diff --git a/versioned_docs/version-3.0/concepts/clinical/notes.mdx b/versioned_docs/version-3.0/concepts/clinical/notes.mdx index 1bc54b40..56e0ae8b 100644 --- a/versioned_docs/version-3.0/concepts/clinical/notes.mdx +++ b/versioned_docs/version-3.0/concepts/clinical/notes.mdx @@ -4,61 +4,42 @@ sidebar_position: 13 # Clinical Notes -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. +A **[clinical note](https://build.fhir.org/communication.html)** in Care is written commentary about a patient. The care team uses notes for narrative, hand-offs, and discussion, in their own words. Care groups notes into discussion threads, so one topic stays together as a conversation. A note does not replace structured clinical data, such as a condition, an allergy, or an observation. -## What it represents +## Key Attributes -In Care's FHIR-aligned model, clinical notes map to the **Communication** resource — running written exchanges about a patient. A note thread holds: +| Components | What it captures | +| --- | --- | +| Discussion title | A short label for the topic of the discussion, for example "Treatment Plan" | +| Patient | The patient that the discussion is about | +| Encounter | The encounter that the discussion belongs to, when a user starts the discussion from the encounter | +| Messages | The individual entries that care team members post in the discussion | +| Participants | The people who posted a message in the discussion | +| Edit history | The earlier text of each message, with the author and the time of the change | -- **A subject** — every thread is anchored to one patient, and optionally narrowed to a single encounter -- **A title** — a short label for what the thread is about -- **Messages** — the entries posted into the thread over time by the care team -- **A preserved history** — authorship, timestamps, and prior versions of every edited message +### Discussions -A note is not a substitute for structured clinical data. Diagnoses belong in [conditions](../clinical/condition.mdx), allergies in [allergy records](../clinical/allergy-intolerance.mdx), and measurements in [observations](../clinical/observation.mdx). Notes are the human layer that ties that data together — the reasoning, context, and discussion that coded fields can't hold. +A discussion is one conversation about a topic. Care shows discussions in two places: -## Threads and messages +| Where you open notes | What you see | +| --- | --- | +| The **Notes** tab of a patient | Discussions that belong to the patient, and not to a single encounter | +| The **Notes** tab of an encounter | Discussions that belong to that encounter | -Notes live in a two-level structure: **threads** that hold **messages**. +A patient discussion stays with the patient over time. An encounter discussion stays with one visit. Care suggests a set of discussion titles, such as "Treatment Plan", "Medication Notes", "Care Coordination", "General Notes", "Patient History", "Referral Notes", and "Lab Results Discussion". You can also enter your own title. Two discussions of the same patient cannot have the same title. -- A **thread** is one conversation, anchored to a patient and optionally to one of that patient's encounters. -- A **message** is a single entry inside a thread. Many people can add messages to the same thread over time. +### Messages -That anchoring gives a thread its scope: +A message is one entry in a discussion. Many people can post messages in the same discussion. Care shows the author, the time, and the message text. Care formats the message text as rich text. -| Scope | What it means | Typical use | -| --- | --- | --- | -| Patient-level | Attached to the patient, not to any one visit | Longitudinal commentary across encounters — care coordination, ongoing concerns | -| Encounter-level | Attached to a specific [encounter](../clinical/encounter.mdx) | Discussion tied to one admission or visit — shift hand-offs, ward notes | +### Edit history -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. - -## Edit history - -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: - -```text -Posted → Edited → Edited again -``` - -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. - -## Permissions - -Notes have no permission file of their own. Access follows the [patient](../clinical/patient) and [encounter](../clinical/encounter.mdx) permissions, since every thread is anchored to a patient and may be scoped to an encounter. - -| Permission | Description | System Roles | -| --- | --- | --- | -| `can_write_patient` | Create or update a patient-scoped thread or message (used when the note is not tied to an encounter) | Staff, Doctor, Nurse, Administrator, Admin, Facility Admin | -| `can_write_encounter_clinical_data` | Create or update an encounter-scoped thread or message (the encounter must not be closed) | Admin, Doctor, Nurse, Facility Admin | -| `can_view_clinical_data` | Read a patient's clinical record, including their note threads and messages | Staff, Doctor, Nurse, Admin, Facility Admin | -| `can_read_encounter_clinical_data` | Read encounter-scoped threads and messages when patient-level clinical access is not granted | Admin, Doctor, Nurse, Facility Admin | - -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. +A note is an auditable record. If the author edits a message, Care keeps the earlier text. Care adds the earlier text, its author, and the time of the change to the history of the message. Only the author of a message can edit that message. Nobody can erase what the team wrote before. ## Related -- Reference: [Notes (technical)](../../references/clinical/notes.mdx) +- Flow: [Start a note discussion](../../flows/clinical/start-a-note-discussion.mdx) +- Flow: [Add a note message](../../flows/clinical/add-a-note-message.mdx) - Concept: [Patient](../clinical/patient) - Concept: [Encounter](../clinical/encounter.mdx) -- Concept: [Observation](../clinical/observation.mdx) +- Reference: [Notes](../../references/clinical/notes.mdx) diff --git a/versioned_docs/version-3.0/flows/clinical/add-a-note-message.mdx b/versioned_docs/version-3.0/flows/clinical/add-a-note-message.mdx new file mode 100644 index 00000000..041d1599 --- /dev/null +++ b/versioned_docs/version-3.0/flows/clinical/add-a-note-message.mdx @@ -0,0 +1,69 @@ +--- +sidebar_position: 3 +--- + +# How to add a note message + +## Overview + +This flow describes how to post a message in a discussion in [Clinical Notes](../../concepts/clinical/notes.mdx). A message records your commentary about the patient for the rest of the care team. + +## Pre-requisites + +- The patient has at least one discussion. If there is no discussion, start one first. +- You are a member of the facility that gives care to the patient. +- If the discussion belongs to an encounter, that encounter is open. You cannot post a message in a discussion of a completed encounter. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Can view clinical data about patients | Read the discussions and messages of a patient | +| Can Read encounter related clinical data | Read the discussions and messages of an encounter | +| Can Update a Patient's data | Post a message in a discussion of a patient | +| Update Encounter related clinical data | Post a message in a discussion of an encounter | + +## Steps + +### 1. Open the Notes tab + +Open the patient or the encounter, then select **Notes**. In an encounter, you can also press `g n` to go to the **Notes** tab. + +Care opens the most recent discussion. + +### 2. Select the discussion + +Select the discussion in the **Discussions** list. + +On a small screen, select **Threads** first, then select the discussion. + +### 3. Write the message + +Enter your text in the **Type your message...** box. + +| Components | What it captures | +| --- | --- | +| Message | Your commentary about the patient, as rich text | + +### 4. Send the message + +Select the send button. On a computer, you can also press `Shift + Enter`. + +## Expected Outcome + +- Care adds the message at the end of the discussion. +- Care shows your name and the time of the message. +- Care counts you in the participants of the discussion. +- The rest of the care team sees the message in the same discussion. + +## Related + +Concepts: + +- [Clinical Notes](../../concepts/clinical/notes.mdx) +- [Patient](../../concepts/clinical/patient) + +Flows: + +- [Start a note discussion](./start-a-note-discussion.mdx) diff --git a/versioned_docs/version-3.0/flows/clinical/start-a-note-discussion.mdx b/versioned_docs/version-3.0/flows/clinical/start-a-note-discussion.mdx new file mode 100644 index 00000000..6e02bebf --- /dev/null +++ b/versioned_docs/version-3.0/flows/clinical/start-a-note-discussion.mdx @@ -0,0 +1,70 @@ +--- +sidebar_position: 2 +--- + +# How to start a note discussion + +## Overview + +This flow describes how to start a new discussion in [Clinical Notes](../../concepts/clinical/notes.mdx). A discussion groups the messages of the care team about one topic. + +## Pre-requisites + +- The patient is registered in Care. +- You are a member of the facility that gives care to the patient. +- If you start the discussion for an encounter, that encounter is open. You cannot start a discussion for a completed encounter. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Can view clinical data about patients | Open the Notes tab of a patient and read the discussions | +| Can Read encounter related clinical data | Open the Notes tab of an encounter and read its discussions | +| Can Update a Patient's data | Start a discussion for a patient | +| Update Encounter related clinical data | Start a discussion for an encounter | + +## Steps + +### 1. Open the Notes tab + +To start a discussion for a patient, open the patient and select **Notes**. + +To start a discussion for an encounter, open the encounter and select **Notes**. In an encounter, you can also press `g n` to go to the **Notes** tab. + +### 2. Start a new discussion + +Select **New**. On a small screen, select **New Thread**. + +Care opens the **Start New Discussion** dialog. + +### 3. Give the discussion a title + +Select one of the suggested titles, or enter your own title in the **Enter discussion title...** box. + +| Components | What it captures | +| --- | --- | +| Discussion title | The topic of the discussion, up to 255 characters | + +Care shows an error if the patient already has a discussion with that title. Enter a different title. + +### 4. Create the discussion + +Select **Create**. + +## Expected Outcome + +- Care shows the message "Thread created successfully". +- Care adds the discussion to the **Discussions** list. +- Care opens the new discussion, and you can post the first message. + +## Related + +Concepts: + +- [Clinical Notes](../../concepts/clinical/notes.mdx) +- [Encounter](../../concepts/clinical/encounter.mdx) + +Flows: + +- [Add a note message](./add-a-note-message.mdx) diff --git a/versioned_docs/version-3.0/references/clinical/notes.mdx b/versioned_docs/version-3.0/references/clinical/notes.mdx index 84447c40..391b24e5 100644 --- a/versioned_docs/version-3.0/references/clinical/notes.mdx +++ b/versioned_docs/version-3.0/references/clinical/notes.mdx @@ -49,7 +49,7 @@ One message inside a thread. The update spec writes a fixed structure, not a free-form blob. Each edit appends the *previous* message body to a `history` list: -```jsonc +```text { "history": [ { diff --git a/versioned_docs/version-3.1/concepts/clinical/notes.mdx b/versioned_docs/version-3.1/concepts/clinical/notes.mdx index 1bc54b40..56e0ae8b 100644 --- a/versioned_docs/version-3.1/concepts/clinical/notes.mdx +++ b/versioned_docs/version-3.1/concepts/clinical/notes.mdx @@ -4,61 +4,42 @@ sidebar_position: 13 # Clinical Notes -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. +A **[clinical note](https://build.fhir.org/communication.html)** in Care is written commentary about a patient. The care team uses notes for narrative, hand-offs, and discussion, in their own words. Care groups notes into discussion threads, so one topic stays together as a conversation. A note does not replace structured clinical data, such as a condition, an allergy, or an observation. -## What it represents +## Key Attributes -In Care's FHIR-aligned model, clinical notes map to the **Communication** resource — running written exchanges about a patient. A note thread holds: +| Components | What it captures | +| --- | --- | +| Discussion title | A short label for the topic of the discussion, for example "Treatment Plan" | +| Patient | The patient that the discussion is about | +| Encounter | The encounter that the discussion belongs to, when a user starts the discussion from the encounter | +| Messages | The individual entries that care team members post in the discussion | +| Participants | The people who posted a message in the discussion | +| Edit history | The earlier text of each message, with the author and the time of the change | -- **A subject** — every thread is anchored to one patient, and optionally narrowed to a single encounter -- **A title** — a short label for what the thread is about -- **Messages** — the entries posted into the thread over time by the care team -- **A preserved history** — authorship, timestamps, and prior versions of every edited message +### Discussions -A note is not a substitute for structured clinical data. Diagnoses belong in [conditions](../clinical/condition.mdx), allergies in [allergy records](../clinical/allergy-intolerance.mdx), and measurements in [observations](../clinical/observation.mdx). Notes are the human layer that ties that data together — the reasoning, context, and discussion that coded fields can't hold. +A discussion is one conversation about a topic. Care shows discussions in two places: -## Threads and messages +| Where you open notes | What you see | +| --- | --- | +| The **Notes** tab of a patient | Discussions that belong to the patient, and not to a single encounter | +| The **Notes** tab of an encounter | Discussions that belong to that encounter | -Notes live in a two-level structure: **threads** that hold **messages**. +A patient discussion stays with the patient over time. An encounter discussion stays with one visit. Care suggests a set of discussion titles, such as "Treatment Plan", "Medication Notes", "Care Coordination", "General Notes", "Patient History", "Referral Notes", and "Lab Results Discussion". You can also enter your own title. Two discussions of the same patient cannot have the same title. -- A **thread** is one conversation, anchored to a patient and optionally to one of that patient's encounters. -- A **message** is a single entry inside a thread. Many people can add messages to the same thread over time. +### Messages -That anchoring gives a thread its scope: +A message is one entry in a discussion. Many people can post messages in the same discussion. Care shows the author, the time, and the message text. Care formats the message text as rich text. -| Scope | What it means | Typical use | -| --- | --- | --- | -| Patient-level | Attached to the patient, not to any one visit | Longitudinal commentary across encounters — care coordination, ongoing concerns | -| Encounter-level | Attached to a specific [encounter](../clinical/encounter.mdx) | Discussion tied to one admission or visit — shift hand-offs, ward notes | +### Edit history -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. - -## Edit history - -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: - -```text -Posted → Edited → Edited again -``` - -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. - -## Permissions - -Notes have no permission file of their own. Access follows the [patient](../clinical/patient) and [encounter](../clinical/encounter.mdx) permissions, since every thread is anchored to a patient and may be scoped to an encounter. - -| Permission | Description | System Roles | -| --- | --- | --- | -| `can_write_patient` | Create or update a patient-scoped thread or message (used when the note is not tied to an encounter) | Staff, Doctor, Nurse, Administrator, Admin, Facility Admin | -| `can_write_encounter_clinical_data` | Create or update an encounter-scoped thread or message (the encounter must not be closed) | Admin, Doctor, Nurse, Facility Admin | -| `can_view_clinical_data` | Read a patient's clinical record, including their note threads and messages | Staff, Doctor, Nurse, Admin, Facility Admin | -| `can_read_encounter_clinical_data` | Read encounter-scoped threads and messages when patient-level clinical access is not granted | Admin, Doctor, Nurse, Facility Admin | - -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. +A note is an auditable record. If the author edits a message, Care keeps the earlier text. Care adds the earlier text, its author, and the time of the change to the history of the message. Only the author of a message can edit that message. Nobody can erase what the team wrote before. ## Related -- Reference: [Notes (technical)](../../references/clinical/notes.mdx) +- Flow: [Start a note discussion](../../flows/clinical/start-a-note-discussion.mdx) +- Flow: [Add a note message](../../flows/clinical/add-a-note-message.mdx) - Concept: [Patient](../clinical/patient) - Concept: [Encounter](../clinical/encounter.mdx) -- Concept: [Observation](../clinical/observation.mdx) +- Reference: [Notes](../../references/clinical/notes.mdx) diff --git a/versioned_docs/version-3.1/flows/clinical/add-a-note-message.mdx b/versioned_docs/version-3.1/flows/clinical/add-a-note-message.mdx new file mode 100644 index 00000000..041d1599 --- /dev/null +++ b/versioned_docs/version-3.1/flows/clinical/add-a-note-message.mdx @@ -0,0 +1,69 @@ +--- +sidebar_position: 3 +--- + +# How to add a note message + +## Overview + +This flow describes how to post a message in a discussion in [Clinical Notes](../../concepts/clinical/notes.mdx). A message records your commentary about the patient for the rest of the care team. + +## Pre-requisites + +- The patient has at least one discussion. If there is no discussion, start one first. +- You are a member of the facility that gives care to the patient. +- If the discussion belongs to an encounter, that encounter is open. You cannot post a message in a discussion of a completed encounter. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Can view clinical data about patients | Read the discussions and messages of a patient | +| Can Read encounter related clinical data | Read the discussions and messages of an encounter | +| Can Update a Patient's data | Post a message in a discussion of a patient | +| Update Encounter related clinical data | Post a message in a discussion of an encounter | + +## Steps + +### 1. Open the Notes tab + +Open the patient or the encounter, then select **Notes**. In an encounter, you can also press `g n` to go to the **Notes** tab. + +Care opens the most recent discussion. + +### 2. Select the discussion + +Select the discussion in the **Discussions** list. + +On a small screen, select **Threads** first, then select the discussion. + +### 3. Write the message + +Enter your text in the **Type your message...** box. + +| Components | What it captures | +| --- | --- | +| Message | Your commentary about the patient, as rich text | + +### 4. Send the message + +Select the send button. On a computer, you can also press `Shift + Enter`. + +## Expected Outcome + +- Care adds the message at the end of the discussion. +- Care shows your name and the time of the message. +- Care counts you in the participants of the discussion. +- The rest of the care team sees the message in the same discussion. + +## Related + +Concepts: + +- [Clinical Notes](../../concepts/clinical/notes.mdx) +- [Patient](../../concepts/clinical/patient) + +Flows: + +- [Start a note discussion](./start-a-note-discussion.mdx) diff --git a/versioned_docs/version-3.1/flows/clinical/start-a-note-discussion.mdx b/versioned_docs/version-3.1/flows/clinical/start-a-note-discussion.mdx new file mode 100644 index 00000000..6e02bebf --- /dev/null +++ b/versioned_docs/version-3.1/flows/clinical/start-a-note-discussion.mdx @@ -0,0 +1,70 @@ +--- +sidebar_position: 2 +--- + +# How to start a note discussion + +## Overview + +This flow describes how to start a new discussion in [Clinical Notes](../../concepts/clinical/notes.mdx). A discussion groups the messages of the care team about one topic. + +## Pre-requisites + +- The patient is registered in Care. +- You are a member of the facility that gives care to the patient. +- If you start the discussion for an encounter, that encounter is open. You cannot start a discussion for a completed encounter. +- You have the permissions listed below. + +## Permissions + +| Permission | Access | +| --- | --- | +| Can view clinical data about patients | Open the Notes tab of a patient and read the discussions | +| Can Read encounter related clinical data | Open the Notes tab of an encounter and read its discussions | +| Can Update a Patient's data | Start a discussion for a patient | +| Update Encounter related clinical data | Start a discussion for an encounter | + +## Steps + +### 1. Open the Notes tab + +To start a discussion for a patient, open the patient and select **Notes**. + +To start a discussion for an encounter, open the encounter and select **Notes**. In an encounter, you can also press `g n` to go to the **Notes** tab. + +### 2. Start a new discussion + +Select **New**. On a small screen, select **New Thread**. + +Care opens the **Start New Discussion** dialog. + +### 3. Give the discussion a title + +Select one of the suggested titles, or enter your own title in the **Enter discussion title...** box. + +| Components | What it captures | +| --- | --- | +| Discussion title | The topic of the discussion, up to 255 characters | + +Care shows an error if the patient already has a discussion with that title. Enter a different title. + +### 4. Create the discussion + +Select **Create**. + +## Expected Outcome + +- Care shows the message "Thread created successfully". +- Care adds the discussion to the **Discussions** list. +- Care opens the new discussion, and you can post the first message. + +## Related + +Concepts: + +- [Clinical Notes](../../concepts/clinical/notes.mdx) +- [Encounter](../../concepts/clinical/encounter.mdx) + +Flows: + +- [Add a note message](./add-a-note-message.mdx) diff --git a/versioned_docs/version-3.1/references/clinical/notes.mdx b/versioned_docs/version-3.1/references/clinical/notes.mdx index 84447c40..391b24e5 100644 --- a/versioned_docs/version-3.1/references/clinical/notes.mdx +++ b/versioned_docs/version-3.1/references/clinical/notes.mdx @@ -49,7 +49,7 @@ One message inside a thread. The update spec writes a fixed structure, not a free-form blob. Each edit appends the *previous* message body to a `history` list: -```jsonc +```text { "history": [ { diff --git a/versioned_sidebars/version-3.0-sidebars.json b/versioned_sidebars/version-3.0-sidebars.json index 5376f674..aa3be0af 100644 --- a/versioned_sidebars/version-3.0-sidebars.json +++ b/versioned_sidebars/version-3.0-sidebars.json @@ -21,7 +21,11 @@ "type": "category", "label": "Clinical", "key": "clinical-flows", - "items": ["flows/clinical/create-patient"] + "items": [ + "flows/clinical/create-patient", + "flows/clinical/start-a-note-discussion", + "flows/clinical/add-a-note-message" + ] } ] }, diff --git a/versioned_sidebars/version-3.1-sidebars.json b/versioned_sidebars/version-3.1-sidebars.json index 42537320..d3c4728e 100644 --- a/versioned_sidebars/version-3.1-sidebars.json +++ b/versioned_sidebars/version-3.1-sidebars.json @@ -37,7 +37,9 @@ "flows/clinical/patient/manage-patient-users", "flows/clinical/patient/view-patient-appointments" ] - } + }, + "flows/clinical/start-a-note-discussion", + "flows/clinical/add-a-note-message" ] } ]