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 2026-10-06 |
<CodeSystem xmlns="http://hl7.org/fhir">
<id value="document-type-codesystem"/>
<text>
<status value="generated"/>
<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><tr><td style="white-space:nowrap">optical-prescription<a name="document-type-codesystem-optical-prescription"> </a></td><td>Optical prescription</td><td>The eyewear prescription an optometrist or ophthalmologist writes: sphere, cylinder, axis, pupillary distance and visual acuity for each eye at distance and near, the reading addition, the lens type and coating, and the prescriber -- plus the contact lens prescription where one is written.</td></tr><tr><td style="white-space:nowrap">oncology-initial-assessment<a name="document-type-codesystem-oncology-initial-assessment"> </a></td><td>Oncology initial assessment form</td><td>The oncology clinic's first assessment of a new patient: measurements and vital signs, the referral, the diagnosis and stage, the history including family history of cancer, the female patient section, social history, histology and immunohistochemistry, previous treatment, examination with the ECOG performance status, the radiology summary and the treatment plan.</td></tr><tr><td style="white-space:nowrap">cancer-treatment-consent<a name="document-type-codesystem-cancer-treatment-consent"> </a></td><td>Cancer centre informed consent</td><td>The patient's consent to chemotherapy, hormonal or targeted therapy: the diagnosis and the drug regimen explained, the intended purpose of the treatment, the common side effects and risks, and the signatures of the patient, any interpreter and the doctor.</td></tr><tr><td style="white-space:nowrap">hormonal-therapy-treatment-plan<a name="document-type-codesystem-hormonal-therapy-treatment-plan"> </a></td><td>Hormonal therapy treatment plan</td><td>The running sheet for a patient on hormonal therapy, one row per cycle: the date, the cycle number, the drug given, the PSA, calcium and alkaline phosphatase, remarks, and the date to come again.</td></tr></table></div>
</text>
<url
value="https://fhir.slade360.co.ke/fhir/CodeSystem/document-type-codesystem"/>
<version value="0.1.0"/>
<name value="SGHIDocumentTypeCodeSystem"/>
<title value="SGHI Document Type Code System"/>
<status value="active"/>
<experimental value="false"/>
<date value="2026-10-06T18:48:22+00:00"/>
<publisher value="Kathurima Kimathi"/>
<contact>
<name value="Kathurima Kimathi"/>
<telecom>
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<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 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."/>
<caseSensitive value="true"/>
<content value="complete"/>
<count value="67"/>
<concept>
<code value="paediatric-admission-record"/>
<display value="Paediatric admission record"/>
<definition
value="The three-page structured admission record used on the paediatric ward: presenting illness, immunisation, examination by system, investigations ordered and the coded admission diagnoses."/>
</concept>
<concept>
<code value="newborn-admission-record"/>
<display value="Newborn admission record"/>
<definition
value="The structured admission record for a baby admitted to the newborn unit, including intranatal history and the newborn examination."/>
</concept>
<concept>
<code value="newborn-observation-chart"/>
<display value="Newborn observation chart"/>
<definition
value="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."/>
</concept>
<concept>
<code value="maternity-record"/>
<display value="Maternity record"/>
<definition
value="The maternity admission record: present pregnancy, past obstetric history, examination on admission, the plan, and the report on labour or caesarean section."/>
</concept>
<concept>
<code value="bishop-score"/>
<display value="Bishop score"/>
<definition
value="Cervical assessment before induction of labour, scored across dilation, effacement, consistency, position and station."/>
</concept>
<concept>
<code value="paediatric-triage-record"/>
<display value="Paediatric triage record"/>
<definition
value="The casualty triage sheet for a child: triage level, vital signs, the SAMPLE history and the emergency and priority signs looked for."/>
</concept>
<concept>
<code value="surgical-safety-checklist"/>
<display value="Surgical safety checklist"/>
<definition
value="The hospital's pre-operative and post-operative ward checklist together with the WHO three-phase theatre checklist."/>
</concept>
<concept>
<code value="anaesthetic-record"/>
<display value="Anaesthetic record"/>
<definition
value="The intra-operative anaesthetic chart: technique, agents, the observations recorded through the case, blood loss and the reversal and post-operative instructions."/>
</concept>
<concept>
<code value="palliative-care-assessment"/>
<display value="Palliative care assessment"/>
<definition
value="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."/>
</concept>
<concept>
<code value="blood-donor-questionnaire"/>
<display value="Blood donor questionnaire"/>
<definition
value="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."/>
</concept>
<concept>
<code value="haemodialysis-session-record"/>
<display value="Haemodialysis session record"/>
<definition
value="The dialysis flow chart for one session: access and virology screen, the prescription, the machine check and the observations taken through the run."/>
</concept>
<concept>
<code value="imaging-request"/>
<display value="Imaging request"/>
<definition
value="The X-ray and ultrasound request forms, which ask the same four things: what is wanted, why, the clinical summary and how urgently."/>
</concept>
<concept>
<code value="chemotherapy-prescription"/>
<display value="Chemotherapy prescription"/>
<definition
value="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."/>
</concept>
<concept>
<code value="discharge-summary"/>
<display value="Discharge summary"/>
<definition
value="The sheet the patient leaves with: diagnoses, clinical summary, management given, discharge medication and instructions, plus the ward clearance sign-off."/>
</concept>
<concept>
<code value="procedure-consent"/>
<display value="Consent for a procedure or treatment"/>
<definition
value="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."/>
</concept>
<concept>
<code value="icu-neurological-chart"/>
<display value="ICU neurological observation chart"/>
<definition
value="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."/>
</concept>
<concept>
<code value="decline-form"/>
<display value="Decline form"/>
<definition
value="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."/>
</concept>
<concept>
<code value="endoscopy-investigation"/>
<display value="Endoscopy service investigation form"/>
<definition
value="The endoscopy unit's single sheet: the request, the procedure, the findings, the conclusion and the treatment suggested."/>
</concept>
<concept>
<code value="medical-report"/>
<display value="Medical report"/>
<definition
value="A report on a completed admission written for someone outside the treating team -- an insurer, a court, another hospital."/>
</concept>
<concept>
<code value="patient-referral"/>
<display value="Patient referral form"/>
<definition
value="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."/>
</concept>
<concept>
<code value="psychological-review"/>
<display value="Psychological review notes"/>
<definition
value="A counselling or therapy session recorded as a SOAP note, numbered within the episode of care."/>
</concept>
<concept>
<code value="blood-requisition"/>
<display value="Blood requisition form"/>
<definition
value="The blood bank requisition: products requested, recipient group, each issued unit with its bag number and cross-match result, and any transfusion reaction."/>
</concept>
<concept>
<code value="paediatric-nutrition-assessment"/>
<display value="Paediatric nutrition assessment form"/>
<definition
value="The nutrition unit's assessment of a child: family and feeding history, anthropometry, nutritional diagnosis and prescription."/>
</concept>
<concept>
<code value="prescription-pad"/>
<display value="Prescription"/>
<definition
value="The out-patient prescription slip: five numbered lines and a doctor's signature, with no dose or frequency column of its own."/>
</concept>
<concept>
<code value="mortality-committee-findings"/>
<display value="Mortality committee findings and recommendations"/>
<definition
value="The death review: nine numbered questions from the presenting complaint through to the committee's opinion and its recommendation."/>
</concept>
<concept>
<code value="chemotherapy-protocol-cycles"/>
<display value="Chemotherapy protocol cycle record"/>
<definition
value="The 2-, 3- and 4-weekly protocol sheet: one row per cycle carrying the counts and renal function that decide whether the cycle runs."/>
</concept>
<concept>
<code value="family-conference"/>
<display value="Patient, family and doctors' conference record"/>
<definition
value="The record of a conference held with a patient and their family, including any resuscitation decision reached."/>
</concept>
<concept>
<code value="icu-observation-chart"/>
<display value="ICU observation chart"/>
<definition
value="The 24-hour intensive care chart: vitals and CVP, the arterial blood gas, and the ventilator settings, round by round."/>
</concept>
<concept>
<code value="hdu-input-output-chart"/>
<display value="HDU input and output chart"/>
<definition
value="The high dependency unit's hourly fluid balance: parenteral and oral intake against aspirate, vomit, drain, urine and stool, with the 24-hour balance."/>
</concept>
<concept>
<code value="lab-requisition-serology"/>
<display value="Medical laboratory requisition"/>
<definition
value="The general laboratory requisition: specimen, urgency, clinical history and the investigations wanted, with the result and dispatch block on the same sheet."/>
</concept>
<concept>
<code value="newborn-unit-handover"/>
<display value="Newborn unit handover form"/>
<definition
value="The handover taken when a baby arrives in the newborn unit: intranatal history, ANC profile, birth history and the first vital signs."/>
</concept>
<concept>
<code value="newborn-comprehensive-chart"/>
<display value="Newborn comprehensive chart"/>
<definition
value="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."/>
</concept>
<concept>
<code value="plates-and-screws"/>
<display value="Plates and screws"/>
<definition
value="The orthopaedic implant tally: forty printed line items with a count against each, signed at the foot."/>
</concept>
<concept>
<code value="head-injury-chart"/>
<display value="Head injury and craniotomy chart"/>
<definition
value="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."/>
</concept>
<concept>
<code value="theatre-miscellaneous-items"/>
<display value="Theatre miscellaneous items"/>
<definition
value="The tally of consumables issued from theatre stock against one patient."/>
</concept>
<concept>
<code value="outpatient-summary"/>
<display value="Out-patient summary form"/>
<definition
value="The out-patient visit summary: complaints, provisional diagnosis and interventions."/>
</concept>
<concept>
<code value="patient-satisfaction"/>
<display value="Patient satisfaction questionnaire"/>
<definition
value="The service-quality survey given to out-patient, casualty, MCH and in-patient users. The only form in this set with no clinical extraction."/>
</concept>
<concept>
<code value="coagulation-profile-requisition"/>
<display value="Coagulation profile requisition"/>
<definition
value="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."/>
</concept>
<concept>
<code value="mortuary-services-request"/>
<display value="Mortuary services request form"/>
<definition
value="The request that accompanies a body into the mortuary, covering both hospital deaths and bodies brought from home or by the police."/>
</concept>
<concept>
<code value="mortuary-release"/>
<display value="Mortuary release form"/>
<definition
value="The release of a body for transfer to another hospital's morgue."/>
</concept>
<concept>
<code value="mortuary-baby-disposal-consent"/>
<display value="Mortuary consent form, disposal of a baby"/>
<definition
value="The authorisation given by a parent or next of kin for the hospital to dispose of a baby's body."/>
</concept>
<concept>
<code value="mortuary-admission"/>
<display value="Mortuary admission form"/>
<definition
value="The admission of a body into the mortuary: registration tag, where the body came from, next of kin and the relatives accompanying it."/>
</concept>
<concept>
<code value="body-part-disposal-consent"/>
<display value="Body part disposal consent form"/>
<definition
value="The consent taken before surgery for what happens to a removed body part -- released to the family, or disposed of by the hospital."/>
</concept>
<concept>
<code value="paediatric-nebulization-chart"/>
<display value="Paediatric nebulization chart"/>
<definition
value="Each nebulisation given: the drug, the amount and the frequency, with the time it was given and who gave it."/>
</concept>
<concept>
<code value="surgical-irrigation-record"/>
<display value="Surgical continuous irrigation record"/>
<definition
value="The hourly balance of a continuous bladder irrigation: solution and volume in against volume out, with the colour of the return."/>
</concept>
<concept>
<code value="milk-feeding-chart"/>
<display value="Milk feeding chart"/>
<definition
value="The three-hourly feed target against what was actually given, what was retained, and whether the baby passed urine and stool."/>
</concept>
<concept>
<code value="vent-monitoring-chart"/>
<display value="Ventilator monitoring chart"/>
<definition
value="The ventilator settings charted over time: mode, PEEP, peak inspiratory pressure and FiO2, with the changes made."/>
</concept>
<concept>
<code value="cpap-monitoring-chart"/>
<display value="CPAP monitoring chart"/>
<definition
value="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."/>
</concept>
<concept>
<code value="embalming-authorization"/>
<display value="Embalming authorization form"/>
<definition
value="The next of kin's authorisation for a body to be embalmed while the burial is arranged."/>
</concept>
<concept>
<code value="paediatric-vital-sign-chart"/>
<display value="Paediatric vital sign observation chart"/>
<definition
value="Four observation rounds a day over ten days: temperature and how it was controlled, pulse, respiration, blood pressure, oxygen saturation and any oxygen given."/>
</concept>
<concept>
<code value="admission-form"/>
<display value="Admission form"/>
<definition
value="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."/>
</concept>
<concept>
<code value="rehabilitation-services"/>
<display value="Rehabilitation services record"/>
<definition
value="Each rehabilitation contact: the units billed, the devices and materials used, and the progress note."/>
</concept>
<concept>
<code value="nicu-monitoring-chart"/>
<display value="NICU monitoring chart"/>
<definition
value="The neonatal unit's hourly chart: vitals, an assessment including jaundice and apnoea, the ventilator settings and the blood gas."/>
</concept>
<concept>
<code value="theatre-pacu-observation"/>
<display value="Theatre PACU observation form"/>
<definition
value="Timed recovery-room observations after anaesthesia, with the drugs given and remarks."/>
</concept>
<concept>
<code value="pacu-nurses-notes"/>
<display value="PACU nurses notes"/>
<definition
value="The recovery-room nursing narrative, timestamped and signed per entry."/>
</concept>
<concept>
<code value="theatre-note"/>
<display value="Theatre note"/>
<definition
value="The operation note: diagnosis, procedure, incision, the surgical and anaesthetic team, and the description of what was done."/>
</concept>
<concept>
<code value="doctors-notes"/>
<display value="Doctors notes continuation sheet"/>
<definition
value="The ward round narrative, timestamped and signed per entry."/>
</concept>
<concept>
<code value="surgical-dressing-chart"/>
<display value="Surgical dressing chart"/>
<definition
value="Each dressing change, with the sheet's own three-letter grading and a remark."/>
</concept>
<concept>
<code value="feeding-and-position-chart"/>
<display value="Feeding and position chart"/>
<definition
value="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."/>
</concept>
<concept>
<code value="nursing-care-plan"/>
<display value="Nursing care plan"/>
<definition
value="The full nursing process per problem: assessment, nursing diagnosis, expected outcome, intervention, the scientific rationale for it, what was implemented and the evaluation."/>
</concept>
<concept>
<code value="intake-output-record"/>
<display value="Intake and output record"/>
<definition
value="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."/>
</concept>
<concept>
<code value="antenatal-vital-signs"/>
<display value="Antenatal vital signs"/>
<definition
value="Timed antenatal observations: temperature, pulse, respiration and blood pressure with the lie, the presentation, the fetal heart tones and whether the bowels have opened."/>
</concept>
<concept>
<code value="paediatric-tb-icf-screening"/>
<display value="Paediatric TB intensified case finding screening tool"/>
<definition
value="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."/>
</concept>
<concept>
<code value="optical-prescription"/>
<display value="Optical prescription"/>
<definition
value="The eyewear prescription an optometrist or ophthalmologist writes: sphere, cylinder, axis, pupillary distance and visual acuity for each eye at distance and near, the reading addition, the lens type and coating, and the prescriber -- plus the contact lens prescription where one is written."/>
</concept>
<concept>
<code value="oncology-initial-assessment"/>
<display value="Oncology initial assessment form"/>
<definition
value="The oncology clinic's first assessment of a new patient: measurements and vital signs, the referral, the diagnosis and stage, the history including family history of cancer, the female patient section, social history, histology and immunohistochemistry, previous treatment, examination with the ECOG performance status, the radiology summary and the treatment plan."/>
</concept>
<concept>
<code value="cancer-treatment-consent"/>
<display value="Cancer centre informed consent"/>
<definition
value="The patient's consent to chemotherapy, hormonal or targeted therapy: the diagnosis and the drug regimen explained, the intended purpose of the treatment, the common side effects and risks, and the signatures of the patient, any interpreter and the doctor."/>
</concept>
<concept>
<code value="hormonal-therapy-treatment-plan"/>
<display value="Hormonal therapy treatment plan"/>
<definition
value="The running sheet for a patient on hormonal therapy, one row per cycle: the date, the cycle number, the drug given, the PSA, calcium and alkaline phosphatase, remarks, and the date to come again."/>
</concept>
</CodeSystem>