{
  "resourceType": "CodeSystem",
  "status": "draft",
  "content": "complete",
  "name": "EncounterNoteTemplateCS",
  "id": "encounter-note-template-codes",
  "title": "Encounter Note Template CodeSystem",
  "description": "The templates the encounter-note editor can open a note from -- the starting structure a provider\npicked, carried on the note in the `composition-note-setup` extension so a draft reopens the way it\nwas left.\n\n**This is not `CodeSystem/nexus-template`.** That system is the coding view of the stored template\nregistry: its codes are the per-tenant slugs of template `List` resources, its content is\n`not-present` because membership is discovered by search, and it rides `meta.tag` on a letter to say\nwhich stored template that letter was composed from. This system names the fixed catalogue of note\nstructures compiled into the application -- fourteen codes shipped with the software, with no `List`\nbehind any of them. Merging them would claim a completeness `nexus-template` explicitly disclaims,\nand because both value spaces are kebab-case slugs, a tenant-authored letter template could collide\nwith a note template of the same name.\n\n**A template is structure only.** It contributes an ordered run of headings and the empty areas\nbeneath them; no template pre-writes clinical text. The code therefore says which headings a note\nstarted with and nothing about what they ended up saying.\n\n**The code records what the note was opened from, not what it contains.** A provider may switch\ntemplates mid-note, delete every heading the template gave, or type their own. The authoritative\nstructure is always `Composition.section`; this code exists so a draft can be reopened on the same\nfooting.\n\nContent is `complete`: this system lists all of its own codes. The binding from\n`composition-note-setup` is **extensible**, so a template this guide has not named yet is still\nconformant on the wire.",
  "url": "https://fhir.apps.health/CodeSystem/encounter-note-template",
  "concept": [
    {
      "code": "blank-note",
      "display": "Blank note",
      "definition": "Somewhere to write, with no heading at all. Every visit type offers this one, and it is always last in the list."
    },
    {
      "code": "focused-soap",
      "display": "Focused SOAP",
      "definition": "Visit agenda, subjective, vitals, objective, assessment and plan, patient instructions. The default for a same-day urgent visit."
    },
    {
      "code": "antenatal-follow-up",
      "display": "Antenatal follow-up visit",
      "definition": "A routine visit in an established pregnancy: agenda, subjective, vitals, antenatal measures, assessment and plan, patient instructions."
    },
    {
      "code": "first-prenatal-visit",
      "display": "First prenatal visit",
      "definition": "The booking visit: agenda, obstetric and medical history, vitals, antenatal measures, physical exam, assessment and plan, patient instructions."
    },
    {
      "code": "third-trimester-check",
      "display": "Third-trimester check",
      "definition": "Agenda, subjective, vitals, antenatal measures, assessment and plan, and a birth plan section in place of the usual instructions."
    },
    {
      "code": "adult-periodic-health",
      "display": "Adult periodic health",
      "definition": "The full periodic health review: agenda, history, vitals, review of systems, physical exam, screening and prevention, assessment and plan, patient instructions."
    },
    {
      "code": "preventive-health",
      "display": "Preventive health",
      "definition": "A shorter prevention-focused visit: agenda, vitals, screening and prevention, assessment and plan, patient instructions."
    },
    {
      "code": "diabetes-review",
      "display": "Diabetes review",
      "definition": "Agenda, subjective, vitals, a structured diabetes review area, assessment and plan, patient instructions."
    },
    {
      "code": "diabetes-flow-sheet",
      "display": "Diabetes flow sheet",
      "definition": "The measurement-led variant: agenda, vitals, a structured diabetes review area, assessment and plan. No free subjective section."
    },
    {
      "code": "brief-phone-note",
      "display": "Brief phone note",
      "definition": "Reason for call, note, plan. The default for a telephone visit."
    },
    {
      "code": "mental-health-assessment",
      "display": "Mental health assessment",
      "definition": "The initial assessment: agenda, history and presenting concerns, risk assessment, mental status exam, assessment and plan, safety plan and instructions."
    },
    {
      "code": "mental-health-follow-up",
      "display": "Mental health follow-up",
      "definition": "Agenda, subjective, risk assessment, assessment and plan, patient instructions."
    },
    {
      "code": "procedure-note",
      "display": "Procedure note",
      "definition": "Indication, consent, a structured procedure details area, procedure narrative, assessment and plan, aftercare instructions."
    },
    {
      "code": "form-supporting-note",
      "display": "Form-supporting note",
      "definition": "The note written to support completing a form: form requested, relevant history, findings, assessment and plan."
    }
  ],
  "experimental": false,
  "caseSensitive": true,
  "count": 14
}