Gives information about the Clinical Narrative section

Clinical Narrative Section Content

The Clinical Narrative section carries information about the Clinical Narrative details used. PRSB Elements should be formatted as subheadings in any HTML sent.

CLINICAL NARRATIVE          
Data Item Description Cardinality Values Mandatory/required/ optional FHIR Target
Clinical narrative A description detailing a patient’s reason for attendance, any red flags, results from the diagnostic and treatment process. 1 ONLY Free text Mandatory Composition.section.text
CKS Checked Confirmation Yes/No whether the Clinical Knowledge Summaries were checked as part of the referral   Options - “Yes”, “No” Mandatory Composition.section.text
Red Flags Confirmation Yes/No whether the presence of clinical Red Flags were checked as part of the referral   Options - “Yes”, “No” Mandatory Composition.section.text
Red Flag Details Details captured as to the Clinical Red Flags identified if the Red Flags were identified as “Yes”   Free text data entry Mandatory Composition.section.text
Consultation Pharmacist Notes Consultation notes from the pharmacist consultation, in addition to that captured from the referring organisation referral discussion with the patient   Free text data entry Mandatory Composition.section.text
Consultation Outcome The Patient outcome of the referral to Community Pharmacy     Mandatory Composition.section.text
Consent For Onward Referral Confirmation of consent for onward referral to Pharmacy   Options - “Yes”, “No” Mandatory Composition.section.text
GP Notification Form - Referrals for low acuity/minor illness: notification status Confirmation audit trail that the Post Event Message (PEM) has been sent to the patient’s GP Practice once the referral is recorded as “Completed”     Mandatory Composition.section.text
Incident Record of whether the pharmacy is logging feedback on the referral which relates to an incident (or potential incident)   Options - “Yes”, “No” Mandatory Composition.section.text
Incident Pharmacist Feedback Details captured of the incident feedback reported as “Yes”   Free text data entry Mandatory Composition.section.text
Survey Consent Capturing of consent to participate in a patient survey on the Service   Options - “Yes”, “No” Mandatory Composition.section.text
Patient Survey information: notification status Confirmation audit trail that the Patient Survey has been sent to the patient     Mandatory Composition.section.text

Example Clinical Narrative Section

<!--<xml>-->
<!--Clinical Narrative-->
	<section>
		<title value="Clinical Narrative"/>
		<code>
			<coding>
				<system value="http://snomed.info/sct"/>
				<code value="1077901000000108"/>
				<display value="Clinical narrative"/>
			</coding>
		</code>
		<text>
			<status value="additional"/>
			<div xmlns="http://www.w3.org/1999/xhtml">
			<table width="100%">
				<tbody>
				<tr>
					<th>Clinical Narrative</th>
					<td>A description detailing a patient’s reason for attendance, any red flags, results from the diagnostic and treatment process.</td>
				</tr>
				</tbody>
			</table>
			</div>
		</text>
	</section>
<!--</xml>-->
Tags: fhir