Standardization of Clinical Progress Notes in Japan with FHIR

This study established a standard format for progress notes as a training dataset for LLMs. We reviewed existing guidelines and analyzed the structure of the EMR system at the Medical School of Ehime University. The Subjective, Objective, Assessment, and Plan (SOAP) sections in our system were successfully mapped to C-CDA sections. A DocumentReference extension was introduced to handle attachments, such as DICOM images. The results found substantial discrepancies between Japanese EMRs and C-CDA on FHIR, emphasizing the need for further study across multiple vendors to achieve progress in note standardization in Japan.