Observation

Clinical notes are often used to describe patient current status. There are wide variety of references, contexts and documents e.g simple care plan, reporting, observations in IPD rounds, simple handwritten notes, or general observation.

• consultation including vitals, observations
• history and examination
• procedure note
• progress Note Or just a "Narrative"!

In the reference stack, instead of trying to strictly map, interpret or standardise FHIR profiles, we have gone with more generic approach of using Observation, which is a fundamental/central element in FHIR standards. To quote Fhir documentation - "Most observations are simple name/value pair assertions with some metadata, but some observations group other observations together logically, or even are multi-component observations."

Lets say we want to express APGAR score and additionally weight observations made for a baby:

          "resource": {
            "resourceType": "Observation",
            "id":"72a2891a-27da-4694-bade-e65cc2213ee1",
            "status": "final",
            "code": {
              "text": "2 minute Apgar Score"
            },
            "effectiveDateTime": "2016-03-28T10:33:22Z",
            "valueQuantity": {
              "value": 10
            },
            "performer": [
               {
                 "display": "Dr.Rajesh"
               }
            ]
         }

and

          "resource": {
            "resourceType": "Observation",
            "id": "71caf571-9307-484a-9e19-00ec92017191",
            "status": "final",
            "code": {
              "text" : "Body Weight"
            },
            "effectiveDateTime": "2016-03-28",
            "valueString" : "3.1 Kg"
          }

The above should be pretty self explanatory. But do notice the different between "valueQuantity" and "valueString".

If we put these inside the PHR FHIR envelope, it would become

  {
    "resourceType": "Bundle",
    "id": "10801e8f-d722-469a-afe2-7980ac4bee83",
    "type": "collection",
    "entry": [
        {
          "fullUrl":"urn:uuid:72a2891a-27da-4694-bade-e65cc2213ee1",
          "resource": {
            "resourceType": "Observation",
            "id":"72a2891a-27da-4694-bade-e65cc2213ee1",
            "status": "final",
            "code": {
              "text": "2 minute Apgar Score"
            },
            "effectiveDateTime": "2016-03-28T10:33:22Z",
            "valueQuantity": {
              "value": 10
            },
            "performer": [
               {
                 "display": "Dr.Rajesh"
               }
             ]
          }
        },
        {
          "fullUrl": "urn:uuid:71caf571-9307-484a-9e19-00ec92017191",
          "resource": {
            "resourceType": "Observation",
            "id": "71caf571-9307-484a-9e19-00ec92017191",
            "status": "final",
            "code": {
              "text" : "Body Weight"
            },
            "effectiveDateTime": "2016-03-28",
            "valueString" : "3.1 Kg"
          }
        }
    ]
  }

INFO:

• Notice the difference in the value - valueString, valueQuantity. There are other valueX types as well in FHIR Observation. See the FHIR documentation for more details.
• Notice the additional information like Performer. It really depends on HIPs capability of sending such information, and/or the end-user interface capability to display such information.
• The above is only for guidance and serves as example. For any definition of any standard, structure of profile contextual to use case should be addressed by a recognised and appointed standards body.