Document Classification Guide

This guide details how the different documents are classified within athenaNet. Most document classes support subclasses (bulleted lists below), though not all do. Subclasses trigger message/task routing rules in athenaClinicals and should be provided whenever an applicable sublcass is available.

An ad hoc document descriptor can also be added to many document classes. These descriptions are called “document types,” and an API is provided for accessing the current list of available document types.  Document types significantly improve the usability of the document in the patient’s chart and should be provided whenever possible.

Admin

Miscellaneous administrative documents, whether associated with a patient or not, e.g. registration information, conferences invitations, payer notices, etc. These documents are accessible through the chart but not typically viewed by clinical staff. By default, admin documents will be created in an open status.

  • Admin – Billing Document: Documents with claim billing information, e.g. invoices, benefit investigation forms, etc.
  • Admin – Consent: General patient consent forms, e.g. HIV testing, vaccination, surgical consent forms, etc.
  • Admin – HIPAA/Privacy: Practice-generated forms signed by patients acknowledging they were made aware of their patient rights.
  • Admin – Insurance Approval Notification: Letters sent from an insurance organization (state or private) indicating that a provider may bill for certain types of medical care, e.g. imaging studies, medications, procedures, etc.
  • Admin – Insurance Card: Photocopies of patient insurance cards taken during patient visits.
  • Admin – Insurance Denial Notification: Letters from insurance organizations indicating that a provider may not bill for certain types of medical care, e.g. imaging studies, procedures, medications.
  • Admin – Legal: Legal documents, e.g. DNRs, police reports, birth or death certificates.
  • Admin – Medical Records Request: Patient-signed forms authorizing the release of their medical records to a third party, e.g. medical practices, legal representatives, Social Security Administration etc.
  • Admin – Referral: All incoming referral orders from an outside provider for consultation or treatment, e.g. appointment scheduling requests, supporting documentation.
  • Admin – Signed Forms and Letters: Patient-related forms or letters that have already signed by the provider and require no further action, e.g. school health forms, disability eligibility forms, compassionate "do not shut off service” utility company letters, etc.

Note: Subclassification is not necessary for this document class

Note: Admin documents are one of the only documents which can be created without a patient ID because some documents may apply to no patients or to >1 patient

Clinical Document

Miscellaneous documents providing details of a patient’s condition or care—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 will be created in an open status.

  • Clinical Document – Admission/Discharge Summary: Patient Admission or Discharge documentation typically provided as informational-only to the ambulatory athena provider, e.g. inpatient, behavioral/mental health admissions, discharges from an neonatal facility, etc.
  • Clinical Document – Consult Note:
    • Consults 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, etc.
    • 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, etc.
      • Neurologist notes should be classified as 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.

      Encounter Document

      By default, encounter documents will be created in a closed status, as the documents are considered documentation in support of a practice’s own encounter. I.e. data the practice has already viewed in some other way but needs to be added to the patient’s chart for record-keeping.  A document subclass is required for this document class. 

      • Encounter Document – Health History Questionnaire: Validated assessment forms completed by the family at home, school, or in a medical office or questionnaires given during the patient’s visit, e.g. lead or TB risk assessments forms.
      • Encounter Document – Image Documentation: Photos taken during procedures performed as part of an ambulatory encounter – not prior or after.
      • Encounter Document – Procedure Documentation: Documentation of procedures done during office visits – not previously scheduled separate surgeries.
      • Encounter Document – Progress Note: Detailed descriptions of a patient’s office visit taken on paper and faxed or scanned into the system.

      Imaging/Diagnostic Result

      Reports returned by internal or external facilities that include information about imaging or other diagnostic tests, e.g. x-rays, MRIs, colonoscopies, Holter monitor reports, ultrasounds, EKGs, sleep studies, etc. Imaging and diagnostic results appear in the Results section of the patient’s chart. By default, imaging result documents will be created in an open status.

      Note: Subclassification is not available for this document class.

      Lab Result

      Lab results obtained from a blood draw, fluid specimen, or a biopsy/surgical excision.  Lab results appear in the Results section of a patient’s chart.  By default, lab result documents will be created in an open status.  However, creating lab results in a closed status is encouraged if the practice has already reviewed this data via another mechanism. 

      Whenever possible, structured analytes should be entered on documents, and clinicalordertype (test type) and clinicalprovider (performing lab/data source) should always be specified 

      Note: Subclassification is not available for this document class.

      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 will be 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, etc.
      • 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, etc.
      • 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, etc.
      • 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.

      Order (Already Signed)

      A document showing a test, other diagnostic service, or referral that the patient requires as part of their medical care, signed by the athena provider.  These documents represent orders placed outside of athenaClinicals (e.g. prescription note pad, lab requisition form).  By default, order documents will be created in a closed status.

      Note: Subclassification is not available for this document class.

      Patient Case

      Documents patient communications outside an encounter. See the Patient Cases documentation for more detailed information. 

      Phone Message

      Message typically received over fax, e.g. including messages with notes that patients were triaged.  May include/list multiple patients on one page.  Messages pertaining to patient care should be documented as individual patient cases (see above).  By default, phone message documents will be created in an open status.

      Note: Subclassification is not available for this document class.

      Note: Phone messages are the other document class that can be created without a patient ID because some documents may apply to no patients or to >1 patient

      Physician Authorization

      Requires physician approval via signature in order to continue patient care and typically contains a space for “Physician Signature.”

      Approval may be required by insurance companies to continue with specific medications or equipment, or to continue care from a specialist or nursing home. Requests for provider confirmation of awareness of patient admission to a hospital can also be found here.  By default, physician authorization documents will be created in an open status.

      • Physician Authorization – Care Plan Oversight:
        • Documentation submitted by visiting nurses, physical therapists, rehabilitation facilities, etc., regarding plans of action for patients.
        • Typically requires a physician's signature or approval and needs to be faxed to the sending facility.

      Note: Subclassification is not necessary for this document class

      Prescription

      By default, prescription documents will be created in an open status. 

      • Prescription – Change: Requests from pharmacies to substitute prescribed drugs, e.g. a request to substitute an on-formulary medication of the same class.
      • Prescription – Clarification: Clarifying questions from pharmacies regarding prescriptions, e.g. correct dosage amounts or the original quantity provided on the prescription.
      • Prescription – New: Requests from pharmacies for new prescriptions. This document class should not be used for adding new orders to an existing encounter or order group.  See Order Prescription for more details.
      • Prescription – Prior Authorization Request: Requests from pharmacies for further authorization, typically for insurance reasons.
      • Prescription – Renewal: Requests to refill previously prescribed medication. The words “refill”, “renewal”, or “renew” typically appear on these forms.

      Note: Subclassification is necessary for this document class

      Deprecated Generic Document Endpoint

      In 2016, POST /patients/{patientid}/documents was replaced by our class-specific document endpoints, such as POST /patients/{patientid}/documents/admin, which offer addition inputs and functionality.

      If you are still using POST /patients/{patientid}/documents to upload documents, the following subclasses are available:

      • ADMIN_BILLING
      • ADMIN_CONSENT
      • ADMIN_HIPAA
      • ADMIN_INSURANCEAPPROVAL
      • ADMIN_INSURANCECARD
      • ADMIN_INSURANCEDENIAL
      • ADMIN_LEGAL
      • ADMIN_MEDICALRECORDREQ
      • ADMIN_REFERRAL
      • ADMIN_SIGNEDFORMSLETTERS
      • ADMIN_VACCINATIONRECORD
      • CLINICALDOCUMENT_ADMISSIONDISCHARGE 
      • CLINICALDOCUMENT_CONSULTNOTE
      • CLINICALDOCUMENT_MENTALHEALTH
      • CLINICALDOCUMENT_OPERATIVENOTE
      • CLINICALDOCUMENT_URGENTCARE
      • ENCOUNTERDOCUMENT_IMAGEDOC
      • ENCOUNTERDOCUMENT_PATIENTHISTORY
      • ENCOUNTERDOCUMENT_PROCEDUREDOC
      • ENCOUNTERDOCUMENT_PROGRESSNOTE
      • MEDICALRECORD_CHARTTOABSTRACT
      • MEDICALRECORD_COUMADIN
      • MEDICALRECORD_GROWTHCHART
      • MEDICALRECORD_HISTORICAL
      • MEDICALRECORD_PATIENTDIARY
      • MEDICALRECORD_VACCINATION
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