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| 1 | Advance Directives | Examples include Personal Advance Care Plans, Portable Medical Orders, Mental Health Advance Directives, Episodic Advance Directives |
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| 2 | Allergies | List of allergies the patient has |
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| 3 | Behavioral Health | TODO |
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| 4 | Functional Status | Examples include assessments, mental status, mobility, activities of daily livings, swallowing, devices needed |
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| 5 | Immunizations | List of immunizations patient has received and when |
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| 6 | Instructions | Narrative instructions and notes |
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| 7 | Medication Equipment | List of equipment patient needs to take medications |
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| 8 | Medications | List of medications prescribed for the patient. Examples include medications received (administration lists, discharge lists, discontinued lists), high risk drug classes, opioids |
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| 9 | Plan of Care | Care plan created for the patient. Care plans can include conditions and their treatment, substance abuse, care management, and nutrition information |
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| 10 | Problems | Examples include fever, vomiting, dehydration, internal bleeding, shortness of breath, pain |
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| 11 | Procedures | List of procedures the patient has undergone |
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| 12 | Reason for Referral | Examples include discharge summary (reason, destination, location, status, setting, admitted from) |
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| 13 | Reason for Visit | TODO |
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| 14 | Results | Examples include lab results|
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| 15 | Social History | Examples include medical history, prior level of functioning, substance abuse, ethnicity, race, coverage (Medicare, Medicaid, private, self), transportation, demographics, dental |
<td>Examples include Personal Advance Care Plans, Portable Medical Orders, Mental Health Advance Directives, Episodic Advance Directives</td>
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</tr>
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<tr>
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<td>Allergies</td>
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<td>List of allergies the patient has</td>
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</tr>
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<tr>
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<td>Behavioral Health</td>
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<td>TODO</td>
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</tr>
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<tr>
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<td>Functional Status</td>
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<td>Examples include assessments, mental status, mobility, activities of daily livings, swallowing, devices needed</td>
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</tr>
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<tr>
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<td>Immunizations</td>
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<td>List of immunizations patient has received and when</td>
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</tr>
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<tr>
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<td>Instructions</td>
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<td>Narrative instructions and notes</td>
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</tr>
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<tr>
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<td>Medication Equipment</td>
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<td>List of equipment patient needs to take medications</td>
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</tr>
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<tr>
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<td>Medications</td>
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<td>List of medications prescribed for the patient. Examples include medications received (administration lists, discharge lists, discontinued lists), high risk drug classes, opioids</td>
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</tr>
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<tr>
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<td>Plan of Care</td>
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<td>Care plan created for the patient. Care plans can include conditions and their treatment, substance abuse, care management, and nutrition information</td>
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</tr>
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<tr>
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<td>Problems</td>
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<td>Examples include fever, vomiting, dehydration, internal bleeding, shortness of breath, pain</td>
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</tr>
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<tr>
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<td>Procedures</td>
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<td>List of procedures the patient has undergone</td>
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This implementation guide supports the [R4]({{site.data.fhir.path}}index.html) version of the FHIR standard and builds on the [US Core Implementation Guide](http://hl7.org/fhir/us/core) and implementers need to familiarize themselves with the profiles in that guide. Implementers should also familiarize themselves with the FHIR resources used within the guide:
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* **Hospital to Home Health Agency** - A patient has suffered an acute event and has been in the hospital recovering. Based on ongoing assessment at the hospital, their acuity has lowered to the point of transitioning to a post-acute setting, e.g., Home Health. The hospital care team coordinates the transition with the Home Health intake team, including the transition of information through a variety of tools like portals, referral management platforms, but also still a high volume of phone and fax based care transitions. Services needed (RN, PT, OT, etc.) are determined based on patient condition with collaboration from the physician signing off on the discharge. Information captured by the hospital is often dense, and both the intake and medical records teams pour over accompanying documentation to properly inform the care team. The initial visit is scheduled in accordance with the hospital discharge and any home medical equipment delivery. An OASIS is completed by the RN or PT conducting the initial visit, and while the hospital is capturing similar information it is generally not structured in a manner that transfers over to inform the OASIS on a one to one basis; this is where the role of the intake and records team is pivotal in obtaining the right clinical context to inform clinicians.
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### High-Level Use Case Examples
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#### Intake staff
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* As a member of the intake team, I need a referral sent to my desired system electronically (EHR, CRM, etc)
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* As a member of the intake team, I need a consolidated record from the referring provider that reduces or eliminates the effort spent searching for clinical documentation to qualify the referral and ensure a smooth transition.
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* As a member of the intake team, I need the ability to bring information into my health record including key information like Diagnosis, Allergies, Insurance, Lab results, and prior vital signs.
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#### Care team
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* As a member of the care team, I need clinical information captured by the previous provider in order to provide efficient and effective care.
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* As a member of the care team, I need the specific information that concerns my clinical discipline identified.
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* As a member of the care team, I need the ability to assess and add clinical information captured by the referring provider like medications, treatments, and care plans to my health record.
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* As a member of the care team, I need the ability to review relevant quality measures captured by the referring provider to inform the completion of my organization's measures (OASIS, MDS)
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#### Medical records team
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* As a member of the medical records team, I need the ability to compare quality measures captured in the previous setting to quality measures captured by the care team (OASIS, MDS), as significant disparities may result in audits.
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