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ClinicalNote FHIR Resource Proposal

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ClinicalNote

Owning committee name

Patient_Care

Committee Approval Date

TBD

Contributing or Reviewing Work Groups

FHIR Resource Development Project Insight ID

Project 1128 [1]


Scope of coverage

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. Clinical Notes could be as simple as a single sentence or as comprehensive as a History & Physical (H&P). 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. Because notes are a form of human communication, nearly anything can described in the narrative of a clinical note.

When a clinical note type conveys that the contents are specific to a single resource, then the resource-specific Narrative (DomainResource.text) should be used. The DomainResource.text Narrative [2] is a "human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative." For example....

Because "a Composition [3] defines the structure, it does not actually contain the content" there is a need for a resource that defines the narrative content within a clinical note.

Because Annotation is a data type, Annotations are not discoverable on their own. Workflow capabilities (e.g. read/unread, review/cosignature) are not features of an annotations. Furthermore, additional codified attributes, such as note type, are not available via Annotations. The FHIR Annotation [4] data type is meant to be a collection of "text note which also contains information about who made the statement and when" in context of another resource (e.g. AllergyIntolerance, Procedure, MedicationOrder, Encounter). As such, a benefit of using a separate resource for Clinical Note is that there could be users who have privileges to create a Clinical Note, but might not have privileges to modify the resource-specific annotation.


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:
  • 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


Resource Relationships

Timelines

gForge Users

When Resource Proposal Is Complete

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