SDOH Clinical Care
0.0.4C3 - CI Build

SDOH Clinical Care - Local Development build (v0.0.4C3). See the Directory of published versions

SDOH Coded Content

Previous Page - Patient Story 1

The following types of information are relevant when Exchanging Clinical Information or Doing a Referral.

Core Clinical Content

Following a clinical encounter, an encounter summary is used to exchange the clinical information documented in and relevant to the patient visit. A Discharge Summary, History and Physical note, or Progress Note are common types of encounter summaries. A Continuity of Care Document is a summary of the patient’s relevant health history over a span of time. It is a common type of structured document used to share clinical information. Structured documents contain standardized sections of information that include well defined clinical data such as: Problem List, Allergies, Procedures, Test Results, Medication List and clinical assessment and treatment plan information.

It is however important to note, when doing a referral for community-based services, a summary of the patient’s full clinical history or full clinical encounter notes may not be needed to supply a community-based organization (CBO) with the information needed to initiate the referral. The Referral Note document treats all the standardized structured section content as optional, allowing information exchange to be limited to include only the information needed to support the referral. Additionally, in some situations only small amounts of very specific data may be needed. Both a document exchange paradigm and a data exchange paradigm may be needed when exchanging clinical information or doing a referral for services.

Type of Information Description Resource: Profile
Patient Basic patient demographics, name, birthdate, gender, address, telecom. Patient: US Core Patient
Practitioner Practitioner information, name, role, NPI number, organization associated with, gender, address, telecom, location where seen. PractitionerRole: US Core PractitionerRole,
PractitionerRole: US Core Practitioner,
PractitionerRole: US Core Organization,
PractitionerRole: US Core Location
Care Plan Information Issues being addressed, goals established for those issues, interventions already provided, planned interventions. CarePlan: US Core CarePlan
Clinical Note Any SOAP Note type of visit summary documentation containing relevant patient information gathered <during a patient encounter and <needed when initiating a referral for SDOH services. ​Bundle (Document): C-CDA on FHIR Composition (such as Progress Note Document, or Discharge Document)
Bundle (Collection): SDOHCC Referral Data Collection
Referral Note Who is referring to whom, and the digital contact points to be used for each, Patient Demographics, Reason for the referral, Requested Intervention to be performed, other information relevant to the organization receiving the referral. Composition: C-CDA on FHIR Referral Note (Note: for this type of C-CDA document the section content is optional, so the information exchange can be limited to include only the information needed to support the referral.)
Assessment Observation Clinical assessment of specific SDOH Issue, i.e. Food Insecurity Absent/Present/Unknown. Clinical narrative note with relevant info about the patients situation. Observation: SDOHCC Food Insecurity Observation 1 (may include a Note Comment) (used to initially assess if food insecurity is present or absent and can be the evidence for assigning a diagnosis. Later, this observation can be used to assess goal achievement status.)
DocumentReference: US Core DocumentReference
Screening Information A Standardized screening questionnaire with associated responses SDC Questionnaire Response and associated SDC Questionnaire (See How to use LHC Form builder tool for additional information on how to create a standard digital screening instrument using the FHIR Questionnaire resource. Also, to download the current master list of data elements identified for potential representation in the Gravity project including codes (permanent or temporary) visit About SDOH-CC Master List Temporary Code System and Temporary Codes
Care Plan Overall picture of what interventions are planned or have been completed to make progress toward a goal that was set for addressing a patient’s condition (needs). CarePlan: SDOHCC CarePlan (a further constraint on US Core CarePlan)
Condition: SDOHCC Condition Food Insecurity 1 (a further constraint on US Core Condition),
Goal: SDOHCC Goal Food Insecurity 1 (a further constrain on US Core Goal),
Procedure: SDOHCC Procedure Food Insecurity 1 (a further constraint on US Core Procedure) (for completed or planned interventions)
ServiceRequest: SDOHCC ServiceRequest Food Insecurity 1 (a further constraint on BSeR ServiceRequest (for services requested/completed)
Patient Care Team Care team members responsible for services being delivered to the patient. It tells who each is, what organization each works for, and how to communication by phone, secure fax, or secure email (Direct) and data processing endpoints CareTeam: US Core CareTeam
PractionerRole: US Core PractitionerRole
Practitioner: US Core Practitioner
Organization: US Core Organization
Location: US Core Location
Endpoint: Endpoint
Progress Note A collection of information produced following a patient encounter where progress is noted regarding existing issues are documented. C-CDA Progress Note or
C-CDA on FHIR Progress Note
Patient Summary A collection of information that summarizes a patient’s health history over a range of time. C-CDA CCD
C-CDA on FHIR CCD
Discharge Summary A collection of information produced following an Inpatient stay or Emergency Room visit. C-CDA Discharge Summary
C-CDA on FHIR Discharge Summary
Referral Note A collection of information provided when requesting services to be provided or performed. C-CDA Referral Note or
C-CDA on FHIR Referral Note (could be the payload of the referral.)
Consultation Note A collection of information produced following a patient encounter that was performed at the request of someone else. It is the collection of information returned to the requesting party. C-CDA Consultation Note or
C-CDA on FHIR Consultation Note (could be the payload of the response to the completed referral.)


SDOH Food Insecurity Content

SDOH content can also be shared in the context of a clinical encounter and to support broader whole-person care.

Type of Information Description Resource: Profile
Screening Tool A set of standardized questions and answers developed as a screening instrument that may be used to inform a clinical assessment of the patient’s situation.
In addition, a screening instrument may include derived interpretations which are defined as a computational expression based on the answers to the questions in the instrument. This type of observation is computed after the screening responses have been gathered. They are included as additional observations referenced by the questionnaire response.		 Questionaire: SDC Questionaire
(Note: In order to support interoperable use of questionnaires, systems must populate and maintain the Questionnaire.identifier information associated with the digital screening instrument.)
QuestionnaireResponse: SDC Questionnaire Response, Observation
(See How to use LHC Form builder tool for additional information on how to create a standard digital screening instrument using the FHIR Questionnaire resource.)
Assessment Observation Uses clinical judgment to make an observation of the situation Observation: SDOHCC_Observation_FoodInsecurity_1
Clinical Diagnosis Adds a diagnosis or health concern to be followed up on that is an SDOH concern Condition: SDOHCC_Condition_FoodInsecurity_1
Patient-centered Goal Clarifies and documents the goal Goal: SDOHCC_Goal_FoodInsecurity_1
Planned /Complete Procedure A service or care action performed or to be performed for a patient Procedure: SDOHCC_Procedure_FoodInsecurity_1
Referral A request for services for a patient to be provided by another provider, organization or program ServiceRequest: SDOHCC_ServiceRequest_FoodInsecurity_1


Message, Transaction, Consent and Workflow Content

Additional types of content are needed to support the gathering and sharing SDOH information in the context of delivering clinical care and when referring a patient for community-based services.

Type of Information Description Resource: Profile
Patient Screening Task A task requesting a certain questionnaire be given to a patient or a provided list of patients, and administered and returned to the task initiator when consented. Expectations for the use of Task.status need to be discussed to develop greater concensus about the business states and situations associated with the Task status model. SDOHCC Task Screening 1
List of Patients to be Screened A list of patients for whom screening of a certain type (using a designated questionnaire) is being requested. SDOHCC List Food Insecurity 1
Screening Instrument A Questionnaire designed to represent a set of screening questions with associated answers and computed result observation(s) SDC Questionnaire
Patient Consent A consent describing what type of information sharing has been permitted by the patient. Category codes to support within various use cases need to be confirmed by data sharing partners and need to take relevant legal and regulatory mandates into consideration. SDOHCC Consent FoodInsecurity 1
Solicited Communication Information shared with another organization after performing an intervention that was requested to be performed (solicited) CDex Communication Request
CDex Communication
Unsolicited Communication A communication of information performed without being requested (unsolicited) CDex Communication


Next Page - Use Cases, System and Technical Actors