A FHIR-based system for the generation and retrieval of clinical documents

Clinical information exchange among heterogeneous systems is a complex process. It is necessary to use dictionaries, coding standards (e.g. LOINC and SNOMED), and terminology services, in order to: i) produce machine-interpretable information and coded data, ii) reduce information exchange complexity, and iii) allow the fulfillment of semantic interoperability among several systems. This work presents a system to support healthcare professionals in the creation of clinical documents using appropriate standards and in the information reading and retrieval of interest on clinical documents. The system allows healthcare professionals to use standard codes easily (via terminology server) during the creation of documents. Similarly, it also permits the decoding of health standard codes, during the read documents process, to facilitate the obtaining of information. In summary, it makes use of a simple and intuitive graphical user interface and a Fast Healthcare Interoperability Resources (FHIR) terminology server to support healthcare professionals in diagnosing and treating patients.