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Difference between revisions of "ClinicalNote FHIR Resource Proposal"
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==Example Scenarios== | ==Example Scenarios== | ||
+ | |||
+ | {|border="1" cellpadding="2" cellspacing="0" | ||
+ | | width="25%" colspan="1" align="left" style="background:#f0f0f0;"|'''Type''' <br/> | ||
+ | | width="45%" colspan="1" align="left" style="background:#f0f0f0;"|'''Contents''' | ||
+ | | width="10%" colspan="1" align="left" style="background:#f0f0f0;"|'''Author''' | ||
+ | | width="10%" colspan="1" align="left" style="background:#f0f0f0;"|'''Context''' | ||
+ | | width="10%" colspan="1" align="left" style="background:#f0f0f0;"|'''Point in Time'''<br/> | ||
+ | |- | ||
+ | || Physician Inpatient Expectation || CMS 2 midnight rule; physician attesting to why the patient needs to remain in the hospital (if no admitting order within 24 hours) || Physician || Encounter || Yes | ||
+ | |- | ||
+ | || Office Note or ED Note || Chief Complaint, HPI, Review of Systems, Physical Exam, Subjective/Constitutional, Assessment/Impression and Plan (orders), Follow-Up, Billing Notes, Chart data || Physician || Encounter || Yes | ||
+ | |- | ||
+ | || H&P || Diagnosis/Chief Complaint, Advance Directive, HPI, Past Medical History, Family/Social History, Chart Data (allergies, meds), Review of System, Physical Exam, Assessment and Plan (more comprehensive than the Office Note) || Physician || Encounter || Yes | ||
+ | |- | ||
+ | || Consult Note || similar to H&P, except only comprehensive within a given specialty || Physician || Encounter || Yes | ||
+ | |- | ||
+ | || Inpatient Progress Note || SOAP format or freetext format (used when something significant happens after the day's progress note was already written) || Physician || Encounter || Yes | ||
+ | |- | ||
+ | || Operative Note || Date of Surgery, Surgeon, Assistant, Pre-Op Dx, Post-Op Dx, Operation/procedure codes, Anesthesiologist, Anesthesia used, complications, estimated blood loss, specimens removed, description of surgery/findings (instruments used, etc.) || Physician || Procedure || Yes | ||
+ | |- | ||
+ | || Shift (Nursing Progress) Note || Major events of the shift, such as: <br> | ||
+ | * patient ate well, so tube feeding decreased and scheduled insulin given <br> | ||
+ | * patient general state, meds held, care provided, repositioned patient, fall precautions <br> | ||
+ | * eye crusty and purulent, doctor paged, waiting for call back <br> | ||
+ | || Nurse || Encounter || Yes | ||
+ | |- | ||
+ | || Physician Communication || Communication for various reasons, such as: <br> | ||
+ | * clinical reason - lab result, patient status change (vomit, fever, etc) <br> | ||
+ | * family reason - family availability if doctor wanted to call family <br> | ||
+ | * anesthesia or OR cancels surgery, need to notify physician <br> | ||
+ | || Anyone || Encounter || Yes | ||
+ | |- | ||
+ | || Pharmacy Intervention Note || Pharmacist reviews medications; found patient was on duplicate therapy or found cheaper therapy; actions the pharmacist took or is recommending; billing note about pharmacist time spent; || Pharmacist || Encounter || Yes | ||
+ | |- | ||
+ | || Pharmacy Monitoring Note || Anticoagulation (monitor labs, intervene if unsafe); Antibiotics || Pharmacist || Encounter || Yes | ||
+ | |- | ||
+ | || Rehab Notes (OT, Speech, PT) || Chief Complaint, HPI, Physical Therapy Assessment, Treatment, Plan, Goals, Billing || Rehab Services || Encounter || Yes | ||
+ | |- | ||
+ | || Nutrition Therapy Note || general note, overall dietary note with tube feeding, amount taken orally, how doing with meals, estimated % of caloric intake or protein intake, admit weight to current weight comparison, labs, medications, nutrition diagnosis, RD recommendations, measurable goals || RD || Encounter || Yes | ||
+ | |- | ||
+ | || Physician Clarification Request from Medical Records (HIM query) || example: Anemia Specificity; Coder will pull things out of chart and say I was confused by these facts....physician(s) reply by comments on the note or addendums on the note || Medical Records || Encounter || Yes | ||
+ | |- | ||
+ | |} | ||
<!-- Provide a listing of the types of scenarios to be represented in the examples produced for this resource. They should demonstrate the full scope of the resource and allow exercising of the resources capabilities (full element coverage, inclusion & omission of optional elements, repeating and singleton repeating elements, etc.) --> | <!-- Provide a listing of the types of scenarios to be represented in the examples produced for this resource. They should demonstrate the full scope of the resource and allow exercising of the resources capabilities (full element coverage, inclusion & omission of optional elements, repeating and singleton repeating elements, etc.) --> |
Revision as of 17:46, 19 February 2016
Contents
- 1 ClinicalNote
- 1.1 Owning committee name
- 1.2 Committee Approval Date
- 1.3 Contributing or Reviewing Work Groups
- 1.4 FHIR Resource Development Project Insight ID
- 1.5 Scope of coverage
- 1.6 RIM scope
- 1.7 Resource appropriateness
- 1.8 Expected implementations
- 1.9 Content sources
- 1.10 Example Scenarios
- 1.11 Resource Relationships
- 1.12 Timelines
- 1.13 gForge Users
- 1.14 When Resource Proposal Is Complete
ClinicalNote
Owning committee name
Committee Approval Date
TBD
Contributing or Reviewing Work Groups
- Orders_&_Observations_WG -- as it pertains to Observation boundaries
- Structured_Documents - as it pertains to Composition/DocumentReference boundaries
FHIR Resource Development Project Insight ID
Project 1128 [1]
Scope of coverage
RIM scope
Resource appropriateness
Expected implementations
Content sources
Example Scenarios
Type |
Contents | Author | Context | Point in Time |
Physician Inpatient Expectation | CMS 2 midnight rule; physician attesting to why the patient needs to remain in the hospital (if no admitting order within 24 hours) | Physician | Encounter | Yes |
Office Note or ED Note | Chief Complaint, HPI, Review of Systems, Physical Exam, Subjective/Constitutional, Assessment/Impression and Plan (orders), Follow-Up, Billing Notes, Chart data | Physician | Encounter | Yes |
H&P | Diagnosis/Chief Complaint, Advance Directive, HPI, Past Medical History, Family/Social History, Chart Data (allergies, meds), Review of System, Physical Exam, Assessment and Plan (more comprehensive than the Office Note) | Physician | Encounter | Yes |
Consult Note | similar to H&P, except only comprehensive within a given specialty | Physician | Encounter | Yes |
Inpatient Progress Note | SOAP format or freetext format (used when something significant happens after the day's progress note was already written) | Physician | Encounter | Yes |
Operative Note | Date of Surgery, Surgeon, Assistant, Pre-Op Dx, Post-Op Dx, Operation/procedure codes, Anesthesiologist, Anesthesia used, complications, estimated blood loss, specimens removed, description of surgery/findings (instruments used, etc.) | Physician | Procedure | Yes |
Shift (Nursing Progress) Note | Major events of the shift, such as:
|
Nurse | Encounter | Yes |
Physician Communication | Communication for various reasons, such as:
|
Anyone | Encounter | Yes |
Pharmacy Intervention Note | Pharmacist reviews medications; found patient was on duplicate therapy or found cheaper therapy; actions the pharmacist took or is recommending; billing note about pharmacist time spent; | Pharmacist | Encounter | Yes |
Pharmacy Monitoring Note | Anticoagulation (monitor labs, intervene if unsafe); Antibiotics | Pharmacist | Encounter | Yes |
Rehab Notes (OT, Speech, PT) | Chief Complaint, HPI, Physical Therapy Assessment, Treatment, Plan, Goals, Billing | Rehab Services | Encounter | Yes |
Nutrition Therapy Note | general note, overall dietary note with tube feeding, amount taken orally, how doing with meals, estimated % of caloric intake or protein intake, admit weight to current weight comparison, labs, medications, nutrition diagnosis, RD recommendations, measurable goals | RD | Encounter | Yes |
Physician Clarification Request from Medical Records (HIM query) | example: Anemia Specificity; Coder will pull things out of chart and say I was confused by these facts....physician(s) reply by comments on the note or addendums on the note | Medical Records | Encounter | Yes |
Resource Relationships
Timelines
gForge Users
When Resource Proposal Is Complete
When you have completed your proposal, please send an email to FMGcontact@HL7.org