Journalnotes

A number of actions performed in SFM are information that should be included in the "Clinical Note" (Løpende journal).

Changes that are considered journal-worthy are stored in JournalNotes in SFM, and can be transferred to the EPJ so that these can be automatically recorded in the EPJs Clinical Note.

A Patient has a consultation with a Doctor.

The EPJ controls how long such a consultation/period lasts.

1) When the SFM is opened from the EPJ, the EPJ sends an ID indicating that the SFM has been opened in the context of this consultation.

2) All events that the doctor then does in the SFM are logged in a "Journalnotes" table in the SFM - in the context of this "consultation" (ID).

3) When the doctor signs (and sends) the list in the SFM, an "indication" will be sent to the EPJ that there are journal-worthy events related to the ongoing consultation, and will be a signal to the EPJ to request events.

4) The EPJ will then ask for and download signed events for the current consultation and record what is relevant in the Ongoing Journal.

Usecases that triggers events in Journalnote

Triggered Events	Doctor creates a new treatment without Resept sign&send	Doctor creates a new treatment with Resept sign&send	Doctor renew a Resept sign&send	Doctor changes a treatment with Resept sign&send	Doctor seponates a treatment with resept reason: dobbeltoppføring sign&send

Opprettet behandling	X	X
Forny resept			X
Endret behandling				X
Seponert behandling					X*
Sendt resept		X	X	X
Sendt PLL	(X)	(X)	(X)	(X)	(X)

*Can be filtered out based on reason for discontinuation (seponeringsårsak)

NOTE: When "someone" signs, a signal is sent to the EPJ. The EPJ does not know "who" has signed, i.e. what role - whether it is, for example, a Nurse or a Doctor.

SFM will not create events when drafts are created, only when a treatment is created by a doctor, or a draft is approved by a doctor or doublesigned ny a nurse (not a draft anymore).

Triggered Events	Assistant (medhjelper) creates, renews, changes or seponates a treatment with Resept sign lokalt	Assistant (medhjelper) creates, renews, changes or seponates a treatment without Resept sign lokalt	Doctor approves a draft sign&send	Nurse double-signs sign draft	Doctor rejects a draft

Opprettet behandling	X*	X*	X	X
Forny resept	X*	X*	X	X
Endret behandling	X*	X*	X	X
Seponert behandling	X*	X*	X	X
Sendt resept			(X)
Sendt PLL			(X)

*The red Xs creates events today, but will soon be removed, https://thula.atlassian.net/browse/SFM-22650.

Triggered Events	Doctor creates, renews, changes or seponates a treatment with Resept	Doctor regrets creating, renewing, changing, seponating the treatment (only non-signed events can be regretted)*	Doctor creates, renews, changes or seponates a treatment sign&send	Doctor deletes creating, renewing, changing, seponating the treatment	Lege bekrefter importert behandling i bruk

Opprettet behandling	X	X	X
Forny resept	X	X	X
Endret behandling	X	X	X
Seponert behandling	X	X	X
Sendt resept			X
Bekreftet behandling					X
Slettet ordinasjon				X
Sendt PLL			X	X	X

*Note that unsigned events may be regretted, and regretted events will not be returned when retrieving events after the time of the regret-action. If the EPJ retrieves events before they are signed and record these events in the Journal, there is a risk of recording events that will be regretted. We therefore recommend not recording events to the journal, before the signal of signed Lib.

Triggers for events, and recommended recordings in Clinical Note

The recommendations presented in this table is prepared based on discussions in SFMs medical advisory group, january 2025.

Note that it may be relevant to extend the information from JournalNote with additional information from the related treatments (retrived by Lib-list) - to be stored in the Clinical Note.

Event	Triggered	Recommendation for recordings in Clinical Note

Opprettet behandling	When treatment (with or without Resept) is created in SFM	Recommended to be recorded after signing
Forny resept	When a Resept is renewed (pure renewal, without change)	Recommended to be recorded after signing (This may be a renewal of an entry made outside the organisation, it is desirable that this is recorded in the Medical Note)
Endret behandling	When a treatment (with or without Resept) is changed	Recommended to be recorded after signing
Seponert behandling	When a treatment is seponated	Recommended to be recorded after signing Reason and Note should be included in the Clinical Note. It is possible to filter out reasons for discontinuation that are not relevant (e.g. dobbeltoppføring).
Sendt resept	When a Resept (M1) has been sent to RF	Recommended to be recorded after signing May be merged with the actions above, if the ReseptId is the same. I.e "Endret og sendt resept" on one line.
Bekreftet behandling	When a treatment is included in LIB. Is triggered both when the treatment is actively included, or when it is "automatically" included when i.e signing the list.	NOT recommended to be recorded in the Medical Note for GP offices as this will generate a large number of entries. Must be considered for PLO or for other organisational types.
Slettet ordinasjon	When the treatment is actively deleted	Recommended to be recorded after signing
Gjennomført legemiddelgjennomgang	When the date of completed drug review is stored in SFM	Recommended to be recorded after signing
Opprettet CAVE	When a new CAVE is created in SFM by a user (regardless of whether it is synchronized to Kritisk Info in Kjernejournal or not).	Recommended to be recorded after signing
Endret CAVE	When a CAVE is changed in SFM by a user (regardless of whether it is synchronized to Kritisk Info in Kjernejournal or not).	Recommended to be recorded after signing
Avkreftet CAVE	NWhen a CAVE is "avkreftet" in SFM by a user (regardless of whether it is synchronized to Kritisk Info in Kjernejournal or not).	Recommended to be recorded after signing
Søknad sendt til Helfo	When an application is returned by a new lookup to Helfos vedtaksspørring, that was not returned by the first lookup. Derived and assumed, since the application portal is outside of SFM.	Recommended to be recorded after signing
Registrert multidoseansvar	When M27.1 is sent to RF with Registreringsstatus "Registrering"	Recommended to be recorded after signing
Avregistrert multidoseansvar	When M27.1 is sent to RF with Registreringsstatus "Avregistrering"	Recommended to be recorded after signing
Opprettet første PLL	When the first PLL (M25.1) is sent to RF for a patient, after using the "Opprett PLL" functionality in SFM	Recommended to be recorded after signing
Sendt PLL	When PLL (M25.1) is sent to RF	NOT recommended to be recorded in the Clinical Note

Documentation on Simplifier

Flow description: https://simplifier.net/guide/SFMAPIDatadeling/Journal-notes?version=current

FHIR Resource: https://simplifier.net/guide/SFMAPIDatadeling/SfmJournalNote?version=current