HL7 FHIR® R4 Implementation Guide: FHIR Clinical Documents, Edition 1.1

DESCRIPTION

This standard helps healthcare systems share clinical documents, like discharge summaries and progress notes, in a clear and consistent way using FHIR (a health data standard). It defines how to build these documents using FHIR so that they work across different hospitals and clinics around the world.

The main idea is to create a document that people can read and that computers can use. It uses a structure called a "Bundle" that includes important parts like the main document (called a Composition) and other related health information. It also includes ways to track versions of a document and show which ones are the latest.

This standard gives clear instructions for how to:

• Format the documents;
• Add extra details when needed;
• Update or replace documents over time;
• Convert documents into a format that can be processed by FHIR servers.

Doctors, healthcare organizations, and health IT developers can use this to create and share clinical documents more easily. It helps different systems work together (called interoperability) and supports moving from older systems (like CDA) to newer FHIR-based ones.

 

See the specification at http://hl7.org/fhir/uv/fhir-clinical-document/STU1.1

ALTERNATIVE NAMES

HL7 FHIR® R4 Implementation Guide: FHIR Clinical Documents, Edition 1.1 may also go by the following names or acronyms:

BENEFITS

•  Defines a canonical representation of a clinical document in FHIR
• Creates a common universal starting point for those creating their own FHIR clinical document specifications
•  Supports CDA users who wish to migrate to a FHIR-based representation of clinical documents.

IMPLEMENTATIONS/CASE STUDIES

• Anticipate that future International Patient Summary IG will derive from FHIR Clinical Documents

RELATED DOCUMENTS

HL7 FHIR® R4 Implementation Guide: FHIR Clinical Documents, Edition 1.1

STU DOCUMENTS

HL7 FHIR® R4 Implementation Guide: FHIR Clinical Documents, Edition 1.1 See the standard at http://hl7.org/fhir/uv/fhir-clinical-document/STU1.1.

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ADDITIONAL DETAILS

This implementation guide defines a canonical representation of a clinical document in FHIR. It serves as a common universal starting point for those creating their own FHIR clinical document specifications, and supports CDA users who wish to migrate to a FHIR-based representation of clinical documents. This is a universal realm guide for use worldwide to facilitate consistency.

TOPIC

• Medical Records

BALLOT TYPE

• STU

STATUS DATE

2025-06-26

RESPONSIBLE WORK GROUP

PRODUCT TYPE

• Implementation Guide

STAKEHOLDERS

• Clinical and Public Health Laboratories
• Clinical Decision Support Systems Vendors
• EHR, PHR Vendors
• Healthcare Institutions
• Local and State Departments of Health
• Quality Reporting Agencies
• Standards Development Organizations (SDOs)

FAMILY

• FHIR

CURRENT STATE

• Active

REALM

• Universal