More comments on FHIR documents

With the emphasis on Documents in the coming connectathon, there have been a few questions on the skype chat about that. I suspect that most people who plan to attend connectathon will be monitoring that conversation (if not then you really should!) but just thought I’d post some of them here in case they got missed.

The correct way to represent section titles in a composition

From Ewout

Section.code is the “structured” name, and could contain a text as well, that’s what you would use. The section/content/display is a short label that’s part of the ResourceReference. This ResourceReference points to the actual Resource (often a List resource) that contains, say, a list of current medications. This ResourceReference.display may contain a textual short summary of this list, but more often than not, it will be empty. So, section/content/display is not what you want to use for the title.

So section/code/text is the recommended display – assuming, of course that that the section code is present (it is optional). If not present then you’ll need to get the display from the actual resource – however, in general, the code is highly recommended. And note that the spec has more comments on document presentation.

Querying DocumentReference

A reminder that a query will always return a bundle. If there were no matching resources in the query – then the bundle will be empty – it will have no entries. And remember that you can query on the subject (or other properties) within the DocumentReference. The samples given were:

A reference stylesheet for FHIR documents

In progress – not yet ready.

Narrative only sections

The example given was ‘reason for visit’ which – in CCDA – has no coded data.

FHIR still needs a resource, so either Observation (if that applies) or ‘Other’ is the best alternative to use.  And don’t forget the List resource, when the section can (or should) contain multiple entries as show here. Although not a specific recommendation, if a section could contain multiple resources (like medications on discharge) then using a List with 1 resource in it is more consistent than only using a List when there is more than one.

About David Hay
I'm an independent contractor working with a number of Organizations in the health IT space. I'm an HL7 Fellow, Chair Emeritus of HL7 New Zealand and a co-chair of the FHIR Management Group. I have a keen interest in health IT, especially health interoperability with HL7 and the FHIR standard. I'm the author of a FHIR training and design tool - clinFHIR - which is sponsored by InterSystems Ltd.

One Response to More comments on FHIR documents

  1. Note that we’ve now introduced a “title” element on section.

    For narrative only sections, you use the resource that reflects the semantics of the section – List for allergy, medication and problem lists, Encounter, Procedure, FamilyHistory, etc. You only fall back to Other if the section content is so broad/unknown that you can’t select an appropriate resource.

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