Patient Care Coordination (PCC) Implementation Guide
0.1.1-current - ci-build
Patient Care Coordination (PCC) Implementation Guide
0.1.1-current - ci-build
Patient Care Coordination (PCC) Implementation Guide - Local Development build (v0.1.1-current) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: https://fhir.virtually.healthcare/Questionnaire/ConsultationNote | Version: 0.1.1-current | |||
| Draft as of 2025-08-14 | Computable Name: | |||
Formal definition of the Consultation Note
The consultation note forms the basis of IM1 Consultation Writeback and GP Connect Send Document. It is also related to the EMIS consultation screen sections and PRSB section headings.
The consultation note consists of three main structures:
Both archetype/template and entities are data capture related and will often relate to a data entry screen within an application. Compositions provide a high-level structure to the consultation, but they are generally assembled from both archetype/templates and resource entities; it is a data aggregate.
Many questions within the archetype / template will be the same and also overlap with directly captured entities. I.e., in remote patient monitoring (virtual wards) a patient's weight, pulse rate and blood pressure can be captured from device data. These data items also exist in vital signs.
Where a template/archetype question may have multiple uses, it is persisted as a resource entity.
These questions will be SNOMED or LOINC coded.
The basic structure of a composition is shown above, in its aggregated form it is known as a FHIR Document and a redendered example is shown below:
Each section is coded using Document Section Codes, which can be found Value Set: Document Section Codes.
This is not required to be SNOMED CT coded.
As composition is not for data capture, we need an archetype to form the high framework for the consulation-note.
The current model is shown below. Historically this is related to SOAP Note and also Nursing Process (ADPIE) which are also included for documentation purposes.
Consultation Note Map
| LinkID | Text | Cardinality | Type | Description & Constraints |
|---|---|---|---|---|
  | Formal definition of the Consultation Note | Questionnaire | https://fhir.virtually.healthcare/Questionnaire/ConsultationNote#0.1.1-current | |
  LOINC/42348-3 | Consent | 0..1 | group | Definition: https://fhir.virtually.healthcare/StructureDefinition/Consent |
   consentType | Type of Consent | 0..* | text | |
| Encounter | Consultation | 0..1 | group | Definition: |
 encounterdate | Date and time of consultation | 0..1 | dateTime | Definition: Encounter.period.start |
 encountertype | Type of Consultation | 0..1 | choice | Definition: Encounter.type Options: 3 options |
| encounterservice | Service Provided | 0..1 | choice | Definition: Encounter.serviceType Options: 1 option |
| LOINC/61150-9 | Presenting Complaint | 0..1 | group | |
| narrative | Symptoms | 0..* | text | |
| complaint | Complaint | 0..* | open-choice | Definition: Observation.valueCodeableConcept Value Set: http://snomed.info/sct/900000000000207008?fhir_vs=ecl/%3C404684003 |
| AllergyIntolerance | Allergies | 0..1 | group | Definition: |
| substance | Substance Allergy | 0..* | open-choice | Definition: AllergyIntolerance.code Value Set: http://snomed.info/sct/900000000000207008?fhir_vs=ecl/%3C105590001 |
| drug | Drug Allergy | 0..* | open-choice | Definition: AllergyIntolerance.code Value Set: http://snomed.info/sct/900000000000207008?fhir_vs=ecl/%3C416098002 |
| History | History | 0..1 | group | |
| historynarrative | Patient History | 0..* | text | |
| Examination | Examination | 0..1 | group | |
| LOINC/8716-3 | Vital signs | 0..1 | group | |
  SCT/27113001 | Weight | 0..1 | decimal | Definition: Observation.valueQuantity Initial Value: Quantity = ? kilogram |
| SCT/50373000 | Height | 0..1 | decimal | Definition: Observation.valueQuantity Initial Value: Quantity = ? centimeter |
| SCT/363811000 | Head Circumference | 0..1 | decimal | Definition: Observation.valueQuantity Initial Value: Quantity = ? centimeter |
| SCT/276885007 | Body temperature | 0..1 | decimal | Definition: Observation.valueQuantity Initial Value: Quantity = ? Cel |
| SCT/75367002 | Blood pressure | 0..1 | group | Definition: Observation.component |
| SCT/72313002 | Systolic blood pressure | 1..1 | decimal | Definition: Observation.valueQuantity Initial Value: Quantity = ? millimeter of mercury |
| SCT/1091811000000102 | Diastolic blood pressure | 1..1 | decimal | Definition: Observation.valueQuantity Initial Value: Quantity = ? millimeter of mercury |
| LOINC/61149-1 | Comment | 0..1 | group | |
| questions | Questions | 0..* | group | |
| question | Question | 0..1 | text | |
| answer | Answer | 0..* | text | |
| LOINC/29762-2 | Lifestyle- smoking and alcohol status, diet | 0..1 | group | |
| SCT/365981007 | Smoking Status | 0..1 | choice | Definition: Observation.valueCodeableConcept Value Set: Smoking Status |
| LOINC/10160-0 | Medications | 0..1 | group | Definition: https://fhir.virtually.healthcare/StructureDefinition/MedciationDispense |
| medication | Medications Dispensed | 0..* | group | |
| drug | Drug | 0..1 | text | |
| dosage | Dosage | 0..1 | text | |
| FollowUp | Follow up | 0..1 | group | Definition: |
| task | Tasks | 0..1 | text | |
| Documents | Document | 0..1 | group | |
 images | Images | 0..* | attachment | Definition: DocumentReference |
| Referral | Sign Posting | 0..1 | group | Definition: |
| serviceRequest | Services | 0..* | group | |
| serviceType | Type of Signposting | 0..1 | text | |
| Documentation for this format | ||||
Options Sets
Answer options for encountertype
Answer options for encounterservice
The current model with the addition of Questionnaire (the definition for archetype/template discussed above) is shown below:
Consultation Note Model
The main changes are:
category should be populated in order to support creation of the composition aggregate.