Gives information about the Clinical summary section
Important: Under all circumstances, including any discrepancies, compliance with NHS Digital’s specifications for implementers takes precedence over published PRSB standards.
The latest version of the PRSB documentation should be consulted for further information regarding Section headings and content http://theprsb.org
The latest version of the PRSB documentation should be consulted for further information regarding Section headings and content http://theprsb.org
Clinical Summary Section content
The Clinical summary section carries a narrative summary of the episode, where possible very brief. PRSB Elements should be formatted as subheadings in any HTML sent.
| Section | Description | Card. | MRO* | FHIR Target and Guidance |
|---|---|---|---|---|
| Clinical summary | A brief description of the encounter. | 1 only | M | Carried in the CodeableConcept of Composition.section.code FHIR element. |
| PRSB Element | Description | Card. | MRO* | FHIR Target and Guidance |
| Clinical summary | Summary of the encounter. Where possible, very brief. This may include interpretation of findings and results; differential diagnoses, opinion and specific action(s). Planned actions will be recorded under 'plan'. | 1 only | M | Free text |
| Formulation | An account, shared by a therapist and person, of the personal meaning and origins of a person’s difficulties. This is viewed in the context of multiple factors including relationships, social circumstances and life events and will indicate the most helpful way forward. | 0 to 1 | R | Free text |
| Treatments and interventions and changes made to treatments. | The relevant treatments and interventions which the patient received during the inpatient stay. Include psychological therapies. All medications should be recorded under the medications section. | 0 to 1 | R | Free text |
| * M=Mandatory R=Required O=Optional | ||||
Example Clinical Summary Section
Coded Resources
This text section should be linked to the following FHIR Resources to provide the textual information in a coded format.
- The ITK3 FHIR Mental Health eDischarge does not currently support a coded clinical summary.