir:v "The endoscopy unit's single sheet: the request, the procedure, the findings, the conclusion and the treatment suggested." ] ] [ fhir:code [ fhir:v "medical-report" ] ; fhir:display [ fhir:v "Medical report" ] ; fhir:definition [ fhir:v "A report on a completed admission written for someone outside the treating team -- an insurer, a court, another hospital." ] ] [ fhir:code [ fhir:v "patient-referral" ] ; fhir:display [ fhir:v "Patient referral form" ] ; fhir:definition [ fhir:v "The form on which a patient is referred on to another unit or facility, carrying the history, the working diagnosis, the treatment already given and the reason for referral." ] ] [ fhir:code [ fhir:v "psychological-review" ] ; fhir:display [ fhir:v "Psychological review notes" ] ; fhir:definition [ fhir:v "A counselling or therapy session recorded as a SOAP note, numbered within the episode of care." ] ] [ fhir:code [ fhir:v "blood-requisition" ] ; fhir:display [ fhir:v "Blood requisition form" ] ; fhir:definition [ fhir:v "The blood bank requisition: products requested, recipient group, each issued unit with its bag number and cross-match result, and any transfusion reaction." ] ] [ fhir:code [ fhir:v "paediatric-nutrition-assessment" ] ; fhir:display [ fhir:v "Paediatric nutrition assessment form" ] ; fhir:definition [ fhir:v "The nutrition unit's assessment of a child: family and feeding history, anthropometry, nutritional diagnosis and prescription." ] ] [ fhir:code [ fhir:v "prescription-pad" ] ; fhir:display [ fhir:v "Prescription" ] ; fhir:definition [ fhir:v "The out-patient prescription slip: five numbered lines and a doctor's signature, with no dose or frequency column of its own." ] ] [ fhir:code [ fhir:v "mortality-committee-findings" ] ; fhir:display [ fhir:v "Mortality committee findings and recommendations" ] ; fhir:definition [ fhir:v "The death review: nine numbered questions from the presenting complaint through to the committee's opinion and its recommendation." ] ] [ fhir:code [ fhir:v "chemotherapy-protocol-cycles" ] ; fhir:display [ fhir:v "Chemotherapy protocol cycle record" ] ; fhir:definition [ fhir:v "The 2-, 3- and 4-weekly protocol sheet: one row per cycle carrying the counts and renal function that decide whether the cycle runs." ] ] [ fhir:code [ fhir:v "family-conference" ] ; fhir:display [ fhir:v "Patient, family and doctors' conference record" ] ; fhir:definition [ fhir:v "The record of a conference held with a patient and their family, including any resuscitation decision reached." ] ] [ fhir:code [ fhir:v "icu-observation-chart" ] ; fhir:display [ fhir:v "ICU observation chart" ] ; fhir:definition [ fhir:v "The 24-hour intensive care chart: vitals and CVP, the arterial blood gas, and the ventilator settings, round by round." ] ] [ fhir:code [ fhir:v "hdu-input-output-chart" ] ; fhir:display [ fhir:v "HDU input and output chart" ] ; fhir:definition [ fhir:v "The high dependency unit's hourly fluid balance: parenteral and oral intake against aspirate, vomit, drain, urine and stool, with the 24-hour balance." ] ] [ fhir:code [ fhir:v "lab-requisition-serology" ] ; fhir:display [ fhir:v "Medical laboratory requisition" ] ; fhir:definition [ fhir:v "The general laboratory requisition: specimen, urgency, clinical history and the investigations wanted, with the result and dispatch block on the same sheet." ] ] [ fhir:code [ fhir:v "newborn-unit-handover" ] ; fhir:display [ fhir:v "Newborn unit handover form" ] ; fhir:definition [ fhir:v "The handover taken when a baby arrives in the newborn unit: intranatal history, ANC profile, birth history and the first vital signs." ] ] [ fhir:code [ fhir:v "newborn-comprehensive-chart" ] ; fhir:display [ fhir:v "Newborn comprehensive chart" ] ; fhir:definition [ fhir:v "The newborn unit's daily sheet: the feed and fluid prescription, the IV nursing plan, the interventions in place, hourly observations, and a shift note with the baby's acuity category." ] ] [ fhir:code [ fhir:v "plates-and-screws" ] ; fhir:display [ fhir:v "Plates and screws" ] ; fhir:definition [ fhir:v "The orthopaedic implant tally: forty printed line items with a count against each, signed at the foot." ] ] [ fhir:code [ fhir:v "head-injury-chart" ] ; fhir:display [ fhir:v "Head injury and craniotomy chart" ] ; fhir:definition [ fhir:v "The one- or two-hourly neurological chart used after a head injury or a craniotomy: its own four-point conscious level, pupils per side, fits, spontaneous movement and paralysis by limb." ] ] [ fhir:code [ fhir:v "theatre-miscellaneous-items" ] ; fhir:display [ fhir:v "Theatre miscellaneous items" ] ; fhir:definition [ fhir:v "The tally of consumables issued from theatre stock against one patient." ] ] [ fhir:code [ fhir:v "outpatient-summary" ] ; fhir:display [ fhir:v "Out-patient summary form" ] ; fhir:definition [ fhir:v "The out-patient visit summary: complaints, provisional diagnosis and interventions." ] ] [ fhir:code [ fhir:v "patient-satisfaction" ] ; fhir:display [ fhir:v "Patient satisfaction questionnaire" ] ; fhir:definition [ fhir:v "The service-quality survey given to out-patient, casualty, MCH and in-patient users. The only form in this set with no clinical extraction." ] ] [ fhir:code [ fhir:v "coagulation-profile-requisition" ] ; fhir:display [ fhir:v "Coagulation profile requisition" ] ; fhir:definition [ fhir:v "The coagulation requisition, which prints its own reference ranges for PT, INR and APTT -- the INR range applying only to a patient on stabilised oral anticoagulants." ] ] [ fhir:code [ fhir:v "mortuary-services-request" ] ; fhir:display [ fhir:v "Mortuary services request form" ] ; fhir:definition [ fhir:v "The request that accompanies a body into the mortuary, covering both hospital deaths and bodies brought from home or by the police." ] ] [ fhir:code [ fhir:v "mortuary-release" ] ; fhir:display [ fhir:v "Mortuary release form" ] ; fhir:definition [ fhir:v "The release of a body for transfer to another hospital's morgue." ] ] [ fhir:code [ fhir:v "mortuary-baby-disposal-consent" ] ; fhir:display [ fhir:v "Mortuary consent form, disposal of a baby" ] ; fhir:definition [ fhir:v "The authorisation given by a parent or next of kin for the hospital to dispose of a baby's body." ] ] [ fhir:code [ fhir:v "mortuary-admission" ] ; fhir:display [ fhir:v "Mortuary admission form" ] ; fhir:definition [ fhir:v "The admission of a body into the mortuary: registration tag, where the body came from, next of kin and the relatives accompanying it." ] ] [ fhir:code [ fhir:v "body-part-disposal-consent" ] ; fhir:display [ fhir:v "Body part disposal consent form" ] ; fhir:definition [ fhir:v "The consent taken before surgery for what happens to a removed body part -- released to the family, or disposed of by the hospital." ] ] [ fhir:code [ fhir:v "paediatric-nebulization-chart" ] ; fhir:display [ fhir:v "Paediatric nebulization chart" ] ; fhir:definition [ fhir:v "Each nebulisation given: the drug, the amount and the frequency, with the time it was given and who gave it." ] ] [ fhir:code [ fhir:v "surgical-irrigation-record" ] ; fhir:display [ fhir:v "Surgical continuous irrigation record" ] ; fhir:definition [ fhir:v "The hourly balance of a continuous bladder irrigation: solution and volume in against volume out, with the colour of the return." ] ] [ fhir:code [ fhir:v "milk-feeding-chart" ] ; fhir:display [ fhir:v "Milk feeding chart" ] ; fhir:definition [ fhir:v "The three-hourly feed target against what was actually given, what was retained, and whether the baby passed urine and stool." ] ] [ fhir:code [ fhir:v "vent-monitoring-chart" ] ; fhir:display [ fhir:v "Ventilator monitoring chart" ] ; fhir:definition [ fhir:v "The ventilator settings charted over time: mode, PEEP, peak inspiratory pressure and FiO2, with the changes made." ] ] [ fhir:code [ fhir:v "cpap-monitoring-chart" ] ; fhir:display [ fhir:v "CPAP monitoring chart" ] ; fhir:definition [ fhir:v "The CPAP settings charted over time: the distending pressure, the gas flow and FiO2, with the change made at each reading and any remark. The ventilator chart's shape with two fewer columns." ] ] [ fhir:code [ fhir:v "embalming-authorization" ] ; fhir:display [ fhir:v "Embalming authorization form" ] ; fhir:definition [ fhir:v "The next of kin's authorisation for a body to be embalmed while the burial is arranged." ] ] [ fhir:code [ fhir:v "paediatric-vital-sign-chart" ] ; fhir:display [ fhir:v "Paediatric vital sign observation chart" ] ; fhir:definition [ fhir:v "Four observation rounds a day over ten days: temperature and how it was controlled, pulse, respiration, blood pressure, oxygen saturation and any oxygen given." ] ] [ fhir:code [ fhir:v "admission-form" ] ; fhir:display [ fhir:v "Admission form" ] ; fhir:definition [ fhir:v "The nursing admission: where the patient came from and how they arrived, the presenting symptoms, a head-to-toe assessment, the chronic illness history, and the investigations and treatment ordered on arrival." ] ] [ fhir:code [ fhir:v "rehabilitation-services" ] ; fhir:display [ fhir:v "Rehabilitation services record" ] ; fhir:definition [ fhir:v "Each rehabilitation contact: the units billed, the devices and materials used, and the progress note." ] ] [ fhir:code [ fhir:v "nicu-monitoring-chart" ] ; fhir:display [ fhir:v "NICU monitoring chart" ] ; fhir:definition [ fhir:v "The neonatal unit's hourly chart: vitals, an assessment including jaundice and apnoea, the ventilator settings and the blood gas." ] ] [ fhir:code [ fhir:v "theatre-pacu-observation" ] ; fhir:display [ fhir:v "Theatre PACU observation form" ] ; fhir:definition [ fhir:v "Timed recovery-room observations after anaesthesia, with the drugs given and remarks." ] ] [ fhir:code [ fhir:v "pacu-nurses-notes" ] ; fhir:display [ fhir:v "PACU nurses notes" ] ; fhir:definition [ fhir:v "The recovery-room nursing narrative, timestamped and signed per entry." ] ] [ fhir:code [ fhir:v "theatre-note" ] ; fhir:display [ fhir:v "Theatre note" ] ; fhir:definition [ fhir:v "The operation note: diagnosis, procedure, incision, the surgical and anaesthetic team, and the description of what was done." ] ] [ fhir:code [ fhir:v "doctors-notes" ] ; fhir:display [ fhir:v "Doctors notes continuation sheet" ] ; fhir:definition [ fhir:v "The ward round narrative, timestamped and signed per entry." ] ] [ fhir:code [ fhir:v "surgical-dressing-chart" ] ; fhir:display [ fhir:v "Surgical dressing chart" ] ; fhir:definition [ fhir:v "Each dressing change, with the sheet's own three-letter grading and a remark." ] ] [ fhir:code [ fhir:v "feeding-and-position-chart" ] ; fhir:display [ fhir:v "Feeding and position chart" ] ; fhir:definition [ fhir:v "How much a patient was fed and how they were positioned, entry by entry -- turning is what prevents pressure injury and this is where it is evidenced." ] ] [ fhir:code [ fhir:v "nursing-care-plan" ] ; fhir:display [ fhir:v "Nursing care plan" ] ; fhir:definition [ fhir:v "The full nursing process per problem: assessment, nursing diagnosis, expected outcome, intervention, the scientific rationale for it, what was implemented and the evaluation." ] ] [ fhir:code [ fhir:v "intake-output-record" ] ; fhir:display [ fhir:v "Intake and output record" ] ; fhir:definition [ fhir:v "The 24-hour fluid balance: oral, IV and nasogastric intake against urine, stool, vomit, nasogastric suction and drainage, with the totals the sheet asks to be circled." ] ] [ fhir:code [ fhir:v "antenatal-vital-signs" ] ; fhir:display [ fhir:v "Antenatal vital signs" ] ; fhir:definition [ fhir:v "Timed antenatal observations: temperature, pulse, respiration and blood pressure with the lie, the presentation, the fetal heart tones and whether the bowels have opened." ] ] [ fhir:code [ fhir:v "paediatric-tb-icf-screening" ] ; fhir:display [ fhir:v "Paediatric TB intensified case finding screening tool" ] ; fhir:definition [ fhir:v "The five-question intensified case finding screen asked of every child at every contact -- cough of any duration, fever, failure to thrive or poor weight gain, lethargy, and contact with a TB case -- and the action the answers decide. Table 22.9 of the paediatric TB guideline." ] ] ) . #
IG © 2025+ Kathurima Kimathi. Package silfhirprofileig#0.1.0 based on FHIR 5.0.0. Generated 2026-09-15
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