{ "resourceType" : "CodeSystem", "id" : "inpatient-document-type-codesystem", "text" : { "status" : "generated", "div" : "

Generated Narrative: CodeSystem inpatient-document-type-codesystem

This case-sensitive code system https://fhir.slade360.co.ke/fhir/CodeSystem/inpatient-document-type-codesystem defines the following codes:

CodeDisplayDefinition
progress-note Progress noteInterval change since the last entry, and the plan from here.
admission-note Admission noteThe narrative account of why the patient was admitted.
nursing-note Nursing noteNursing observation and care given during a shift.
ward-round-note Ward roundThe consultant round entry: findings, decisions and jobs for the team.
shift-handover-note Shift handoverWhat the next shift needs to know about the patient.
discharge-note Discharge noteThe summary the patient and their next clinician leave with.
death-note Death noteThe record of a death, its circumstances and who was informed. Distinct from the death certificate, which is a civil registration document.
adult-general-admission-assessment Adult general admission assessmentThe baseline taken on arrival to the ward, for any adult admission.
obstetric-admission-assessment Obstetric admission assessmentTaken on admission to the maternity ward, before the first review.
surgical-preoperative-assessment Surgical pre-operative assessmentCompleted before theatre, confirming fitness and consent.
critical-care-assessment Critical care assessmentOrgan support and conscious level, for a patient in critical care.
paediatric-admission-assessment Paediatric admission assessmentThe baseline for a child, including who is staying with them.
falls-and-pressure-ulcer-risk-assessment Falls and pressure ulcer riskBraden and falls risk together, reassessed daily and on any change.
nutrition-screening Nutrition screening (MUST)Malnutrition screening, repeated weekly for an inpatient.
mental-health-risk-assessment Mental health risk assessmentMood, risk and capacity, with any safeguarding concern.
" }, "url" : "https://fhir.slade360.co.ke/fhir/CodeSystem/inpatient-document-type-codesystem", "version" : "0.1.0", "name" : "SGHIInpatientDocumentTypeCodeSystem", "title" : "SGHI Inpatient Document Type Code System", "status" : "active", "experimental" : false, "date" : "2026-09-15T11:40:24+00:00", "publisher" : "Kathurima Kimathi", "contact" : [{ "name" : "Kathurima Kimathi", "telecom" : [{ "system" : "url", "value" : "https://www.linkedin.com/in/kathurima-kimathi/" }, { "system" : "email", "value" : "kathurimakimathi415@gmail.com" }] }, { "name" : "Oscar John", "telecom" : [{ "system" : "email", "value" : "oscarjohnotieno@gmail.com", "use" : "work" }] }, { "name" : "Kennedy Omondi", "telecom" : [{ "system" : "email", "value" : "kennankole@gmail.com", "use" : "work" }] }], "description" : "The notes and assessments written against an inpatient stay. LOINC already names four of these — progress note, history and physical, nurse note and discharge summary — and each carries its LOINC code alongside its SGHI code. The other eleven have no LOINC equivalent that says the same thing. It is a document classification, so it serves Composition.type and DocumentReference.type once a note is filed.", "caseSensitive" : true, "content" : "complete", "count" : 15, "concept" : [{ "code" : "progress-note", "display" : "Progress note", "definition" : "Interval change since the last entry, and the plan from here." }, { "code" : "admission-note", "display" : "Admission note", "definition" : "The narrative account of why the patient was admitted." }, { "code" : "nursing-note", "display" : "Nursing note", "definition" : "Nursing observation and care given during a shift." }, { "code" : "ward-round-note", "display" : "Ward round", "definition" : "The consultant round entry: findings, decisions and jobs for the team." }, { "code" : "shift-handover-note", "display" : "Shift handover", "definition" : "What the next shift needs to know about the patient." }, { "code" : "discharge-note", "display" : "Discharge note", "definition" : "The summary the patient and their next clinician leave with." }, { "code" : "death-note", "display" : "Death note", "definition" : "The record of a death, its circumstances and who was informed. Distinct from the death certificate, which is a civil registration document." }, { "code" : "adult-general-admission-assessment", "display" : "Adult general admission assessment", "definition" : "The baseline taken on arrival to the ward, for any adult admission." }, { "code" : "obstetric-admission-assessment", "display" : "Obstetric admission assessment", "definition" : "Taken on admission to the maternity ward, before the first review." }, { "code" : "surgical-preoperative-assessment", "display" : "Surgical pre-operative assessment", "definition" : "Completed before theatre, confirming fitness and consent." }, { "code" : "critical-care-assessment", "display" : "Critical care assessment", "definition" : "Organ support and conscious level, for a patient in critical care." }, { "code" : "paediatric-admission-assessment", "display" : "Paediatric admission assessment", "definition" : "The baseline for a child, including who is staying with them." }, { "code" : "falls-and-pressure-ulcer-risk-assessment", "display" : "Falls and pressure ulcer risk", "definition" : "Braden and falls risk together, reassessed daily and on any change." }, { "code" : "nutrition-screening", "display" : "Nutrition screening (MUST)", "definition" : "Malnutrition screening, repeated weekly for an inpatient." }, { "code" : "mental-health-risk-assessment", "display" : "Mental health risk assessment", "definition" : "Mood, risk and capacity, with any safeguarding concern." }] }