FHIR Chat · Daily Progress Notes - Assessment & Plans

Stream: implementers

Topic: Daily Progress Notes - Assessment & Plans

Nilesh Pagare (Apr 19 2019 at 05:49):

Hi All, which resource(s) in FHIR R4 is used to maintain initial H&P (history physical notes), daily assessment & plan / Event Notes captured by a practitioner in hospital ? Within that , how do I identify A&P captured by specialty of the practitioner ? Thank you.

Nilesh Pagare (Apr 19 2019 at 13:59):

Hi All, which resource(s) in FHIR R4 is used to maintain initial H&P (history physical notes), daily assessment & plan / Event Notes captured by a practitioner in hospital ? Within that , how do I identify A&P captured by specialty of the practitioner ? Thank you.

@Lloyd McKenzie , @Grahame Grieve Any thoughts ? Thank you.

Lloyd McKenzie (Apr 19 2019 at 14:08):

Two options - Observation and DocumentReference. DocumentReference has become the (badly named) resource typically used for clinical notes. And all such information can also be reasonably represented as an Observation. @Brett Marquard may have additional guidance.

Brett Marquard (Apr 19 2019 at 14:20):

This is a difficult question -- we spent a lot of time in Argonaut project discussing 'how a client will find' all the clinical notes for a patient. After circling round/round we always came back to the idea that many notes will HAVE to be indexed by DocumentReference. For example, you could have a scanned 'progress note', a 'C-CDA progress note', or even a 'Composition Progress Note'. Rather than invent some complex guidance to say query this resource for this note type, or this for another, we settled on DocumentReference as an indexer for all. Checkout guidance in Argonaut IG: http://www.fhir.org/guides/argonaut/clinicalnotes/1.0.0/guidance.html

Nilesh Pagare (Apr 19 2019 at 14:24):

@Lloyd McKenzie , @Brett Marquard - thank you. So for my purpose it looks like the Consult Note (https://s.details.loinc.org/LOINC/11488-4.html?sections=Comprehensive) is going to suffice. Is there any API example that reads/updates consult notes ? May be in Argonaut IG ?

Rob Hausam (Apr 19 2019 at 16:23):

I don't think that Observation is very appropriate for what typically are considered to be clinical notes (e.g. the items that Nilesh has noted) - unless you take the position that Observation is potentially appropriate for anything and everything, ,which definitely isn't how we've described it in the resource documentation. I think that you and Grahame still don't like to consider Composition for this purpose, Lloyd, but clinically I think it can make sense, particularly for more complex and structured notes, and as Brett noted it is an option (likely indexed by DocumentReference, as he said).

Nilesh Pagare (Apr 19 2019 at 17:00):

@Rob Hausam - appreciate your guidance. what's your thought on the link related to Consult Note ? I am trying to retrieve daily progress notes, H&P and Event Notes from EHR for the admitted patient in the Hospital.

Michele Mottini (Apr 19 2019 at 18:36):

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Brett Marquard (Apr 19 2019 at 18:58):

checkout the guide - there is an example query be note type - http://www.fhir.org/guides/argonaut/clinicalnotes/1.0.0/StructureDefinition-argo-clinicalnotes.html

Nilesh Pagare (Apr 19 2019 at 19:04):