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hl7-fhirhapi-fhir

Clinical Notes (SOAP) representation FHIR


My question is more about modeling simple clinical notes in SOAP (Subjective, Objective, Assessment, Plan) into the FHIR specification.

I have been trying to look into the documentation but it doesn't provide a clear way of doing it or a clear way of which resources to use.

Does anyone have an idea of the best resources to use from FHIR for clinical notes?


Solution

  • Most EHRs will utilize DocumentReference and Binary. DocumentReference would hold the metadata about the note, such as the author and creation date/time. Binary would hold the content in a base64-encoded string.

    There is the possibility of forgoing the Binary and using the content.attachment.data attribute in DocumentReference to directly hold the base64-encoded string, but this isn't as common.