Clinical Note and Documentation
| Appears In: |
Diagnostic Imaging Reporting LDM Subject Area, Medication Request, Statement, Administration LDM Subject Area, Clinical Notes and Documentation LDM Subject Area, Health Care Service Event LDM Subject Area, Family History LDM Subject Area, Reported Clinical Information LDM Subject Area, Observation LDM Subject Area, Encounter LDM Subject Area, Procedure LDM Subject Area, Immunization LDM Subject Area, Laboratory Test Result Reporting LDM Subject Area |
A note about a patient's clinical course. Can be related to a health care service event (e.g., immunization, procedure, medication administration) or to reported information (e.g. immunization history as subjectively reported by a patient). Can be a formal clinical note, expected to be exchanged among health care professionals, or less-formal documentation. <br/><br/>
- Attributes
- Associations To
- Associations From
- Constraints
| Attribute |
Type |
|
Note Identifier
|
Identifier
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Notes:
|
An alphanumeric value that uniquely identifies a clinical note. This is a machine-generated backend attribute. <br/>
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Note Date Time
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Date Time
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Notes:
|
The date and, if known, the time when the note was created. <br/>
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Note Type Code
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Codeable Concept
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Notes:
|
A coded concept that specifies the type of person who reported the information. May be same as or different from note author party role type. <br/><br/><b>Value Set</b>: To be developed.<br/>
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Note Status Code
|
Codeable Concept
|
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Notes:
|
A coded concept that specifies the status of the note (e.g., preliminary, final, amended).<br/><br/><b>Value set</b>: <a href="https://hl7.org/fhir/R4/valueset-composition-status.html"><font color="#0000ff"><u>https://hl7.org/fhir/R4/valueset-composition-status.html</u></font></a> <br/>
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Note Text
|
String
|
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Notes:
|
Free-text content of the note. <br/>
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| Constraint |
| XOR(Health Care Service Event, Reported Clinical Information, Encounter Patient, Observation, Observation Component) |
