Clinical Record Exchange Standard: Detailed Guidelines using FHIR US Core
Clinical Notes - Elation Help Center
Summary
This document details the technical specifications for exchanging 'clinical notes,' which are crucial for communicating a patient's current status. It defines how eight common clinical note types and three diagnostic report categories must be handled based on the HL7 FHIR standard.
Details
These guidelines specify the technical requirements for exchanging diverse patient documents (for care transitions, planning, billing, etc.) between healthcare systems. Specifically, the 'Clinical Notes' section details the data structure and search methods using the US Core DocumentReference profile. Eight common clinical notes are supported, including Consultation Note, Discharge Summary, History & Physical Note, Progress Note, etc., each assigned a specific code (e.g., 11488-4). The standard adopts FHIR R4 for data exchange, defining mandatory elements such as status, type, patient information, and content via the DocumentReference resource, which can use either a URL or Base64 encoded data. Technically, it specifies combinations of search parameters (e.g., `patient={Type/}[id]` or `category=...|clinical-note`), providing concrete implementation guidelines to enhance interoperability. This serves as an important specification for electronic medical record linkage and regional healthcare information network construction in Japan.
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