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..1string
id0..1string
extensionI0..*Extension
versionIdΣ0..1id
lastUpdatedΣ1..1instant
sourceΣ1..1uri
profileΣ0..*canonical(StructureDefinition)
securityΣ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
textS1..1Narrative
contained0..*Resource
extensionI0..*Extension
modifierExtension?! I0..*Extension
masterIdentifierΣ0..1Identifier
identifierS Σ1..1Identifier
statusS Σ ?!1..1codeBinding
docStatusS Σ0..1codeBinding
typeS Σ0..1CodeableConceptBinding
categoryΣ0..*CodeableConcept
subjectΣ I1..1Reference(Patient | Practitioner | Group | Device)
dateS Σ0..1instant
authorS Σ I1..1Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)
authenticatorI0..1Reference(Practitioner | PractitionerRole | Organization)
custodianI0..1Reference(Organization)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
codeΣ1..1codeBinding
targetΣ I1..1Reference(DocumentReference)
descriptionΣ0..1string
securityLabelΣ0..*CodeableConceptBinding
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
id0..1string
extensionI0..*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
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
encounterS I0..*Reference(Encounter | EpisodeOfCare)
event0..*CodeableConcept
periodΣ I0..1Period
facilityType0..1CodeableConcept
practiceSetting0..1CodeableConcept
sourcePatientInfoI0..1Reference(Patient)
relatedI0..*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

DwDocumentRefClinicalNote

Example

{
      "resourceType": "DocumentReference",
      "id": "pss-CDK5-DocumentReference-5745454",
      "meta": {
         "source": "urn:telus:emr:pss:CDK5",
         "lastUpdated": "2023-05-05T12:52:45.000Z",
         "security": [
            {
               "system": "http://terminology.hl7.org/CodeSystem/v3-Confidentiality",
               "code": "N",
               "display": "normal"
            }
         ]
      },
      "identifier": [
         {
            "system": "urn:telus:emr:pss:CDK5:DocumentReference",
            "use": "usual",
            "value": "5745454"
         }
      ],
      "status": "current",
      "type": {
         "coding": [
            {
               "system": "http://loinc.org",
               "code": "11506-3",
               "display": "Progress Note"
            }
         ]
      },
      "category": [],
      "subject": {
         "reference": "Patient/pss-CDK5-Patient-93277",
         "type": "Patient"
      },
      "date": "2023-04-04T04:00:00.000Z",
      "author": [
         {
            "reference": "Practitioner/pss-CDK5-Practitioner-15",
            "display": "Dr. Hanna Hook MD",
            "type": "Practitioner"
         }
      ],
      "content": [
         {
            "attachment": {
               "contentType": "text/plain; charset=utf-8",
               "data": "UzogbHVtcCBvbiBuZWNrIGFib3V0IHRoZSBzaXplIG9mIGEgdG9vbmllLiAgUGFpbmZ1bCAgCk86ICBzZWJhY2VvdXMgY3lzdCBvbiBuZWNrIGEgQzIgbGV2ZWwgYXBwcm94IDMgY20gaW4gc2l6ZSwgcmVkIGFuZCB3YXJtIHRvIHRoZSB0b3VjaC4gCkJQOiAxMjAvODAgICBIUjogODggCkE6IGluZmVjdGVkIHNlYmFjaW91cyBjeXN0ClA6IGFudGlib3RpY3MgZXRj",
               "size": 207,
               "hash": "38dee42e60549b332f579e6d1313ea64b317e371",
               "title": "Progress note",
               "creation": "2023-04-04T18:02:24.000Z"
            }
         }
      ],
      "context": {
         "encounter": [
            {
               "reference": "Encounter/pss-CDK5-Encounter-5745454",
               "type": "Encounter"
            }
         ]
      }
   }