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Narrative

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Source1

{
  "resourceType": "CodeSystem",
  "id": "inpatient-document-type-codesystem",
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "url": "https://fhir.slade360.co.ke/fhir/CodeSystem/inpatient-document-type-codesystem",
  "version": "0.1.0",
  "name": "SGHIInpatientDocumentTypeCodeSystem",
  "title": "SGHI Inpatient Document Type Code System",
  "status": "active",
  "experimental": false,
  "date": "2026-10-02T07:33:51+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 notes and assessments written against an inpatient stay. LOINC already names four of these — progress note, history and physical, nurse note and discharge summary — and each carries its LOINC code alongside its SGHI code. The other eleven have no LOINC equivalent that says the same thing. It is a document classification, so it serves Composition.type and DocumentReference.type once a note is filed.",
  "caseSensitive": true,
  "content": "complete",
  "count": 15,
  "concept": [
    {
      "code": "progress-note",
      "display": "Progress note",
      "definition": "Interval change since the last entry, and the plan from here."
    },
    {
      "code": "admission-note",
      "display": "Admission note",
      "definition": "The narrative account of why the patient was admitted."
    },
    {
      "code": "nursing-note",
      "display": "Nursing note",
      "definition": "Nursing observation and care given during a shift."
    },
    {
      "code": "ward-round-note",
      "display": "Ward round",
      "definition": "The consultant round entry: findings, decisions and jobs for the team."
    },
    {
      "code": "shift-handover-note",
      "display": "Shift handover",
      "definition": "What the next shift needs to know about the patient."
    },
    {
      "code": "discharge-note",
      "display": "Discharge note",
      "definition": "The summary the patient and their next clinician leave with."
    },
    {
      "code": "death-note",
      "display": "Death note",
      "definition": "The record of a death, its circumstances and who was informed. Distinct from the death certificate, which is a civil registration document."
    },
    {
      "code": "adult-general-admission-assessment",
      "display": "Adult general admission assessment",
      "definition": "The baseline taken on arrival to the ward, for any adult admission."
    },
    {
      "code": "obstetric-admission-assessment",
      "display": "Obstetric admission assessment",
      "definition": "Taken on admission to the maternity ward, before the first review."
    },
    {
      "code": "surgical-preoperative-assessment",
      "display": "Surgical pre-operative assessment",
      "definition": "Completed before theatre, confirming fitness and consent."
    },
    {
      "code": "critical-care-assessment",
      "display": "Critical care assessment",
      "definition": "Organ support and conscious level, for a patient in critical care."
    },
    {
      "code": "paediatric-admission-assessment",
      "display": "Paediatric admission assessment",
      "definition": "The baseline for a child, including who is staying with them."
    },
    {
      "code": "falls-and-pressure-ulcer-risk-assessment",
      "display": "Falls and pressure ulcer risk",
      "definition": "Braden and falls risk together, reassessed daily and on any change."
    },
    {
      "code": "nutrition-screening",
      "display": "Nutrition screening (MUST)",
      "definition": "Malnutrition screening, repeated weekly for an inpatient."
    },
    {
      "code": "mental-health-risk-assessment",
      "display": "Mental health risk assessment",
      "definition": "Mood, risk and capacity, with any safeguarding concern."
    }
  ]
}