Argonaut Clinical Notes Implementation Guide (Release 1.0.0 )

This page is part of the Argonaut Clinical Notes Implementation Guide (v1.0.0: Release) based on FHIR R3. This is the current published version. For a full list of available versions, see the Directory of published versions

StructureDefinition-argo-clinicalnotes

This profile sets minimum expectations for searching and fetching Clinical Notes using the DocumentReference resource. It identifies the mandatory core elements, extensions, vocabularies and value sets which SHALL be present in the DocumentReference resource when using this profile.

Example Usage Scenarios:

The following are example usage scenarios for the Argonaut Clinical Notes profile:

  • Query for a specific Clinical Note type (e.g. Discharge Summary)
  • Query for all Clinical Notes belonging to a Patient
  • Write a new Note to a Patient’s Chart
Mandatory Data Elements and Terminology

The following data-elements are mandatory (i.e data MUST be present). These are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.

Each Clinical Note DocumentReference must have:

  1. a category of the DocumentReference, referred to as class
  2. an author

Additional mandatory elements copied from US Core DocumentReference

  1. a patient
  2. a code describing the type of document
  3. a status
  4. date and time the reference was created (STU3 requirement, removed in R4)
  5. an https address (url) where the document can be retrieved or data inline (data). This is the only deviation from US Core DocumentReference which prohibited a ‘profile of profile’. US Core R4 matches the invariant added to this guide.

In addition it should have (if available):

  1. the organization responsible for the document, referred to as custodian.
  2. a business identifier for the DocumentReference (possibly generated by the transcription system or EHR)
  3. a document creation date
  4. a code identifying the specific details about the format of the document — over and above the content’s MIME type
  5. the patient encounter date that is being referenced

Profile specific implementation guidance:

The DocumentReference.type binding must support at a minimum these 5 concepts and may extend to the any LOINC document concepts.

The “Differential” View below only displays the Clinical Notes Profile elements. The “Full” View displays the combination of Clinical Notes Profile, and FHIR core.

Examples

Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: http://fhir.org/guides/argonaut/clinicalnotes/StructureDefinition/argo-clinicalnotes

Published on Tue Apr 10 23:48:14 AEST 2018 as a active by .

This profile builds on DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference I0..*Argonaut Clinical Notes Profile
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
Max Binding: All Languages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier SΣ0..1IdentifierOther identifiers for the document
... status ?!SΣ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... docStatus Σ0..1codepreliminary | final | appended | amended | entered-in-error
Binding: CompositionStatus (required)
... type SΣ1..1CodeableConceptKind of document (LOINC if possible)
Binding: Document Type Value Set (required)
Min Binding: Argonaut DocumentReferences Type Value Set
... class SΣ1..1CodeableConceptCategorization of document
Binding: Argonaut DocumentReferences Category Value Set (extensible)
... subject SΣ1..1Reference(US Core Patient Profile)Who/what is the subject of the document
... created SΣ0..1dateTimeDocument creation time
... indexed SΣ1..1instantWhen this document reference was created
... author SΣ0..*Reference(US Core Practitioner | US Core Organization Profile | Device | US Core Patient Profile | RelatedPerson)Who and/or what authored the document
... authenticator Σ0..1Reference(Practitioner | Organization)Who/what authenticated the document
... custodian SΣ0..1Reference(US Core Organization Profile)Organization which maintains the document
... relatesTo ?!ΣI0..*BackboneElementRelationships to other documents
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description Σ0..1stringHuman-readable description (title)
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible)
... content SΣI1..1BackboneElementDocument referenced
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... attachment SΣI1..1AttachmentWhere to access the document
argonaut-6: There shall be a url referencing the data or inline content.
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ1..1codeMime type of the content, with charset etc.
Binding: mimetypes (required)
Example General': text/plain; charset=UTF-8, image/png
..... language Σ0..1codeHuman language of the content (BCP-47)
Binding: Common Languages (extensible)
Max Binding: All Languages
Example General': en-AU
..... data S0..1base64BinaryData inline, base64ed
..... url SΣ0..1uriUri where the data can be found
Example General': http://www.acme.com/logo-small.png
..... size Σ0..1unsignedIntNumber of bytes of content (if url provided)
..... hash Σ0..1base64BinaryHash of the data (sha-1, base64ed)
..... title Σ0..1stringLabel to display in place of the data
Example General': Official Corporate Logo
..... creation Σ0..1dateTimeDate attachment was first created
.... format SΣ0..1CodingFormat/content rules for the document
Binding: DocumentReference Format Code Set (extensible)
... context SΣI0..1BackboneElementClinical context of document
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... encounter SΣ0..1Reference(US Core Encounter Profile)Context of the document content
.... event Σ0..*CodeableConceptMain clinical acts documented
Binding: ActCode (example)
.... period Σ0..1PeriodTime of service that is being documented
.... facilityType Σ0..1CodeableConceptKind of facility where patient was seen
Binding: Facility Type Code Value Set (example)
.... practiceSetting Σ0..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty)
Binding: Practice Setting Code Value Set (example)
.... sourcePatientInfo Σ0..1Reference(Patient)Patient demographics from source
.... related ΣI0..*BackboneElementRelated identifiers or resources
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... identifier Σ0..1IdentifierIdentifier of related objects or events
..... ref Σ0..1Reference(Resource)Related Resource

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference I0..*Argonaut Clinical Notes Profile
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
Max Binding: All Languages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier SΣ0..1IdentifierOther identifiers for the document
... status ?!SΣ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... docStatus Σ0..1codepreliminary | final | appended | amended | entered-in-error
Binding: CompositionStatus (required)
... type SΣ1..1CodeableConceptKind of document (LOINC if possible)
Binding: Document Type Value Set (required)
Min Binding: Argonaut DocumentReferences Type Value Set
... class SΣ1..1CodeableConceptCategorization of document
Binding: Argonaut DocumentReferences Category Value Set (extensible)
... subject SΣ1..1Reference(US Core Patient Profile)Who/what is the subject of the document
... created SΣ0..1dateTimeDocument creation time
... indexed SΣ1..1instantWhen this document reference was created
... author SΣ0..*Reference(US Core Practitioner | US Core Organization Profile | Device | US Core Patient Profile | RelatedPerson)Who and/or what authored the document
... authenticator Σ0..1Reference(Practitioner | Organization)Who/what authenticated the document
... custodian SΣ0..1Reference(US Core Organization Profile)Organization which maintains the document
... relatesTo ?!ΣI0..*BackboneElementRelationships to other documents
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description Σ0..1stringHuman-readable description (title)
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible)
... content SΣI1..1BackboneElementDocument referenced
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... attachment SΣI1..1AttachmentWhere to access the document
argonaut-6: There shall be a url referencing the data or inline content.
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ1..1codeMime type of the content, with charset etc.
Binding: mimetypes (required)
Example General': text/plain; charset=UTF-8, image/png
..... language Σ0..1codeHuman language of the content (BCP-47)
Binding: Common Languages (extensible)
Max Binding: All Languages
Example General': en-AU
..... data S0..1base64BinaryData inline, base64ed
..... url SΣ0..1uriUri where the data can be found
Example General': http://www.acme.com/logo-small.png
..... size Σ0..1unsignedIntNumber of bytes of content (if url provided)
..... hash Σ0..1base64BinaryHash of the data (sha-1, base64ed)
..... title Σ0..1stringLabel to display in place of the data
Example General': Official Corporate Logo
..... creation Σ0..1dateTimeDate attachment was first created
.... format SΣ0..1CodingFormat/content rules for the document
Binding: DocumentReference Format Code Set (extensible)
... context SΣI0..1BackboneElementClinical context of document
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... encounter SΣ0..1Reference(US Core Encounter Profile)Context of the document content
.... event Σ0..*CodeableConceptMain clinical acts documented
Binding: ActCode (example)
.... period Σ0..1PeriodTime of service that is being documented
.... facilityType Σ0..1CodeableConceptKind of facility where patient was seen
Binding: Facility Type Code Value Set (example)
.... practiceSetting Σ0..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty)
Binding: Practice Setting Code Value Set (example)
.... sourcePatientInfo Σ0..1Reference(Patient)Patient demographics from source
.... related ΣI0..*BackboneElementRelated identifiers or resources
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... identifier Σ0..1IdentifierIdentifier of related objects or events
..... ref Σ0..1Reference(Resource)Related Resource

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron


Quick Start

Below is an overview of the required set of RESTful FHIR interactions - for example, search and read operations - for this profile. See the Conformance requirements for a complete list of supported RESTful interactions for this IG.

Retrieve a Clinical Note with a given DocumentReference id:

GET [base]/DocumentReference/[id]

Example: GET [base]/DocumentReference/2169591

Support: Mandatory to support retrieve by a specific DocumentReference id.

Implementation Notes: This will return a pointer to the Binary resource which then can be retrieved using:

GET [base]/Binary/[id]

All other searches expect this two step process of locating the Clinical Note, and then retrieving the Binary.

Retrieve all Clinical Notes for a given Patient:

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

Example: GET [base]/DocumentReference?patient=1235541&class=clinical-note

Support: Mandatory to support search by patient to locate all Clinical Notes.

Implementation Notes: Search for all Clinical Notes for a patient (how to search by reference) fetches a bundle of all DocumentReference resources for the specified patient. Retrieving specific Notes will require a secondary request on the Binary resource.

Retrieve a Patient’s Clinical Notes by Searching with a date range:

GET [base]/DocumentReference?patient=[id]&class=clinical-note&created=[date]

Example: GET [base]/DocumentReference?patient=1316024&class=clinical-note&created=ge2018-04-11

Support: Mandatory to support search by date range.

Implementation Notes: Search for all Clinical Notes for a patient (how to search by reference) for a date range (how to search by date) fetches a bundle of all DocumentReference resources for the specified patient. Retrieving specific Notes will require a secondary request on the Binary resource.

Retrieve a specific Note type for a Patient:

GET [base]/DocumentReference?patient=[id]&type=[note type (LOINC)]

Example: GET [base]/DocumentReference?patient=1316024&type=http://loinc.org 18842-5

Support: Mandatory to support search by Note type.

Implementation Notes: Search for a specific Note type (how to search by token) for a patient (how to search by reference) fetches a bundle of all DocumentReference resources for the specified patient. Retrieving specific Notes will require a secondary request on the Binary resource.

Write new note to a Patient’s Chart:

POST [base]/DocumentReference

An example to demonstrate writing a note to the server.

Clinical Note


POST [base]/DocumentReference
Request Headers:
 content-type: "application/json"
 prefer: "return=REPRESENTATION"
 accept: "application/fhir+json"
Request Body:
 {
   "resourceType": "DocumentReference",
   "type": {
       "coding": [
           {
               "system": "http://loinc.org",
               "code": "18842-5",
               "display": "Discharge Summary"
           }
       ],
       "text": "Discharge Summary"
   },
   "subject": {
       "reference": "[base]/Patient/eso2MXsmcJloTEUEls5DzbA3"
   },
   "content": [{"attachment": {
       "contentType": "text/plain",
       "data": "Tm8gYWN0aXZpdHkgcmVzdHJpY3Rpb24sIHJlZ3VsYXIgZGlldCwgZm9sbG93IHVwIGluIHR3byB0byB0aHJlZSB3ZWVrcyB3aXRoIHByaW1hcnkgY2FyZSBwcm92aWRlci4="
   } }],
   "context": {"encounter": {"reference": "[base]/Encounter/eIOY6XJQw0hvmvCqTtkg6vQ3"} }
 }

Note Content

The content is Base64 encoded and states: “No activity restriction, regular diet, follow up in two to three weeks with primary care provider.”


Support: Mandatory to support write capability.