This page is part of the US Core (v4.1.0: STU5 Ballot 1) based on FHIR R4. The current version which supercedes this version is 5.0.1. For a full list of available versions, see the Directory of published versions

Clinical Notes Guidance

​This section provides implementers with important definitions, requirements, and guidance to create, use, and share Clinical Notes.

Clinical Notes

Clinical notes are a key component to communicate the current status of a patient. In the context of this implementation guide, the term “clinical notes” refers to the wide variety of documents generated on behalf of a patient in many care activities. They include notes to support transitions of care, care planning, quality reporting, billing and even handwritten notes by providers. This implementation guide does not define new note types or set content requirements per note type. Instead, this implementation guide focuses on exposing clinical notes stored in existing systems.

This implementation guide defines how systems exchange eight “Common Clinical Notes” and three DiagnosticReport categories.

Systems SHALL support, at minimum, these eight “Common Clinical Notes”:

1. Consultation Note (11488-4)
2. Discharge Summary (18842-5)
3. History & Physical Note (34117-2)
4. Procedures Note (28570-0)
5. Progress Note (11506-3)
6. Imaging Narrative (18748-4)
7. Laboratory Report Narrative (11502-2)
8. Pathology Report Narrative (11526-1)

Systems SHALL support, at minimum, these three DiagnosticReport categories:

1. Cardiology (LP29708-2)
2. Pathology (LP7839-6)
3. Radiology (LP29684-5)

A DiagnostisReport category query allows a Client to retrieve multiple documents in a single query (see Support Requirements).

The Argonaut project team provided this initial list to HL7 after surveying the participants in Argonaut and the US Veterans Administration (VA). They represent the minimum set a system must support to claim conformance to this guide. In addition, systems are encouraged to support other common notes types such as:

• Referral Note (57133-1)
• Surgical Operation Note (11504-8)
• Nurse Note (34746-8)

The full list of note (document) types is available in the US Core DocumentReference Type Value Set.

FHIR Resources to Exchange Clinical Notes

The US Core DocumentReference Profile and US Core DiagnosticReport Profile for Report and Note exchange support the exchange of clinical notes. (See Resource Selection for a full discussion on the decision to use these resources.)

DocumentReference is the best choice when the narrative is broader then a specific order or report, such as a Progress Note or Discharge Summary Note. The DocumentReference Resource can point to a short 2-3 sentence status of the patient, or reference a complex CDA or Composition document which can include both a narrative and a discrete information.

DiagnosticReport is the best choice when a system needs to share discrete information or coded interpretations. The DiagnosticReport.result element supports the discrete information and the entire narrative report can be represented by the DiagnosticReport.presentedForm element.

There is no single best practice for representing a scanned, or narrative-only report due to the overlapping scope of the underlying resources and variability in system implementation. Reports may be represented by either a DocumentReference or a DiagnosticReport as demonstrated by the green area in Figure 1. For example, some systems consider any scanned report, or note, a DocumentReference. Other systems allow users to categorize the scanned report as Lab and store to DiagnosticReport.¹

In order to enable consistent access to scanned narrative-only clinical reports the Clinical Note Server SHALL expose these reports through both DiagnosticReport and DocumentReference by representing the same attachment url using the corresponding elements listed below.² Exposing the content in this manner guarantees the client will receive all the clinical information available for a patient and can easily identify the duplicate data.

• DocumentReference.content.attachment.url
• DiagnosticReport.presentedForm.url

For example, when DiagnosticReport.presentedForm.url references a Scan (PDF), that Attachment SHALL also be accessible through DocumentReference.content.attachment.url.(See Figure 2) This guide requires servers implement the duplicate reference to allow a client to find a Pathology report, or other Diagnostic Reports, in either Resource. If servers properly categorized scanned reports and used the correct resource per report type (e.g. Pathology scan in DiagnosticReport) this wouldn’t be required, however at the time of this IG’s development, this duplication requirement is necessary due to a lack of consistency in proper use of these resources.

Example JSON Snippets Referencing Common Binary in DocumentReference and DiagnosticReport

DocumentReference:

{
  ...snip...
    "content": [
        {
            "attachment": {
                "contentType": "application/xhtml",
                "url": "http://example.org/fhir/Binary/1e404af3-077f-4bee-b7a6-a9be97e1ce32",
                "creation": "2005-12-24"
            }
        }
    ]
}

DiagnosticReport:

{
  ...snip...
   "presentedForm": [
        {
            "contentType": "application/xhtml",
            "url": "http://example.org/fhir/Binary/1e404af3-077f-4bee-b7a6-a9be97e1ce32",
            "creation": "2005-12-24"
        }
    ]
}

Note that not all scanned information stored through DocumentReference will be exposed through DiagnosticReport since DocumentReference stores other non-clinical information. For example, DocumentReference can point to an insurance card.

Support Requirements

This guide requires systems implement the US Core DocumentReference Profile and to support a minimum of all eight Common Clinical Notes listed above. Systems and may extend there capabilities to the full US Core DocumentReference Type Value Set. This requirement is necessary because some systems scan lab reports and don’t store them in the DiagnosticReport resource. See FHIR Resources to Exchange Clinical Notes for more detail.

This guide requires systems implement the US Core DiagnosticReport Profile for Report and Note exchange and to support a minimum of the three report categories:

• Cardiology (LP29708-2)
• Pathology (LP7839-6)
• Radiology (LP29684-5)

Other categories may be supported as well.

The vendors that participated in the development of this guide didn’t differentiate between the Diagnostic Report categories of Imaging and Radiology in their servers. Client applications that query with category code of Radiology (LP29684-5) will receive Radiology and other imaging reports.

The following SHOULD be exposed via DiagnosticReport

• Imaging Narrative
• Laboratory Report Narrative
• Pathology Report Narrative
• Procedure Note

Servers that support DiagnosticReport will include the clinical note narrative content in DiagnosticReport.presentedForm.

A method for discovery of the types of notes and reports that a server supports is described in the Determining Server Note Type section below.

Note that this guide focuses on exposing existing information, and not how systems allow their users to capture information. The contents of the notes or reports, even using standard LOINC concepts, may vary widely by health system or even location. For example, CT Spleen WO contrast (LOINC 30621-7) may include individual sections for history, impressions, conclusions, or just an impressions section. Discharge Summaries may have different facility or regulatory content requirements.

Search

To retrieve clinical notes and reports, the standard FHIR search API is used. In this guide, the US Core CapabilityStatement and the Quick Start sections for the US Core Clinical Notes and Diagnostic Report profiles define the required search parameters and describe how they are used.

Common client search scenarios include:

1. A client interested in all Radiology reports can use the following query:

   GET [base]/DiagnosticReport?patient=[id]&category=http://loinc.org|LP29684-5

2. A client interested in all Clinical Notes can use the following query:

   GET [base]/DocumentReference?patient=[id]&category=clinical-note

3. A client interested in all Discharge Summary Notes can use the following query:

   GET [base]/DocumentReference?patient=[id]&type=http://loinc.org|18842-5

Determining Server Note Type

In addition to inspecting a server CapabilityStatement, a client can determine the note and report types support by a server by invoking the standard FHIR Value Set Expansion ($expand) operation defined in the FHIR R4 specification. Because servers may support different read and write formats, it also is used to determine the formats (for example, text, pdf) the server supports read and write transactions. A FHIR server claiming support to this guide SHOULD support the $expand operation.

Discovering Note and Report Types

The note and report types for a particular server are discovered by invoking the #expand operation as follows:

GET [base]/ValueSet/$expand?context=[context]&contextDirection=[contextDirection]

where:

• [contextDirection] = incoming for write operations and outgoing for read operations.
• [context] = DiagnosticReport.category for DiagnosticReport report category discovery, DiagnosticReport.code for DiagnosticReport report type discovery, DocumentReference.category for DocumentReference note category discovery, DocumentReference.type for DocumentReference note type discovery.

Examples

Click on Here To See Scenario 1 Example

GET [base]/ValueSet/$expand?context=DiagnosticReport.codes&contextDirection=incoming

HTTP/1.1 200 OK
[other headers]

{
 "resourceType": "ValueSet",
 "id": "scenario1-server-diagnosticreport-codes",
 "url": "http://acme.org/ValueSet/diagnosticreport-codes",
 "version": "3.0.1",
 "name": "acme-diagnosticreport-codes",
 "title": "Acme DiagnosticReport Codes",
 "status": "draft",
 "date": "2018-11-08T20:29:00+00:00",
 "expansion": {
   "identifier": "urn:uuid:5fc51f5a-4dbc-44f8-8fe5-203d261222f0",
   "timestamp": "2018-11-13T02:55:48.405Z",
   "parameter": [
     {
       "name": "context",
       "valueString": "DiagnosticReport.codes"
     },
     {
       "name": "contextDirection",
       "valueString": "outgoing"
     }
   ],
   "contains": [
     {
       "system": "http://acme.org",
       "code": "foo",
       "display": "Foo"
     },
     {
       "system": "http://acme.org",
       "code": "bar",
       "display": "Bar"
     },
     {
       "system": "http://acme.org",
       "code": "baz",
       "display": "baz"
     }
   ]
 }
}

Click on Here To See Scenario 2 Example

GET [base]/ValueSet/$expand?context=DocumentReference.type&contextDirection=outgoing

HTTP/1.1 200 OK
[other headers]

{
  "resourceType": "ValueSet",
  "id": "scenario2-server-clinical-note-type",
  "url": "http://fhir.org/guides/argonaut-clinicalnotes/ValueSet/argonaut-clinical-note-type",
  "version": "3.0.1",
  "name": "ArgonautClinicalNotes",
  "title": "Argonaut DocumentReferences Type Value Set",
  "status": "draft",
  "date": "2018-11-08T20:29:00+00:00",
  "expansion": {
    "identifier": "urn:uuid:5fc51f5a-4dbc-44f8-8fe5-203d261222f0",
    "timestamp": "2018-11-13T02:55:48.405Z",
    "parameter": [
      {
        "name": "context",
        "valueString": "DocumentReference.type"
      },
      {
        "name": "contextDirection",
        "valueString": "outgoing"
      }
    ],
    "contains": [
      {
        "system": "http://loinc.org",
        "code": "18842-5",
        "display": "Discharge Summary"
      },
      {
        "system": "http://loinc.org",
        "code": "11488-4",
        "display": "Consultation Note"
      },
      {
        "system": "http://loinc.org",
        "code": "34117-2",
        "display": "History & Physical Note"
      },
      {
        "system": "http://loinc.org",
        "code": "11506-3",
        "display": "Progress Note"
      },
      {
        "system": "http://loinc.org",
        "code": "28570-0",
        "display": "Procedures Note"
      }
    ]
  }
}

Click on Here To See Scenario 3 Example

GET [base]/ValueSet/$expand?context=DocumentReference.category&contextDirection=outgoing

HTTP/1.1 200 OK
[other headers]

{
  "resourceType": "ValueSet",
  "id": "scenario3-server-documentreference-category",
  "url": "http://fhir.org/guides/argonaut-clinicalnotes/ValueSet/documentreference-category",
  "version": "3.0.1",
  "name": "ArgonautDocumentReferenceCategoryCodes",
  "title": "Argonaut DocumentReference Category Codes",
  "status": "draft",
  "date": "2018-11-08T20:29:00+00:00",
  "expansion": {
    "identifier": "urn:uuid:5fc51f5a-4dbc-44f8-8fe5-203d261222f0",
    "timestamp": "2018-11-13T02:55:48.405Z",
    "parameter": [{
        "name": "context",
        "valueString": "DocumentReference.class"
      },
      {
        "name": "contextDirection",
        "valueString": "outgoing"
      }
    ],
    "contains": [{
        "system": "http://fhir.org/guides/argonaut-clinicalnotes/CodeSystem/documentreference-category",
        "code": "clinical-note",
        "display": "Clinical Note"
      }
    ]
  }
}

Click on Here To See Scenario 4 Example

GET [base]/ValueSet/$expand?context=DiagnosticReport.category&contextDirection=incoming

HTTP/1.1 200 OK
[other headers]

{
  "resourceType": "ValueSet",
  "id": "scenario4-server-diagnosticreport-category",
  "url": "http://fhir.org/guides/argonaut-clinicalnotes/ValueSet/diagnosticreport-category",
  "version": "3.0.1",
  "name": "ArgonautDiagnosticReportCategoryCodes",
  "title": "Argonaut DiagnosticReport Category Value Set",
  "status": "draft",
  "date": "2018-11-08T20:29:00+00:00",
  "expansion": {
    "identifier": "urn:uuid:5fc51f5a-4dbc-44f8-8fe5-203d261222f0",
    "timestamp": "2018-11-13T02:55:48.405Z",
    "parameter": [
      {
        "name": "context",
        "valueString": "DiagnosticReport.category"
      },
      {
        "name": "contextDirection",
        "valueString": "outgoing"
      }
    ],
    "contains": [
      {
        "system": "http://loinc.org",
        "code": "LP29684-5",
        "display": "Radiology"
      },
      {
        "system": "http://loinc.org",
        "code": "LP29708-2",
        "display": "Cardiology"
      },
      {
        "system": "http://loinc.org",
        "code": "LP7839-6",
        "display": "Pathology"
      }
    ]
  }
}

Discovering Server Read and Write Formats

The read and write formats for a particular server are discovered by invoking the #expand operation as follows:

GET [base]/ValueSet/$expand?context=[context]&contextDirection=[contextDirection]

where:

• [contextDirection] = incoming for write operations and outgoing for read operations.
• [context] = DocumentReference.content.attachment.contentType for DocumentReference note content type discovery and DiagnosticReport.presentedForm.contentType for DiagnosticReport report content type discovery.

Examples

Click on Here To See Scenario 1 Example

GET [base]/ValueSet/$expand?context=DocumentReference.content.attachment.contentType&contextDirection=incoming

HTTP/1.1 200 OK
[other headers]

{
  "resourceType": "ValueSet",
  "id": "scenario1-server-write-contenttype",
  "url": "http://acme.org/fhir/ValueSet/in-mimetypes-1",
  "version": "3.0.1",
  "name": "ArgonautServerWriteMimeTypes",
  "title": "Argonaut Server Write Mime Types Value Set",
  "status": "draft",
  "date": "2018-11-08T20:29:00+00:00",
  "expansion": {
    "identifier": "urn:uuid:5fc51f5a-4dbc-44f8-8fe5-203d261222f0",
    "timestamp": "2018-11-13T02:55:48.405Z",
    "parameter": [
      {
        "name": "context",
        "valueString": "DocumentReference.content.attachment.contentType"
      },
      {
        "name": "contextDirection",
        "valueString": "incoming"
      }
    ],
    "contains": [
      {
        "system": "urn:ietf:bcp:13",
        "code": "text/plain"
      }
    ]
  }
}

GET [base]/ValueSet/$expand?context=DocumentReference.content.attachment.contentType&contextDirection=outgoing

HTTP/1.1 200 OK
[other headers]

{
  "resourceType": "ValueSet",
  "id": "scenario1-server-read-contenttype",
  "url": "http://acme.org/fhir/ValueSet/out-mimetypes-1",
  "version": "3.0.1",
  "name": "ArgonautServerReadMimeTypes",
  "title": "Argonaut Server Read Mime Types Value Set",
  "status": "draft",
  "date": "2018-11-08T20:29:00+00:00",
  "expansion": {
    "identifier": "urn:uuid:5fc51f5a-4dbc-44f8-8fe5-203d261222f0",
    "timestamp": "2018-11-13T02:55:48.405Z",
    "parameter": [
      {
        "name": "context",
        "valueString": "DocumentReference.content.attachment.contentType"
      },
      {
        "name": "contextDirection",
        "valueString": "outgoing"
      }
    ],
    "contains": [
      {
        "system": "urn:ietf:bcp:13",
        "code": "text/html"
      }
    ]
  }
}

Click on Here To See Scenario 2 Example

GET [base]/ValueSet/$expand?context=DocumentReference.content.attachment.contentType&contextDirection=incoming

HTTP/1.1 200 OK
[other headers]

{
  "resourceType": "ValueSet",
  "id": "scenario2-server-write-contenttype",
  "url": "http://acme.org/fhir/ValueSet/in-mimetypes-2",
  "version": "3.0.1",
  "name": "ArgonautServerWriteMimeTypes",
  "title": "Argonaut Server Write Mime Types Value Set",
  "status": "draft",
  "date": "2018-11-08T20:29:00+00:00",
  "expansion": {
    "identifier": "urn:uuid:5fc51f5a-4dbc-44f8-8fe5-203d261222f0",
    "timestamp": "2018-11-13T02:55:48.405Z",
    "parameter": [
      {
        "name": "context",
        "valueString": "DocumentReference.content.attachment.contentType"
      },
      {
        "name": "contextDirection",
        "valueString": "incoming"
      }
    ],
    "contains": [
      {
        "system": "urn:ietf:bcp:13",
        "code": "text/xhtml"
      }
    ]
  }
}

GET [base]/ValueSet/$expand?context=DocumentReference.content.attachment.contentType&contextDirection=outgoing

HTTP/1.1 200 OK
[other headers]

{
  "resourceType": "ValueSet",
  "id": "scenario2-server-read-contenttype",
  "url": "http://acme.org/fhir/ValueSet/out-mimetypes-2",
  "version": "3.0.1",
  "name": "ArgonautServerReadMimeTypes",
  "title": "Argonaut Server Read Mime Types Value Set",
  "status": "draft",
  "date": "2018-11-08T20:29:00+00:00",
  "expansion": {
    "identifier": "urn:uuid:5fc51f5a-4dbc-44f8-8fe5-203d261222f0",
    "timestamp": "2018-11-13T02:55:48.405Z",
    "parameter": [
      {
        "name": "context",
        "valueString": "DocumentReference.content.attachment.contentType"
      },
      {
        "name": "contextDirection",
        "valueString": "outgoing"
      }
    ],
    "contains": [
      {
        "system": "urn:ietf:bcp:13",
        "code": "application/pdf"
      }
    ]
  }
}

Resource Selection

When reviewing the minimal number of elements required for each Resource, the FHIR Version 4.0.1 specification includes several appropriate places to include clinical notes such as Composition, ClinicalImpression, DocumentReference, DiagnosticReport, etc. The developers of this guide also considered creating a new ClinicalNotes resource. To differentiate which resource was most appropriate these characteristics were considered:

• Discrete result information
• Note types
• Consistent Client access to scanned, or narrative-only, reports

While several resources work well for a specific use case, they don’t solve the question “find all Clinical Notes for a patient?” especially when considering the variability of Note formats. For example systems use text, XHTML, PDF, CDA to capture clinical notes. This variability led the designers to select the DocumentReference and DiagnosticReport resources as an index mechanisms to the underlying content. In other words, a client can query one of these resources and it will return a pointer to specific resource or the underlying binary content.

For example, consider the following situation for a Discharge Summary Note:

• System A supports the Discharge Summary as a Composition resource
• System B supports the Discharge Summary as a CDA Document
• System C supports the Discharge Summary as a PDF Document

The following single query into DocumentReference supports all 3 scenarios:

GET [base]/DocumentReference?patient=[id]&type=http://loinc.org|18842-5

The server returns either a pointer to the Composition or the Binary resource. If other more specific resources are developed for Clinical Notes systems can update their pointers to the new resource.

Clinical Notes vs ClinicalImpression

ClinicalImpression resource supports the record of a clinical assessment.

A record of a clinical assessment performed to determine what problem(s) may affect the patient and before planning the treatments or management strategies that are best to manage a patient’s condition. Assessments are often 1:1 with a clinical consultation / encounter, but this varies greatly depending on the clinical workflow. This resource is called “ClinicalImpression” rather than “ClinicalAssessment” to avoid confusion with the recording of assessment tools such as Apgar score

However, in existing EHRs, the clinical impression is often contained with in a broader note construct and the Argonauts didn’t find the boundary between a clinical note and ClinicalImpression clear enough to leverage the resources to share clinical notes.

Footnotes