ClinicalNote FHIR Resource Proposal

ClinicalNote

Owning committee name

Patient_Care

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

Overview

Clinical Notes allow EHR users to view and enter textual information that is stored in the patient's chart. Text can be entered manually, created from transcribed dictation, or automatically generated based on other structured data in the patient's chart, which is subsequently annotated and/or summarized. Clinical Notes could be as simple as a single sentence or as comprehensive as a History & Physical (H&P). ClinicalNotes can range from pure narrative to partial narrative to fully encoded, but it is more commonly narrative and less commonly fully encoded (since it may not be efficient to do so). Often the structure of the narrative is just a bold piece of text signifying a section heading within the note. Clinical Notes can be authored by a physician, nurse, pharmacist, or any other practitioner. Note types, such as H&P, Consult Note, Progress Note, Operative Note, Nursing Note, Physician Communication, Pharmacy Intervention Note, Rehab Note, and Nutrition Therapy Note as well as date, author, status, and encounter help organize notes.

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: patient ate well, so tube feeding decreased and scheduled insulin given patient general state, meds held, care provided, repositioned patient, fall precautions eye crusty and purulent, doctor paged, waiting for call back	Nurse	Encounter	Yes
Physician Communication	Communication for various reasons, such as: clinical reason - lab result, patient status change (vomit, fever, etc) family reason - family availability if doctor wanted to call family anesthesia or OR cancels surgery, need to notify physician	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

gForge Users

Lloyd McKenzie and/or Michelle M Miller

When Resource Proposal Is Complete

When you have completed your proposal, please send an email to FMGcontact@HL7.org