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Packagesilfhirprofileig
Resource TypeCodeSystem
IdCodeSystem-clinical-form-category-codesystem.json
FHIR VersionR5
Sourcehttps://build.fhir.org/ig/savannahghi/sil_fhir_profile_ig/CodeSystem-clinical-form-category-codesystem.html
URLhttps://fhir.slade360.co.ke/fhir/CodeSystem/clinical-form-category-codesystem
Version0.1.0
Statusactive
Date2026-10-02T07:33:51+00:00
NameSGHIClinicalFormCategoryCodeSystem
TitleSGHI Clinical Form Category Code System
DescriptionThe 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.
Contentcomplete

Resources that use this resource

ValueSet
silfhirprofileig#currentclinical-form-categorySGHI Clinical Form Category

Resources that this resource uses

No resources found


Narrative

Note: links and images are rebased to the (stated) source

Generated Narrative: CodeSystem clinical-form-category-codesystem

This case-sensitive code system https://fhir.slade360.co.ke/fhir/CodeSystem/clinical-form-category-codesystem defines the following codes:

CodeDisplayDefinition
admission-record Admission recordThe structured record made when a patient is taken onto a ward: presenting illness, the examination on admission, and the plan the admission starts from.
triage-record Triage recordThe sheet a patient is sorted on at the front door — how urgently they need to be seen, and the signs that decided it.
clinical-assessment Clinical assessmentA structured assessment by one service, completed once per episode: palliative, nutrition, psychological, rehabilitation intake and the like.
scored-instrument Scored instrumentA form whose output is a score rather than a set of findings — Bishop, Apgar, Glasgow, MUAC-based screens. Scored instruments are kept apart from assessments because the score is comparable over time and a free assessment is not.
observation-chart Observation chartVital signs and physiological observations charted round by round through an admission.
monitoring-chart Monitoring chartA chart tracking one device or one therapy over time — ventilator, CPAP, dialysis, neurological observations, a chemotherapy cycle. Distinct from an observation chart because the columns are settings and responses to a treatment rather than the patient's own vitals.
fluid-balance-chart Fluid balance chartIntake and output charted over a shift or a day, with the totals that decide the next fluid order.
feeding-chart Feeding chartWhat a patient — usually a baby — was fed, when, how much and by what route.
nursing-care-plan Nursing care planThe nursing problem list with the care planned against each problem and the evaluation of it.
medication-chart Medication chartA prescription or an administration record: what was ordered or given, at what dose, by what route.
wound-care-record Wound care recordDressing changes, irrigation and the state of a wound or a surgical site over time.
rehabilitation-record Rehabilitation recordTherapy given and progress against it, session by session — physiotherapy, occupational therapy, speech therapy.
progress-note Progress noteA dated clinical entry continuing the record of a stay: doctors' notes, ward round entries, review notes.
procedure-record Procedure recordThe record of a procedure actually performed — the operation note, the anaesthetic chart, the endoscopy record.
recovery-record Recovery recordObservations and care in the recovery period immediately after a procedure, before the patient goes back to a ward.
safety-checklist Safety checklistA checklist completed to confirm a step was taken before, during or after a procedure. Its value is the record that somebody checked, which is why an unfilled box is a finding rather than a blank.
handover-record Handover recordWhat one team tells the next about a patient at a shift change or a transfer between units.
referral ReferralA patient sent on to another unit or facility, with the history and the reason for sending them.
discharge-summary Discharge summaryThe account of a completed admission that the patient leaves with and the next clinician reads.
requisition RequisitionA request to another department for a test, an image, a blood product or a supply.
consent ConsentA record of permission given or refused for a procedure, a treatment, a disclosure or a disposal.
clinical-report Clinical reportA report on a patient written for someone outside the treating team — an insurer, a court, another hospital, a mortality review.
mortuary-record Mortuary recordAdmission to, release from, or a consent connected with the mortuary.
survey SurveyA questionnaire whose answers are about the service rather than about the patient's health, and which produces no clinical resource.

Source1

{
  "resourceType": "CodeSystem",
  "id": "clinical-form-category-codesystem",
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "url": "https://fhir.slade360.co.ke/fhir/CodeSystem/clinical-form-category-codesystem",
  "version": "0.1.0",
  "name": "SGHIClinicalFormCategoryCodeSystem",
  "title": "SGHI Clinical Form Category Code System",
  "status": "active",
  "experimental": false,
  "date": "2026-10-02T07:33:51+00:00",
  "publisher": "Kathurima Kimathi",
  "contact": [
    {
      "name": "Kathurima Kimathi",
      "telecom": [
        {
          "system": "url",
          "value": "https://www.linkedin.com/in/kathurima-kimathi/"
        },
        {
          "system": "email",
          "value": "kathurimakimathi415@gmail.com"
        }
      ]
    },
    {
      "name": "Oscar John",
      "telecom": [
        {
          "system": "email",
          "value": "oscarjohnotieno@gmail.com",
          "use": "work"
        }
      ]
    },
    {
      "name": "Kennedy Omondi",
      "telecom": [
        {
          "system": "email",
          "value": "kennankole@gmail.com",
          "use": "work"
        }
      ]
    }
  ],
  "description": "The 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.",
  "caseSensitive": true,
  "content": "complete",
  "count": 24,
  "concept": [
    {
      "code": "admission-record",
      "display": "Admission record",
      "definition": "The structured record made when a patient is taken onto a ward: presenting illness, the examination on admission, and the plan the admission starts from."
    },
    {
      "code": "triage-record",
      "display": "Triage record",
      "definition": "The sheet a patient is sorted on at the front door — how urgently they need to be seen, and the signs that decided it."
    },
    {
      "code": "clinical-assessment",
      "display": "Clinical assessment",
      "definition": "A structured assessment by one service, completed once per episode: palliative, nutrition, psychological, rehabilitation intake and the like."
    },
    {
      "code": "scored-instrument",
      "display": "Scored instrument",
      "definition": "A form whose output is a score rather than a set of findings — Bishop, Apgar, Glasgow, MUAC-based screens. Scored instruments are kept apart from assessments because the score is comparable over time and a free assessment is not."
    },
    {
      "code": "observation-chart",
      "display": "Observation chart",
      "definition": "Vital signs and physiological observations charted round by round through an admission."
    },
    {
      "code": "monitoring-chart",
      "display": "Monitoring chart",
      "definition": "A chart tracking one device or one therapy over time — ventilator, CPAP, dialysis, neurological observations, a chemotherapy cycle. Distinct from an observation chart because the columns are settings and responses to a treatment rather than the patient's own vitals."
    },
    {
      "code": "fluid-balance-chart",
      "display": "Fluid balance chart",
      "definition": "Intake and output charted over a shift or a day, with the totals that decide the next fluid order."
    },
    {
      "code": "feeding-chart",
      "display": "Feeding chart",
      "definition": "What a patient — usually a baby — was fed, when, how much and by what route."
    },
    {
      "code": "nursing-care-plan",
      "display": "Nursing care plan",
      "definition": "The nursing problem list with the care planned against each problem and the evaluation of it."
    },
    {
      "code": "medication-chart",
      "display": "Medication chart",
      "definition": "A prescription or an administration record: what was ordered or given, at what dose, by what route."
    },
    {
      "code": "wound-care-record",
      "display": "Wound care record",
      "definition": "Dressing changes, irrigation and the state of a wound or a surgical site over time."
    },
    {
      "code": "rehabilitation-record",
      "display": "Rehabilitation record",
      "definition": "Therapy given and progress against it, session by session — physiotherapy, occupational therapy, speech therapy."
    },
    {
      "code": "progress-note",
      "display": "Progress note",
      "definition": "A dated clinical entry continuing the record of a stay: doctors' notes, ward round entries, review notes."
    },
    {
      "code": "procedure-record",
      "display": "Procedure record",
      "definition": "The record of a procedure actually performed — the operation note, the anaesthetic chart, the endoscopy record."
    },
    {
      "code": "recovery-record",
      "display": "Recovery record",
      "definition": "Observations and care in the recovery period immediately after a procedure, before the patient goes back to a ward."
    },
    {
      "code": "safety-checklist",
      "display": "Safety checklist",
      "definition": "A checklist completed to confirm a step was taken before, during or after a procedure. Its value is the record that somebody checked, which is why an unfilled box is a finding rather than a blank."
    },
    {
      "code": "handover-record",
      "display": "Handover record",
      "definition": "What one team tells the next about a patient at a shift change or a transfer between units."
    },
    {
      "code": "referral",
      "display": "Referral",
      "definition": "A patient sent on to another unit or facility, with the history and the reason for sending them."
    },
    {
      "code": "discharge-summary",
      "display": "Discharge summary",
      "definition": "The account of a completed admission that the patient leaves with and the next clinician reads."
    },
    {
      "code": "requisition",
      "display": "Requisition",
      "definition": "A request to another department for a test, an image, a blood product or a supply."
    },
    {
      "code": "consent",
      "display": "Consent",
      "definition": "A record of permission given or refused for a procedure, a treatment, a disclosure or a disposal."
    },
    {
      "code": "clinical-report",
      "display": "Clinical report",
      "definition": "A report on a patient written for someone outside the treating team — an insurer, a court, another hospital, a mortality review."
    },
    {
      "code": "mortuary-record",
      "display": "Mortuary record",
      "definition": "Admission to, release from, or a consent connected with the mortuary."
    },
    {
      "code": "survey",
      "display": "Survey",
      "definition": "A questionnaire whose answers are about the service rather than about the patient's health, and which produces no clinical resource."
    }
  ]
}