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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.

Gaurav Daga
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  • Where would a Clinical Note be shown in another format such as HL7v2 or CCDA? If you know that, you might be able to find the equivalent in FHIR by looking for recommendations for how to map the CCDA/HL7v2 location to FHIR. – Freiheit Nov 11 '16 at 14:44

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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:

ci5er
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  • Having its own separate entity makes more sense. Reason I want to stay away from Narrative text, is it does not provide a way to provide additional information about note ( for example note type, note status ) which are important while processing notes information. – Gaurav Daga Nov 11 '16 at 15:28
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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.

Freiheit
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    A subset of clinical notes can be stuffed into Clinical Impression but I think notes have broader context as it covers assessment, plan of treatment and other clinically relevant information. – Gaurav Daga Nov 11 '16 at 15:31
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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.

Ritesh Bhambhani
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