Here is the details on the Clinical Information Specification we discussed during the meeting:
| FAMILY HISTORY & RISK FACTORS CONSUMER ENTERED Interaction | ||||||||||
| Data Source | Conceptual Data Item | Logical Data Item | Logical Data Item Description | Logical Data Item Code | Logical Data Item Field Type | ValueSet Value | ValueSet Code & Description | Format | Cardinality | ValueSet Reference |
| Harmonised (H) or Operational (Op) | BOLD equals Harmonised data | Name of the Data Item | The description of the logical data item | SNOMED Code and description or FHIR (if handled by FHIR values) | Eg text, date | BOLD equals Harmonised data | eg. SNOMED, LOINC | Format and Example | Relationship of x to y eg IHI is 1..2 | Link to NCTS, FHIR or Sharepoint |
| OP | Identity Identifier (Child) | IHI | The numerical identifier that uniquely identifies each individual in the Australian healthcare system | FHIR | Numeric | Numeric | 1..1 | |||
| DOB | The date of birth of the person | FHIR | Date | Date | 1..1 | |||||
| First Name | First Name of individual | FHIR | Text | Text | 1..1 | |||||
| Last Name | Last Name of individual | FHIR | Text | Text | 1..1 | |||||
| Sex | Sex used to identify the patient against the HI Service | FHIR | Text | Text | 1..1 | |||||
| Risk Factors | SNOMED 80943009 | ||||||||||
| H | Need Oxygen > 48hrs | At Birth did your baby need oxygen for 48 hours or longer? | Did the baby at birth require oxygen for 48hrs or more | SNOMED 1402861000168108 | H/O: neonate requiring oxygen for 48 hours or more | Value Set | Yes | SNOMED 373066001 | Yes | Text | 0..1 | http://build.fhir.org/ig/hl7au/au-fhir-childhealth/ValueSet-ncdhc-generic-yes-no-1.html |
| No | SNOMED 373067005 | No | |||||||||
| H | Birth Weight <1500gms | At birth did your baby weigh less than 1500 grams? | Did the baby at birth weigh 1500gms or less | SNOMED 1376591000168102 | H/O: low birth weight status, less than 1500 g | Value Set | Yes | SNOMED 373066001 | Yes | Text | 0..1 | http://build.fhir.org/ig/hl7au/au-fhir-childhealth/ValueSet-ncdhc-generic-yes-no-1.html |
| No | SNOMED 373067005 | No | |||||||||
| H | Intensive Care >24hrs | At birth did your baby need to stay in the intensive care unit or special care nursery for more than two days? | Did the baby stay in the Intensive Care Unit or Special Care Nursery for more than 24hrs | SNOMED 1402871000168102 | H/O: neonate requiring intensive care for 24 hours or more | Value Set | Yes | SNOMED 373066001 | Yes | Text | 0..1 | http://build.fhir.org/ig/hl7au/au-fhir-childhealth/ValueSet-ncdhc-generic-yes-no-1.html |
| No | SNOMED 373067005 | No | |||||||||
| Familial Risk Factor | SNOMED 102486008 | ||||||||||
| H | Hearing / Deafness / Hearing Problems | Have any of your baby's close relatives been deaf or had a hearing problem from childhood? | Questionnaire around family history associated with hearing problems | SNOMED 439750006 | Family history of hearing loss | Value Set | Yes | SNOMED 373066001 | Yes | Text | 0..1 | http://build.fhir.org/ig/hl7au/au-fhir-childhealth/ValueSet-ncdhc-generic-yes-no-1.html |
| No | SNOMED 373067005 | No | |||||||||
| H | Vision / Sight / Blindness / Eye Problems | Did anyone in the family have eye problems in childhood? | Questionnaire around family history associated with vision problems | SNOMED 430723005 | Family history of visual disturbance | Value Set | Yes | SNOMED 373066001 | Yes | Text | 0..1 | http://build.fhir.org/ig/hl7au/au-fhir-childhealth/ValueSet-ncdhc-generic-yes-no-1.html |
| No | SNOMED 373067005 | No | |||||||||
| H | Dysplasia of the Hips / Hip Problems | Is there family history of hip problems in childhood? Example - dysplasia of the hips | Questionnaire around family history associated with hip problems | SNOMED 700191004 | Family history of developmental hip dysplasia | Value Set | Yes | SNOMED 373066001 | Yes | Text | 0..1 | http://build.fhir.org/ig/hl7au/au-fhir-childhealth/ValueSet-ncdhc-generic-yes-no-1.html |
| No | SNOMED 373067005 | No | |||||||||
| H | Allergies / Adverse Reactions | Agent | Name of Allergy | Text | Text | 0..* | 19/03 - Out of Scope | |||
| Description | Description about the allergy | Text | Text | 0..* | ||||||
| Op | Interaction Type | Interaction Type | This will be used to identify the health interaction type | FHIR | Text | 1..1 | ||||
| Op | Attestation | Attestation | Used to indicate the author of the composition | FHIR | Text | 1..1 | ||||
| Date and Time | Date and Time of Examiner attesting the information | FHIR | Date (YYYY-MM-DD) Time (HH-MM-SS) | Date | 0..1 | |||||
| Op | Author | Author | Used to indicate where the information has been sent from i.e. System | FHIR | Text | 1..1 | ||||