Stream: implementers
Topic: Patient Instructions
AbdulMalik Shakir (Oct 14 2020 at 22:46):
What resource is used to convey patient instructions such as discharge instructions and other such notes like those included in section 69730-0 of the CCD?
Lloyd McKenzie (Oct 15 2020 at 02:42):
My leaning would be CarePlan. @Michelle (Moseman) Miller ?
Michele Mottini (Oct 15 2020 at 14:05):
I think those would be reports - so DiagnosticReport
Jose Costa Teixeira (Oct 15 2020 at 20:40):
instructions as DiagnosticReport?
Michele Mottini (Oct 15 2020 at 20:57):
Yes - discharge summary - https://www.hl7.org/fhir/us/core/clinical-notes-guidance.html
Jose Costa Teixeira (Oct 15 2020 at 21:15):
I find that strange. DiagnosticReport is what happened.
Jose Costa Teixeira (Oct 15 2020 at 21:15):
actually a conclusion about something that happened
Jose Costa Teixeira (Oct 15 2020 at 21:17):
I would expect that a DiagnosticReport has an element to link to "now what happens" - which is a request.
Michele Mottini (Oct 15 2020 at 21:19):
'Discharge summary is a synopsis of a patient's admission to a hospital; it provides pertinent information for the continuation of care following discharge. '
Michele Mottini (Oct 15 2020 at 21:19):
From https://loinc.org/18842-5.html/
Brett Esler (Oct 15 2020 at 21:44):
I expect this is in a document bundle as a continuity of care document? I would also think CarePlan would work in a 'patient instructions' section for structured instructions; and perhaps another CarePlan resource in a 'recommendations/care plan' section for clinicians. For unstructured notes would use the section narrative or if I wanted a 'note' atomic resource maybe a DocumentReference with DocumentReference.content entered with attachment holding the (formatted?) note inline.
Brett Esler (Oct 15 2020 at 21:46):
or how about just use CarePlan.text for plans that are just notes
Vassil Peytchev (Oct 15 2020 at 21:48):
'Discharge summary is a synopsis of a patient's admission to a hospital; it provides pertinent information for the continuation of care following discharge. '
That doesn't sound like a DiagnosticReport at all. A Discharge Summary is a classical example of a clinical document.
Michele Mottini (Oct 15 2020 at 22:28):
As per the US core implementation guide that I linked above that is a clinical note that can be represented as either a DiagnosticReport or a DocumentReference - so in the US it will be one of those resources - in other places I do not know
Jose Costa Teixeira (Oct 15 2020 at 22:32):
I don't see any reason why (or how) DiagnosticReport is used for Patient instructions. They can link to instructions as part of a bigger document. I can understand DocumentReference (because it's a document), but I hope other countries don't do use DiagnosticReport for instructions
Michele Mottini (Oct 15 2020 at 22:41):
Don't know...in the end is a free text note entered by a caregiver in the EHR...seems ok to me to render them all as DiagnosticReport
Vassil Peytchev (Oct 15 2020 at 23:44):
The DiagnosticReport / DocumentReference duality that was mentioned above was mainly to make sure that DiagnosticReports with clinical notes as part of their content didn't "hide" that content from searches for DocumentReference. It was not intended to allow clinical documents like a discharge summary or an after visit summary to be represented as a DiagnosticReport.
Patient instructions are usually sections within a discharge summary or an after visit summary. I think it is less likely to be part of a procedure report, for example. There are patient instructions as part of a pharmacy dispense as well, but these are specific to the medication obtained by the patient.
As a stand-alone resource, CarePlan seems to be a best fit for patient instructions...
Lin Zhang (Oct 16 2020 at 00:47):
Discharge instructions should be a formal part of a discharge summary. But patient instructions are more broader. To enable some automation regarding discharge instructions, an additional machine-readable/structured copy of such instructions might be needed to create the stand-alone resource.
Lloyd McKenzie (Oct 16 2020 at 01:21):
Instructions are "what the patient/care-givers should do" - and CarePlan is how we provide a formally structured description of "what the patient/care-givers should do".
John Moehrke (Oct 16 2020 at 14:16):
Michele Mottini said:
As per the US core implementation guide that I linked above that is a clinical note that can be represented as either a DiagnosticReport or a DocumentReference - so in the US it will be one of those resources - in other places I do not know
also... this was a statement about supporting the past (current) facts that documents exist, not a statement forbidding more FHIR friendly methods in the future.
Jose Costa Teixeira (Oct 16 2020 at 15:54):
@Robin Bosman
Michelle (Moseman) Miller (Oct 19 2020 at 15:16):
It's been a while since Patient Care last discussed this (see https://chat.fhir.org/#narrow/stream/179166-implementers/topic/Encounter.20Resource), but I think discharge instructions could be part of CarePlan, DocumentReference, or Composition.
Lloyd McKenzie (Oct 19 2020 at 15:26):
Composition doesn't have any semantics of its own. DocumentReference would be for a binary document and wouldn't allow any coding. If you wanted coded instructions, CarePlan would be your only option.
Michelle (Moseman) Miller (Oct 22 2020 at 22:30):
Patient Care discussed again and re-confirmed our previous guidance:
A lot of things are labeled as instructions, but have no similarities except that they are a communication with a patient or family member.
For example:
- For discharge instructions, specifically, it's ok to use CarePlan (part of care planning / discharge planning process).
- For medication request, MedicationRequest.dosageInstruction.patientInstruction would be used.
- For CCDs, use Composition
- For instructions prior to the procedure, use ServiceRequest.patientInstruction
- For instructions after the procedure, use Procedure.followUp
Vassil Peytchev (Oct 22 2020 at 22:38):
Sounds like this is missing a big chunk of use cases where chronic conditions would benefit from a CarePlan.
Last updated: Apr 12 2022 at 19:14 UTC
