Clinical Note Document

This profile specialises the FHIR Clinical Document Bundle for the purposes of the Clinical Note Document in Australia. All the guidelines and conformance requirements defined of the FHIR Clinical Document Bundle apply.

This profile specialises the FHIR Clinical Document Composition Profile for the purposes of a Clinical Note Document in Australia. All the guidelines and conformance requirements defined of the FHIR Clinical Document Composition apply.

This profile constrains AU Core Organization to meet the requirements of this Implementation Guide for a healthcare organisation department or unit. Implementers are highly encouraged to review AU Core Organization profile before using this profile.

This profile of Document Reference supports Clinical Note Documents attachments such as, pathology reports and medication charts. This profile also supports describing a document that is made available to a system and is used for documents that are not authored and assembled in FHIR e.g. documents whose form is an attachment.

This profile constrains AU Core Medicationto meet the requirements of this Implementation Guide for medications. Implementers are highly encouraged to review AU Core Medication profile before using this profile. The purpose of this profile is to provide a representation of a medication for the electronic exchange of health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia.

This profile constrains AU Core MedicationStatementto meet the requirements of this Implementation Guide for medication statements. Implementers are highly encouraged to review AU Core MedicationStatement profile before using this profile. This profile defines a medication statement structure that localises core concepts, including terminology, for use in a Clinical Note Document context. A medication statement is a statement of current and/or past medications taken by the patient. This is not a prescription or a legally recognised medicine chart.

This profile constrains AU Core Organization to meet the requirements of this Implementation Guide for a healthcare organisation. Implementers are highly encouraged to review AU Core Organization profile before using this profile.

This profile constrains AU Core Patient to meet the requirements of this Implementation Guide for a patient or consumer. Implementers are highly encouraged to review AU Core Patient profile before using this profile. This profile defines a patient or a consumer of Clinical Note Document.

This profile constrains AU Core Practitioner to meet the requirements of this Implementation Guide for a practitioner. Implementers are highly encouraged to review AU Core Practitioner profile before using this profile. This profile defines a practitioner, in a Clinical Note Document context.

This profile constrains AU Core PractitionerRole to meet the requirements of this Implementation Guide for a practitioner role. Implementers are highly encouraged to review AU Core PractitionerRole profile before using this profile. This profile of PractitionerRole defines a Clinical Note Document Practitioner Role.

This extension can be used to represent information about an informal carer of a patient. An informal carer includes any person, such as a family member, friend or neighbour, who is giving regular, ongoing assistance to another person. This may provide healthcare providers with additional information on the patients support system and identified contact person. The definition for the patient’s informal carer existence indicator is the same described in the definition section of the NMDS. Additionally, this extension allows for the representation of the carer information.

The Informal Carer Existence Indicator value set defines concepts for the existence of Informal Carer.

Subset of codes from v3-ParticipationType for use as Clinical Document Information Recipient codes.

An example of a patient, Anne Thompson, that conforms to the Clinical Note Document - Patient. Anne lives at Sunshine Residential Home.

An example of a document reference that conforms to Clinical Note Document - DocumentReference profile. This example represents managing blood pressure guide by the Heart Foundation.

An example of an organization, Bobrester Medical Center, that conforms to Clinical Note Document - Organization profile. Bobrester Medical Center is where Dr Mayo practices as a GP.

An example of a document Bundle that conforms to the requirements of a Clinical Note Document. This example is a representation of Use Case 2.

An example of a composition that conforms to Clinical Note Document - Composition.

An example of a practitioner, Dr Helen Mayo, that conforms to Clinical Note Document - Practitioner profile. Dr Mayo practices at the Bobrester Medical Center as a GP and visits Sunshine Residential Home on regular basis.

An example of a PractitionerRole that conforms to Clinical Note Document - PractitionerRole. It represent Dr Mayo practicing as a GP at the Bobrester Medical Center.

An example of a department, Memory Care Unit at Sunshine Residential Home, that conforms to Clinical Note Document - Department profile. The Memory Care Unit is a specialised dementia care unit within Sunshine Residential Home.

An example of a medication that conforms to Clinical Note Document - Medication profile.

An example of medication statement that conforms to Clinical Note Document - MedicationStatement. This statement was made by Dr Mayo during a visit to Sunshine Residential Home.

An example of an aged care patient, John Smith, that conforms to the Clinical Note Document - Patient. John Smith lives at Sunshine Residential Home.

An example of a care facility, Sunshine Residential Home, that conforms to Clinical Note Document - Organization profile. Sunshine Residential Home is where Mrs. Anne Thompson resides and where Dr Mayo attends on regular basis.