Stream: implementers
Topic: Physical Exam & Review of Systems
Aleksandra Pavlyshina (Aug 25 2016 at 10:29):
Hi All. Are there any existing guidelines or best practices on implementing Physical Exam and Review of Systems in FHIR? Could someone please point if any? Thanks.
Michelle (Moseman) Miller (Sep 01 2016 at 18:52):
There have been some past discussions/debates about whether this should be represented in the existing ClinicalImpression resource (http://hl7-fhir.github.io/clinicalimpression.html) or whether a new resource is warranted for ClinicalNote (http://wiki.hl7.org/index.php?title=ClinicalNote_FHIR_Resource_Proposal)
Eric Haas (Sep 01 2016 at 19:52):
If you arereferring to the CCDA H& P then it s a composition
Michelle (Moseman) Miller (Sep 01 2016 at 20:02):
To elaborate on the (unresolved) debate:
The Patient Care work group discussion included: "Can a dictated H&P (all text) be Composition? Composition is never the primary source of information. Purpose of Composition is to define a table of contents."
http://wiki.hl7.org/index.php?title=2016-02-04_Patient_Care_FHIR_Call#Define_boundaries_between_ClinicalImpression.2C_Observation.2C_and_a_new_ClinicalNote_resource
http://wiki.hl7.org/index.php?title=2016-02-18_Patient_Care_FHIR_Call#ClinicalNote
http://wiki.hl7.org/index.php?title=2016-02-11_Patient_Care_FHIR_Call#Note_vs_ClinicalImpression_Boundaries
The Composition resource says "Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained."
http://hl7-fhir.github.io/composition.html
Grahame Grieve (Sep 01 2016 at 21:22):
the composition could be the entire contents, but then the contents would be just narrative - effectively, a document. The usual pattern would be for the Composition to wrap a resource that actually captures the clinical content.
Eric Haas (Sep 01 2016 at 21:36):
yes that is what I meant - technically a FHIR document.
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Last updated: Apr 12 2022 at 19:14 UTC
