This page is part of the FHIR Specification (v3.3.0: R4 Ballot 2). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3

Work Group Patient Care

Ballot Status: Informative

9.0 Clinical Summary Module

9.0.1 Introduction

This Clinical Summary Module focuses on the FHIR Resources that represent core clinical information for a patient. The information contained in these Resources are those frequently documented, created or retrieved by healthcare providers during the course of clinical care. Resources generated during the course of diagnostic studies can be found in the Diagnostics Module, whereas the Resources related to medication ordering and administration process can be found in the Medications Module.

As an introduction to FHIR APIs and Resources, please see the Developer's Introduction or Clinical Introduction in the Overview section of the Foundation Module.

9.0.2 Index

The Clinical Summary Module covers the following resources:

FHIR Resources have a low, moderate or high levels of complexity with respect to the number of primary and child elements as well as the number of referenced Resources, found in this module and others. To better understand the relationships between Resources, we recommend beginning with the lower complexity, core Resources such as Patient, Condition, and FamilyMemberHistory before addressing a high complexity Resource such as CarePlan.

9.0.3 Security and Privacy

The diagnostic resources often represent patient-related data, and as such are susceptible to data breaching. Necessary privacy and security provision must be in place for searching and fetching this information. For more general considerations, see the Security and Privacy module.

9.0.4 Common use Cases

• Documenting a patient's condition - The Condition Resource is used extensively throughout FHIR Resources to associate information and activities with specific conditions. The Condition Resource is broadly defined to include problems, diagnoses and health concerns.
• Retrieving a list of the patient's Problem List
• Documenting and retrieving the patient's allergies - The AllergyIntolerance Resource is used to represent the patient's allergy or intolerance to a substance. There is vibrant debate within clinical community regarding what is appropriate to document as an allergy or intolerance. These terms are used both formally by the Allergy and Immunology community as well as informally by patients leading to confusion. Readers are referred to the Resource definition for the Scope and Usage of this resource. The AllergyIntolerance Resource also supports the documenting of the absence of an allergy.
• Family History - The FamilyMemberHistory Resource can be used to document known conditions of family members and support the creation of pedigrees.
• Care Plans - The CarePlan resource supports a problem based care plan with references to other Resources including CareTeam, Condition, Goal, and activities such as ServiceRequest

9.0.5 Developmental Roadmap

Over the next 18 months, we will continue to advance the resources through the Maturity Levels through the process of development and testing of the Resources. We anticipate more widespread implementation of core Resources such as Condition. Complex Resources such as CarePlan are dependent on the maturation of its referred Resources and are expected to mature more gradually. The clinical community will need to develop use cases to test and further mature the and ServiceRequest Resources at opportunities such as the Clinicians on FHIR sessions at the HL7 Working Group Meetings.