IE (Ireland) Core Implementation Guide
0.3.0 - draft Ireland flag

IE (Ireland) Core Implementation Guide - Local Development build (v0.3.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Clinical Notes

Clinical Notes Guidance

Clinical notes in IE Core are represented using a combination of the IE Core DiagnosticReport for Report and Note Exchange and IE Core DocumentReference profiles.

Clinical Note Types

The following clinical note types are supported:

Note Type LOINC Code Description
Consultation Note 11488-4 Notes from clinical consultations
Discharge Summary 18842-5 Discharge summaries from hospital stays
History and Physical 34117-2 History and physical examination notes
Progress Note 11506-3 Clinical progress notes
Procedure Note 28570-0 Notes about procedures performed
Operative Note 11504-8 Notes about surgical operations
Imaging Narrative 18748-4 Radiology and imaging reports
Laboratory Narrative 11502-2 Laboratory result narratives
Pathology Report 11526-1 Pathology examination reports
Referral Note 57133-1 Referral letters and notes

Searching for Clinical Notes

To search for clinical notes, use the following approach:

GET [base]/DocumentReference?patient=[id]&category=clinical-note&type=[LOINC code]

GET [base]/DiagnosticReport?patient=[id]&category=[category code]&code=[LOINC code]

Guidance for GP Practices

In the context of Irish general practice:

  • GP consultation notes SHOULD use the Consultation Note type (LOINC 11488-4)
  • Referral letters to hospital consultants SHOULD use the Referral Note type (LOINC 57133-1)
  • Discharge summaries from hospitals SHOULD be received as Discharge Summary type (LOINC 18842-5)
  • All clinical notes SHALL reference the patient and encounter where applicable