FHIR Chat · Resource to use for clinical notes

Stream: new zealand

Topic: Resource to use for clinical notes

David Moorhouse (Jan 17 2018 at 03:18):

We're looking to capture clinical notes related to an Encounter and wonder what is the best resource to use.
David Hay blogged about this 4 years ago and suggested using Observations linked to the Encounter via a Composition.
https://fhirblog.com/tag/encounter/
Alternatively the Clinicalmpression resource looks like it could be useful.
The notes will contain text only as well as related meta data such as Patient, Author (Practitioner), DateTime etc.

What is the current thinking on how to structure this ?

Peter Jordan (Jan 17 2018 at 04:40):

Subject to any alternative advice @David Hay might provide, I'd suggest trying that Clinicalmpression resource, although it is only FMM Level 0 so subject to breaking changes. IMO it's a far better fit for your use case (which I know well from GP2GP) than Observations.

David Hay (Jan 17 2018 at 05:23):

It would certainly be worth seeing what the gaps between ClinicalImpression and your use case are - and ideally to feed those gaps back to the community. I'm sure there will be interest in your findings... I think Observation remains an option if the data items to capture are simple, but certainly CI is intended for the more comprehensive Use Case...

David Hay (Jan 20 2018 at 18:46):

FYI: https://chat.fhir.org/#narrow/stream/implementers/topic/GP.20Encounter.20Report

David Moorhouse (Jan 22 2018 at 20:28):

That's a useful link David - thanks.
It is pointing towards Composition resource so I will take another look at it.

Peter Jordan (Jan 29 2018 at 18:14):

@David Hay @David Moorhouse. The discussion in Q2 at the WGM today was somewhat inconclusive. The clear advice is NOT to use the ClinicalImpression resource for this purpose - the proposed alternatives are to use a re-scoped version of the Composition resource or create a new resource. It's certainly feasible to use Composition and an example of using that resource to render a SOAP note was shown; however, there was pushback against the notion of placing content in the Composition resource that is not available elsewhere.