Veiledning kliniske notater
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Kliniske notater
I kontekst av denne implementasjonsguiden vil termen “kliniske notater” referere til en stor variasjon av dokumenter som er generert på vegne av en pasient i et behandlingsløp. Denne guiden definerer ikke nye notattyper eller setter innholdskrav pr. notattype, istedet fokuserer guiden på å eksponere og skrive kliniske notater i/til eksisterende systemer.
Denne guiden definerer utveksling for følgende to “kliniske notater” som systemer er påkrevet å støtte:
I tillegg er systemer oppfordret til å støtte følgende typer:
Komplett liste med DocumentReference typer er tilgjengelig i ValueSet - NO HelseAPI DocumentReference Type.
Utveksling av kliniske notater
MERK: I fremtiden er det stor sannsynlighet for at begrepet kliniske notater vil referere til også andre ressurs typer enn DocumentReference og Binary, eksempelvis DiagnosticReport og Composition.
DocumentReference er et godt valg når det handler om et generelt behov for å kunne dokumentere til pasientens løpende journal. DocumentReference ressursen kan peke til korte notater om pasientens tilstand, røntgenbilder og andre medier eller et større dokument som helseattest, epikrise, osv.
Søk
For å søke opp og hente ut av kliniske notater benyttes det standardiserte FHIR søke-APIet. I denne guiden defineres påkrevde søkeparametere og hvordan de skal benyttes i seksjonen Konformitetskrav og i de enkelte Profilene.
Vanlige søkescenarioer inkluderer:
En klient interessert i alle konsultasjonsnotater kan benytte følgende spørring:
GET [base]/DocumentReference?patient=[id]&type=http://snomed.info/sct|371530004En klient interessert i alle kliniske notater kan benytte følgende spørring:
GET [base]/DocumentReference?category=clinical-note
Lagring
For å kunne lagre kliniske notater benyttes den standardiserte create interaksjonen beskrevet i FHIR RESTful API.
Serveren SKAL støtte create interaksjoner for endepunktene Binary og HelseAPI DocumentReference ressursene, i tillegg anbefales det å støtte transaction interaksjonen.
Eksempel på payload for en transaction interaksjon:
{
"resourceType": "Bundle",
"id": "urn:uuid:0138f9b0731c4c518aa19ea85bd4807a",
"type": "transaction",
"entry": [
{
"fullUrl": "urn:uuid:B0B56521-7FC5-4F15-ABE0-3AEC42FF240C",
"resource": {
"resourceType": "Binary",
"contentType": "text/plain",
"securityContext": { "reference": "urn:uuid:B0B56521-7FC5-4F15-ABE0-3AEC42FF240D" },
"data": "RGV0dGUgZXIgcGxhaW4vdGV4dA=="
},
"request": {
"method": "POST",
"url": "Binary"
}
},
{
"fullUrl": "urn:uuid:B0B56521-7FC5-4F15-ABE0-3AEC42FF240D",
"resource": {
"resourceType": "DocumentReference",
"status": "current",
"docStatus": "final",
"type": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "371530004",
"display": "Clinical consultation report"
}
],
"text": "Clinical consultation report"
},
"category": [
{
"coding": [
{
"system": "http://hl7.no/fhir/CodeSystem/no-helseapi-documentreference-category",
"code": "clinical-note",
"display": "Clinical Note"
}
],
"text": "Clinical Note"
}
],
"subject": { "reference": "Patient/123" },
"date": "2019-11-25T08:25:18.406722+00:00",
"author": [ { "reference": "Practitioner/456" } ],
"authenticator": { "reference": "Practitioner/456" },
"content": [
{
"attachment": {
"contentType": "text/plain",
"url": "urn:uuid:B0B56521-7FC5-4F15-ABE0-3AEC42FF240C"
}
}
],
"context": { "encounter": [ { "reference": "Encounter/789" } ] }
},
"request": {
"method": "POST",
"url": "DocumentReference"
}
},
{
"fullUrl": "urn:uuid:CB2ADB6F-06B0-458A-AA37-2B8B7CE4E17A",
"resource": {
"resourceType": "Binary",
"contentType": "application/pdf",
"securityContext": { "reference": "urn:uuid:CB2ADB6F-06B0-458A-AA37-2B8B7CE4E17B" },
"data": "JVBERi0xLjQKJeLjz9MKMSAwIG9iago8PAovQ3JlYXRpb25EYXRlIChEOjIwMjAwMjEzMjAzNzA3KzAxJzAwJykKL0NyZWF0b3JUb29sIChQREYtWENoYW5nZSBMaXRlIFwoNy4wIGJ1aWxkIDMyOC4yXCkgW0dESV0gW1dpbmRvd3MgMTAgRW50ZXJwcmlzZSB4NjQgXChCdWlsZCAxODM2M1wpXSkKL01vZERhdGUgKEQ6MjAyMDAyMTMyMDM3MjUrMDEnMDAnKQovUHJvZHVjZXIgKFBERi1YQ2hhbmdlIExpdGUgXCg3LjAgYnVpbGQgMzI4LjJcKSBbR0RJXSBbV2luZG93cyAxMCBFbnRlcnByaXNlIHg2NCBcKEJ1aWxkIDE4MzYzXCldKQo+PgplbmRvYmoKMiAwIG9iago8PAovTWV0YWRhdGEgMyAwIFIKL1BhZ2VzIDQgMCBSCi9UeXBlIC9DYXRhbG9nCj4+CmVuZG9iagozIDAgb2JqCjw8Ci9MZW5ndGggMzA4MwovU3VidHlwZSAvWE1MCi9UeXBlIC9NZXRhZGF0YQo+PgpzdHJlYW0KPD94cGFja2V0IGJlZ2luPSLvu78iIGlkPSJXNU0wTXBDZWhpSHpyZVN6TlRjemtjOWQiPz4KPHg6eG1wbWV0YSB4bWxuczp4PSJhZG9iZTpuczptZXRhLyIgeDp4bXB0az0iWE1QIENvcmUgNS41LjAiPgoJPHJkZjpSREYgeG1sbnM6cmRmPSJodHRwOi8vd3d3LnczLm9yZy8xOTk5LzAyLzIyLXJkZi1zeW50YXgtbnMjIj4KCQk8cmRmOkRlc2NyaXB0aW9uIHJkZjphYm91dD0iIgoJCQkJeG1sbnM6ZGM9Imh0dHA6Ly9wdXJsLm9yZy9kYy9lbGVtZW50cy8xLjEvIgoJCQkJeG1sbnM6eG1wTU09Imh0dHA6Ly9ucy5hZG9iZS5jb20veGFwLzEuMC9tbS8iCgkJCQl4bWxuczp4bXA9Imh0dHA6Ly9ucy5hZG9iZS5jb20veGFwLzEuMC8iCgkJCQl4bWxuczpwZGY9Imh0dHA6Ly9ucy5hZG9iZS5jb20vcGRmLzEuMy8iPgoJCQk8ZGM6Zm9ybWF0PmFwcGxpY2F0aW9uL3BkZjwvZGM6Zm9ybWF0PgoJCQk8eG1wTU06RG9jdW1lbnRJRD51dWlkOjViODgyYjhkLTNhMWMtNGM4Zi04ZjFlLWI5OTAzYTYwMGRhNjwveG1wTU06RG9jdW1lbnRJRD4KCQkJPHhtcE1NOkluc3RhbmNlSUQ+dXVpZDphY2FkYmQxOC04YjZjLTQwNzQtODIwNS1kODRmNGJlZDVjODk8L3htcE1NOkluc3RhbmNlSUQ+CgkJCTx4bXA6Q3JlYXRlRGF0ZT4yMDIwLTAyLTEzVDIwOjM3OjA3KzAxOjAwPC94bXA6Q3JlYXRlRGF0ZT4KCQkJPHhtcDpNb2RpZnlEYXRlPjIwMjAtMDItMTNUMjA6Mzc6MjUrMDE6MDA8L3htcDpNb2RpZnlEYXRlPgoJCQk8cGRmOlByb2R1Y2VyPlBERi1YQ2hhbmdlIExpdGUgKDcuMCBidWlsZCAzMjguMikgW0dESV0gW1dpbmRvd3MgMTAgRW50ZXJwcmlzZSB4NjQgKEJ1aWxkIDE4MzYzKV08L3BkZjpQcm9kdWNlcj4KCQkJPHBkZjpDcmVhdG9yVG9vbD5QREYtWENoYW5nZSBMaXRlICg3LjAgYnVpbGQgMzI4LjIpIFtHREldIFtXaW5kb3dzIDEwIEVudGVycHJpc2UgeDY0IChCdWlsZCAxODM2MyldPC9wZGY6Q3JlYXRvclRvb2w+CgkJPC9yZGY6RGVzY3JpcHRpb24+Cgk8L3JkZjpSREY+CjwveDp4bXBtZXRhPgogICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgCiAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAKICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgIAogICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgCiAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAKICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgIAogICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgCiAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAKICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgIAogICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgCiAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAKICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgIAogICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgCiAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAKICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgIAogICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgCiAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAKICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgIAogICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgCiAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAKICAgICAgICAgICAgICAgICAgICAgICAgICAgCjw/eHBhY2tldCBlbmQ9InciPz4KZW5kc3RyZWFtCmVuZG9iago0IDAgb2JqCjw8Ci9Db3VudCAxCi9LaWRzIFs1IDAgUl0KL1R5cGUgL1BhZ2VzCj4+CmVuZG9iago1IDAgb2JqCjw8Ci9Bbm5vdHMgWzYgMCBSIDcgMCBSXQovQ29udGVudHMgOCAwIFIKL01lZGlhQm94IFswIDAgNTk1LjIgODQxLjkyXQovUGFyZW50IDQgMCBSCi9SZXNvdXJjZXMgPDwKL0V4dEdTdGF0ZSA8PAovR1MwIDkgMCBSCj4+Ci9Gb250IDw8Ci9GMCAxMCA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"
},
"request": {
"method": "POST",
"url": "Binary"
}
},
{
"fullUrl": "urn:uuid:CB2ADB6F-06B0-458A-AA37-2B8B7CE4E17B",
"resource": {
"resourceType": "DocumentReference",
"status": "current",
"docStatus": "final",
"type": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "371529009",
"display": "History & physical report"
}
],
"text": "History & physical report"
},
"category": [
{
"coding": [
{
"system": "http://hl7.no/fhir/CodeSystem/no-helseapi-documentreference-category",
"code": "clinical-note",
"display": "Clinical Note"
}
],
"text": "Clinical Note"
}
],
"subject": { "reference": "Patient/123" },
"date": "2019-11-25T08:25:18.4113618+00:00",
"author": [ { "reference": "Practitioner/456" } ],
"authenticator": { "reference": "Practitioner/456" },
"content": [
{
"attachment": {
"contentType": "application/pdf",
"url": "urn:uuid:CB2ADB6F-06B0-458A-AA37-2B8B7CE4E17A"
}
}
],
"context": { "encounter": [ { "reference": "Encounter/789" } ] }
},
"request": {
"method": "POST",
"url": "DocumentReference"
}
}
]
}