CareRecord

Care and nursing record for daily care activities, ADL (Activities of Daily Living) assessments, nursing interventions, and care team observations. Separate from MedicalRecord to focus on care team workflows and prevent information overload. Based on Ogirys dual-record pattern.

15 properties

Schema

Properties

Property	Type	Mode	Description	Required
patient	Patient	stored	Reference to the patient this care record belongs to	Required
recordType	string	enum	Type of care record (which care discipline) Values: `nursing, therapy, social_work, nutrition, psychology, rehabilitation, general_care` Example: `"nursing"`	Required
recordedBy	Practitioner	stored	Care professional who created/updated this record	Required
recordedAt	DateTime	stored	Timestamp when this care record was documented Example: `"2024-11-12T14:30:00Z"`	Required
adlAssessment	object	stored	Activities of Daily Living assessment (bathing, dressing, eating, toileting, transferring, continence) Example: `{"bathing":"independent","dressing":"needs_assistance","eating":"independent","toileting":"independent","transferring":"needs_supervision","continence":"independent"}`	Optional
mobilityStatus	string	enum	Current mobility status of the patient Values: `independent, needs_assistance, wheelchair, bedridden` Example: `"needs_assistance"`	Optional
nutritionStatus	string	enum	Nutritional status assessment Values: `normal, at_risk, malnourished, tube_feeding, parenteral_nutrition` Example: `"normal"`	Optional
skinCondition	string	enum	Skin integrity assessment (pressure ulcer prevention) Values: `intact, at_risk, pressure_ulcer_stage_1, pressure_ulcer_stage_2, pressure_ulcer_stage_3, pressure_ulcer_stage_4` Example: `"intact"`	Optional
painLevel	number	stored	Pain level assessment (0-10 scale) Example: `3`	Optional
riskFlags	object	stored	Embedded risk flags for quick identification Example: `{"fallRisk":true,"pressureUlcerRisk":false,"malnutritionRisk":false,"elopementRisk":false,"selfHarmRisk":false}`	Optional
nursingInterventions	string[]	stored	List of nursing interventions performed Example: `["vital_signs_monitoring","wound_care","medication_administration"]`	Optional
careNotes	string	stored	Free-text care notes and observations Example: `"Patient ate 75% of lunch. Assisted with afternoon walk in corridor."`	Optional
vitalSigns	object	stored	Vital signs measurements Example: `{"temperature":36.8,"bloodPressure":"120/80","heartRate":72,"respiratoryRate":16,"oxygenSaturation":98}`	Optional
relatedCarePlan	CarePlan	stored	Reference to the active care plan this record relates to	Optional
relatedEncounter	Encounter	stored	Reference to the clinical encounter if applicable	Optional

Examples

Example 1

{
  "@type": "CareRecord",
  "patient": {
    "@type": "Patient",
    "patientId": "PAT-2024-1234"
  },
  "recordType": "nursing",
  "recordedBy": {
    "@type": "Practitioner",
    "practitionerId": "NURSE-001",
    "name": "Marie Dubois",
    "profession": "Registered Nurse"
  },
  "recordedAt": "2024-11-12T14:30:00Z",
  "adlAssessment": {
    "bathing": "needs_assistance",
    "dressing": "independent",
    "eating": "independent",
    "toileting": "independent",
    "transferring": "needs_supervision",
    "continence": "independent"
  },
  "mobilityStatus": "needs_assistance",
  "nutritionStatus": "normal",
  "skinCondition": "intact",
  "painLevel": 2,
  "riskFlags": {
    "fallRisk": true,
    "pressureUlcerRisk": false,
    "malnutritionRisk": false
  },
  "nursingInterventions": [
    "vital_signs_monitoring",
    "medication_administration",
    "fall_prevention_measures"
  ],
  "careNotes": "Patient ate 75% of lunch. Assisted with afternoon walk in corridor. Gait steady with walker.",
  "vitalSigns": {
    "temperature": 36.8,
    "bloodPressure": "130/85",
    "heartRate": 76,
    "respiratoryRate": 16,
    "oxygenSaturation": 98
  }
}