Clinical Notes

Overview

Clinical Notes Information addresses:

Clinical Notes HL7® FHIR® description US Core 6.1.0

Clinical notes are a key component in communicating a patient’s current status. In the context of this implementation 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 defines how systems exchange eight “Common Clinical Notes” and three DiagnosticReport categories.

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

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

Example Usage Scenarios:

The following are example usage scenarios for the US Core DocumentReference profile. See the Clinical Notes section for additional detail on using this profile for Clinical Notes:

Query for all documents belonging to a Patient
Query for a specific Clinical Note type (e.g. Discharge Summary or Continuity of Care Document (CCD))
Query for all Clinical Notes belonging to a Patient
Write a new Note to a Patient’s Chart

Each DocumentReference has next elements:

a status
a code describing the type of document
a document category
a patient
an address (e.g. url) where the document can be retrieved or the content as inline base64 encoded data
the MIME type (i.e. contentType) of the document

Each DocumentReference must support:

a business identifier for the DocumentReference (possibly generated by the transcription system or EHR)
date and time the reference was created
an author
a code identifying the specific details about the format of the document — over and above the content’s MIME type
the patient encounter that is being referenced
clinically relevant date

Profile specific implementation guidance:

See Clinical Notes
The DocumentReference.type binding must support at a minimum the 5 Common Clinical Notes and may extend to the full US Core DocumentReference Type Value Set
For a C-CDA Clinical Summary of Care (CCD):
- The document type code is the LOINC code 34133-9 Summary of episode note.
- The format code is urn:hl7-org:sdwg:ccda-structuredBody:2.1
The DocumentReference resources can represent the referenced content using either an address where the document can be retrieved using DocumentReference.attachment.url or the content as inline base64 encoded data using DocumentReference.attachment.data.
- Although both are marked as must support, the server system is not required to support both an address and inline base64 encoded data, but SHALL support at least one of these elements.
- The client application SHALL support both elements.
- The content.url may refer to a FHIR Binary Resource (i.e. [base]/Binary/[id]), FHIR Document Bundle (i.e [base]/Bundle/[id] or other endpoint.
  - If the endpoint is outside of the FHIR base URL, it SHOULD NOT require additional authorization to access.
The organization responsible for the DocumentReference SHALL be present either in DocumentReference.custodian or accessible in the Provenance resource targeting the DocumentReference using Provenance.agent.who or Provenance.agent.onBehalfOf.
- Some system may also expose the same organization in referenced Encounter in Encounter.serviceProvider.

This resource conforms to USCDI V3 profile For DocumentReference - refers to StructureDefinition US Core DocumentReference.

DocumentReference response will be provided in JSON (refers to Capability Statement) format as per FHIR standard R4 version.

Must support elements, mandatory and optional search parameters

DocumentReferencemust support these elements:

identifier
status
type
category
subject
date
author
content
- attachment
  - contentType
  - data
  - url
- format
context
- encounter
- period

The syntax used to describe the interactions is described here.

Please note, the DocumentReference.content.attachment.url field uses a different base URL from the Elation FHIR host. We host these attachments from the Elation APIv2 root URLs, these are https://sandbox.elation.com/ (for the FHIR sandbox environment) and https://app.elationemr.com/ (for the FHIR production environment). In addition, you will need to request an Elation APIv2 token (as per the APIv2 authentication documentation) to be able to download these attachments. Please contact support if you require assistance.

The following search parameters and search parameter combinations SHALL be supported (mandatory):

SHALL support fetching a DocumentReference using the _id search parameter: GET [base url]/DocumentReference?_id=[id]

SHALL support searching for all DocumentReference for a patient using the patient search parameter:

GET [base url]/DocumentReference?patient={Type/}[id]

SHALL support searching using the combination of the patient and category search parameters: GET [base url]/DocumentReference?patient={Type/}[id]&category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note

SHALL support searching using the combination of the patient and category and date search parameters:

including support for these date comparators: gt,lt,ge,le
including optional support for AND search on date (e.g. date=[date]&date=[date]]&...) GET [base url]/DocumentReference?patient={Type/}[id]&category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

SHALL support searching using the combination of the patient and type search parameters: GET [base url]/DocumentReference?patient={Type/}[id]&type={system|}[code]

The following search parameters and search parameter combinations SHOULD be supported (optional):

SHOULD support searching using the combination of the patient and status search parameters:

including support for OR search on status (e.g. status={system|}[code],{system|}[code],...) GET [base url]/DocumentReference?patient={Type/}[id]&status={system|}[code]{,{system|}[code],...}

SHOULD support searching using the combination of the patient and type and period search parameters:

including support for these period comparators: gt,lt,ge,le
including optional support for AND search on period (e.g. period=[date]&period=[date]]&...) GET [base url]/DocumentReference?patient={Type/}[id]&type={system|}[code]&period={gt|lt|ge|le}[date]{&period={gt|lt|ge|le}[date]&...}

DocumentReference By Id

Search for DocumentReference by id.

METHOD GET

GET [base url]/DocumentReference/[id]

GET [base url]/DocumentReference?_id=[id]

PARAMS [base url] - FHIR base url [id] - Id for the DocumentReference

HEADERS

The Authorization token SHALL be obtained during Authentication and Authorization process. Goto Authentication and Authorization for further details.

Header	Type	Required/Optional	Value
Authorization	string	required	`Bearer <token>`

RESPONSES

Code	Description	Comment
200	OK	The request was processed successfully
400	Bad request	Invalid request parameters or FHIR operation outcome resource returned
401	Unauthorized	This code indicates that the client request has not been completed because it lacks valid authentication credentials for the requested resource
404	no Route matched with those values	The request was able to communicate with a given server, but the server could not find what was requested
500	Internal Server Error	The server has encountered a situation it doesn't know how to handle

EXAMPLE:

curl --location --request GET 'https://sandbox.fhir.elationemr.com/fhir/DocumentReference/a11b21f6-1ac7-ca23-1ba2-a021f6532a5d' \
--header 'Authorization: Bearer fe1cd986-1ac7-4c26-b8b3-d632a48408fd'

DocumentReference By patient

Search for All DocumentReference by a specific patient.

METHOD GET

GET [base url]/DocumentReference?patient={Type/}[id]

PARAMS [base url] - FHIR base url {Type/} - Type for the Reference. Example: Patient/ [id] - Id for Patient resource

HEADERS

The Authorization token SHALL be obtained during Authentication and Authorization process. Goto Authentication and Authorization for further details.

Header	Type	Required/Optional	Value
Authorization	string	required	`Bearer <token>`

RESPONSES

Code	Description	Comment
200	OK	The request was processed successfully
400	Bad request	Invalid request parameters or FHIR operation outcome resource returned
401	Unauthorized	This code indicates that the client request has not been completed because it lacks valid authentication credentials for the requested resource
404	no Route matched with those values	The request was able to communicate with a given server, but the server could not find what was requested
500	Internal Server Error	The server has encountered a situation it doesn't know how to handle

EXAMPLE:

curl --location --request GET 'https://sandbox.fhir.elationemr.com/fhir/DocumentReference?patient=Patient/1137192' \
--header 'Authorization: Bearer fe1cd986-1ac7-4c26-b8b3-d632a48408fd'

DocumentReference By patient and category

Fetches a bundle of all DocumentReference resources for the specified patient and category = clinical-note

METHOD GET

GET [base url]/DocumentReference?patient={Type/}[id]&category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note

PARAMS [base url] - FHIR base url {Type/} - Type for the Reference. Example: Patient/ [id] - Id for Patient resource

HEADERS

The Authorization token SHALL be obtained during Authentication and Authorization process. Goto Authentication and Authorization for further details.

Header	Type	Required/Optional	Value
Authorization	string	required	`Bearer <token>`

RESPONSES

Code	Description	Comment
200	OK	The request was processed successfully
400	Bad request	Invalid request parameters or FHIR operation outcome resource returned
401	Unauthorized	This code indicates that the client request has not been completed because it lacks valid authentication credentials for the requested resource
404	no Route matched with those values	The request was able to communicate with a given server, but the server could not find what was requested
500	Internal Server Error	The server has encountered a situation it doesn't know how to handle

EXAMPLE:

curl --location --request GET 'https://sandbox.fhir.elationemr.com/fhir/DocumentReference?patient=Patient/1137192&category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note' \
--header 'Authorization: Bearer fe1cd986-1ac7-4c26-b8b3-d632a48408fd'

DocumentReference By patient and category and date

Fetches a bundle of all DocumentReference resources for the specified patient and category = clinical=note and date

METHOD GET

GET [base url]/DocumentReference?patient={Type/}[id]&category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

PARAMS [base url] - FHIR base url {Type/} - Type for the Reference. Example: Patient/ [id] - Id for Patient resource {gt|lt|ge|le} - Search modifiers for the date. See Search specification for more information. [date] - Beginning and/or ending for a period

HEADERS

The Authorization token SHALL be obtained during Authentication and Authorization process. Goto Authentication and Authorization for further details.

Header	Type	Required/Optional	Value
Authorization	string	required	`Bearer <token>`

RESPONSES

Code	Description	Comment
200	OK	The request was processed successfully
400	Bad request	Invalid request parameters or FHIR operation outcome resource returned
401	Unauthorized	This code indicates that the client request has not been completed because it lacks valid authentication credentials for the requested resource
404	no Route matched with those values	The request was able to communicate with a given server, but the server could not find what was requested
500	Internal Server Error	The server has encountered a situation it doesn't know how to handle

EXAMPLE:

curl --location --request GET 'https://sandbox.fhir.elationemr.com/fhir/DocumentReference?patient=Patient/1235541&category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note&date=ge2020-01-01T00:00:00Z' \
--header 'Authorization: Bearer fe1cd986-1ac7-4c26-b8b3-d632a48408fd'

DocumentReference By patient and type

Fetches a bundle of all DocumentReference resources for the specified patient and type

METHOD GET

GET [base url]/DocumentReference?patient={Type/}[id]&type={system|}[code]

HEADERS

The Authorization token SHALL be obtained during Authentication and Authorization process. Goto Authentication and Authorization for further details.

Header	Type	Required/Optional	Value
Authorization	string	required	`Bearer <token>`

RESPONSES

Code	Description	Comment
200	OK	The request was processed successfully
400	Bad request	Invalid request parameters or FHIR operation outcome resource returned
401	Unauthorized	This code indicates that the client request has not been completed because it lacks valid authentication credentials for the requested resource
404	no Route matched with those values	The request was able to communicate with a given server, but the server could not find what was requested
500	Internal Server Error	The server has encountered a situation it doesn't know how to handle

EXAMPLE:

curl --location --request GET 'https://sandbox.fhir.elationemr.com/fhir/DocumentReference?patient=Patient/1316024&type=http://loinc.org|18842-5' \
--header 'Authorization: Bearer fe1cd986-1ac7-4c26-b8b3-d632a48408fd'

DocumentReference By patient and status

Fetches a bundle of all DocumentReference resources for the specified patient and status

METHOD GET

GET [base url]/DocumentReference?patient={Type/}[id]&status={system|}[code]{,{system|}[code],...}

PARAMS [base url] - FHIR base url {Type/} - Type for the Reference. Example: Patient/ [id] - Id for Patient resource {system|} - Status system. FHIR search token parameter. See Search specification for more information. [code] - Status code. FHIR search token parameter. See Search specification for more information.

HEADERS

The Authorization token SHALL be obtained during Authentication and Authorization process. Goto Authentication and Authorization for further details.

Header	Type	Required/Optional	Value
Authorization	string	required	`Bearer <token>`

RESPONSES

Code	Description	Comment
200	OK	The request was processed successfully
400	Bad request	Invalid request parameters or FHIR operation outcome resource returned
401	Unauthorized	This code indicates that the client request has not been completed because it lacks valid authentication credentials for the requested resource
404	no Route matched with those values	The request was able to communicate with a given server, but the server could not find what was requested
500	Internal Server Error	The server has encountered a situation it doesn't know how to handle

EXAMPLE:

curl --location --request GET 'https://sandbox.fhir.elationemr.com/fhir/DocumentReference?patient=Patient/1316024&status=superseded' \
--header 'Authorization: Bearer fe1cd986-1ac7-4c26-b8b3-d632a48408fd'

DocumentReference By patient and type and period

Fetches a bundle of all DocumentReference resources for the specified patient and type and period.

METHOD GET

GET [base]/DocumentReference?patient={Type/}[id]&type={system|}[code]&period={gt|lt|ge|le}[date]{&period={gt|lt|ge|le}[date]&...}

PARAMS [base url] - FHIR base url {Type/} - Type for the Reference. Example: Patient/ [id] - Id for Patient resource {system|} - Type system. FHIR search token parameter. See Search specification for more information. [code] - Type code. FHIR search token parameter. See Search specification for more information. {gt|lt|ge|le} - Search modifiers for the date. See Search specification for more information. [date] - Beginning and/or ending for a period

HEADERS

The Authorization token SHALL be obtained during Authentication and Authorization process. Goto Authentication and Authorization for further details.

Header	Type	Required/Optional	Value
Authorization	string	required	`Bearer <token>`

RESPONSES

Code	Description	Comment
200	OK	The request was processed successfully
400	Bad request	Invalid request parameters or FHIR operation outcome resource returned
401	Unauthorized	This code indicates that the client request has not been completed because it lacks valid authentication credentials for the requested resource
404	no Route matched with those values	The request was able to communicate with a given server, but the server could not find what was requested
500	Internal Server Error	The server has encountered a situation it doesn't know how to handle

EXAMPLE:

curl --location --request GET 'https://sandbox.fhir.elationemr.com/fhir/DocumentReference?patient=Patient/1316024&type=http://loinc.org |34133-9&period=ge2020-01-01T00:00:00Z' \
--header 'Authorization: Bearer fe1cd986-1ac7-4c26-b8b3-d632a48408fd'