2015May core #193 - Rename clinicalNotes to reason or indication

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    • Type: Change Request
    • Resolution: Persuasive with Modification
    • Priority: Medium
    • FHIR Core (FHIR)
    • DSTU1 [deprecated]
    • Orders & Observations
    • DiagnosticRequest (see ServiceRequest) [deprecated]
    • 4.22.7
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      1) * (preapplied) change .clinicalNotes to *.*reason 0.. type = codeableConcept

      definition "An explanation or justification for why this diagnostic investigation is being requested. This is often for billing purposes. May relate to the resources referred to in supportingInformation"

      comment:" : "This may be used to decide how the diagnostic investigation will be performed, or even if it will be performed at all. Use CodeableConcept text element if the data is free (uncoded) text as shown in the [CT Scan example](diagnosticorder-example-di.html)."

      2) remove the extension " * http://hl7.org/fhir/StructureDefinition/diagnosticorder-reason" since no longer necessary moved to core*

      3) (preapplied) add .note 0..* type Annotation datatype. definition: Any other notes associated with this patient or specimen or order -(e.g. "patient hates needles")

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      1) * (preapplied) change .clinicalNotes to *.*reason 0.. type = codeableConcept definition "An explanation or justification for why this diagnostic investigation is being requested. This is often for billing purposes. May relate to the resources referred to in supportingInformation" comment:" : "This may be used to decide how the diagnostic investigation will be performed, or even if it will be performed at all. Use CodeableConcept text element if the data is free (uncoded) text as shown in the [CT Scan example] (diagnosticorder-example-di.html)." 2) remove the extension " * http://hl7.org/fhir/StructureDefinition/diagnosticorder-reason " since no longer necessary moved to core* 3) (preapplied) add .note 0..* type Annotation datatype. definition: Any other notes associated with this patient or specimen or order -(e.g. "patient hates needles")
    • Eric Haas/Clem McDonald: 13-0-0
    • Clarification
    • Compatible, substantive
    • Yes
    • DSTU1 [deprecated]

      Existing Wording: DiagnosticOrder.clinicalNotes - An explanation or justification for why this diagnostic investigation is being

      requested.

      Comment:

      This has usually been called reason for study or indication.

      Don't think the current name conveys that. For lab tests in the US it has to be coded. And if the dx codes don't line up wit those acceptable to 3rd parties, they don't get paid. There does not seem to be an option for a coded reason for study. For radiology a narrative reason is usually required.

            Assignee:
            Unassigned
            Reporter:
            clemmcdonald
            clemmcdonald
            Watchers:
            2 Start watching this issue

              Created:
              Updated:
              Resolved: