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FHIR and Narrative content

Publication date: Jun 11, 2025

All FHIR resources SHOULD have narrative content, and according to Rene FHIR Documents SHALL have narrative content. If you're using FHIR Documents in a context where narrative is not of importance you may wish to consider using a Collection Bundle instead.

Years ago I wrote a whitepaper related to the use of narrative in FHIR resources, which was published in the Dutch and German affiliate publications. I created a brief overview of the subject for a European FHIR meeting in June. This served as input into a discussion around the use of narrative in (EU Mandated) EHDS FHIR-based documents.

Narrative content

There's a bit of a troubled history related to the use of narrative. The FHIR spec states that all resources SHOULD have a textual summary. Grahame would have liked it to be a SHALL, but he wasn't able to convince the FHIR community to do so. You don't need text in a tight trading context, but the more a resource is used and re-used outside of its own context (in a different project, a different country, 30 years from today) the more value the textual form will provide to ensure interoperability. This is a clinical safety issue, not all systems will be able to fully understand the ecosystem that produced the resource. Understandably there is resistance to this - why spend money today to solve a problem that will occur tomorrow.

The originator of the FHIR resources is well aware of the context of the resource, it is aware of the extensions, it does know the semantics of the codes used. It is best positioned to create a clinically safe summary. There are multiple consumers and only one author, so it's best to burden the authoring system with having to generate narrative.

If you were to create narrative, then what should the content have to be? The FHIR specification doesn't provide a lot of guidance when it comes to this. A project like Nictiz in the Netherlands provides its own guidance based on the 5Ws (wh/when/where/..) and the inclusion of data elements flagged as must-support or is-modifiers. Another way of identifying elements that should be included in the narrative is to study any logical models (e.g. NHS Data Set, USCDI, ZIB) used in a given context.

Summary

To summarize the conslusions of the presentations:
  • Documents are meant to be exchanged between different contexts, thus leading to a requirement to include narrative;
  • One can't assume a particular viewer to be used, so if there is no narrative present one has no idea as to how things will be presented;
  • The originator of the document should produce the narrative;
  • A project implementation guide should specify what the scope of narrative should be.

-Rene

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Ringholm bv is a group of European experts in the field of messaging standards and systems integration in healthcare IT. We provide the industry's most advanced training courses and consulting on healthcare information exchange standards.
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