Difference between revisions of "2016-02-18 Patient Care FHIR Call"
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| − | ClinicalNote | + | '''ClinicalNote'''<br> |
| − | + | identifier 0..1 Identifier The logical identifier for the contents.<br> | |
| − | + | dateAuthored 1..1 dateTime The ‘clinically relevant’ time of the note E.g. when the user saw the patient.<br> | |
| − | + | dateReleased 1..1 dateTime The date and time the note was marked 'complete' or 'signed' by the author(s)<br> | |
| − | + | author 1..n Reference(Practitioner) The person or group that contributed that contributed to the note content.<br> | |
| − | + | actor 0..n Backbone Element Other people/devices that played some role in the note creation or (e.g. scribes, voice to text or transcriptionists), or played some role in the note such as cosigning.<br> | |
| − | + | - role 1..n Code data entry person |data entry device | witness | officiating<br> | |
| − | + | - time 0..n dateTime The date/time of the action.<br> | |
| − | + | - actor 1..n Reference(Practitioner|Patient|Related Person|Device|Organization).<br> | |
| − | + | subject 1..n Reference(Any) The patient or group or subject that this note is about. Typically 1, but may be 2 (patient/mother) or groups in psychotherapy<br> | |
| − | + | code 0..n CodeableConcept Identifies what kind of note - E.g. LOINC code for 'H&P'<br> | |
| − | + | title 0..1 string A name for the note.<br> | |
| − | + | status 1..1 Code preliminary, final, amended, etc.<br> | |
| − | + | confidentiality 0..1 Code As defined by affinity domain.<br> | |
| − | + | encounter 0..n Reference(Encounter) The associated encounter(s). Typically 1, but often ambiguous such as for telephone notes<br> | |
| − | + | body 1..1 Choice. The note contents which may be either 1 single text block, or 1 media reference, or composed of smaller subparts.<br> | |
| − | + | - text Narrative If small note or even large text dictation, the note might be just a single unparsed piece of text only identified by the note code.<br> | |
| − | + | - content Reference(Media) If the note is a scanned image or pdf, or sound file, etc.<br> | |
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=== gForge Change Requests === | === gForge Change Requests === | ||
Revision as of 23:15, 18 February 2016
Contents
Meeting Information
| Patient Care FHIR Resources Conference Call Location: Conference Call |
Date: 2016-02-18 Time: 5-6:30pm ET | ||
| Facilitator | Michelle M Miller | Note taker(s) | Michelle M Miller |
| Attendee | Name | Affiliation
| |
| Elaine Ayres | NIH/Department of Clinical Research Informatics | ||
| X | Stephen Chu | ||
| X | Eric Haas | Haas Consulting | |
| X | Rob Hausam | Hausam Consulting LLC | |
| Laura Heermann-Langford | Intermountain Healthcare | ||
| Emma Jones | Allscripts | ||
| X | Russ Leftwich | InterSystems | |
| X | Jay Lyle | Ockham Information Services LLC, VA | |
| Sarah Maulden | VA | ||
| Jim McClay | Univ of Nebraska Medical Center | ||
| X | Russell McDonell | Telstra Health | |
| X | Lloyd McKenzie | Gevity (HL7 Canada) | |
| X | Larry McKnight | Cerner | |
| X | Michelle M Miller | Cerner | |
| Lisa Nelson | Life Over Time Solutions | ||
| X | Viet Nguyen | Systems Made Simple | |
| Craig Parker | Intermountain Healthcare | ||
| Scott Robertson | Kaiser Permanente | ||
| X | Simon Sum | Academy of Nutrition and Dietetics | |
| Iona Thraen | Dept of Veterans Affairs | ||
| Quorum Requirements Met: yes | |||
Agenda
Agenda Topics
- Agenda review
- Approve previous meeting minutes 2016-02-11_Patient_Care_FHIR_Call
- Motion: Rob/Lloyd Abstain - 2, Negative - 0, Approve - 7
- Prior Action Item Follow-up
- gForge change request
Supporting Information
FHIR Resources owned by Patient Care
Maturity levels [1]
- Questionnaire (2) -- Lloyd will QA to get to 3
- Questionnaire Response (2) -- Lloyd will QA to get to 3
- Condition (2)
- AllergyIntolerance (1) -- Rob
- Procedure (1)
Connectathon candidates
- CarePlan (1)
- Goal (1)
- Referral Request (1)
- FamilyMemberHistory (1)
Lower priority resources
- Procedure Request (1)
- Flag (1)
- ClinicalImpression (0) -- goal to move to level 1 by next release
- Communication (1)
- CommunicationRequest (1)
Note: Contraindication and Risk Assessment are owned by CDS, not Patient Care
Minutes
Prior Action Item Follow-up
Care Team
Care Team (which includes the patient and/or related persons) will hopefully be on the FMG agenda next week.
CareTeam_FHIR_Resource_Proposal -- moved Russ/Russell: abstain-0; negative-0; approve -10
ClinicalNote
Listserv thread [2] with ClinicalNote resource strawman, which looks a lot like Composition (e.g. has sections, titles). Can still send discretes (e.g. prescription, allergies) without document/composition. If want to send H&P, what is the structure/root to be used before applying the human-presentation or organization of sections/titles?
ClinicalNotes can range from pure narrative to partial narrative to fully encoded. More common to be pure narrative or partial narrative. Less commonly fully encoded (may not be efficient to do so). Often the "structure" is just a bold piece of text within the note.
Composition supports structured notes well, but the question is the narrative.
FHIR tries to avoid having a general resource for any narrative. It is preferred to add narrative to a specific resource. There isn't a good solution for capturing text such that the EHR doesn't have the context to know which specific resource it applies to. Undifferentiated narrative (e.g. nursing note "saw patient, consult report coming")
If there is a document type, then use that to determine which resource is appropriate. A dictated H&P (all text) could be Composition, but Composition is never the primary source of information. Purpose of Composition is to define TOC of a full blown clinical document.
ClinicalNote
identifier 0..1 Identifier The logical identifier for the contents.
dateAuthored 1..1 dateTime The ‘clinically relevant’ time of the note E.g. when the user saw the patient.
dateReleased 1..1 dateTime The date and time the note was marked 'complete' or 'signed' by the author(s)
author 1..n Reference(Practitioner) The person or group that contributed that contributed to the note content.
actor 0..n Backbone Element Other people/devices that played some role in the note creation or (e.g. scribes, voice to text or transcriptionists), or played some role in the note such as cosigning.
- role 1..n Code data entry person |data entry device | witness | officiating
- time 0..n dateTime The date/time of the action.
- actor 1..n Reference(Practitioner|Patient|Related Person|Device|Organization).
subject 1..n Reference(Any) The patient or group or subject that this note is about. Typically 1, but may be 2 (patient/mother) or groups in psychotherapy
code 0..n CodeableConcept Identifies what kind of note - E.g. LOINC code for 'H&P'
title 0..1 string A name for the note.
status 1..1 Code preliminary, final, amended, etc.
confidentiality 0..1 Code As defined by affinity domain.
encounter 0..n Reference(Encounter) The associated encounter(s). Typically 1, but often ambiguous such as for telephone notes
body 1..1 Choice. The note contents which may be either 1 single text block, or 1 media reference, or composed of smaller subparts.
- text Narrative If small note or even large text dictation, the note might be just a single unparsed piece of text only identified by the note code.
- content Reference(Media) If the note is a scanned image or pdf, or sound file, etc.
gForge Change Requests
Adjourn
Adjourned at <hh:mm am/pm> <timezone>.
Meeting Outcomes
Actions
|
Next Meeting/Preliminary Agenda Items
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