This resouce allows for the definition of some activity to be performed, independent of a particular patient, practitioner, or other performance context.

Risk of harmful or undesirable physiological response which is specific to an individual and associated with exposure to a substance.

A booking of a healthcare event among patient(s), practitioner(s), related person(s) and/or device(s) for a specific date/time. This may result in one or more Encounter(s).

A profile on the R5 CarePlan resource to represent a patient's treatment or management plan, such as a chemotherapy regimen.

A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.).

A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.

A record of a healthcare consumer’s choices or choices made on their behalf by a third party, which permits or denies identified recipient(s) or recipient role(s) to perform one or more actions within a given policy context, for specific purposes and periods of time.

SGHI's profile for DiagnosticReport

A reference to a document of any kind for any purpose.

An interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient. Encounter is primarily used to record information about the actual activities that occurred, where Appointment is used to record planned activities.

An association between a patient and an organization / healthcare provider(s) during which time encounters may occur. The managing organization assumes a level of responsibility for the patient during this time.

SGHI profile for location

SGHI's Medication profile for Medication resource

SGHI's profile for Medication Dispense resource

An order or request for both supply of the medication and the instructions for administration of the medication to a patient. The resource is called 'MedicationRequest' rather than 'MedicationPrescription' or 'MedicationOrder' to generalize the use across inpatient and outpatient settings, including care plans, etc., and to harmonize with workflow patterns.

Measurements and simple assertions made about a patient, device or other subject.

SGHI's profile for Organization

Demographics and other administrative information about an individual or animal receiving care or other health-related services.

This resource allows for the definition of various types of plans as a sharable, consumable, and executable artifact.

SGHI's Practitioner used in SGHI systems

PractitionerRole describes the types of services that practitioners provide to SGHI Organization at specific location(s). The profile a specific set of Roles/Locations/specialties/services that a practitioner may perform at an organization for a period of time.

This resource is used to record the details of current and historical procedures performed on, with, or for a patient, practitioner, device, organization, or location. Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counseling, physiotherapy, personal support services, adult day care services, non-emergency transportation, home modification, exercise, verification of enrollment qualifications for a social program etc. Procedures may be performed by a healthcare professional, a service provider, a friend or relative or in some cases by the patient themselves.

A QuestionnaireResponse captures the questions and answers to a Questionnaire.

An assessment of the likely outcome(s) for a patient or other subject as well as the likelihood of each outcome.

ServiceRequest represents an order or proposal or plan, as distinguished by ServiceRequest.intent to perform a diagnostic or other service on or for a patient. ServiceRequest represents a proposal or plan or order for a service to be performed that would result in a Procedure or DiagnosticReport, which in turn may reference one or more Observations, which summarize the performance of the procedures and associated documentation such as observations, images, findings that are relevant to the treatment/management of the subject. This resource may be used to share relevant information required to support a referral or a transfer of care request from one practitioner or organization to another when a patient is required to be referred to another provider for a consultation /second opinion and/or for short term or longer term management of one or more health issues or problems.

A sample to be used for analysis.

Profile for representing substances in the SGHI context

SGHI's profile for Task

A text note which also contains information about who made the statement and when.

A custom document used for capturing the source of consent

A CodeableConcept represents a value that is usually supplied by providing a reference to one or more terminologies or ontologies but may also be defined by the provision of text. This is a common pattern in healthcare data.

A reusable CodeableReference within SGHI systems

A custom contact point with stricter cardinality

A comprehensive Dosage profile for SGHI prescriptions, ensuring structured routes, methods, timing, and dose details.

A specialized human name data type with stricter cardinalities.

SGHI Reference

All codes from ICD-11

All codes from ICHI

A ValueSet that includes all codes from the LOINC code system.

Behaviour Value Sets

Units used for measuring blood pressure.

Cancer Stages Value Sets

Distance Metastatis Value Sets

Version 1

Grade Value Sets

Hormone Receptor Status

First Version

Laterality Value Sets

Molecular Markers Value Sets

Version 1

A ValueSet defining the possible routes of drug administration.

A ValueSet for a generic 0–10 labelled scale used for symptom severity or functional status.

The four ABO groups.

A ValueSet of comorbid conditions recorded during Antenatal Care (ANC) visits.

A ValueSet for nutritional supplements prescribed or dispensed during Antenatal Care.

A ValueSet indicating a patient's current antiretroviral (ARV) or HAART therapy status.

The American Society of Anesthesiologists physical status grade recorded on a pre-operative assessment. Extracted as an Observation against LOINC 97816-3.

The four-point AVPU conscious level screen. Kept apart from the Glasgow Coma Scale rather than mapped onto it: AVPU has four points and GCS fifteen, and translating one into the other would assert a conscious level nobody assessed. A child scored P or U on the triage sheet is an emergency by ETAT+, which is why the triage record asks for AVPU and not GCS.

On whose authority treatment proceeds. Absent means not recorded yet, which is a real and expected state on admission.

Why a queued admission is no longer needed. Reasons carrying ours-to-fix = true are the ones the hospital could have prevented.

Clinical priority of an admission request. Orders the admission queue and the bed board. A narrower set than SGHIActPriority: admissions has no ASAP band.

Whether a queued admission request is ready to proceed.

Where the patient was immediately before this admission.

Lifecycle of an admission, from the request through to discharge or cancellation.

Whether an admission raised from a consultation happens now or is booked for a date.

The kind of admission being requested. Changing it on an in-flight request requires a stated reason.

Where a patient was admitted from, from the two the admission form prints.

The clinical service taking responsibility for an admitted patient. A subset of the SGHI practitioner specialties, each mapped to a ward.

The bed states offered when allocating a bed on admission. Only an unoccupied bed qualifies; occupied, reserved, housekeeping, maintenance, contaminated, isolated and closed beds are all withheld.

The technique used, from the five the anaesthetic record offers. Sedation is listed as its own technique rather than as a depth of general anaesthesia, which is how the chart treats it and how the theatre bills it.

The three appearance bands of the Apgar score, weighted 0 to 2. Reused at one, five and ten minutes: the sign is the same at each time and only the LOINC question code changes.

The three muscle tone bands of the Apgar score, weighted 0 to 2.

The three pulse bands of the Apgar score, weighted 0 to 2. Bands, not a heart rate: the measured rate is a separate Observation coded to LOINC 8867-4, and the extraction map records both when the chart carries both.

The three reflex irritability bands of the Apgar score, weighted 0 to 2.

The three respiratory effort bands of the Apgar score, weighted 0 to 2.

Estimated age band of a patient who cannot identify themselves.

Apparent sex of a patient who cannot identify themselves. Recorded as an observation of appearance, not an assertion about the person.

The six arm-power grades on the ICU neurological observation chart, weighted 0 to 5.

How the patient physically arrived, as recorded on the emergency admission screen.

Who brought an unidentified patient in. Wider than SGHIArrivalMode, which records the manner of arrival rather than the party responsible for it.

The kind of bed a location represents, as distinct from its form, its class of room and its operational status.

A preference carried from the admission request. Absent means no preference; it is not a code.

Codes that can be used to indicate the operating status of an organization's location

The benefit package an admission is claimed against. Not asked for an emergency SHA episode, which routes to the emergency fund instead.

A ValueSet for the outcome of the birth.

The three cervical position bands of the Bishop score, weighted 0 to 2.

The three consistency bands of the Bishop score, weighted 0 to 2.

The four dilation bands of the Bishop score, weighted 0 to 3.

The four effacement bands of the Bishop score, weighted 0 to 3. Each band gives both readings the examiner may have taken — a percentage effaced or a cervical length — because the sheet prints both and the examiner uses whichever they measured.

The four station bands of the Bishop score, weighted 0 to 3. Bishop's own table collapses -1 and 0 into one band and +1 and +2 into another, which is what the sheet prints, so the value set does the same rather than offering the five stations separately.

The four products the blood requisition form offers.

A ValueSet for random blood sugar (RBS) screening results used in ANC workflows.

What is to happen to a body part removed at surgery, from the two options the disposal consent form prints.

Custom body site value set

Whether the bowels have opened, from the column the antenatal vital signs sheet prints.

The answers to the six Braden pressure ulcer scale items. The extracted Observation carries the total as its value and these as component values, coded against the LOINC Braden panel.

Why a clinician opened a record they are not assigned to. Recorded, not prevented.

A ValueSet for breast examination results recorded during ANC visits.

A ValueSet for the state of the breasts assessed during Postnatal Care visits.

A ValueSet for the state of the caesarean section wound site during PNC follow-up.

A ValueSet for central nervous system complications in chronic disease follow-up.

A ValueSet for danger signs assessed in children during Child Welfare Clinic visits.

A ValueSet for follow-up service types offered at the Child Welfare Clinic.

Whether a caesarean section was booked in advance or decided once labour or an urgent indication had begun. Offered only where the mode of delivery is #delivery-cs. It is asked rather than inferred because nothing else on the record carries the distinction: the time of operation does not give it, and it is the split maternity audit reports on.

Why an admission request was cancelled.

Whether the patient has capacity for the decision in front of them. Fluctuating is a distinct answer, not a hedge: it says the assessment holds only for the moment it was made.

The three bands the newborn sheet offers instead of a time in seconds. The sheet also prints an X for 'not possible'; that is an unanswered question, not a fourth band, and is deliberately absent.

A ValueSet for cardiac complications in chronic disease follow-up.

A ValueSet for the cervical cancer-related activity performed during today's visit.

A ValueSet for the method of cervical cancer screening performed during a visit.

A ValueSet for cervical cancer screening (VIA/VILI) results recorded in special-clinic workflows.

A ValueSet for the type of cervical cancer clinic visit.

The three answers a surgical safety checklist item takes. 'Not applicable' is a distinct answer and not a polite form of 'not done': the WHO checklist prints it for items such as site marking, where not applicable is correct completion, and an audit of checklist compliance has to be able to tell a correctly skipped item from a missed one.

A ValueSet for conditions managed during a chronic care follow-up visit.

The twelve chronic illnesses the admission form prints as a tick list with a date beside each. Local rather than SNOMED because the list is the hospital’s own shorthand – one column is headed CD4 and means HIV – and because a tick against a printed word is not a diagnosis, it is a reported history.

Why a discharge clearance was signed off without its check. A hard gate fails at two in the morning when the cashier has gone home, and somebody who cannot proceed goes round the system instead, which leaves no trace. This is what makes the gap reviewable: the reason is recorded against a named person, and a later signature does not remove it.

The kind of clinical form a Questionnaire represents. Bound at Questionnaire.useContext where the context code is workflow, so a form can be found by shape — every observation chart, every consent — across facilities rather than by the title one hospital prints on its own paper.

A ValueSet for colposcopy and cervicography findings.

The state the patient is leaving in, against the state they arrived in. Recorded on the clinical readiness clearance. The codes carry a condition- prefix because #improved already names a reason an admission was no longer needed, and the two are different axes.

Which of the hospital's three consent forms is being completed. Chooses the procedure-specific block and, on the extracted Consent, the provision the signature covers.

The admission types that can be requested from a consultation.

What a consultation decided to do with the patient.

Code used to indicate contact use

Contact relationship types used in SGHI systems

Code used to indicate what communications system is required to make use of the contact.

Whether a newborn's cord is fresh, dry or infected, as the newborn unit handover form asks it. Distinct from SGHIUmbilicusAppearance, which grades the stump on examination: this one tracks normal drying over the first days and that one looks for infection.

Whether a cross-match was compatible. Two answers, and the second is a stop: an incompatible unit must not be issued.

Where the patient is going after declining care. Recorded because a patient leaving for another hospital and a patient going home carry different follow-up obligations.

What the patient is refusing. The sheet prints 'care/procedure/assessment' as one slashed phrase; in practice a patient refuses one of the three or all of them, so the item repeats over this list rather than offering the phrase as a single answer.

SGHI Default Code Value Sets

Default identifier types used in SGHI's systems

A ValueSet for complications that occurred during delivery.

Which instrument was applied for an assisted vaginal delivery. Offered only where the mode of delivery is #delivery-avd, and required there: 'assisted' on its own does not say what was used, and a vacuum and a forceps birth carry different neonatal injury profiles that no later reading of the record can separate.

A ValueSet for developmental milestones assessed during Child Welfare Clinic (CWC) visits.

How the patient receives an ordered device. Bound to the device order form's 'How it is supplied' question, and carried through to DeviceRequest.parameter.valueCodeableConcept. The parameter identifier itself, #supply-method, is deliberately not in this value set: it names the question, not an answer to it.

ICD-11 codes used for diagnostic conclusions in SGHI

The vascular access used for a haemodialysis session. The four the unit uses, ordered as the guidelines prefer them: a fistula first, then a graft, then a tunnelled line, and a temporary catheter last.

How the account was dealt with before the patient left. Recorded on the financial clearance. Carries no balance: the figure belongs to billing, and one restated here would be signed against as though this were the authority for it.

Where the patient is going. Asked only of a living patient leaving with an agreed plan: a death has no disposition, and a transfer out names the receiving facility instead.

Who had the take-home medicines explained to them. Recorded on the patient education clearance. Includes a code for nobody having been told, because that is a fact worth stating rather than a blank to be read as an oversight.

How much help the patient needs to move at discharge, which decides what has to be waiting for them at home. Recorded on the clinical readiness clearance.

Whether the patient is managing food and drink well enough to leave. Recorded on the clinical readiness clearance.

Whether pain is held well enough on what the patient can take at home. Recorded on the clinical readiness clearance.

How an admission ended. Decides what the exit requires: a transfer out names the receiving facility, leaving against advice takes a signed form, an absconsion records the last sighting instead of a signature, and a death defers to the record of death.

Whether the collection is whole blood or an apheresis procedure. The two the KTTA form offers.

Whether a blood donor is replacing blood used for a named patient, donating voluntarily, or donating for their own later use. The KTTA form asks it because a replacement donation is tied to a recipient and a voluntary one is not, which changes what the unit may be used for.

A ValueSet defining the possible frequencies for medication intake in SGHI's systems.

A ValueSet defining the possible units of measurement for medication dosage in SGHI's systems.

Identifier types used across dm+d hierarchy

Why a booked elective admission was deferred.

What an emergency admission leaves outstanding. The stay carries these until someone closes them.

A ValueSet for emotional health symptoms reported during a clinical encounter.

Urgency of an encounter

The five studies the endoscopy investigation form lists. A different list from SGHIEndoscopyProcedure on the consent form, and deliberately so: the consent authorises a procedure and this records which one was done, and the hospital's two forms do not offer the same five.

The four procedures the endoscopy consent form lists. The paper asks the clinician to strike through those that do not apply; this asks them to tick those that do, which is the same information the other way up and far harder to misread.

A ValueSet for the healing state of an episiotomy wound assessed during PNC.

A ValueSet defining the possible timing options for events in SGHI's systems.

A ValueSet for eye-related complications in chronic disease follow-up.

A ValueSet enumerating complications associated with Female Genital Mutilation (FGM).

A ValueSet enumerating family planning methods offered or selected in special-clinic workflows.

How a newborn feed is given. Cup, nasogastric or orogastric — the three the chart prints.

What a newborn is being fed, from the feed prescription on the newborn comprehensive chart.

The relation of the fetal long axis to the uterine long axis. Separate from presentation, which LOINC 11876-0 covers and the maternity record asks for on the next line: lie says which way the fetus lies, presentation says which part is coming first.

What is presenting at the pelvic brim. The antenatal vital signs sheet takes this as free text; coding it makes a change from cephalic to breech across a series of rows visible as a change rather than as two different strings.

A ValueSet for the final HIV result at an ANC visit, capturing previously known status.

The three-point grading the paediatric and newborn sheets print as 0 / + / +++, used for jaundice and for pallor. Three points, not a continuum: the paper offers no middle grade and grading one in would put a reading on the chart that nobody made.

A ValueSet for fistula types used in gynaecological and obstetric workflows.

Which of the three daily rounds a newborn follow-up row belongs to — the chart's M, E and N columns.

The four eye-opening grades of the Glasgow Coma Scale, weighted 1 to 4. Reuses the IG's own clinical-score-codesystem.

The six motor-response grades of the Glasgow Coma Scale, weighted 1 to 6. Reuses the IG's own clinical-score-codesystem.

The five verbal-response grades of the Glasgow Coma Scale, weighted 1 to 5. Reuses the IG's own clinical-score-codesystem.

A ValueSet for a general positive / negative / not-applicable result used across clinical workflows.

The answers to the three Glasgow Coma Scale components. The extracted Observation carries the total against LOINC 9269-2 and these as component values against the eye, verbal and motor codes.

A ValueSet for HIV rapid test results: Positive (P), Negative (N), Invalid (I), and Not Applicable (NA).

A ValueSet indicating whether the HIV test at a visit is an initial test or a retest.

The four-point conscious level printed on the head injury and craniotomy chart. Deliberately not the Glasgow Coma Scale and deliberately not AVPU: this chart prints its own four levels with its own wording, and mapping them onto either scale would invent a precision the chart does not have.

A ValueSet for height/length-for-age growth categories used in Child Welfare Clinic (CWC) workflows.

A ValueSet for Intermittent Preventive Treatment (IPT) doses administered during ANC.

Which of the two request forms this is. The answer decides whether the ultrasound pick list is shown and which ServiceRequest category the extraction map assigns.

Immunisation status as reported by the carer on a paediatric admission. Extracted as an Observation against LOINC 11370-4, which is explicitly the reported status rather than a dose given.

The infant ARV prophylaxis given for PMTCT, as the newborn handover form prints it.

The concepts the inpatient forms record that LOINC has no code for. Used as Observation.code, RiskAssessment.code, Task.code, ServiceRequest.code and CarePlan.category on resources extracted from those forms.

The kind of note or assessment written against an inpatient stay. Binds Composition.type and DocumentReference.type for a filed inpatient note.

ValueSet containing SGHI investigation codes

The colour of the return on the surgical continuous irrigation record. Clots are listed separately from blood staining because clots are what obstruct a catheter and call a surgeon, and a colour scale that cannot say "clots" loses the one observation the chart exists to catch.

Antigens recorded on the MOH 510 Immunisation Permanent Register. Bound by Immunization.vaccineCode on resources extracted from the register.

Micronutrient supplements recorded alongside immunisation on the MOH 510 register. Bound by MedicationAdministration.medication.concept on resources extracted from section Z.

The three degrees of urgency the medical lab requisition and the coagulation profile form print. Separate from the blood requisition’s set, whose third option is worded "elective" rather than "routine" — the same idea, but these are the words on these forms.

The five leg-power grades on the ICU neurological observation chart, weighted 0 to 4. One grade fewer than the arms: the chart offers no spastic flexion for a leg.

The intensity of nursing and monitoring an admission needs. Ranked by the care-rank property: a request outranking what a ward can nurse warns rather than blocks.

The post-operative check's three levels. The sheet prints a fourth box, 'unconscious'; that is deliberately not here, because an unconscious post-operative patient needs a Glasgow Coma Scale charted rather than a tick, and the checklist item should be left unanswered.

Which line of systemic anti-cancer therapy is being prescribed. Asked on the chemotherapy prescription because the line is what decides the regimen, and because a patient moving to a later line has progressed, which the record should show.

Physical form of the location, e.g. building, room, vehicle, road, virtual.

Codes that can be used to indicate the mode of a location

A ValueSet for the state of lochia (postpartum vaginal discharge) assessed during PNC.

A ValueSet for Mid-Upper Arm Circumference (MUAC) nutritional status categories used in special-clinic workflows.

Which malaria test is being ordered. Repeatable, because the sheet lets a clinician order both.

The answers to the three MUST steps: body mass index, unplanned weight loss and acute disease effect. The extracted Observation carries the total, banded low, medium or high per BAPEN.

The mother's status in the programme for prevention of mother-to-child transmission of HIV, as known when her child is admitted. Includes 'unknown' because on an unbooked admission it frequently is, and a child of unknown maternal status is managed as exposed until tested — so the unknown has to be recordable.

What happened to a medication dose at the drug round. Recorded alongside MedicationAdministration.status rather than in it: status is a required binding on which Refused and Omitted are both #not-done.

ValueSet containing SGHI medication codes

ValueSet containing SGHI medication form codes

ValueSet containing SGHI medication forms

Why a dose was held. A held dose is withheld on clinical grounds and expected to be given later, which is what separates it from an omitted one.

Every reason a dose was not given, across held, refused and omitted. Bound at MedicationAdministration.statusReason, where the HL7 binding is example strength. Which outcome a reason implies comes from the narrower set it belongs to.

Why a dose passed without being given. A reason carrying supply-failure = true is a stock-out rather than a clinical decision, and is escalated to pharmacy.

Why a patient did not take a dose. The patient's own decision, as distinct from a clinical decision to hold and from a dose that simply passed.

Whether the membranes are intact or ruptured at the time of examination. Recorded on both the maternity examination and every Bishop assessment, because rupture changes what a vaginal examination is allowed to do next.

Custom methods of administering medication

What a baby was fed on the milk feeding chart. The chart prints two columns, breast milk and a formula named by brand.

How the patient physically arrived on the ward. The admission form prints ambulance, wheelchair and cart; walked is added because a patient who walked in is a different patient and the paper records that by leaving all three boxes empty, which is indistinguishable from nobody asking.

A ValueSet for the mode of delivery recorded in PNC and ANC workflows.

How the baby was born, as the maternity and newborn records print it. Breech is listed separately from spontaneous vaginal delivery because the forms print it as its own box, and the two carry different neonatal risk.

The answers to the six falls risk items. The items are the Morse Fall Scale verbatim, so the extracted Observation is coded against the LOINC Morse panel and these are its component values.

Where a body received into the mortuary came from. This is the field that decides whether the deceased was a patient of this hospital at all, which is why it is coded rather than left as free text.

A ValueSet for the status of the baby after delivery.

A ValueSet for musculoskeletal complications in chronic disease follow-up.

The three acuity categories printed at the foot of the newborn comprehensive chart. They drive how often the baby is observed, which is why they are recorded per shift rather than once.

Pink or blue, as the skin-to-skin observation row asks it. Coarser than the three-band Apgar appearance on purpose: this is a two-hourly nursing check, not a scored assessment.

What the person briefed alongside the patient is to them. Recorded on the patient education clearance.

Why a patient was admitted without taking a deposit.

Interpretation codes used to flag an observation's value against its reference range. Screening and triage flagging only, not diagnostic criteria.

How far up the body oedema extends. Ordered by severity, because in a malnourished child the distribution is the grade: feet alone is +, to the knees is ++, and involvement of the face is +++.

Why an ordered item was stopped before it was done, as offered to the person cancelling it. #ordered-in-error is the odd one out and is deliberately included: the other four stop a request that was validly placed, while that one says it never should have been, and an audit that cannot tell those apart cannot tell a change of plan from a mistake. #parent-order-cancelled is deliberately excluded: the server sets it when a whole order is cancelled, and it is not a choice anyone makes.

A ValueSet defining the possible order forms in SGHI's systems.

Identifier types used to identify an organization across in SIL's systems

The modes of delivery that 'Other (specify)' stands for, offered only where the mode of delivery is #delivery-other. Closed and coded rather than free text so that a delivery recorded here can still be counted later; a free-text box returns several spellings of the same operation and no denominator. Every entry is a mode in its own right, not a reason for one.

The other-injury sites the head injury chart asks the examiner to tick. Repeating, because a patient can have more than one.

How oxygen was given during newborn resuscitation, from the three the handover form prints.

How supplemental oxygen or ventilatory support is being delivered, from room air through to invasive ventilation. Extracted as an Observation against LOINC 107117-4.

A ValueSet for the timing of Postnatal Care (PNC) visits relative to delivery.

A ValueSet indicating the presence or absence of postpartum haemorrhage (PPH).

Mild, moderate or severe, which is how the paediatric triage sheet grades pain. Not interchangeable with the 0 to 10 numeric rating the ward pain chart uses, and the extraction map codes it differently for that reason.

A ValueSet for the 0–10 labelled pain scale.

How the patient reached the palliative care service. The sheet prints five boxes — clinic, ward, private, staff and self — and the last three all mean the patient came without an internal referral, so they share one answer with the detail captured as text beside it.

A ValueSet for pallor severity assessed during PNC or ANC examinations.

A ValueSet for Pap smear results in cervical cancer screening.

A ValueSet capturing the HIV testing status of the patient's partner.

How a ventilated patient is positioned, recorded on the ICU observation chart because turning is what prevents pressure injury and the chart is where it is evidenced.

The kind of scheme behind a cover, which decides what the cover is capped in.

Who settles the admission. An unresolved payer holds the bill, never the bed: payment does not block admitting.

How a cash deposit was taken.

What happened to the perineum at delivery: intact, torn, or deliberately incised and repaired. A tear and an episiotomy are kept apart because one is a complication and the other a decision, and an audit that folds them together cannot measure either.

Normal or weak, the only two the paediatric sheet offers. A weak pulse with a capillary refill over three seconds is shock, which is why the sheet asks for both on the same line.

Identifier types used to identify patient, practitioner, animal or a live actor in the healthcare context in SGHI's systems

A ValueSet for physical health symptoms reported during a clinical encounter.

Where the baby was born, as the newborn admission record asks it: home, a facility, or somewhere else. Coarse on purpose — the form is establishing whether the birth was attended, not identifying the facility, which it asks for separately as free text.

A ValueSet indicating where the baby was delivered.

Whether the placenta and membranes came away complete. Two answers only, and the second is an instruction as much as a finding: incomplete means the uterus must be explored before the woman leaves the room.

The clinical specialties a practitioner can hold across SGHI's environment.

Custom practioner role value set

State of a pre-authorisation request to a payer. An admission may proceed with one still pending.

Whether a finding was observed. Separate from a plain yes/no because the head injury chart prints "present" and "absent" beside the fits row, and a finding that was looked for and not seen is a different statement from an unanswered question.

A value set for categorizing procedures, using LOINC codes where applicable.

Custom follow up procedure codes

The outcome of the procedure - did it resolve the reasons for the procedure being performed?

A value set for the status of a procedure, based on the FHIR ProcedureStatus codes.

How a pupil responds to light. 'Closed' is included and is not a synonym for 'fixed': a closed eye was not assessed, and a fixed pupil was assessed and did not react — which is the difference between missing data and a neurosurgical emergency.

Qualifies what a reference range on an observation represents.

A ValueSet for the source or destination of a patient referral in special-clinic workflows.

A ValueSet defining the possible identifiers that can be used for searching in SGHI's registries.

A ValueSet for renal complications in chronic disease follow-up.

How urgently a requisition is needed. 'Desperate' is the hospital's own word and sits above urgent — it means the patient is bleeding now. Kept as a local list rather than mapped onto ServiceRequest.priority, which has stat / asap / urgent / routine and no equivalent of the top band; the extraction map maps it down to stat and records the original alongside.

The decision recorded at a patient, family and doctors’ conference. Recorded explicitly in both directions: a conference that agreed resuscitation should be attempted is a different record from one where nobody asked.

What watching the child needs after admission. Repeatable: the sheet prints both boxes and a sick child gets both.

A ValueSet for body systems covered in the Review of Systems (ROS) assessment.

Rhesus D positive or negative.

The class of a room, used to filter free beds when allocating. A bed belonging to no room is an open bay.

Social Health Authority intervention codes claimable on an inpatient admission. Each carries whether it needs pre-authorisation and whether it draws on the emergency fund.

The five safety checks a team clears before a procedure starts: identity, site and side, allergies, equipment and implants, and team introductions. Built from the WHO checklist's own codes rather than local ones, so the short pause and the full three-phase checklist are countable together. Each check takes its answer from SGHIChecklistAnswer — confirmed, not applicable, or not done — which is what keeps a correctly skipped check distinguishable from a missed one. The reused codes are broader than the wording of the pause: identity arrives bundled with site, procedure and consent, and neither laterality nor implants is separately expressible.

The material a sample consists of, as chosen when collecting it. Distinct from SGHISpecimenTypeVs, which names the procedure that obtained the sample rather than the material.

The ultrasound request form's own seventeen-item pick list, in the order and grouping the paper prints — general, small parts, then the Doppler studies. Repeatable, because one request can ask for more than one.

The risk of self-harm identified on a mental health assessment. Extracted as a RiskAssessment whose qualitativeRisk carries both an HL7 risk-probability code and the answer itself, because four answers map onto five probability concepts and two of them share one.

The four-point rating on the patient satisfaction questionnaire.

How far up the limb the skin is still warm. Ordered by severity: the higher the level, the worse the peripheral perfusion.

How the draw went, recorded by whoever took the sample. A difficult or short draw does not reject the sample; it travels with it so the laboratory can read the result in light of it.

The container a sample is collected into. The collection screen offers the container the ordered test requires first, then the rest of this set.

ValueSet containing SGHI substance codes

The three grading letters printed over the columns of the surgical dressing sheet. The sheet never expands them, so the codes carry the letters as printed rather than an invented expansion – guessing at what B, M and S stand for and being wrong would be worse than recording the letter the nurse ticked.

Which of the WHO checklist's three phases a set of answers belongs to. Carried on the extracted Observation so a sign-out that never happened is visibly missing rather than indistinguishable from a sign-out with nothing ticked.

A ValueSet for the type of syphilis test performed during ANC screening.

A ValueSet for tuberculosis (TB) screening results in special-clinic workflows.

Whether an intervention is claimed for each night or once for the episode.

A ValueSet for tetanus toxoid (TT) doses administered during ANC.

The kind of move a patient is being made within the facility. Bound to the transfer form's 'Transfer type' question. A ward transfer gives up the sending bed, an escalation or de-escalation changes the level of care as well, and theatre and procedure are temporary moves the patient returns from with the bed held.

How urgently a child needs to be seen, from the four levels printed on the paediatric triage record. Local rather than the Canadian CTAS (LOINC 75910-0) or a five-level ESI: this is the Kenyan ETAT+ shorthand of emergency, priority, less urgent and well baby, and the timings printed beside it — immediate, and fifteen minutes — belong to ETAT+, not to either published scale.

The three states the newborn sheet offers for a cord stump. The third — pus with redness of the surrounding skin — is periumbilical cellulitis and is a separate answer from pus alone because it changes the management from cord care to systemic antibiotics.

A ValueSet for uterotonic drugs administered during delivery.

A ValueSet for the state of the uterus assessed during Postnatal Care visits.

A ValueSet for VIA, VILI, and HPV test results in cervical cancer screening.

A ValueSet for vaginal examination results recorded during labor and delivery.

The ventilator modes printed on the ICU observation chart. Local rather than SNOMED: the chart uses the unit’s own shorthand and a guessed SNOMED code for a ventilation mode is worse than a local one.

A ValueSet defining the possible visit categories in SGHI's systems.

A ValueSet defining the possible visit types in SGHI's systems.

A ValueSet for Vitamin A supplementation status in children attending the Child Welfare Clinic.

Where a patient waiting for a bed physically is, so the ward knows where to fetch them from.

Why a ward was removed from the facility setup. Recorded for audit. Removal is for a record that should never have existed; a ward that has stopped taking patients is closed rather than removed.

The kind of ward a bed sits in. Used to route an admission to a ward that can nurse the level of care asked for.

A ValueSet for weight-for-age nutritional status categories used in Child Welfare Clinic (CWC) workflows.

Whether the patient is consenting for themselves or someone is consenting on their behalf. Decides whether a relationship has to be recorded, and whether Consent.grantor is the patient or another party.

Yes, no, or not established. Bound only to the history questions where the answer comes from a carer who may not know — immunisation history, maternal serology, prior treatment — and never to an examination finding or a safety check, where an unanswered question must stay unanswered rather than becoming a recorded 'not known'.

A ValueSet categorizing different types of service requests.

Specimen Type Value Sets

Type Of Test Value Sets

Condition severity

Speciality

Based on ICD102019-covid

This version contains the latest version of ICD-11 (2024)

First Version

First Version

Obsolete identifier-type codes encountered in R4 data.

A collection of CIEL codes formerly in use for clinical observations.

A collection of FHIR R 4 codes formerly in used in R4

A code system enumerating the concepts used to request, triage, place and track an inpatient admission across SGHI's environment.

The answers the pick lists offer, where the list is local to these forms and carries no ordinal weight. Displays are the wording printed on the paper form and should not be reworded without reprinting the form, because the form is the contract with the ward. Answers that belong to a scored instrument live in SGHIScoreCodeSystem instead, since those also carry a weight.

A code system enumerating the different cancer stages used across SGHI's environment.

The kind of clinical form a Questionnaire represents, at the granularity a clinician would use to find one: an admission record, an observation chart, a theatre record, a consent. Facility-independent by design, so the same code means the same thing across every hospital in the deployment and a form can be found by shape rather than by the name one hospital happens to print on it.

The answers to the scored instruments used on inpatient assessments: the Braden pressure ulcer scale, the Morse falls score, MUST nutrition screening and the Glasgow Coma Scale. Each answer is a concept so a response records what was observed rather than a bare number. Codes are namespaced instrument-item-weight; the weight is in the code because within an item it is what tells one answer from another, and because two items in an instrument can share a label. The extraction maps rely on that: they read the weight off the tail of the code when a client submits no calculated total.

What the forms record where no code system this IG can resolve says the same thing. These appear as Observation.code, Observation.component.code, ServiceRequest.code, Procedure.code, CarePlan.category, RiskAssessment.code and RiskAssessment.prediction.outcome on the resources the extraction maps build. Anything LOINC already names — the vital signs, the Glasgow Coma Scale, the Apgar components, body weight and height, head circumference, MUAC — is coded to LOINC in the map and is deliberately absent here.

The concepts the device order form records that FHIR has nowhere to put. DeviceRequest carries the device, the intent, the priority and the quantity as named elements, but how the patient actually receives the device has no element of its own, so it is carried as a DeviceRequest.parameter and both halves of that parameter — the one naming what the parameter is, and the ones naming the answers — are defined here.

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.

A single code system enumerating the many local identifier types used across SGHI's environment.

The single-select answers offered by the inpatient assessments that are not part of a scored instrument: ASA grade, oxygen support, immunisation status, risk of self-harm and capacity to consent. Local pick lists get local codes. The displays are the wording shown to the clinician and should not be reworded without changing the form. Scored-instrument answers live in SGHIClinicalScoreCodeSystem instead, because they also carry an ordinal weight.

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.

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.

Antigens administered under the Kenya Expanded Programme on Immunisation, as recorded on the MOH 510 Immunisation Permanent Register. One concept per antigen: the dose within a series is carried separately on Immunization.protocolApplied.doseNumber, which is what keeps IPV distinct from bivalent OPV and separates the three pentavalent doses. Pending a mapping to CVX or the national antigen list.

Micronutrient supplements recorded alongside immunisation on the MOH 510 Immunisation Permanent Register. Held apart from the antigen code system because a supplement is not a vaccine and must not count towards the Fully Immunised Child milestone.

A a subset of LOINC codes used across SGHI's environment.

A code system enumerating what happened to a medication dose at the drug round, and the reasons a dose was held, refused or omitted that have no home in HL7 terminology.

A custom CodeSystem defining different forms in which medications come in

Why an ordered item was stopped before it was done. Recorded against the item and not the order: an order carries several items, and one test no longer being needed says nothing about the prescription beside it.

Payer schemes, benefit packages, tariff rules and the Social Health Authority intervention codes read when admitting an insured patient.

A code system enumerating practitioner specialties used across SGHI's environment.

Qualifies the critical bands of a vital-sign reference range. HL7's referencerange-meaning has no concept for either, and a machine-readable code is needed so consumers can colour or escalate a band without parsing its label.

The answers to the scored instruments on the forms: the Bishop score for cervical ripeness and the five Apgar components. Codes are namespaced instrument-item-weight, the same convention SGHIClinicalScoreCodeSystem uses and for the same reason — within an item the weight is what tells one answer from another, two items in an instrument can share a label, and the extraction maps read the weight off the tail of the code when a client submits no calculated total. LOINC publishes answer lists for the Apgar components (LL384-9 through LL388-0) but not their member LA codes as a usable set, so the Apgar answers are local while the Apgar questions stay on LOINC.

A custom CodeSystem defining different elements of service requests.

A code system enumerating local codes used across ANC, PNC, CWC and other special-clinic workflows within SGHI's environment. Codes are used wherever a suitable LOINC, SNOMED-CT or HL7 code does not exist.

A Specialty Code System to be used in SGHI's environment.

A code system enumerating the specimen collection concepts with no home in HL7 terminology: the containers a sample is collected into, and how the draw itself went.

The kind of move a patient is being made within the facility. Recorded on the transfer form alongside the destination and the reason, and distinct from both: this says what sort of move it is, which decides whether the bed is held and whether the level of care changes.

A code system enumerating the different category types used across SGHI's environment.

A code system enumerating the different visit types used across SGHI's environment.

A single code system enumerating severity levels for clinical conditions within the SGHI ecosystem.

A single code system enumerating severity levels for clinical conditions within the SGHI ecosystem.

A code system enumerating the different units of measurement used to specify medication intake frequency in a day.

A code system enumerating the different units of measurement used to specify medication dosages across SGHI's environment.

A code system enumerating the different options used to specify event timing across SGHI's environment.

A code system enumerating the different options used to specify order forms across SGHI's environment.

A single code system enumerating the identifier types used identify organisations across SIL's environment.

A code system different identifiers used to identify an animal, patient, practitioner or any other live actior in the healthcare context

A code system enumerating the different route options used to specify medication administration routes across SGHI's environment.

A SOAP note extracts as a ClinicalImpression whose summary is the assessment – that is what ClinicalImpression.summary is for – with the subjective and objective sections as Observations under LOINC 61150-9 and 61149-1 that the impression names in supportingInfo, and the plan as a CarePlan. Four resources rather than one narrative, because the point of SOAP is that a reader can find the assessment without reading the subjective account first, and because a plan a counsellor set at session four is a thing the next session has to review. LOINC has Subjective and Objective Narrative but no plain Assessment or Plan term, so those two carry local concept codes.

The measurements and vitals on arrival as their own Observations under their real LOINC codes; the head-to-toe nursing assessment as one panel, because it is read as a picture of the patient on arrival and no single line means much alone; the chronic illness tick list as one Condition per illness with the reported onset; and one ServiceRequest per investigation and treatment ordered. The chronic illnesses carry verificationStatus 'unconfirmed' – a tick against a printed word on an admission sheet is a reported history, not a diagnosis.

The anaesthetic chart out as: one Procedure for the anaesthesia itself, carrying the technique as its category, the anaesthetist as its performer and the start and completion times as its period; one Observation per timed reading taken through the case, each with its own effective time, because the paper chart is a graph and a graph is a time series; one MedicationAdministration per drug and per fluid, because those were given rather than ordered; and the estimated blood loss as its own Observation under the LOINC operation-note code, marked as an estimate.

Each round out as the four vitals under their real LOINC codes plus an obstetric panel carrying the lie, the presentation and whether the bowels have opened, and the fetal heart rate as its own Observation under LOINC 55283-6 with an interpretation. Outside 110 to 160 is what that column exists to catch, and a reader should not have to remember the range.

Appointment Transforms: R4 → SGHI R5

The Bishop score out as one Observation carrying the total, with the five weighted items as components and the fetal heart rate, the position of the presenting part and the membrane status alongside them. The total prefers what the form submitted and otherwise sums the item weights itself, and it only extracts when all five items have been answered — a Bishop of 6 out of three items answered reads as a favourable cervix and is not one.

The KTTA donor form out as: one Observation carrying the thirteen deferral questions as components, because eligibility is a judgement over the whole set; the screening measurements each as their own Observation, so a haemoglobin below the 12.5 g/dL line is findable by its LOINC code; the eligibility decision as its own Observation with an abnormal interpretation when the donor was deferred, and the reason beside it; a Consent from the signed declaration, with the research opt-in as a second provision because it is a separate question the form asks separately; a Procedure for the collection itself; and one Observation carrying the nine post-donation adverse events.

The requisition is the whole transfusion chain on one sheet, and it extracts as the chain: a ServiceRequest per product asked for, coded SNOMED 116859006 and carrying its own quantity and urgency, so two units of packed cells and one of platelets are two orders and not one; a Consent recording that the patient agreed; Observations for the recipient's ABO and Rh under LOINC 883-9 and 10331-7 and for each issued unit's group under the blood-product-unit codes 14578-9 and 14907-0, with the bag number as the specimen identity; the cross-match result per unit, interpreted abnormal when incompatible; and any transfusion reaction as an Observation coded SNOMED 82545002 and flagged abnormal. The two abnormal flags are the point: an incompatible cross-match and a reaction are the two findings on this form that have to be impossible to miss.

A Consent whose provision is the disposition chosen – released to the family, or disposed of by the hospital. Both are permissions, so the decision stays 'permit' and the disposition rides in the provision rather than flipping the decision: refusing to let the hospital dispose of a part is not refusing the surgery, it is choosing the other option, and a Consent with decision 'deny' would say the wrong thing entirely.

The LOINC Braden scale panel out as one Observation carrying the total, with the six sub-scores as components, plus a RiskAssessment for the band the total falls in. The total prefers what the form submitted and otherwise sums the answers itself, and it only extracts when all six sub-scores have been answered: a Braden computed from four of six items is not a Braden score, and banding one would put a number a nurse can act on next to a risk tier that is wrong.

One settings panel per reading rather than three loose Observations, for the same reason as the ventilator chart: a flow of 8 L/min means one thing at a distending pressure of 5 cmH2O and another at 8, and nobody joins three separate Observations by timestamp to see it. The panel is coded to LOINC 35410-0, continuous positive airway pressure, and the three columns ride as components under the codes the paper actually labels them with.

The LOINC CNPI panel out as one Observation carrying the total, with the with-movement and at-rest scores and all twelve observed behaviours as components, and whether any pain behaviour was seen at all as its interpretation. Each score prefers what the form submitted and otherwise counts the behaviours itself, and a score only extracts when all six of its behaviours have been answered.

One cycle out as: a MedicationRequest per cytotoxic drug and per named premedication, each carrying the drug as written because the hospital's formulary is not coded and a guessed code on a cytotoxic is a dosing risk; a ServiceRequest per investigation the sheet makes mandatory before every cycle, so the requirement becomes an order the laboratory sees rather than a reminder on paper; the height, this cycle's weight and the body surface area derived from them as Observations, because every dose on the sheet is calculated from that BSA and it has to be auditable; and the pre- and post-chemotherapy hydration as MedicationRequests of their own.

One laboratory Observation per value per cycle, each taking the cycle's own date rather than the form's, because the whole reason this sheet exists is to be read as a series: a neutrophil count means one thing on its own and another as the third fall in a row. The absolute neutrophil count carries an interpretation, low below 1.0 and critically low below 0.5, because those are the thresholds that defer a cycle.

PT under LOINC 5964-2, INR under 6301-6 and APTT under 3173-2, each carrying the reference range printed on the form. The INR range is the reason this map needs a question answered: the printed 2.0 to 3.5 applies only to a patient on stabilised oral anticoagulant therapy, so it is attached only when the form says yes. Attaching it unconditionally would flag every patient not on warfarin as out of range, which is the opposite of useful.

Composition Transforms: R4 to SGHI R5

Condition Transforms: R4 → SGHI R5

Consent Transforms: R4 → SGHI R5

The refusal out as a Consent with decision = 'deny' – the only deny decision in this whole set – with one provision per thing actually being refused, so a patient refusing a single procedure is not recorded as having refused all care. An Observation records whether they understood the explanation and in which language, because that is what makes the refusal informed and it is the fact a later dispute turns on.

DiagnosticReport Transforms: R4 → SGHI R5

Turns the discharging clinician's readiness attestation into four survey Observations: oral intake, mobility, pain control and the condition the patient is leaving in. Each is its own Observation because a clinician answers four separate questions and one flat resource would let an answer to one stand in for an answer to another. The handover sentence rides as a note on the condition Observation rather than becoming a fifth: it is prose about the discharge, and an Observation whose value is a paragraph answers no query. Nothing here writes to the Encounter – closing the stay and recording the discharge disposition belong to the EMR's discharge workflow, and the condition a patient leaves in is a different axis from where they went. The signature the form collects is a typed name, which SGHIObservation cannot carry as a performer, so it stays in the response and out of the extracted resources.

Turns the cashier's record that the account was dealt with into one survey Observation, with the clerk's note against it. A Task is the FHIR-correct home for work that has to be done, and this clearance is born completed – a Task created in the completed state carries no workflow, and SGHITask would force an owner, a requester and a requestedPerformer that all resolve to the facility asking itself to settle the account. So this follows the other two clearances and stays an Observation, which keeps one extraction pattern across the three forms. It carries no balance: the figure belongs to billing, and one restated here would be signed against as though this were the authority for it. If billing later wants a workable item, a Task rule can be added to this map without changing anything the frontend sends.

Turns the record of what the patient and their family were told into three survey Observations: the danger signs explained, who was briefed alongside the patient, and whether the take-home medicines were gone through. Communication would be the truer resource for a briefing, and this IG has no Communication profile and no map that creates one, so the briefing is recorded as an assertion that it happened rather than as the message itself. Name and relationship ride on one Observation as value and component, the way a blood pressure carries systolic and diastolic, rather than minting a RelatedPerson per discharge for a relative the record may already know. The follow-up arrangement rides as a note: the discharge note already raises a ServiceRequest for the follow-up it arranges, and a second request from here would leave one patient with two.

The discharge summary out as: a Composition coded to LOINC 18842-5, with the clinical summary, the management and the discharge instructions as its sections, because a discharge summary is a document and this is the resource for one; a Condition per discharge diagnosis, reconciled against the problem list where the clinician picked an existing one; a MedicationRequest per line of discharge medication, which is what the pharmacy dispenses against; a ServiceRequest for the follow-up; and an Observation for the ward clearance sign-off, because whether the medication was actually issued is an auditable fact and not a formality.

One Observation per entry, under LOINC 11506-3, each carrying its own timestamp and the doctor who wrote it. A ward round note is evidence of when a decision was made and by whom, and merging the continuation sheet into a single narrative destroys both.

DocumentReference Transforms: R4 to SGHI R5

A Consent recorded in both directions – 'permit' where embalming was authorised and 'deny' where it was refused – because a refusal is something the mortuary has to act on and an absent consent is not the same thing. The identifier is whichever of the IP, OB or permit number identifies the body: one brought from home or by the police has no IP number, and that number is the only handle linking it to its paperwork.

Encounter Transforms: R4 → SGHI R5

Encounter Transforms: R4 → SGHI R5

The endoscopy form is a request, a procedure and a report on one sheet, so it extracts as all three: a Procedure coded by whichever scope was done, taking its own coding from the answer so a colonoscopy is coded as a colonoscopy and not as 'endoscopy'; a DiagnosticReport under LOINC 18751-8 whose conclusion is the endoscopist's conclusion and whose result points at the findings Observation; a MedicationAdministration per drug given during the procedure; and a CarePlan for the suggested treatment. The findings live in an Observation rather than only in the report's narrative so that what was seen stays queryable after the report is filed.

EpisodeOfCare Transforms: R4 → SGHI R5

The conference record as a Composition, and the resuscitation decision as its own Consent – decision 'deny' for do-not-resuscitate, 'permit' where the conference agreed resuscitation should be attempted. A Consent and not a note, because the team on the next shift has to be able to find it without reading a conference narrative, and because an absent decision and a decision to resuscitate are not the same thing.

One Observation per entry carrying the position and the volume fed, each with its own timestamp. Position is a coded answer rather than free text because turning is what prevents a pressure injury and this chart is where it is evidenced – a gap in the column is the finding, and a gap is only visible if the entries either side are comparable.

One Observation for the Glasgow Coma Scale, carrying the total as its value, the eye, verbal and motor sub-scores as components, and the severity band the total falls in as its interpretation. The total prefers the calculated total the form submits and falls back to summing the answer weights itself, so the score still extracts from a client that does not evaluate SDC expressions.

The 24-hour totals under LOINC 9108-2 fluid intake and 9192-6 urine output, plus the balance, and each hourly row as its own pair of panels. The totals are what every fluid decision on the unit turns on and what a later reader actually queries; the hourly rows are kept so the total can be audited against them, which matters because on paper the total is arithmetic done by hand at the end of a twelve-hour shift.

One dialysis session out as: a Procedure for the session itself, coded to SNOMED 302497006, with the treatment time as its period and the access as a note; the pre-, target and post-dialysis weights each as their own Observation, because the nephrologist reads them against each other over weeks; the fluid actually removed as its own Observation; the prescription and the machine's function check as two panels, because neither of their parts means anything alone; and one Observation per timed reading through the run, each keeping the reading's own time, since the flow chart is a time series and the circuit pressures are what a run is judged on.

The conscious level goes out under the chart's own four-point scale and a local code, not as a Glasgow Coma Scale total. This sheet prints four levels with its own wording – fully conscious, conscious but confused, semi conscious, coma – and forcing them onto GCS or AVPU would invent a precision the paper does not have. Coma carries a critically-low interpretation because that is the row that gets someone to theatre. Pupils are one Observation per eye with a SNOMED body site, because which side is dilating is the whole question, and movement and paralysis are recorded limb by limb for the same reason.

Each round of the ICU neurological chart out as: one Observation for the Glasgow Coma Scale under LOINC 9269-2, carrying the total as its value and the three components under their own LOINC codes, with the total computed by the map when the client submits none; one for limb power; one per eye for pupil size and reaction, because a unilaterally dilating pupil is the finding that matters and it has to be findable per side; and the four vitals each as their own Observation. Every one takes the round's own time, not the form's, because the chart is a time series and a deteriorating conscious level is only visible as one.

Each round out as: the four vitals and the central venous pressure as their own Observations; the arterial blood gas as one panel with seven components, because a gas is interpreted whole and a pH of 7.25 means one thing beside a pCO2 of 8 and another beside a bicarbonate of 12; and the ventilator settings as a second panel. Every one takes the round's own time rather than the form's – a deteriorating gas exchange is only visible as a series, and collapsing twenty-four rounds onto one instant would destroy it.

The X-ray and ultrasound request forms out as ServiceRequests: one per scan type ticked on an ultrasound request, or a single one carrying the region and view for an X-ray. The clinical question rides as a supporting Observation the request points at, because the SGHI ServiceRequest profile binds reason required to LOINC and the form takes free text – so the indication cannot go in reason without inventing a code for it.

Turns a response to the inpatient admission note into a Composition with one section per heading, plus a Condition for the impression – the one line on this form that belongs on the problem list. The Condition is verificationStatus provisional because an admitting impression is exactly that; the team confirms or replaces it as the stay goes on. Its code carries the clinician's wording as text rather than an ICD-11 coding, because the form asks for prose and guessing a diagnosis code from prose is not something a map should do.

Turns a response to the adult general admission assessment into a chief-complaint Observation, one Observation per vital, and a Composition that files the assessment and carries the allergies and medication the assessor reviewed. Nothing is copied: the allergies and medication are already AllergyIntolerance and MedicationRequest resources – the form loads them off the server – so they become section entries. The Composition exists for exactly that reason; without a container those two rows of the assessment extract to nothing at all.

One Observation for the Glasgow Coma Scale, carrying the total as its value and the eye, verbal and motor sub-scores as components; one for the method of oxygen delivery; one for the organ support narrative; and a MedicationAdministration for the vasopressor the patient is on. The GCS total prefers the calculated total the form submits and falls back to summing the answer weights itself, so the score still extracts from a client that does not evaluate SDC expressions.

The richest of the seven notes, and the only one that changes a record that already exists. It produces a Composition attested by the clinician who confirmed the death, a Condition carrying the cause as stated, and a FHIRPath PATCH that sets Patient.deceasedDateTime. The PATCH touches that one element and nothing else – the response carries no demographics, so rebuilding and PUTting the Patient would erase the record. Note this uses the add operation: extracting the same death note twice will fail the second time rather than silently overwrite, which is the safer direction for a fact recorded once.

Turns a response to the inpatient discharge note into a discharge-summary Composition and a ServiceRequest for the follow-up. Medication on discharge is referenced, never copied: those MedicationRequests already exist on the server – the form picks them from it – so they become section entries rather than new resources. The follow-up is intent plan rather than an Appointment because the form captures it as free text with no date to book against; give the item a date and an Appointment becomes the truer target. The Encounter is deliberately untouched: closing the stay – Encounter.status and the discharge disposition – belongs to the EMR's discharge workflow, which knows about bed release, billing and the actual moment the patient left. Writing a note is not the same event as being discharged, and a map that conflated them would close stays early.

Two scored instruments out. Braden becomes one Observation carrying the total with its six sub-scores as components, plus a RiskAssessment for the band; the falls score – which is the Morse Fall Scale item for item – becomes the same shape against the LOINC Morse panel. The measures put in place become a CarePlan. A total is only emitted when every sub-score has been answered: a Braden computed from four of six items is not a Braden score, and banding one would put a number a nurse can act on next to a risk tier that is wrong.

Mood and capacity become Observations, the risk of self-harm becomes a RiskAssessment carrying what the patient said as its note, and a safeguarding concern becomes a Flag on the patient. This is the one instrument here that is not scored: the band comes from which of four answers was picked, not from arithmetic, so each answer is banded explicitly. The answer's own coding and wording ride along in qualitativeRisk, so a reader never has to infer what was said from a risk tier.

Turns a response to the inpatient nursing note into a single Composition with one section per heading. A nursing note is a document, so nothing discrete is extracted alongside it; observations recorded at the bedside come from the observation templates, not from here.

The MUST score becomes one Observation carrying the total with its three steps as components, plus a RiskAssessment for the band. The nutritional plan becomes a CarePlan, and a score in the high-risk band raises a dietitian referral. That referral is intent proposal and status draft deliberately: a map should not put an active order in a dietitian's queue on its own, so it arrives as something a clinician signs.

Four measurements out, four Observations. Gestation, fetal heart rate and cervical dilatation are readings taken at the bedside, so they carry category exam; the obstetric history is reported rather than measured, so it carries social-history. Every LOINC code here was checked against tx.fhir.org before use.

Weight, immunisation status and feeding become Observations; the guardian at the bedside becomes a RelatedPerson. Immunisation status is an Observation rather than an Immunization because the form records what the guardian says, not a dose given with a vaccine, a date and a batch – an Immunization built from Partially immunised would be a fiction. The guardian is a new RelatedPerson rather than a patch to Patient.contact: repeated assessments would append a duplicate contact each time with nothing to deduplicate on, and moh-510-extractor already mints guardian RelatedPersons this way.

Turns a response to the inpatient progress note into a single Composition with one section per SOAP heading. Nothing here is a discrete clinical fact – a progress note is a document – so no Observation, Condition or Task is produced. The QuestionnaireResponse remains the signed record and the Composition points back at it through relatesTo.

Turns a response to the inpatient shift handover into a single Composition with one section per heading. The outstanding jobs stay narrative here rather than becoming Tasks: the handover form captures them as one free-text block for the incoming shift to read, and splitting one block into Tasks would invent boundaries the writer did not draw. Ward round jobs, which the design does treat as work items, become Tasks in their own map.

The planned procedure becomes a ServiceRequest, the ASA grade and the last oral intake become Observations, and the clinician who took consent becomes a Consent verified by them. The procedure carries the surgeon's wording rather than a procedure code – the form is free text and matching prose to a code system would guess at what is being operated on. Consent.decision is permit because the form only exists once consent has been obtained; a refusal is not something this assessment records.

Turns a response to the inpatient ward round into a Composition with a section per heading, one attester per clinician who was on the round, and a Task carrying the jobs the round left for the team. The jobs item is a single free-text block, so it becomes a single Task: splitting it would invent boundaries the writer did not draw. Making it several Tasks means first making the form item repeat.

The 24-hour totals under LOINC 9108-2 fluid intake and 9192-6 urine output, plus the balance and each hourly row as its own pair of panels. The sheet's own instruction is to add the columns and circle the figure; the form computes it instead, because that circled number at the end of a twelve-hour shift is the most error-prone arithmetic on any ward chart – and the hourly rows are still extracted so the total can be audited against them.

Extracts a transaction Bundle from a QuestionnaireResponse to the Kenya MOH 510 Immunisation Permanent Register: guardian RelatedPersons, growth-monitoring Observations, one Immunization per antigen dose for sections L-Y/AA-AB/AD, Vitamin A MedicationAdministrations for section Z, danger-signs and education Observations, and an Appointment for the next scheduled visit. It creates no Patient, Encounter or EpisodeOfCare – the register is launched from inside a visit the EMR has already opened, so all three arrive as context on the QuestionnaireResponse and are referenced rather than minted. QuestionnaireResponse.subject and .encounter are therefore both required.

The maternity record out as: the pregnancy dates and the parity as their own Observations, because a booking is read from them; an AllergyIntolerance per allergy, since that is the one thing on this record that has to reach whoever prescribes next; the family, social and obstetric histories as panels; the admission examination and the vital-plus-rapid assessment as Observations, with the blood pressure paired; a Condition per provisional and differential diagnosis; a Procedure for the delivery itself, coded by its mode and carrying the stage durations; the third-stage findings and both mother's and baby's observations as Observations of their own; a CarePlan for the management plan; and a Consent for the admission.

One ServiceRequest per investigation asked for, category SNOMED 108252007 laboratory, with the urgency mapped onto the three request-priority codes; and one laboratory Observation per result the sheet carries, because this form is a requisition and a report on one page. The clinical history rides on every request: a serology result without it is uninterpretable, which is exactly why the form asks for it.

A medical report is written once, read as a whole, and handed to whoever asked for it – an insurer, a court, another hospital – so it extracts as a Composition under LOINC 34133-9 with one section per printed heading, plus a Condition per diagnosis line so the report does not become the only place the diagnosis is written down. Each section names an Observation carrying its text: Narrative.div is an XhtmlType this engine cannot build from FML, and referencing an Observation is the better shape anyway, because the text becomes something a query can reach rather than a blob inside a document. The stay itself lands in Composition.event.period, which is what makes the report answer 'when was this admission'.

MedicationRequest Transforms: R4 → SGHI R5

A NutritionIntake per feed carrying what was given and how much, plus an Observation panel for the row's target, what was retained and the diaper. The retained volume is the point: the difference between given and retained is what says whether a baby is tolerating feeds, and a chart that only records what was offered cannot answer that.

The LOINC Morse Fall Scale panel out as one Observation carrying the total, with the six weighted questions as components, plus a RiskAssessment for the band the total falls in. The total prefers what the form submitted and otherwise sums the answers itself, and it only extracts when all six questions have been answered: a Morse score short of an item is not a Morse score, and banding one puts a number a nurse can act on next to a risk tier that is wrong.

The death review as a Composition under LOINC 34133-9, one section per numbered question, each section naming an Observation that carries its text. A governance document rather than a clinical note, so it is kept whole: the committee's opinion means nothing separated from the initial management it is an opinion about.

A Composition for the admission, with the registration tag number as its identifier – that tag is the mortuary's own handle and in practice the only thing that reliably links a body to its paperwork. Where the body came from and the cause of death extract as Observations, for the same reason as on the services request: whether the deceased was ever a patient here has to be answerable from the data.

A Consent, recorded in both directions: decision 'permit' where disposal was authorised and 'deny' where it was refused. A refusal is a fact the record has to carry, not an absence – an absent consent and a declined one look identical unless the form says which, and the two have entirely different consequences for what the mortuary may do next.

A Composition with an attester per signature. Three signatures on the paper – the mortuary attendant, the relative receiving the body and a witness – because a body leaving custody is a chain-of-custody event, and each one becomes a separate attester so the chain survives in the record rather than collapsing into one author.

A Composition for the request itself, plus Observations for the cause of death and for where the body came from. Where it came from is extracted as a coded Observation rather than left in the document because it is the fact that decides whether this record belongs to a patient of the hospital at all – and that is a question a deployment has to be able to ask of the data, not of the paper.

Each hourly round out as vitals under their real LOINC codes, an assessment panel, a ventilator panel and the blood gas as a single panel – all taking the round's own timestamp. Jaundice takes the chart's own 0 / + / +++ scale, which grades by how far down the body the jaundice has spread, face at + and feet at +++, because that is what decides phototherapy. Apnoea is flagged abnormal wherever it is recorded.

The newborn unit's admission record out as: the birth and current measurements each as their own Observation, so a weight chart can graph them from the first day; the intranatal and newborn history as one panel; the newborn examination as a second panel with its graded findings coded and its rates as quantities; the Apgar carried over from the delivery record as two Observations under the LOINC score codes; a Condition per admission diagnosis; a CarePlan for the supportive care planned; and a Consent from the parent's signature.

The feed and fluid prescription as a CarePlan – it is a prescription the next shift has to follow, not an observation – with the volume per kilogram per day extracted as its own Observation because that is the number the prescription is actually judged against. Each monitoring round becomes vitals plus a respiratory-support panel plus a fluid panel, all taking the round's own time. The shift note carries the baby's acuity category, which is what sets how often the baby is observed at all.

The newborn chart out as: one Observation per Apgar time point, coded to the LOINC panel with the five weighted signs as components and the total as its value, computed by the map when the client submits none; one Observation per timed skin-to-skin round; one Observation per follow-up round over the first four days; the birth and discharge weights as their own Observations; the immediate newborn care given as one panel rather than as Immunization or MedicationAdministration resources, which the chart gives no doses or times for; and a Procedure for resuscitation when it was done.

The mother's ANC serology becomes laboratory Observations on the baby's own record rather than staying as prose on a sheet that lives at the cot – her blood group, VDRL, HIV status and third-trimester urinalysis all govern the baby's management and are the part most often lost in a verbal handover. Gestation, birth weight, Apgar and the first vitals extract under their real LOINC codes; the intranatal and birth histories become panels.

One CarePlan with an activity per problem, plus a Condition per nursing diagnosis and an Observation carrying the assessment, rationale, implementation and evaluation for that row. Every column is kept, including the scientific rationale – this sheet is the one place the reasoning behind a nursing action is written down, and without it the intervention reads as arbitrary.

Observation Transforms: R4 to SGHI R5

Organization Transforms: R4 → SGHI R5

A ClinicalImpression whose summary is the provisional diagnosis and whose supportingInfo names the complaints Observation, plus a Condition with verificationStatus provisional. Provisional is the point: this is written at the end of a single out-patient visit, and a Condition that does not say so reads as settled to everything downstream that looks at it.

One Observation per note, under LOINC 34746-8, each carrying its own timestamp and the nurse who wrote it. Recovery is the window in which a patient deteriorates fastest, and a note that cannot say when it was written is not usable evidence of what was noticed.

The three-page paediatric admission record out as: the anthropometry and vital signs each as their own Observation so a growth chart can graph them; the IMCI history and the ABCD examination as two panels, because a sign only means anything as part of the set the clinician worked through; the immunisation card as one dose-count panel rather than as Immunization resources, which the sheet gives no dates for; a Condition per admission diagnosis, primary first; a ServiceRequest per investigation ordered; a CarePlan for the supportive care; and a Consent from the carer's signature at the foot of the sheet.

One MedicationAdministration per row. Unlike the tick-box charts in this set, this one records the drug, the amount and the time it was given – which is exactly what a MedicationAdministration needs in order to be an honest claim. The drug name and the amount travel as written: the hospital's formulary is not coded and a guessed code on a bronchodilator dose is the wrong place to be wrong.

The anthropometry is the part of this form that has to be a time series, so every measurement becomes its own Observation under its real LOINC code – birth weight 8339-4, weight 29463-7, height 8302-2, head circumference 9843-4, MUAC 56072-2 – rather than components of a panel nobody can plot. Admission and discharge weight are both 29463-7 and are told apart by their code text, because they are the same measurement taken twice and a growth chart should show them on one line. The two Z-score-style derivations the form computes are decimals with the unit attached by the map. The nutritional diagnosis becomes a Condition and the prescription a CarePlan, so a child discharged on a feeding regimen leaves with a plan and not a paragraph.

The paediatric intensified case finding screen out as one Observation carrying the screen result, with the five questions as components, plus a RiskAssessment for the band that result falls in. The tool has no score: it is answered yes to any one question or no to all five, so the band is binary and the arithmetic is a disjunction rather than a sum. Both branches extract. A screen that came back negative is the record that the screen was done, which is what makes the guideline's repeat screening on subsequent visits a thing the notes can show, and it is what carries the IPT workup as its mitigation. The result is derived from the five answers rather than read off an outcome item the form does not have, so the questions and the conclusion cannot disagree.

The triage sheet out as the triage decision, the readings taken at the door, and the two sign panels. The triage level is its own Observation because it is the decision the sheet exists to record; each vital sign is its own Observation so a growth or fever chart can graph it; and the eleven emergency and twelve priority signs become two panels rather than twenty-three loose Observations, because a sign only means anything as part of the set the nurse worked through. Allergies from the SAMPLE history become AllergyIntolerance.

Every reading as its own Observation under its real LOINC code, taking the round's own timestamp. The paper prints four fixed rounds a day over ten days; the form takes a full timestamp instead, so a round done two hours late is recorded as late rather than as on time – and so a ward can actually graph a fever, which is the whole reason the sheet is ten days wide.

The palliative care assessment out as: one symptom-assessment Observation carrying all twenty-two symptoms as components, because the panel is the assessment and a patient with no symptoms ticked has said something a set of absent Observations could not; a Condition for the diagnosis, reconciled against the problem list where the assessor picked an existing one; one Observation for the prior oncological treatment; separate Observations for the patient's own goals and the carer's, because the two often differ and the form asks both; and a CarePlan whose activities are the problem-and-action rows.

A referral extracts as a ServiceRequest – the thing the receiving unit has to act on – carrying the destination, the specialty sought, the priority and who is asking. Everything the receiving clinician needs to read lands in Observations alongside it: the history and investigations, the treatment already given, the reason for referral under LOINC 42349-1, and any further comments. The working diagnosis becomes a Condition with clinicalStatus active and verificationStatus provisional, because a referral is precisely the case where the diagnosis is not yet confirmed and saying so is the point.

Patient Transforms: R4 → SGHI R5

One DeviceUsage per implant actually used, and only where the count is above zero – forty DeviceUsage resources of quantity nil would be worse than none at all. What went into a patient is the question an implant recall asks, and a tally sheet in a theatre file cannot answer it. The implant type carries the printed line as its text: the hospital's implant stock is not coded and a guessed SNOMED device code on an orthopaedic implant is worse than the words on the paper.

One MedicationRequest per line written. The paper is five numbered lines with no dose, route or frequency column, so the whole line goes to medication.concept.text exactly as the prescriber wrote it. Nothing is parsed out of it: a guessed dose is the one error on this form that reaches the patient rather than a report, and the hospital's formulary is not coded, so an invented RxNorm or ATC code would be worse than none.

The three consent forms out as one Consent, with a provision per authorisation actually given: the procedure itself, the further-measures clause, the anaesthesia clause, and on an endoscopy form the tissue-disposal clause and each procedure ticked. Each provision is written only when its box was answered yes, so a consent nobody gave never appears as one. An Observation records whether the explanation was given in a language the person consenting understood, because that is what makes the consent informed and what an audit or a complaint turns on.

A Procedure per contact carrying the units billed and the devices used, plus a ClinicalImpression per contact for the progress note. Per contact and not per episode, because the question asked of a rehabilitation episode is whether the patient is improving across it – and that needs each contact to keep its own date.

RiskAssessment Transforms: R4 → SGHI R5

ServiceRequest Transforms: R4 → SGHI R5

A Procedure per dressing change, each with its own timestamp and the nurse who did it, plus an Observation carrying the sheet's own grading. The grading answer records the letter that was ticked – B, M or S – because the sheet never expands them anywhere on it and putting an invented expansion into the record would be worse than recording the letter.

The 24-hour urine output under LOINC 9192-6 – out less in, which on a bladder irrigation is the urine the patient actually made and the only number anyone reads off this chart – plus each hourly row as its own panel. A return carrying clots is flagged abnormal: clots obstruct the catheter and call a surgeon, and that is the observation the chart exists to catch.

The checklist out as one Observation per WHO phase, so a sign-out that never happened is a missing resource rather than a resource full of blanks – which is the only shape that lets a compliance audit tell an unperformed phase from an unticked one. The ward's pre-operative preparation and post-operative checks become two further panels, every investigation ticked becomes a ServiceRequest, the vital signs before and after theatre become their own Observations tagged with which side of theatre they were taken on, and the instrument count gets an Observation of its own because a wrong count is a never event.

Task Transforms: R4 → SGHI R5

One SupplyDelivery per line issued. This is a stores record that happens to name a patient, so it extracts as a supply movement and not as anything clinical – treating it as an Observation or a Procedure would put stock issues into the clinical record, where nobody querying the patient's care wants to find them.

A Procedure with the whole team as performers and the operator's description as its note. The procedure name travels as written rather than coded: theatre lists are not coded here, and a guessed SNOMED procedure code on an operation note is a claim about what was done to a patient – the one place in this set where being wrong is not a reporting problem.

Every reading as its own Observation under its real LOINC code, taking the round's own timestamp, plus a MedicationAdministration for anything given. Recovery is the window in which a patient deteriorates fastest, and a set of observations collapsed onto one instant cannot show a trend at all.

One settings panel per reading rather than four loose Observations, because a ventilator setting only means something beside the others: a peak inspiratory pressure of 30 is unremarkable at a PEEP of 5 and alarming at a PEEP of 15. The changes column is kept as a note on the panel – a chart that records the settings but not the decisions behind them is a chart nobody can review afterwards.

Maps obsolete identifier-type codes to the SGHI canonical codes.

An example of SGHIActivityDefinition resource

SGHI CarePlan demonstration.

An example of consent conforming to the SGHIConsent profile.

An example of an episode of care conforming to the SGHIEpisodeOfCare profile.

An example Organization resource conforming to the SGHIOrganization profile.

An example of an AllergyIntolerance resource conforming to the SGHI AllergyIntolerance profile.

An example of an Appointment resource conforming to the SGHI Appointment profile.

An example of a Condition resource conforming to the SGHI Condition profile.

An example of an DiagnosticReport resource conforming to the SGHI DiagnostiReport profile.

An example of an DocumentReference resource conforming to the SGHI SGHIDocumentReference profile.

An example of an Encounter resource conforming to the SGHI Encounter profile.

An example of an Location resource conforming to the SGHI Location profile.

An example of a MedicationRequest resource conforming to the SGHI MedicationRequest profile.

An example of an Observation resource conforming to the SGHI Observation profile

An example of a patient profile.

An example of a Practitioner resource conforming to the SGHI Practitioner profile

An example of a PractitionerRole resource conforming to the SGHI PractitionerRole profile.

An example of a Procedure resource conforming to the SGHI Procedure profile.

An example of SGHI QuestionnaireResponse conforming to SGHI Implementation Guide

An example of a RiskAssessment resource conforming to the SGHI RiskAssessment profile.

An example of a ServiceRequest resource conforming to the SGHI ServiceRequest profile.

An example of Specimen resource that conforms to SGHI Specimen profile

An example of a substance profile

An example of a Task resource conforming to the SGHI Task profile.

A blood pressure panel extracted from a vitals questionnaire response, with each component flagged against its own reference range and the worst component tier rolled up to the panel.

A body temperature vital sign carrying both the normal band and the critical thresholds as separate reference range entries.

An example of an PlanDefintion resource conforming to the SGHI PlanDefinition profile.

An expanded Composition demonstration.

An example of a Medication Dispense resource adhering to SGHI's Medication Dispense

An example of SGHI Medication resource Example