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="inpatient-clinical-concept-codesystem"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: CodeSystem inpatient-clinical-concept-codesystem</b></p><a name="inpatient-clinical-concept-codesystem"> </a><a name="hcinpatient-clinical-concept-codesystem"> </a><p>This case-sensitive code system <code>https://fhir.slade360.co.ke/fhir/CodeSystem/inpatient-clinical-concept-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">must-bmi-score<a name="inpatient-clinical-concept-codesystem-must-bmi-score"> </a></td><td>BMI score (MUST)</td><td>The body mass index step of the Malnutrition Universal Screening Tool, scored 0 to 2. LOINC has a code for the MUST screening itself (101789-6) but none for its three steps.</td></tr><tr><td style="white-space:nowrap">must-weight-loss-score<a name="inpatient-clinical-concept-codesystem-must-weight-loss-score"> </a></td><td>Unplanned weight loss score (MUST)</td><td>The unplanned weight loss step of the Malnutrition Universal Screening Tool, scored 0 to 2 over the preceding three to six months.</td></tr><tr><td style="white-space:nowrap">must-acute-disease-score<a name="inpatient-clinical-concept-codesystem-must-acute-disease-score"> </a></td><td>Acute disease effect score (MUST)</td><td>The acute disease effect step of the Malnutrition Universal Screening Tool, scored 0 or 2 on whether the patient has had no nutritional intake for five days or more.</td></tr><tr><td style="white-space:nowrap">organ-support<a name="inpatient-clinical-concept-codesystem-organ-support"> </a></td><td>Organ support needed</td><td>A narrative account of the organ support a critically ill patient is receiving. LOINC has codes for individual supports but none for the summary the critical care assessment asks for.</td></tr><tr><td style="white-space:nowrap">feeding<a name="inpatient-clinical-concept-codesystem-feeding"> </a></td><td>Feeding</td><td>A narrative account of how a child is being fed, as recorded on a paediatric admission assessment.</td></tr><tr><td style="white-space:nowrap">mood-and-affect<a name="inpatient-clinical-concept-codesystem-mood-and-affect"> </a></td><td>Mood and affect</td><td>The mood and affect component of a mental state examination, recorded as narrative.</td></tr><tr><td style="white-space:nowrap">capacity-to-consent<a name="inpatient-clinical-concept-codesystem-capacity-to-consent"> </a></td><td>Capacity to consent</td><td>Whether the patient has capacity to consent to the decision in front of them, and whether that capacity is fluctuating.</td></tr><tr><td style="white-space:nowrap">self-harm-risk<a name="inpatient-clinical-concept-codesystem-self-harm-risk"> </a></td><td>Risk of self-harm</td><td>The type of a risk assessment whose predicted outcome is self-harm. LOINC 93374-7 covers suicide risk specifically; self-harm is the wider concept the mental health assessment asks about.</td></tr><tr><td style="white-space:nowrap">ward-round-job<a name="inpatient-clinical-concept-codesystem-ward-round-job"> </a></td><td>Job for the team from a ward round</td><td>A piece of work the ward round left for the team. The HL7 task-code system enumerates what to do to a request (fulfil, abort, replace) rather than what a ward round asks for.</td></tr><tr><td style="white-space:nowrap">discharge-follow-up<a name="inpatient-clinical-concept-codesystem-discharge-follow-up"> </a></td><td>Follow-up arranged on discharge</td><td>The follow-up a discharge note arranges, as a request rather than a booked appointment. The discharge note captures it as free text, so no date is available to book against.</td></tr><tr><td style="white-space:nowrap">planned-procedure<a name="inpatient-clinical-concept-codesystem-planned-procedure"> </a></td><td>Planned procedure</td><td>The procedure a pre-operative assessment was carried out for. The form captures it as free text, so the request carries the wording rather than a procedure code.</td></tr><tr><td style="white-space:nowrap">dietitian-referral<a name="inpatient-clinical-concept-codesystem-dietitian-referral"> </a></td><td>Referral to a dietitian</td><td>A request for dietetic assessment, raised from a nutrition screening that scored in the high-risk band.</td></tr><tr><td style="white-space:nowrap">falls-prevention-plan<a name="inpatient-clinical-concept-codesystem-falls-prevention-plan"> </a></td><td>Falls and pressure ulcer prevention measures</td><td>The category of a care plan recording the measures put in place because of a falls or pressure ulcer risk score.</td></tr><tr><td style="white-space:nowrap">nutrition-care-plan<a name="inpatient-clinical-concept-codesystem-nutrition-care-plan"> </a></td><td>Nutritional plan</td><td>The category of a care plan recording what will be done about a patient's nutrition after screening.</td></tr><tr><td style="white-space:nowrap">oral-intake-at-discharge<a name="inpatient-clinical-concept-codesystem-oral-intake-at-discharge"> </a></td><td>Oral intake tolerated at discharge</td><td>Whether the patient is managing food and drink well enough to leave. Answered from SGHIDischargeOralIntake.</td></tr><tr><td style="white-space:nowrap">mobility-at-discharge<a name="inpatient-clinical-concept-codesystem-mobility-at-discharge"> </a></td><td>Mobility at discharge</td><td>How much help the patient needs to move as they leave, which decides what has to be waiting for them at home. LOINC's mobility terms belong to scored instruments — the IRF-PAI and LCDS items, and 83186-7 for ambulation as functional ability — and carry those instruments' answer lists rather than this question's. Answered from SGHIDischargeMobility.</td></tr><tr><td style="white-space:nowrap">pain-control-at-discharge<a name="inpatient-clinical-concept-codesystem-pain-control-at-discharge"> </a></td><td>Pain control at discharge</td><td>Whether pain is held well enough on what the patient can take at home. LOINC 99997-9, 'Demonstrates AndOr reports adequate pain control', is close in wording but is an instrument item answered yes or no, where this question grades the control on four levels. Answered from SGHIDischargePainControl.</td></tr><tr><td style="white-space:nowrap">patient-condition-at-discharge<a name="inpatient-clinical-concept-codesystem-patient-condition-at-discharge"> </a></td><td>Condition at discharge</td><td>The state the patient is leaving in, against the state they arrived in. Not the discharge disposition: LOINC 52523-8 and HL7's discharge-disposition both say where the patient went, which is a different axis with its own value set. Answered from SGHIConditionAtDischarge.</td></tr><tr><td style="white-space:nowrap">danger-signs-explained<a name="inpatient-clinical-concept-codesystem-danger-signs-explained"> </a></td><td>Danger signs explained at discharge</td><td>What the patient and their family were told to watch for, in the clinician's words. The absence of this is what brings a patient back.</td></tr><tr><td style="white-space:nowrap">next-of-kin-briefed<a name="inpatient-clinical-concept-codesystem-next-of-kin-briefed"> </a></td><td>Next of kin briefed at discharge</td><td>The person briefed alongside the patient, named as the ward wrote them down. Their relationship rides as a component rather than a second Observation, because a name and what that person is to the patient are two halves of one fact.</td></tr><tr><td style="white-space:nowrap">relationship-to-patient<a name="inpatient-clinical-concept-codesystem-relationship-to-patient"> </a></td><td>Relationship to the patient</td><td>What the person briefed alongside the patient is to them. Names the Observation.component that carries it; the answer comes from SGHINextOfKinRelationship.</td></tr><tr><td style="white-space:nowrap">medicines-explained-at-discharge<a name="inpatient-clinical-concept-codesystem-medicines-explained-at-discharge"> </a></td><td>Take-home medicines explained at discharge</td><td>Who had the take-home medicines gone through with them, including nobody, which is a fact worth stating rather than a blank. Answered from SGHIDischargeEducationRecipient.</td></tr><tr><td style="white-space:nowrap">account-settlement-at-discharge<a name="inpatient-clinical-concept-codesystem-account-settlement-at-discharge"> </a></td><td>How the account was settled at discharge</td><td>The cashier's or billing clerk's record that the account was dealt with before the patient left. Answered from SGHIAccountSettlement.</td></tr></table></div>
</text>
<url
value="https://fhir.slade360.co.ke/fhir/CodeSystem/inpatient-clinical-concept-codesystem"/>
<version value="0.1.0"/>
<name value="SGHIInpatientClinicalConceptCodeSystem"/>
<title value="SGHI Inpatient Clinical Concept 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 concepts the inpatient notes and assessments record that no LOINC or HL7 concept covers. Every code here was minted only after searching LOINC and finding nothing equivalent; where LOINC does have the concept the extraction maps use LOINC and nothing is added here. These appear as Observation.code, RiskAssessment.code, Task.code, ServiceRequest.code and CarePlan.category on the resources the maps extract."/>
<caseSensitive value="true"/>
<content value="complete"/>
<count value="23"/>
<concept>
<code value="must-bmi-score"/>
<display value="BMI score (MUST)"/>
<definition
value="The body mass index step of the Malnutrition Universal Screening Tool, scored 0 to 2. LOINC has a code for the MUST screening itself (101789-6) but none for its three steps."/>
</concept>
<concept>
<code value="must-weight-loss-score"/>
<display value="Unplanned weight loss score (MUST)"/>
<definition
value="The unplanned weight loss step of the Malnutrition Universal Screening Tool, scored 0 to 2 over the preceding three to six months."/>
</concept>
<concept>
<code value="must-acute-disease-score"/>
<display value="Acute disease effect score (MUST)"/>
<definition
value="The acute disease effect step of the Malnutrition Universal Screening Tool, scored 0 or 2 on whether the patient has had no nutritional intake for five days or more."/>
</concept>
<concept>
<code value="organ-support"/>
<display value="Organ support needed"/>
<definition
value="A narrative account of the organ support a critically ill patient is receiving. LOINC has codes for individual supports but none for the summary the critical care assessment asks for."/>
</concept>
<concept>
<code value="feeding"/>
<display value="Feeding"/>
<definition
value="A narrative account of how a child is being fed, as recorded on a paediatric admission assessment."/>
</concept>
<concept>
<code value="mood-and-affect"/>
<display value="Mood and affect"/>
<definition
value="The mood and affect component of a mental state examination, recorded as narrative."/>
</concept>
<concept>
<code value="capacity-to-consent"/>
<display value="Capacity to consent"/>
<definition
value="Whether the patient has capacity to consent to the decision in front of them, and whether that capacity is fluctuating."/>
</concept>
<concept>
<code value="self-harm-risk"/>
<display value="Risk of self-harm"/>
<definition
value="The type of a risk assessment whose predicted outcome is self-harm. LOINC 93374-7 covers suicide risk specifically; self-harm is the wider concept the mental health assessment asks about."/>
</concept>
<concept>
<code value="ward-round-job"/>
<display value="Job for the team from a ward round"/>
<definition
value="A piece of work the ward round left for the team. The HL7 task-code system enumerates what to do to a request (fulfil, abort, replace) rather than what a ward round asks for."/>
</concept>
<concept>
<code value="discharge-follow-up"/>
<display value="Follow-up arranged on discharge"/>
<definition
value="The follow-up a discharge note arranges, as a request rather than a booked appointment. The discharge note captures it as free text, so no date is available to book against."/>
</concept>
<concept>
<code value="planned-procedure"/>
<display value="Planned procedure"/>
<definition
value="The procedure a pre-operative assessment was carried out for. The form captures it as free text, so the request carries the wording rather than a procedure code."/>
</concept>
<concept>
<code value="dietitian-referral"/>
<display value="Referral to a dietitian"/>
<definition
value="A request for dietetic assessment, raised from a nutrition screening that scored in the high-risk band."/>
</concept>
<concept>
<code value="falls-prevention-plan"/>
<display value="Falls and pressure ulcer prevention measures"/>
<definition
value="The category of a care plan recording the measures put in place because of a falls or pressure ulcer risk score."/>
</concept>
<concept>
<code value="nutrition-care-plan"/>
<display value="Nutritional plan"/>
<definition
value="The category of a care plan recording what will be done about a patient's nutrition after screening."/>
</concept>
<concept>
<code value="oral-intake-at-discharge"/>
<display value="Oral intake tolerated at discharge"/>
<definition
value="Whether the patient is managing food and drink well enough to leave. Answered from SGHIDischargeOralIntake."/>
</concept>
<concept>
<code value="mobility-at-discharge"/>
<display value="Mobility at discharge"/>
<definition
value="How much help the patient needs to move as they leave, which decides what has to be waiting for them at home. LOINC's mobility terms belong to scored instruments — the IRF-PAI and LCDS items, and 83186-7 for ambulation as functional ability — and carry those instruments' answer lists rather than this question's. Answered from SGHIDischargeMobility."/>
</concept>
<concept>
<code value="pain-control-at-discharge"/>
<display value="Pain control at discharge"/>
<definition
value="Whether pain is held well enough on what the patient can take at home. LOINC 99997-9, 'Demonstrates AndOr reports adequate pain control', is close in wording but is an instrument item answered yes or no, where this question grades the control on four levels. Answered from SGHIDischargePainControl."/>
</concept>
<concept>
<code value="patient-condition-at-discharge"/>
<display value="Condition at discharge"/>
<definition
value="The state the patient is leaving in, against the state they arrived in. Not the discharge disposition: LOINC 52523-8 and HL7's discharge-disposition both say where the patient went, which is a different axis with its own value set. Answered from SGHIConditionAtDischarge."/>
</concept>
<concept>
<code value="danger-signs-explained"/>
<display value="Danger signs explained at discharge"/>
<definition
value="What the patient and their family were told to watch for, in the clinician's words. The absence of this is what brings a patient back."/>
</concept>
<concept>
<code value="next-of-kin-briefed"/>
<display value="Next of kin briefed at discharge"/>
<definition
value="The person briefed alongside the patient, named as the ward wrote them down. Their relationship rides as a component rather than a second Observation, because a name and what that person is to the patient are two halves of one fact."/>
</concept>
<concept>
<code value="relationship-to-patient"/>
<display value="Relationship to the patient"/>
<definition
value="What the person briefed alongside the patient is to them. Names the Observation.component that carries it; the answer comes from SGHINextOfKinRelationship."/>
</concept>
<concept>
<code value="medicines-explained-at-discharge"/>
<display value="Take-home medicines explained at discharge"/>
<definition
value="Who had the take-home medicines gone through with them, including nobody, which is a fact worth stating rather than a blank. Answered from SGHIDischargeEducationRecipient."/>
</concept>
<concept>
<code value="account-settlement-at-discharge"/>
<display value="How the account was settled at discharge"/>
<definition
value="The cashier's or billing clerk's record that the account was dealt with before the patient left. Answered from SGHIAccountSettlement."/>
</concept>
</CodeSystem>