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.
Endpoints
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Primary
Add medical record document action note
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❙ Request Body
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Expand allGet medical record document's action note
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Output Parameters
Expand allAdd medical record document to patient's chart
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❙ Request Body
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Expand allGet list of patient's medical record documents
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Output Parameters
Expand allGet patient's medical record document
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Output Parameters
Expand allGet list of patient's medical record documents
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Expand allMark patient's medical record document as deleted
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Output Parameters
Expand allGet page from patient's medical record document
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Output Parameters
Expand allGet patient's original medical record document
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