When do I need to use the Notes Data Model?
The Notes Data Model is used to convey free text or RTF content to or from an EHR. Typically this is non-structured documentation about the clinical care of a patient. Applications typically use Notes to summarize actions taken by users in their system and file it back into a hospital’s EHR. Alternatively, notes created in the EHR may be sent outbound to applications for reference or analysis.
Notes is a good choice for customers that want to send plain text or rich text to an EHR, especially if they want to show it in the EHR context with advanced text parsing capabilities (NLP, searching of the chart, etc).
When and where can the Notes Data Model be supported?
While there is widespread support across EHR vendors for the related Media Data Model, not all EHR vendors have a separate concept or capability to use the Notes Data Model. EHR vendors with robust interfacing capabilities will typically offer this capability through an MDM HL7v2 interface or an API.
How is the Notes Data Model different from the Media data model?
The Notes data model is similar to the Media data model, in that it is often used for sending a summary back to an EHR, but differs in that:
- Media, when sent as a PDF, has a guaranteed layout that is consistent across EHRs.
- Notes sent as plain text or rich text are subject to the rendering capabilities of the EHR.
- Direct Display:
- Media is generally represented as a link (a user clicks a link to launch a separate program to show the PDF, play the WAV, display the JPEG, etc).
- Notes are shown within the EHR context.
- Searchability and Analytics:
- Notes may offer superior searchability (if the EHR has that capability) and usability for things like Natural Language Processing (where software analyzes the note content for things like diagnoses, problems, and medications and offers them to the user to be added discretely)
What data is required in order to file Notes to the patient’s chart?
This will depend on how the users want to access the information within their EHR and the information needed by the EHR to file it as expected. To file Notes to the patient’s chart for general information purposes, most EHRs will require the patient identifier in addition to other basic patient demographics such as name and DOB.
Additional required items include relevant provider information (i.e. who generated the document), the note type, a unique note ID, and whether or not the note has been authenticated by a physician and is authorized to be shared in the patient’s chart. To file a note to a specific visit or to show up associated with specific areas or actions in the EHR, a visit number is often required to provide more specificity.