Document Type - Clinical Document
Document Type - Clinical Document. It provides details of a patient's condition or care documents. This feature allows the user to retrieve, add or modify information of a specific patient or a specific clinical document of a patient. It also provides a facility to retrieve clinical document in HTML. The document content could be images, XML.etc.
Clinical Document
Miscellaneous documents providing details of a patient’s condition or care. These should only be used when no other classification is appropriate, and the care in question was not provided by a provider or entity within the practice (e.g., in-house lab). By default, clinical documents are created in an open status.
Clinical Document – Admission/Discharge Summary: Patient Admission or Discharge documentation typically provided as informational-only to the ambulatory athenahealth provider, e.g., inpatient, behavioral/mental health admissions, discharges from an neonatal facility.
Clinical Document – Consult Note: Consult and supporting documentation incoming from other providers. Consult notes are medical documents from an outside provider that report on a patient’s visit or procedure performed by that provider, e.g., physician correspondence, medical record photocopies, checklists of patient plans. Standalone Lab, Imaging and Diagnostic Results/Reports have their own classes.
Clinical Document – Emergency/Urgent Care Note: Emergency Department notes and notifications, e.g., ER daily lists. Notes from walk-in clinics, urgent care, and retail clinic facilities, e.g., Minute Clinic, Express Care.
Clinical Document – Mental Health Consult: Mental health notes, e.g., behavioral assessments, completed by psychologists, social workers, licensed mental health counselors. Neurologist notes should be classified as a Consult Note. This class should only include questionnaires if they are attached to more detailed mental health notes.
Clinical Document – Operative Note: Letters or forms from outside physicians, medical groups, or internal providers describing surgical procedures. The words “Operative Note” or “Operative Report” typically appear at the top of these forms. Describes surgical procedures performed in hospital or surgical center settings, typically requiring both an incision and anesthesia/analgesia, as well as booking in a surgical center or dental/ophtho office. Endoscopic procedures with biopsy should be classified under Imaging/Diagnostic Result.
Note: Subclassification is not necessary for this document class.
Endpoints
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Primary
Creates an action note for a specific clinical document
Input Parameters
Expand all❙ Request Body
Expand allOutput Parameters
Expand allRetrieves action note information of a specific clinical document
Input Parameters
Expand allOutput Parameters
Expand allCreates a clinical document record of a specific patient
Input Parameters
Expand all❙ Request Body
Expand allRetrieves a list of clinical document information of a specific patient
Input Parameters
Expand all❙ required
Output Parameters
Expand allRetrieves a specific clinical document information
Input Parameters
Expand allOutput Parameters
Expand allModifies a specific clinical document information
Input Parameters
Expand all❙ Request Body
Expand allDeletes the record of a specified clinical document
Input Parameters
Expand allRetrieves a specific page from the specific clinical document of the patient