Flag

Prospective warnings of potential issues when providing care to the patient.

Schema

Properties

Name	Required	Type	Description
identifier		Identifier[]	Business identifier Details Business identifiers assigned to this flag by the performer or other systems which remain constant as the resource is updated and propagates from server to server. This is a business identifier, not a resource identifier (see [discussion](resource.html#identifiers)). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.
status	✓	code	active | inactive | entered-in-error Details Supports basic workflow. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
category		CodeableConcept[]	Clinical, administrative, etc. Details Allows a flag to be divided into different categories like clinical, administrative etc. Intended to be used as a means of filtering which flags are displayed to particular user or in a given context. The value set will often need to be adjusted based on local business rules and usage context.
code	✓	CodeableConcept	Coded or textual message to display to user Details The coded value or textual component of the flag to display to the user. If non-coded, use CodeableConcept.text. This element should always be included in the narrative.
subject	✓	Reference< Patient | Location | Group | Organization | Practitioner | PlanDefinition | Medication | Procedure >	Who/What is flag about? Details The patient, location, group, organization, or practitioner etc. this is about record this flag is associated with.
period		Period	Time period when flag is active Details The period of time from the activation of the flag to inactivation of the flag. If the flag is active, the end of the period should be unspecified.
encounter		Reference<Encounter>	Alert relevant during encounter Details This alert is only relevant during the encounter. If both Flag.encounter and Flag.period are valued, then Flag.period.start shall not be before Encounter.period.start and Flag.period.end shall not be after Encounter.period.end.
author		Reference< Device | Organization | Patient | Practitioner | PractitionerRole >	Flag creator Details The person, organization or device that created the flag.

Search Parameters

Name	Type	Description	Expression
date	date	Time period when flag is active	Flag.period
patient	reference	The identity of a subject to list flags for	Flag.subject.where(resolve() is Patient)
encounter	reference	Alert relevant during encounter	Flag.encounter
author	reference	Flag creator	Flag.author
identifier	token	Business identifier	Flag.identifier
subject	reference	The identity of a subject to list flags for	Flag.subject

Inherited Properties

Name	Required	Type	Description
id		string	Logical id of this artifact Details The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
meta		Meta	Metadata about the resource Details The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
implicitRules		uri	A set of rules under which this content was created Details A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
language		code	Language of the resource content Details The base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
text		Narrative	Text summary of the resource, for human interpretation Details A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
contained		Resource[]	Contained, inline Resources Details These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored Details May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Usage

A flag is a warning or notification of some sort presented to the user - who may be a clinician or some other person involve in patient care. It usually represents something of sufficient significance to warrant a special display of some sort - rather than just a note in the resource. A flag has a subject representing the resource that will trigger its display. This subject can be of different types, as described in the examples below:

• A note that a patient has an overdue account, which the provider may wish to discuss with them - in case of hardship for example (subject = Patient)
• An outbreak of Ebola in a particular region (subject=Location) so that all patients from that region have a higher risk of having that condition
• A particular provider is unavailable for referrals over a given period (subject = Practitioner)
• A patient who is enrolled in a clinical trial (subject=Group)
• Special guidance or caveats to be aware of when following a protocol (subject=PlanDefinition)
• Warnings about using a drug in a formulary requires special approval (subject=Medication)
• etc.

A flag is typically presented as a label in a prominent location in the record to notify the clinician of the potential issues, though it may also appear in other contexts; e.g. notes applicable to a radiology technician, or to a clinician performing a home visit. For patients, the information in the flag will often be derived from the record, and therefore, for a thorough and careful clinician, who has the time to review the notes will be redundant. However, given the volume of information frequently found in patients' records and the potentially serious consequences of losing sight of some facts, this redundancy is deemed appropriate. As well, some flags may reflect information not captured by any other resource in the record. (E.g. "Patient has large dog at home")

In line with its purpose, a flag is concise, highlighting a small set of high-priority issues among the much larger set of data in the chart. Readers who want more detail should consult the chart or other source of information. Caution should be exercised in creating Flag instances. If entries are created for information that could be gleaned in a sufficiently timely fashion by reviewing the patient record, the flag list will itself become overwhelming and will cease to serve its intended purpose.

Flags are expected to persist in a record for some period of time and are, at most, targeted to particular types of practitioners or to practitioners in particular system.

Examples of Patient related issues that might appear in flags:

• Risks to the patient (functional risk of falls, spousal restraining order, latex allergy)
• Patient's needs for special accommodations (hard of hearing, need for easy-open caps)
• Risks to providers (dog in house, patient may bite, infection control precautions)
• Administrative concerns (incomplete information, pre-payment required due to credit risk)

Examples of issues that should not appear only in flags:

• Potential allergy or drug interaction to planned therapy (use DetectedIssue)
• Known adverse reaction to a substance (use AllergyIntolerance)

Note that we include "latex allergy" in the "in scope" list, and "allergy" in the "not in scope" list. The Flag resource is not designed to replace the normal order checking process, and one should not expect to see all allergies in Flags. However, if there is an activity that might occur prior to careful evaluation of the record (e.g. donning of latex gloves) and that activity might pose a risk to the patient, that is the sort of eventuality the Flag is intended to support.

Specific guidelines about what type of information is appropriate to expose using Flag, as well as what categories of individuals should see particular flags, will vary by interoperability community.

Relationships

Flags may highlight a highly condensed view of information found in the AllergyIntolerance, Condition, Observation, Procedure and possibly other resources. A common extension allows the linkage of a Flag to the supporting detail resource. The purpose of these other resources is to provide detailed clinical information. The purpose of a Flag is to alert practitioners to information that is important to influence their interaction with a Patient prior to detailed review of the record.

Flags are not used to convey information to a specific individual or organization (e.g. an abnormal lab result reported to the ordering clinician, reporting of an adverse reaction to a regulatory authority). These are handled using the CommunicationRequest and the Communication resources.

Flags are not raised as a result of a reported or proposed action (e.g. drug-drug interactions, duplicate therapy warnings). These would be handled using DetectedIssue.