Concepts/Clinical Notes: Difference between revisions
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#REDIRECT [[Concepts/Notes]] |
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{{Doc header |
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|type=concept |
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|domain=clinical |
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|title=Clinical Notes |
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|order=13 |
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|introduced=3.0 |
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|fhir=Clinical Notes |
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|concept=Concepts/Observation |
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|reference=References/Notes |
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}} |
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A '''clinical note''' in Care is the care team's written commentary about a patient — the place where staff record narrative, hand-offs, and discussion in their own words rather than in structured fields. Notes are organized into threads, so a single topic stays together as a conversation instead of scattering across the record. |
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== What it represents == |
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In Care's FHIR-aligned model, clinical notes map to the '''Communication''' resource — running written exchanges about a patient. A note thread holds: |
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* '''A subject''' — every thread is anchored to one patient, and optionally narrowed to a single encounter |
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* '''A title''' — a short label for what the thread is about |
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* '''Messages''' — the entries posted into the thread over time by the care team |
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* '''A preserved history''' — authorship, timestamps, and prior versions of every edited message |
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A note is not a substitute for structured clinical data. Diagnoses belong in [[Concepts/Condition|conditions]], allergies in [[Concepts/Allergy & Intolerance|allergy records]], and measurements in [[Concepts/Observation|observations]]. Notes are the human layer that ties that data together — the reasoning, context, and discussion that coded fields can't hold. |
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== Threads and messages == |
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Notes live in a two-level structure: '''threads''' that hold '''messages'''. |
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* A '''thread''' is one conversation, anchored to a patient and optionally to one of that patient's encounters. |
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* A '''message''' is a single entry inside a thread. Many people can add messages to the same thread over time. |
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That anchoring gives a thread its scope: |
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{| class="wikitable" |
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|- |
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! Scope |
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! What it means |
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! Typical use |
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|- |
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| Patient-level |
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| Attached to the patient, not to any one visit |
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| Longitudinal commentary across encounters — care coordination, ongoing concerns |
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|- |
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| Encounter-level |
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| Attached to a specific [[Concepts/Encounter |
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| encounter]] |
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|} |
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Because threads hang off the patient record, they follow the patient over time. Deleting a patient removes their threads; deleting a thread removes its messages. |
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== Edit history == |
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A note is meant to be an auditable record, not just a scratchpad. When someone edits a message, the new text becomes the visible body — but the previous version is never thrown away: |
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<syntaxhighlight lang="text">Posted → Edited → Edited again</syntaxhighlight> |
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Each edit appends the prior text, its author, and the time of the change to the message's history, oldest first. The platform maintains this trail server-side; clients cannot rewrite or erase what was already said. So a thread reliably shows not only what the team currently thinks, but what was written and when. |
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== Permissions == |
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Notes have no permission file of their own. Access follows the [[Concepts/Patient|patient]] and [[Concepts/Encounter|encounter]] permissions, since every thread is anchored to a patient and may be scoped to an encounter. |
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{| class="wikitable" |
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|- |
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! Permission |
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! Description |
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! System Roles |
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|- |
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| <code>can_write_patient</code> |
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| Create or update a patient-scoped thread or message (used when the note is not tied to an encounter) |
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| Staff, Doctor, Nurse, Administrator, Admin, Facility Admin |
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|- |
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| <code>can_write_encounter_clinical_data</code> |
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| Create or update an encounter-scoped thread or message (the encounter must not be closed) |
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| Admin, Doctor, Nurse, Facility Admin |
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|- |
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| <code>can_view_clinical_data</code> |
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| Read a patient's clinical record, including their note threads and messages |
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| Staff, Doctor, Nurse, Admin, Facility Admin |
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|- |
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| <code>can_read_encounter_clinical_data</code> |
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| Read encounter-scoped threads and messages when patient-level clinical access is not granted |
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| Admin, Doctor, Nurse, Facility Admin |
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|} |
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Roles are granted through a person's organization, facility, or patient membership, then cascade down the organization tree — access granted at a parent organization flows to the facilities and patients beneath it. |
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{{Navbox clinical}} |
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{{Related}} |
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Wiki: ohcnwiki.tellmey.fyi |
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Latest revision as of 17:20, 14 August 2026
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