Patient Care Coordination (PCC) Implementation Guide, published by Virtually Healthcare. This guide is not an authorized publication; it is the continuous build for version 0.1.1-current built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Virtually-Healthcare/R4/ and changes regularly. See the Directory of published versions

Consultation Note

References

• HL7 Europe Hospital Discharge Report
• International Patient Summary
• LOINC Consultation note - recommended C-CDA R1.1 sections

Introduction

The consultation note forms the basis of IM1 Consultation Writeback and GP Connect Send Document. It is also related to the EMIS consultation screen sections and PRSB section headings.

Informatics Model

The consultation note consists of three main structures:

• composition which forms the main body of the consultation
• archetype/template, which are a templated set of questions that can be used during a consultation. It will often be referred to as a form, and it is primarily a data capture method. Examples include
  • vital signs
  • daily physical activity
• resource entities, which are the data structures persisted in the clinical repository. The most common resource will be:
  • Observation

Both archetype/template and entities are data capture related and will often relate to a data entry screen within an application. Compositions provide a high-level structure to the consultation, but they are generally assembled from both archetype/templates and resource entities; it is a data aggregate.

Many questions within the archetype / template will be the same and also overlap with directly captured entities. I.e., in remote patient monitoring (virtual wards) a patient's weight, pulse rate and blood pressure can be captured from device data. These data items also exist in vital signs.

Where a template/archetype question may have multiple uses, it is persisted as a resource entity.

These questions will be SNOMED or LOINC coded.

Composition & FHIR Document

Composition - Consultation Note

The basic structure of a composition is shown above, in its aggregated form it is known as a FHIR Document and a redendered example is shown below:

Comosition.section - Document Section Codes

Each section is coded using Document Section Codes, which can be found Value Set: Document Section Codes.

This is not required to be SNOMED CT coded.

EMIS Document Section	LOINC Document Section Codes	PRSB Section Heading	FHIR Observation category
Care Plan	18776-5 Plan of care note	Professional contacts Plan and requested actions
Result	30954-2 Relevant diagnostic tests/laboratory data Narrative	Investigation results	laboratory
Examination	8716-3 Vital signs	Observations Examination findings	vital-signs
	29545-1 Physical examination		exam
Procedure	47519-4 History of procedures		procedure
Allergy	48765-2 Allergies and adverse reactions Document	Allergies and adverse reactions
History	29762-2 Social history Narrative	Social context Educational history	social-history
	10162-6 History of pregnancies Narrative
Test Request	42349-1 Reason for referral (narrative)	Referral details
Comment	61149-1 Objective Narrative
Follow up	18776-5 Plan of treatment (narrative)
Family History	10157-6 History of family member diseases Narrative	Family history
Medication	10160-0 History of medication use Narrative	Medications and medical devices
Problem	11450-4 Problem list - Reported	Problem list
Document
N/a	81338-6 Goals, preferences, and priorities for care experience
N/a	11369-6 Immunization	Vaccinations
N/a	51848-0 Assessment	Clinical risk factors	survey

Domain Archetype

Questionnaire - Consultation Note

As composition is not for data capture, we need an archetype to form the high framework for the consulation-note.

The current model is shown below. Historically this is related to SOAP Note and also Nursing Process (ADPIE) which are also included for documentation purposes.

Consultation Note Map

Resource Model

The current model with the addition of Questionnaire (the definition for archetype/template discussed above) is shown below:

Consultation Note Model

The main changes are:

• 'derivedFrom' should be populated if a Observation has been generated from a Questionnaire.
• category should be populated in order to support creation of the composition aggregate.