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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Endpoints
-
Primary
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
Expand all❙ required
practiceid
integer
practiceid
medicalrecordid
integer
medicalrecordid
Content-Type
string
Content type of the payload
❙ Request Body
Expand allOutput Parameters
Expand all
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
Expand all❙ 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
Expand all
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
Expand all❙ required
practiceid
integer
practiceid
patientid
integer
patientid
Content-Type
string
Content type of the payload
❙ Request Body
Expand allOutput Parameters
Expand all
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
Expand all❙ 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
Expand all
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
Expand all❙ required
practiceid
integer
practiceid
patientid
integer
patientid
medicalrecordid
integer
medicalrecordid
Content-Type
string
Content type of the payload
Output Parameters
Expand all
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
Expand all❙ 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
Expand all
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
Expand all❙ required
practiceid
integer
practiceid
patientid
integer
patientid
medicalrecordid
integer
medicalrecordid
Output Parameters
Expand all
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
Expand all❙ 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
Expand all
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
Expand all❙ required
practiceid
integer
practiceid
patientid
integer
patientid
medicalrecordid
integer
medicalrecordid
Output Parameters
Expand all
attachment
string
The original document in uploaded format.
Example Code