Contact report (MF)

Definition

We describe here a specialization of the standard 'contact' transaction. The contact report documents a consultation, emergency visit, home visit, ...

The additional rules introduced in this specialization are defined to fit the specific needs of the GPSMF and GPPMF. It is recommended to read the 'migration formats' page before proceeding in the reading of this page.

Guidelines

Generalities

This transaction only requires a level 3 of kmehr normalization when used in the GP Software Migration. However, further levels may be applied (see structure overview).

Transaction elements

id	id of the transaction according to the ID-KMEHR convention.
cd	You must use the value 'contact' from CD-TRANSACTION.
date	This is the date of reporting.
time	This is the time of reporting.
author	This is the person assuming the responsibility of medical content of the transaction. It can be specified by a combination of hcparty. There must be at least one hcparty identifying a person. It must contain the ID-HCPARTY of this healthcare professional and it should contains the INSS number.
iscomplete	If this is false, this means that you transfer only part of the information and that the recipient should expect a more complete version later.
isvalidated	If this is false, this means that the information has not been validated medically.

Structure overview

Heading

The transaction is composed of standarized items (from CD-ITEM).

Additionally, it is recommended to gather the medical items within 5 specific headings that are described below.

Each contact in GPSMF should be structured within five headings. The 4 first ones reflect the SOAP approach.

'subjective': Subjective elements
'clinical': Objective elements
'asessement': Assessment elements
'plan': Planned elements

The fifth one is identified by the value 'parameter' of the table CD-HEADING. It gathers all the measurable items. The items within this last heading must be classified according to the CD-PARAMETER table.

Items

Most items of CD-ITEM could be useful, however you should tipically use the following items according to the proposed cardinalities (without attempt at exhaustivity).

Item type (cd)		Item purpose	Item structure
transactionreason	0-1	Describes the reason of the contact.	content (text)
encounterdatetime	1	Encounter date and time.	content (date time) Indicates the date and time of the encounter.
encountertype	0-1	Indicates the type of the encounter.	content (cd) Identifies the encounter type from CD-ENCOUNTER (hospitalisation, emergency, etc ...)
encounterlocation	0-1	Indicates the location of the encounter	Identifies the location where the encounter took place. A formal pattern has not been established for this element. However, the 'location' tag in the 'content' of the item could be used to describe this.
medication	0-*	Specifies a patient's medication.	content (text) Textual description of the medication as given by the GP (may correspond to the medicinal product description if available).
			content (medicinalproduct \| subtanceproduct \| compoundescription) The element ‘medicinalproduct’ identifies the prepacked medicinal product prescribed. It is built using a national medecine code from CD-DRUG-CNK (element intendedcd) and a textual description (element intendedname). The element ‘substanceproduct’ describes the INN or substance based cluster prescribed. It is built using a INN cluster from CD-INNCLUSTER (element intendedcd) and a textual description (element intendedname). The element ‘compoundprescription’ is a textual description of the compound prescription.
			[content (cd)] Value from CD-ATC corresponding to the medication.
			[beginmoment] Specifies the begin date (and time) of the treatment.
			[endmoment] Specifies the end date (and time) of the treatment.
			instructionforpartient Should be built from the detailed posology related items when available. Holds the S/ part of a prescription as written by the pharmacist.
			isrelevant Must be used to distinguish between relevant and irrelevant medications. If the field is set to ‘true’, the medication is ‘relevant’.
			lifecyle Must refer to the fixed value prescribed of CD-LIFECYCLE . Within the heading ‘medication’, this element can have the value delivered or administrated when the product has been delivered/administrated by the prescriber.
			[temporality] Specifies the chronicity of the treatment using a value from CD-TEMPORALITY.
			recorddatetime Date and time of item registration.
			All the item elements (such as posology, frequency) described in pharmaceutical prescription 2.0 may also be used.
vaccine	0-*	Specifies a planned or adiministrated vaccine.	content (cd+) Description of indications for the vaccine, using values from CD-VACCINEINDICATION.
			[content (text)] Textual description of the vaccine as given by the GP (may correspond to the medicinal product description if available).
			[content (medicinalproduct \| substanceproduct)] This content should correspond to the medicinal product administrated for this vaccine (when available). The element medicinalproduct supports the identification the prepacked medicinal product by a code from CD-DRUG-CNK (element intendeddcc) and a textual description (element intendedname) whereas the element substanceproduct describes the INN or substance based cluster prescribed by using a value from CD-INNCLUSTER.
			[beginmoment] Specifies when the vaccine has been administrated or is planned.
			lifecycle Specifies if the vaccine is ‘planned’ or ‘administrated’.
			recorddatetime Date and time of item registration.
adr	0-*	Specifies an adverse drug reaction.	content (text+) [content (cd+)] This item contains a textual content with the label of the risk at least. It should also contain one cd elements content corresponding to the available codifications. Recommended codifications: IBUI, ICPC-2, ICD-10.
			[beginmoment] Specifies when the adr was first detected. This information is recommended.
			recorddatetime Date and time of item registration.
risk	0-*	Specifies a risk factor.	Same structure as ‘adr’.
socialrisk	0-*	Specifies a social risk factor.	Same structure as ‘adr’.
healthcareelement	0-*	Specifies aither a 'current problem' or a 'passive care element'.	content (text+) [content (cd+)] For each healthcare element, an item is provided. This item contains at least a textual content with the label of the risk. It should also contain one cd elements content corresponding to the available codifications. Recommended codifications: IBUI, ICPC-2, ICD-10.
			[beginmoment] Specifies when the problem or care element started.
			[endmoment] Specifies when the problem or care element ended.
			lifecycle Must be used to distinguish between problems and (value ‘active’ from CD-LIFECYCLE) relevant passive care elements (value ‘inactive’).
			isrelevant Must be used to distinguish between relevant and irrelevant healthcare elements. If the field is set to ‘true’, the healthcare elements is ‘relevant’. ‘Active’ healthcare elements are necessarily ‘relevant’.
			recorddatetime Date and time of item registration.
parameter An additional cd element with a value from CD-PARAMETER should be added. When the required parameter type is not present in CD-PARAMETER, the parameter can still be described using a local schema.	0-*	Describes a measurable item.	content(decimal unit(cd)) The unit type is indicated using the values of CD-UNIT or CD-TIMEUNIT.
			[beginmoment] Can be used to indicate the moment where the parameter was measured.
			recorddatetime Date and time of item registration.