Clinical Document

Source Object: Clinical Document

Overview and Usage: The "Clinical Document" source object in athena EHR is a crucial component for managing and documenting clinical documents related to patient care. It is designed to capture detailed information about clinical documents, including document content, providers, and various attributes. Here's an overview of key fields and their usage:

• Clinical Document ID: "clinicaldocumentid" serves as a unique identifier for each clinical document, ensuring accurate association and retrieval.
• Assigned To: "assignedto" identifies the entity or individual assigned to the clinical document, providing clarity in document management and distribution.
• Clinical Provider ID: "clinicalproviderid" links the document to the clinical provider responsible for the document's creation or management.
• Created Date and Time: "createddatetime" records the date and time when the clinical document was created, offering a chronological record of document creation.
• Created User: "createduser" identifies the user or entity responsible for creating the clinical document.
• Department: "departmentid" specifies the department or healthcare unit associated with the clinical document.
• Document Class and Type: "documentclass" and "documenttypeid" categorize the clinical document based on its class and type, facilitating document organization and retrieval.
• Document Description: "documentdescription" provides a brief description or title for the clinical document, making it easily identifiable.
• Document Route and Source: "documentroute" and "documentsource" specify the route and source of the document, helping to track its origin and intended destination.
• Document Subclass: "documentsubclass" further categorizes the document within its class.
• Entity Type: "entitytype" indicates the type of entity or patient to which the document pertains.
• External Note: "externalnote" may contain additional notes or information related to the clinical document.
• File Extension and Size: "fileextension" and "filesize" provide information about the document's file format and size.
• Internal Note: "internalnote" allows for the addition of internal notes or comments related to the clinical document.
• Last Modified Date and Time: "lastmodifieddatetime" records the date and time of the last modification made to the document.
• Last Modified User: "lastmodifieduser" identifies the user or entity that made the last modification to the clinical document.
• Observation Date and Time: "observationdate" and "observationtime" specify the date and time of the clinical observation or event related to the document.
• Order Type: "ordertype" categorizes the document based on its order type, facilitating document organization.
• Original Filename: "originalfilename" contains the original filename of the document before it was uploaded or processed.
• Patient ID: "patientid" links the document to a specific patient's record, ensuring accurate patient-document association.
• Priority: "priority" indicates the document's priority level.
• Provider ID: "providerid" and "providerusername" identify the provider responsible for the document and their username.
• Status: "status" represents the current status or state of the clinical document.
• Tieto Order ID: "tietoorderid" serves as an identifier for the document in Tieto's order system.
• Action Note: "actionnote" allows for the addition of action-related notes or comments.
• Document Data: "documentdata" may contain the actual content or data of the clinical document.
• Original Document Content: "originaldocument.contenttype" and "originaldocument.href" provide information about the content type and location of the original document.
• Pages: The "pages" section includes details about document pages, content type, href, page ID, and page ordering.
• Attachment Contents: "attachmentcontents" may contain additional content related to the document.
• Attachment Type: "attachmenttype" specifies the type of attachment associated with the document.
• Auto Close: "autoclose" indicates whether the document should be automatically closed or not.
• Replace Internal Note: "replaceinternalnote" determines whether the internal note should be replaced.

The "Clinical Document" source object is vital for managing and documenting a wide range of clinical documents, including reports, notes, and observations. It plays a crucial role in maintaining comprehensive patient records and facilitating communication among healthcare providers. Developers can leverage this source object to build features and applications that support clinical document management and enhance the patient care experience within athena EHR.

Mapping Table