Indivo Document Schema: Simple Clinical NoteΒΆ

A full clinical note needs to contain a number of coded problems, etc. Some hospital systems do not have fully normalized clinical notes, in which case they can use this schema to store some simple attributes and the main free-form text of the note.

See also Indivo Coded Values and Indivo Provider Schema.

Schema:

<?xml version="1.0" encoding="ISO-8859-1" ?>
<schema xmlns="http://www.w3.org/2001/XMLSchema" targetNamespace="http://indivo.org/vocab/xml/documents#" xmlns:indivo="http://indivo.org/vocab/xml/documents#"
elementFormDefault="qualified">

  <include schemaLocation="../../common/codes.xsd" />
  <include schemaLocation="../../common/provider.xsd" />

  <!-- this is mostly a chunk o' text. More normalized clinical notes will be in a diff schema -->
  <element name="SimpleClinicalNote">
    <complexType>
      <sequence>
        <element name="dateOfVisit" type="dateTime" minOccurs="1" maxOccurs="1" />
        <element name="finalizedAt" type="dateTime" minOccurs="0" maxOccurs="1" />
        <element name="visitType" type="indivo:CodedValue" minOccurs="0" maxOccurs="1" />
        <element name="visitLocation" type="string" minOccurs="0" maxOccurs="1" />
        <element name="specialty" type="indivo:CodedValue" minOccurs="0" maxOccurs="1" />
        <element name="signature" type="indivo:Signature" minOccurs="1" maxOccurs="unbounded" />
        <element name="chiefComplaint" type="string" minOccurs="0" maxOccurs="1" />
        <element name="content" minOccurs="0" maxOccurs="1" type="string" />
      </sequence>
    </complexType>
  </element>
</schema>

Example:

<SimpleClinicalNote xmlns="http://indivo.org/vocab/xml/documents#">
  <dateOfVisit>2010-02-02T12:00:00Z</dateOfVisit>
  <finalizedAt>2010-02-03T13:12:00Z</finalizedAt>
  <visitType type="http://codes.indivo.org/visit-types#" value="acute">Acute Care</visitType>
  <visitLocation>Longfellow Medical</visitLocation>
  <specialty type="http://codes.indivo.org/specialties#" value="hem-onc">Hematology/Oncology</specialty>

  <signature>
    <at>2010-02-03T13:12:00Z</at>
    
    <provider>
      <name>Kenneth Mandl</name>
      <institution>Children's Hospital Boston</institution>
    </provider>
  </signature>

  <signature>
    <provider>
      <name>Isaac Kohane</name>
      <institution>Children's Hospital Boston</institution>
    </provider>
  </signature>

  <chiefComplaint>stomach ache</chiefComplaint>
  <content>
    Patient presents with ...
  </content>
</SimpleClinicalNote>

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