DwDocumentReferenceClinicalNote

Purpose

This resource will provide the clinical documentation from an interatction between the patient and a healthcare provider. Structured as the full note as displayed within the EMR

idS Σ1..1id
id0..1string
extensionC0..*Extension
versionIdΣ0..1id
lastUpdatedΣ1..1instant
sourceΣ1..1uri
profileΣ0..*canonical(StructureDefinition)
securityΣ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
textS1..1Narrative
contained0..*Resource
extensionC0..*Extension
modifierExtension?! C0..*Extension
masterIdentifierΣ0..1Identifier
identifierS Σ1..1Identifier
statusS Σ ?!1..1codeBinding
docStatusS Σ0..1codeBinding
typeS Σ0..1CodeableConceptBinding
categoryΣ0..*CodeableConcept
subjectΣ C1..1Reference(DwPatient | DwPractitioner)
dateS Σ0..1instant
authorS Σ C1..1Reference(DwOrganization | DwPatient | DwPractitioner | DwPractitionerRole)
authenticatorC0..1Reference(Organization | Practitioner | PractitionerRole)
custodianC0..1Reference(Organization)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
codeΣ1..1codeBinding
targetΣ C1..1Reference(DocumentReference)
descriptionΣ0..1string
securityLabelΣ0..*CodeableConceptBinding
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
id0..1string
extensionC0..*Extension
contentTypeS Σ0..1codeBinding
languageΣ0..1codeBinding
data1..1base64Binary
urlΣ0..1url
sizeS Σ0..1unsignedInt
hashS Σ0..1base64Binary
titleS Σ0..1string
creationS Σ0..1dateTime
formatΣ0..1CodingBinding
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
encounterS C0..*Reference(DwEncounter)
event0..*CodeableConcept
periodΣ C0..1Period
facilityType0..1CodeableConcept
practiceSetting0..1CodeableConcept
sourcePatientInfoC0..1Reference(Patient)
relatedC0..*Reference(Resource)

Usage note

  • .docStatus This will reflect the status of the document within the EMR. When the workflow supports the various status codes they will be provided, otherwise the docStatus will be final.

    FHIR MA PSS CHR
    Preliminary Unsigned note/blue bar/unfinished note
    Final signed note/no blue bar
    Amended modified note
    Entered in Error deleted note

.type these clinical notes will be identified with the Loinc code 11506-3 for Progress note.

Bundle

idS Σ1..1id
id0..1string
extensionC0..*Extension
versionIdΣ0..1id
lastUpdatedΣ1..1instant
sourceΣ1..1uri
profileΣ0..*canonical(StructureDefinition)
securityΣ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
textS1..1Narrative
contained0..*Resource
extensionC0..*Extension
modifierExtension?! C0..*Extension
masterIdentifierΣ0..1Identifier
identifierS Σ1..1Identifier
statusS Σ ?!1..1codeBinding
docStatusS Σ0..1codeBinding
typeS Σ0..1CodeableConceptBinding
categoryΣ0..*CodeableConcept
subjectΣ1..1Reference(DwPatient | DwPractitioner)
dateS Σ0..1instant
authorS Σ1..1Reference(DwOrganization | DwPatient | DwPractitioner | DwPractitionerRole)
authenticator0..1Reference(Organization | Practitioner | PractitionerRole)
custodian0..1Reference(Organization)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
codeΣ1..1codeBinding
targetΣ1..1Reference(DocumentReference)
descriptionΣ0..1string
securityLabelΣ0..*CodeableConceptBinding
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
id0..1string
extensionC0..*Extension
contentTypeS Σ0..1codeBinding
languageΣ0..1codeBinding
data1..1base64Binary
urlΣ0..1url
sizeS Σ0..1unsignedInt
hashS Σ0..1base64Binary
titleS Σ0..1string
creationS Σ0..1dateTime
formatΣ0..1CodingBinding
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
encounterS0..*Reference(DwEncounter)
event0..*CodeableConcept
periodΣ0..1Period
facilityType0..1CodeableConcept
practiceSetting0..1CodeableConcept
sourcePatientInfo0..1Reference(Patient)
related0..*Reference(Resource)

Examples

Example EMR
Command 'link' could not render: File not found for 'subject=example/DocumentReference-chr-on-west-DocumentReferenceClinicalNote-8501.json'
CHR
Command 'link' could not render: File not found for 'subject=example/DocumentReference-ma-ma-schema-1-DocumentReferenceClinicalNote-13001.json'
MA

CHR UI Navigation

The following table shows where each FHIR element comes from in CHR: the UI path a clinician follows to enter or view the data.

FHIR Path CHR Name CHR UI Navigation
DocumentReference.status Encounter Status —
DocumentReference.docStatus Sign & Lock Status Patients → select patient → chart → Encounters → select encounter → Sign & Lock action
DocumentReference.type Note Type (auto: Progress Note) Auto-set to LOINC 'Progress Note' — no user input
DocumentReference.subject Patient —
DocumentReference.date Encounter Date Patients → select patient → chart → Encounters → select encounter
DocumentReference.author Signing / Creating Provider Patients → select patient → chart → Encounters → select encounter → Sign & Lock (or created-by provider if unsigned)
DocumentReference.content.attachment.contentType Note Content Type (auto) Auto-set — no user input
DocumentReference.content.attachment.data Assembled Note Content Patients → select patient → chart → Encounters → select encounter → History section
Patients → select patient → chart → Encounters → select encounter → Physical Exam section
Patients → select patient → chart → Encounters → select encounter → Assessment and Plan section
Patients → select patient → chart → Encounters → select encounter → Prescriptions section
Patients → select patient → chart → Encounters → select encounter → Referrals section
Patients → select patient → chart → Encounters → select encounter → Injections section
Patients → select patient → chart → Encounters → select encounter → Follow-Up Questionnaires section
DocumentReference.content.attachment.title Note Title (auto: Encounter) Auto-set to 'Encounter' — no user input
DocumentReference.content.attachment.creation Encounter Date Patients → select patient → chart → Encounters → select encounter
DocumentReference.context.encounter Encounter Patients → select patient → chart → Encounters → select encounter

MA UI Navigation

The following table shows where each FHIR element comes from in MA: the UI path a clinician follows to enter or view the data.

FHIR Path MA Name MA UI Navigation
DocumentReference.status Visit Task Status Menu → Patients → select patient → Task Management → Create Visit Task (Progress Note / Visit category) → status
DocumentReference.docStatus Visit Task Status (Active / Complete / Cancelled / Deleted) Menu → Patients → select patient → Task Management → Create Visit Task → status
DocumentReference.type Note Type (auto: Progress Note) Auto-set to LOINC 'Progress Note' — no user input
DocumentReference.subject Patient —
DocumentReference.date Visit Date Menu → Patients → select patient → Task Management → Create Visit Task → visit date
DocumentReference.author Revising User Menu → Patients → select patient → Task Management → Create Visit Task → assigned/revising user
DocumentReference.content.attachment.contentType Content Type (auto) Auto-set — no user input
DocumentReference.content.attachment.data SOAP Note Content (Concern / Observation / Assessment / Plan) Menu → Patients → select patient → Task Management → Create Visit Task → SOAP note fields (Concern, Observation, Assessment, Plan)
DocumentReference.content.attachment.hash Content Hash (auto) Auto-computed from note content — no user input
DocumentReference.content.attachment.title Visit Title Menu → Patients → select patient → Task Management → Create Visit Task → title, prefixed 'visit -'
DocumentReference.content.attachment.creation Visit Date Menu → Patients → select patient → Task Management → Create Visit Task → visit date
DocumentReference.context.encounter Visit Menu → Patients → select patient → Task Management → Create Visit Task (the note's own visit task is the encounter)