CODEWITHSUNDEEP
hl7-fhir
Gaurav Daga
Gaurav Daga

Reputation: 343

Representation of clinical notes in FHIR

This is basically a modelling questions. Clinicians keeps lot of important information documented inside Clinical Notes for various type of encounters. How does FHIR specification suggests to model these notes ? Looking at the FHIR documentation does not provide a clear guidance on it.

Appreciate your help in advance.

Upvotes: 6

Views: 2856

Answers (3)

Ritesh Bhambhani
Ritesh Bhambhani

Reputation: 1

I think it would be through DiagnosticReport and DocumentReference. The Proposal of Clinical Notes in Wikki will have different Categories which are mentioned on the page. but if you are looking for a specific category then which is different than the ones listed [Like Surgery/Pathology] it would be difficult in ClinicalNotes. Documentrefernce can achieve this.

Upvotes: 0

ci5er
ci5er

Reputation: 51

There's a sub-WG on that:

I haven't had to deal hugely with interop (yet), so I've been sticking that type of thing in Narrative:

Upvotes: 2

Freiheit
Freiheit

Reputation: 8757

Would a Clinical Impression cover it?

That doesn't seem quite correct as a clinical impression has some really specific fields whereas a note will typically be a block of text.

Upvotes: 0

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