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. Also, when adding documents, the attachmentcontents should be no larger than 20MB for optimal API processing time. Please see here for more best practices on File Uploads.

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Add clinical document action note

POST
/v1/{practiceid}/documents/clinicaldocument/{clinicaldocumentid}/actions
Creates an action note for a specific clinical document
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Input Parameters

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required

practiceid integer practiceid
clinicaldocumentid integer clinicaldocumentid
Content-Type string Content type of the payload

Output Parameters

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errormessage string If there was an error with this call and SUCCESS is set to false, this field may provide additional information.
newdocumentid string The document ID of newly created document as a result of action of Deny-New Prescription To Follow (DNTF).
success string Returns true if the update was a success.
versiontoken string A token representing the current state of this document. Will only be set if VERSIONTOKEN was originally sent to the endpoint.
Example Code

Get clinical document's action note

GET
/v1/{practiceid}/documents/clinicaldocument/{clinicaldocumentid}/actions
Retrieves action note information of a specific clinical document
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Input Parameters

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required

practiceid integer practiceid
clinicaldocumentid integer clinicaldocumentid
limit integer Number of entries to return (default 1500, max 5000)
offset integer Starting point of entries; 0-indexed

Output Parameters

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actionnote string The action notes that are attached to the document.
assignedto string This field will describe who was assigned this document during this document action.
createdby string The username of the person that created this document action.
createddatetime string The datetime this action note was created.
patientid integer The patient ID this document is tied to.
priority integer Priority given for this document action.
status string Status given for this document action.
Example Code

Add clinical document to patient's chart

POST
/v1/{practiceid}/patients/{patientid}/documents/clinicaldocument
Creates a clinical document record of a specific patient
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Input Parameters

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required

practiceid integer practiceid
patientid integer patientid
Content-Type string Content type of the payload

Request Body

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Output Parameters

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clinicaldocumentid integer The document ID of the new or modified document.
errormessage string If the operation failed, this will contain an error message.
success string Returns true/false if the operation was successful.
Example Code

Get list of patient's clinical documents

GET
/v1/{practiceid}/patients/{patientid}/documents/clinicaldocument
Retrieves a list of clinical document information of a specific patient
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Input Parameters

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required

practiceid integer practiceid
patientid integer patientid
showdeleted boolean By default, deleted documents are not listed. Set to list these.
status string The status of the task to filter document results.
departmentid integer The athenaNet department id.
getentityinfo boolean If true, entityid and entitytype will be returned. entityid will be populated in createduser attribute.
encounterid integer Show only documents attached to this encounter.
showmetadata boolean When "true" is passed we will return filetype, filesize and originalfilename if applicable
documentsubclass string The document subclass to filter document results.
limit integer Number of entries to return (default 1500, max 5000)
offset integer Starting point of entries; 0-indexed

Output Parameters

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assignedto string Person the document is assigned to
clinicaldocumentid integer The primary key for the clinical document.
clinicalproviderid integer The ID of the clinical provider associated with this clinical document. Clinical providers are a master list of providers throughout the country. These include providers as well as radiology centers, labs and pharmacies.
createddate string Date the document was created. Please use createddatetime instead.
createddatetime string Date/Time (ISO 8601) the document was created
createduser string The user who created this document.
departmentid string Department for the document
documentclass string Class of document
documentdescription string Description of the document type
documentroute string Explains method by which the document was entered into the AthenaNet (INTERFACE (digital), FAX, etc.)
documentsource string Explains where this document originated.
documentsubclass string Specific type of document
documenttypeid integer The ID of the description for this document
entitytype string Type of entity creating the document. Possible values are PROVIDER, PATIENT and OTHERS.
externalnote string External note for the patient.
fileextension string The file extension of this document.
filesize number The file size of this document.
internalnote string The 'Internal Note' attached to this document
lastmodifieddate string
lastmodifieddatetime string Date/time (ISO 8601) the document was last modified
lastmodifieduser string The user who last modified this document.
observationdate string Date of the encounter associated with this document
ordertype string Order type group name
originalfilename string The original file name of this document.
priority string Document priority, when available. 1 is high, 2 is normal. Some labs use other numbers or characters that are lab-specific.
providerid integer Provider ID for this document
providerusername string The username of the provider associated with this lab result document.
status string Status of the document
tietoorderid integer Order ID of the order this document is tied to, if any
Example Code

Get patient's clinical document

GET
/v1/{practiceid}/patients/{patientid}/documents/clinicaldocument/{clinicaldocumentid}
Retrieves a specific clinical document information
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Input Parameters

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required

practiceid integer practiceid
patientid integer patientid
clinicaldocumentid integer clinicaldocumentid
getentityinfo boolean If true, entityid and entitytype will be returned. entityid will be populated in createduser attribute.
showccdaxml boolean Default false. If set to true, will include CCDAXML string.

Output Parameters

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actionnote string The most recent action note for a document
assignedto string Person the document is assigned to
clinicaldocumentid integer The primary key for the clinical document.
clinicalproviderid integer The ID of the clinical provider associated with this clinical document. Clinical providers are a master list of providers throughout the country. These include providers as well as radiology centers, labs and pharmacies.
createddate string Date the document was created. Please use createddatetime instead.
createddatetime string Date/Time (ISO 8601) the document was created
createduser string The user who created this document.
departmentid string Department for the document
documentclass string Class of document
documentdata string Text data associated with this document.
documentdescription string Description of the document type
documentroute string Explains method by which the document was entered into the AthenaNet (INTERFACE (digital), FAX, etc.)
documentsource string Explains where this document originated.
documentsubclass string Specific type of document
documenttypeid integer The ID of the description for this document
entitytype string Type of entity creating the document. Possible values are PROVIDER, PATIENT and OTHERS.
externalnote string External note for the patient.
internalnote string The 'Internal Note' attached to this document
lastmodifieddate string
lastmodifieddatetime string Date/time (ISO 8601) the document was last modified
lastmodifieduser string The user who last modified this document.
observationdate string Date of the encounter associated with this document
ordertype string Order type group name
originaldocument object URL and content-type to download the original document. "originaldocument" is returned when document source is FAX or UPLOAD and originally faxed or uploaded file is not split into multiple documents. Please use "pages" to download document pages when "originaldocument" is not available.
pages array An array of image pages associated with this document.
priority string Document priority, when available. 1 is high, 2 is normal. Some labs use other numbers or characters that are lab-specific.
providerid integer Provider ID for this document
providerusername string The username of the provider associated with this lab result document.
status string Status of the document
tietoorderid integer Order ID of the order this document is tied to, if any
Example Code

Update patient's clinical document

PUT
/v1/{practiceid}/patients/{patientid}/documents/clinicaldocument/{clinicaldocumentid}
Modifies a specific clinical document information
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Input Parameters

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required

practiceid integer practiceid
patientid integer patientid
clinicaldocumentid integer clinicaldocumentid
Content-Type string Content type of the payload

Output Parameters

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clinicaldocumentid integer The document ID of the new or modified document.
errormessage string If the operation failed, this will contain an error message.
success string Returns true/false if the operation was successful.
Example Code

Mark patient's clinical document as deleted

DELETE
/v1/{practiceid}/patients/{patientid}/documents/clinicaldocument/{clinicaldocumentid}
Deletes the record of a specified clinical document
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Input Parameters

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required

practiceid integer practiceid
patientid integer patientid
clinicaldocumentid integer clinicaldocumentid

Output Parameters

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clinicaldocumentid integer ID for the clinical document.
errormessage string A message to help identify an error.
success string Indicates a successful delete operation.
Example Code

Get page from patient's clinical document

GET
/v1/{practiceid}/patients/{patientid}/documents/clinicaldocument/{clinicaldocumentid}/pages/{pageid}
Retrieves a specific page from the specific clinical document of the patient
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Input Parameters

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required

practiceid integer practiceid
pageid integer pageid
patientid integer patientid
clinicaldocumentid integer clinicaldocumentid
filesize string The file size of the document being requested.

Output Parameters

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attachment string The image of the page in jpeg format.
Example Code

Get patient's original clinical document

GET
/v1/{practiceid}/patients/{patientid}/documents/clinicaldocument/{clinicaldocumentid}/originaldocument
Retrieves original clinical document of the patient. This is applicable when document source is FAX or UPLOAD and originally faxed or uploaded file is not split into multiple documents. Please use "Get page from patient's clinical document" endpoint to download documentpages when original document is not available.
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Input Parameters

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required

practiceid integer practiceid
patientid integer patientid
clinicaldocumentid integer clinicaldocumentid

Output Parameters

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attachment string The original document in uploaded format.
Example Code