Procedure Referral Information Model

DISCLAIMER: EVERYTHING ON THIS PAGE SHALL BE CONSIDERED DRAFT AS LONG AS THIS DISCLAIMER REMAINS PRESENT. - THIS PAGE IS ONGOING DISCUSSED DURING THE PROCEDURE REFERRAL WG.

This page describes the information model for a referral prescription (RP) Once this page is complete, it can be reworked as a FHIR logical datamodel artefact.
For some elements that are less self-evident in what FHIR resource they will be expressed, there is already a mention of the FHIR resource that might be used. As such, this page can already help define the scope of which FHIR artefacts need to be profiled.
The main FHIR resource for the prescription is expected to be the FHIR ServiceRequest.

• Common for all use cases:
  • 1..1 Patient SSIN identifier
  • 1..1 Prescriber NIHDI identifier
  • 1..1 Date creation
  • 0..* NIHDI identifiers of signing healthcare parties (for validity of the RP in certain cases) with dates
  • 1..* NIHDI identifiers that will perform the RP
  • 1..1 Period OR date OR frequency for performing the RP (FHIR ServiceRequest allows for use of theFHIR datatypes dateTime, Period or Timing Is the FHIR datatype Timing sufficient for the frequency requirements (https://www.hl7.org/fhir/datatypes.html#Timing )?)
  • 1..1 Status with date
  • 1..1 Reference ID
  • 1..1 What is actually prescribed as a coded value (is this always possible?)
  • 0..* Some general notes about the prescription (multiple comments by different parties? (e.g. a comment from the practitioner and one from the patient - should that be possible?)
• Per use case:
  • 0..* Structured data linked to the specific model of RP
    • 0..* Observations on the patient (e.g. blood pressure, weight,...) (FHIR Observation)
    • 0..* Problems of the patient (FHIR Condition)
    • 0..* Procedures that the patient underwent (FHIR Procedure)
  • 0..* Not structured data linked to the specific model of RP
    • 0..* Notes on the patient
    • 0..* Attachment
• Diagnostic imaging:
  • 0..* Questionnaire responses (FHIR QuestionnaireResponse - if this can be standardized, possibly also the FHIR Questionnaire ? )
  • 0..* Observations on the patients as coded values or free text
  • 0..* References to documents (FHIR DocumentReference)
• Physiotherapy:
• Nursing: