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Charting

Building a comprehensive charting experience in iEHR involves integrating multiple FHIR® resources to meet the needs of healthcare practitioners. Here are the primary interactions to consider when developing a custom charting interface:

Summarizing Patient History​

A sample charting application, built using iEHR React components, can be found on the iEHR Chart Demo GitHub. When summarizing patient history, start by gathering demographic data from the Patient resource. You can also query all resources related to a given patient using the Patient $everything endpoint. Depending on your use case, querying specific resources like active CarePlans, MedicationRequests, and Conditions may be more appropriate. Utilize the search functionality to construct specific queries that provide the necessary context for a chart. React components such as PatientTimeline, Timeline, SearchControl, ResourceAvatar, FhirPathDisplay, and Tabs can expedite the development of a summarized history.

Capturing Clinical Notes​

There are various ways to capture clinical notes, and the flexibility of a headless system allows for customization. After a practitioner/patient interaction, create the appropriate FHIR® resources. Some implementations use a simple text box for free-form text entry, constructing Encounter and/or ClinicalImpression resources. Others use a library of Questionnaires that practitioners fill out, with Bots driving the workflow and creating resources in a specific manner.

Placing Orders​

Placing orders involves constructing the appropriate resources, which can be created directly or via Questionnaires and Bots. Refer to the sections on Labs and Imaging or Prescriptions for more details.

Key Resources

  • Observation: Represents point-in-time clinical measurements.

  • Condition: Records long-term diagnoses for a patient.

  • RiskAssessment: Models the propensity for an adverse outcome.

  • AllergyIntolerance: Records adverse reactions to drugs or substances.

  • Immunization: Summarizes vaccination records.

  • Medication: Represents instances of given drugs, including MedicationRequest, MedicationAdministration, and MedicationStatement.

  • Encounter: Tracks visits (in-person or virtual).

  • ClinicalImpression: Records unstructured notes.

Key Code Systems

  • LOINC: Used in Observation and RiskAssessment resources for compliance, billing, and reporting.

  • ICD-10: Used in Condition resources for interoperability and billing.

  • HPRA: Used in AllergyIntolerance and MedicationRequest resources to track drugs.

  • SNOMED: Used in AllergyIntolerance resources to track substance intolerances.

  • CVX: Used in Immunization resources to track vaccine types.

  • CPT: Used to annotate Encounter resources for billing.

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