Document Type - Medical Record

Document Type - Medical Record. It provides details of a patient's historical medical record, vaccination, chart of abstraction, flow sheet and patient diary. This feature allows the user to retrieve, add or modify information of a specific patient or a specific medical record document of a patient. It also provides a felicity to retrieve medical record document in HTML. The document content could be images, XML.etc.

Medical Record Document
This document class is used for supplementary medical documentation that does not directly pertain to care delivery by the practice. A document subclass is required for this document class. By default, medical record documents are created in a closed status.

Medical Record Document – Chart for Abstraction: Documents generated prior to data abstraction to transition historical paper charts to an electronic medical record.
Medical Record Document – Flowsheet: Used to track a variety of relevant information pertaining to a particular problem over time, e.g., relevant vitals, result analytes, medications.
Medical Record Document – Growth Chart: Pediatric Growth Charts are parabolic curves charting a patient’s age against height and/or weight. Could be paper flowsheets scanned in by practice users.
Medical Record Document – Historical Medical Record: Requested medical records received from patients and/or previous providers, e.g., mixed records dating prior to a patient’s practice entry or standalone medical record sections.
Medical Record Document – Patient Diary: Any document that appears to be a "diary" or list of information provided to the client for tracking purpose, e.g., home diaries kept by patients, glucose monitoring numbers, blood pressure readings.
Medical Record Document – Vaccination Record: These documents consist of dated lists of administered vaccines. Usually a single sheet of paper with labels affixed in date order, with initials or signatures from the vaccine administer. 

Note: Subclassification is necessary for this document class.

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Add medical record document action note

POST
/v1/{practiceid}/documents/medicalrecord/{medicalrecordid}/actions
Creates an action note for a specific medical record document
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Input Parameters

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required

practiceid integer practiceid
medicalrecordid integer medicalrecordid
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 medical record document's action note

GET
/v1/{practiceid}/documents/medicalrecord/{medicalrecordid}/actions
Retrieves action note information of a specific medical record document
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Input Parameters

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required

practiceid integer practiceid
medicalrecordid integer medicalrecordid
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 medical record document to patient's chart

POST
/v1/{practiceid}/patients/{patientid}/documents/medicalrecord
Creates a medical record 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

Output Parameters

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

Get list of patient's medical record documents

GET
/v1/{practiceid}/patients/{patientid}/documents/medicalrecord
Retrieves a list of medical record 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.
encounterid integer Show only documents attached to this encounter.
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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appointmentid number The appointment ID for this document,
assignedto string Person the document is assigned to
clinicalproviderid number The clinical provider ID of the performing provider
contraindicationreason array List of codes indicating why the order was contraindicated (for vaccines only). If this field is not present, the order does not contain a contraindication reason.
createddate string Date the document was created. Please use createddatetime instead.
createddatetime string Date/Time (ISO 8601) the document was created
declinedreason array List of codes indicating why the order was not given. If this field is not present, the order was not declined. If the array is empty, no reason has been chosen.
declinedreasontext string The user-facing description of the reason the order was not given.
deleteddatetime string Date/time (ISO 8601) the document was deleted
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 (e.g. ENCOUNTER, PORTAL, etc.)
documentsubclass string Specific type of document
documenttype string The description for this document
documenttypeid number The ID of the description for this document
encounterid string Encounter ID
externalaccessionid string The external accession ID for this document. Format depends on the system the ID belongs to.
externalnote string External note for the patient
internalaccessionid string The internal accession ID for this document. Format depends on the system the ID belongs to.
internalnote string The 'Internal Note' attached to this document
lastmodifieddatetime string Date/time (ISO 8601) the document was last modified
medicalrecordid number The primary key for medicalrecord class of documents
observationdatetime string Date/time (ISO 8601) the observation was taken
priority number Document priority, when available.
providerid number Provider ID for this document
receivernote string External note sent to the receiving facility
status string Status of the document
subject string Subject of the document
tietoorderid number Order ID of the order this document is tied to, if any
Example Code

Get patient's medical record document

PUT
/v1/{practiceid}/patients/{patientid}/documents/medicalrecord/{medicalrecordid}
Deletes the record of a specified medical record document
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Input Parameters

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required

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

Output Parameters

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

Get list of patient's medical record documents

GET
/v1/{practiceid}/patients/{patientid}/documents/medicalrecord/{medicalrecordid}
Retrieves a specific medical record document information
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Input Parameters

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required

practiceid integer practiceid
patientid integer patientid
medicalrecordid integer medicalrecordid
getentityinfo boolean If true, entityid and entitytype will be returned. entityid will be populated in createduser attribute.

Output Parameters

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appointmentid integer The appointment ID for this document
assignedto string Person the document is assigned to
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.
deleteddatetime string Date/time (ISO 8601) the document was deleted
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 A specific document type identifier.
encounterid string Encounter ID
entitytype string Type of entity creating the document. Possible values are PROVIDER, PATIENT and OTHERS.
externalaccessionid string The external accession ID for this document. Format depends on the system the ID belongs to.
externalnote string External note for the patient.
facilityid 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.
internalaccessionid string The internal accession ID for this document. Format depends on the system the ID belongs to.
internalnote string The 'Internal Note' attached to this document
lastmodifieddatetime string Date/time (ISO 8601) the document was last modified
lastmodifieduser string The user who last modified this document.
medicalrecordid integer The ID for this medical record document.
observationdatetime string Date/time the observation was taken
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
status string Status of the document
subject string Subject of the document
tietoorderid integer Order ID of the order this document is tied to, if any
Example Code

Mark patient's medical record document as deleted

DELETE
/v1/{practiceid}/patients/{patientid}/documents/medicalrecord/{medicalrecordid}
Modifies a specific medical record document information
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Input Parameters

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required

practiceid integer practiceid
patientid integer patientid
medicalrecordid integer medicalrecordid

Output Parameters

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

Get page from patient's medical record document

GET
/v1/{practiceid}/patients/{patientid}/documents/medicalrecord/{medicalrecordid}/pages/{pageid}
Retrieves a specific page from the specific medical record document of the patient
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Input Parameters

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required

practiceid integer practiceid
pageid integer pageid
patientid integer patientid
medicalrecordid integer medicalrecordid
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 medical record document

GET
/v1/{practiceid}/patients/{patientid}/documents/medicalrecord/{medicalrecordid}/originaldocument
Retrieves original medical record 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 medical record 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
medicalrecordid integer medicalrecordid

Output Parameters

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attachment string The original document in uploaded format.
Example Code