xCaliber healthCare Data Mesh

Encounter Document

Source Object: Encounter Document

Overview and Usage: The "Encounter Document" source object in athena EHR is a pivotal component for documenting and managing documents and notes related to patient encounters. It enables healthcare providers to capture a wide range of information, including clinical notes, documents, and encounter-specific details. Here's an overview of key fields and their usage:

  • Action Note: "actionnote" allows for the inclusion of specific notes or comments related to actions taken or required for the encounter document. It provides additional context for the document's purpose or status.
  • Appointment ID: "appointmentid" specifies the unique identifier for any appointment associated with the encounter document, allowing for tracking and linkage to specific appointments.
  • Assigned To: "assignedto" identifies the user or entity to whom the encounter document is assigned, facilitating task management and responsibility allocation.
  • Created Date and Time: "createddatetime" records the date and time when the encounter document was created, aiding in chronological tracking and reference.
  • Created User: "createduser" indicates the user who created the encounter document, providing information about the document's origin.
  • Deleted Date and Time: "deleteddatetime" captures the date and time when the encounter document was deleted or marked for removal.
  • Department ID: "departmentid" serves as an identifier for the department or unit associated with the encounter document, aiding in organization and categorization.
  • Description: "description" provides a textual description of the encounter document, offering information about the document's content or purpose.
  • Document Data: "documentdata" may include the actual data or content of the encounter document, such as clinical notes, reports, or other document types.
  • Document Source: "documentsource" identifies the source or origin of the encounter document, helping with document attribution and provenance.
  • Document Subclass: "documentsubclass" categorizes the encounter document into a specific subclass, facilitating document classification and management.
  • Encounter Date: "encounterdate" specifies the date of the patient encounter associated with the document, aiding in chronological organization.
  • Encounter Document ID: "encounterdocumentid" serves as a unique identifier for the specific encounter document, enabling efficient tracking and reference.
  • Encounter ID: "encounterid" links the encounter document to a specific encounter, ensuring proper association with patient care events.
  • Entity Type: "entitytype" may indicate the type of entity or user associated with the encounter document, allowing for differentiation between various document creators or contributors.
  • Internal Note: "internalnote" allows for internal comments or notes related to the encounter document, which can be useful for administrative or clinical context.
  • Last Modified Date and Time: "lastmodifieddate" and "lastmodifieduser" record the date and time of the last modification and the user responsible for it, aiding in tracking changes to the document.
  • Pages Content Type: "pages.contenttype," "pages.href," "pages.pageid," and "pages.pageordering" pertain to the content and structure of document pages, enabling detailed document organization and formatting.
  • Patient ID: "patientid" links the encounter document to the patient to whom it pertains, ensuring proper patient data management.
  • Priority: "priority" may indicate the priority level or urgency associated with the encounter document, aiding in document triage and handling.
  • Provider ID and Username: "providerid" and "providerusername" specify the healthcare provider responsible for the encounter document, allowing for proper attribution.
  • Status: "status" indicates the current status or state of the encounter document, helping track its progress or completion.
  • Subject: "subject" provides a title or subject for the encounter document, summarizing its content.
  • Clinical Provider ID: "clinicalproviderid" specifies the clinical provider associated with the encounter document, enabling proper clinical context and reference.
  • Declined Reason Code, Description, and Code Set: Fields related to declined reasons ("declinedreason.code," "declinedreason.description," "declinedreason.codeset") allow for documenting reasons for document declines, aiding in tracking and resolution.
  • Contraindication Reason Code, Description, and Code Set: Fields related to contraindication reasons ("contraindicationreason.code," "contraindicationreason.description," "contraindicationreason.codeset") document contraindication reasons associated with the encounter document, ensuring patient safety and appropriate documentation.

The "Encounter Document" source object is essential for documenting and managing a wide array of documents, notes, and information associated with patient encounters within athena EHR. It plays a crucial role in maintaining comprehensive patient records and facilitating efficient care coordination. Developers can leverage this source object to build features and applications that enhance the documentation, organization, and management of encounter-related information.

Mapping Table

Data FieldExample ValueSource Data Field DescriptionSource Field Data TypeSource Data Field CardinalityMapped FHIR++ ResourceMapped FHIR Data FieldAugmented MappingAssociated Coding SystemAssociated FHIR Data Field ExtensionMapping Context
actionnote-The most recent action note for a document.string0..1DocumentReferenceextension.valueStringaction-noteTop Level
appointmentid-The appointment ID for this document.integer0..1DocumentReferenceextension.valueStringappointment-idTop Level
assignedto-Person the document is assigned to.string0..1DocumentReferenceextension.valueStringassigned-toTop Level
createddatetime-Date the document was created. Please use createddatetime instead.string0..1DocumentReferencedateTop Level
createduser-The user who created this document.string0..1DocumentReferenceextension.valueStringcreated-userTop Level
deleteddatetime-Date/time (ISO 8601) the document was deleted.string0..1DocumentReferenceextension.valueDatetimedeleted-datetimeTop Level
departmentid-Department for the document.string0..1DocumentReferenceextension.valueStringdepartment-idTop Level
description-Description of the document type.string0..1DocumentReferencecategory.coding.displayTop Level
documentdata-Text data associated with this document.string0..1DocumentReferencecontent.attachment.dataTop Level
documentsource-Explains where this document originated.string0..1DocumentReferenceextension.valueStringdocument-sourceTop Level
documentsubclass-Specific type of document.string0..1DocumentReferencecategory.extension.valueStringdocument-subclassTop Level
encounterdate-Date of the encounter associated with this document.string0..1DocumentReferencecontext.extensionencounter-dateTop Level
encounterdocumentid-The primary key for encounter document class of documents.integer0..1DocumentReferenceidTop Level
encounterid-Encounter ID.string0..1DocumentReferencecontext.encounter.referenceTop Level
entitytype-Type of entity creating the document. Possible values are PROVIDER, PATIENT and OTHERS.string0..1DocumentReferenceextension.valueStringentity-typeTop Level
internalnote-The 'Internal Note' attached to this document.string0..1DocumentReferenceextension.valueStringinternal-noteTop Level
lastmodifieddate-Date/time (ISO 8601) the document was last modified.string0..1DocumentReferenceextension.valueDateTimelast-modified-dateTop Level
lastmodifieduser-The user who last modified this document.string0..1DocumentReferenceextension.valueStringlast-modified-userTop Level
pages.contenttype-The content-type that will be returned by the page image call.string0..1DocumentReferencecontent.attachment.contentTypeTop Level
pages.href-The URL to get the document image.string0..1DocumentReferencecontent.attachment.urlTop Level
pages.pageid-The ID to use in a call to get the page image.string0..1DocumentReferencecontent.attachment.idTop Level
pages.pageordering-Within this list of pages, the ordering (starting with 1).string0..1DocumentReferencecontent.attachment.extension.valueStringpage-orderingTop Level
patientid-The athenaNet patient ID.integer0..1DocumentReferencesubject.referenceTop Level
priority-Document priority, when available. 1 is high, 2 is normal. Some labs use other numbers or characters that are lab-specific.string0..1DocumentReferenceextension.valueStringpriorityTop Level
providerid-Provider ID for this document.integer0..1DocumentReferenceauthor.referenceTop Level
providerusername-The username of the provider associated with this lab result document.string0..1DocumentReferenceauthor.reference.displayTop Level
status-Status of the document.string0..1DocumentReferencestatusTop Level
subject-Subject of the document.string0..1DocumentReferenceextension.valueStringsubjectTop Level
clinicalproviderid-The clinical provider ID of the performing provider.number0..1DocumentReferencecustodian.referenceTop Level
declinedreasontext-The user-facing description of the reason the order was not given.string0..1DocumentReferenceextension.valueStringdeclined-reason-textTop Level
documentclass-Class of document.string0..1DocumentReferencecategory.coding.codeTop Level
documentdescription-Description of the document type.string0..1DocumentReferencedescriptionTop Level
documentroute-Explains method by which the document was entered into the AthenaNet (INTERFACE (digital), FAX, etc.).string0..1DocumentReferenceextension.valueStringdocument-routeTop Level
documenttype-The description for this document.string0..1DocumentReferenceextension.valueStringdocument-typeTop Level
documenttypeid-The ID of the description for this document.number0..1DocumentReferenceextension.valueStringdocument-type-idTop Level
externalaccessionid-The external accession ID for this document. Format depends on the system the ID belongs to.string0..1DocumentReferenceextension.valueStringexternal-accession-idTop Level
externalnote-External note for the patient.string0..1DocumentReferenceextension.valueStringexternal-noteTop Level
internalaccessionid-The internal accession ID for this document. Format depends on the system the ID belongs to.string0..1DocumentReferenceextension.valueStringinternal-accession-idTop Level
internalnote-The 'Internal Note' attached to this document.string0..1DocumentReferenceextension.valueStringinternal-noteTop Level
lastmodifieddatetime-Date/time (ISO 8601) the document was last modified.string0..1DocumentReferenceextension.valueDateTimelast-modified-datetimeTop Level
observationdatetime-Date/time (ISO 8601) the observation was taken.string0..1DocumentReferenceextension.valueDateTimeobservation-datetimeTop Level
tietoorderid-Order ID of the order this document is tied to, if any.number0..1DocumentReferencecontext.related.referenceTop Level
receivernote-External note sent to the receiving facility.string0..1DocumentReferenceextension.valueStringreceiver-noteTop Level
declinedreason.code-The code indicating why the order was not given.string0..1DocumentReferenceextension.valueCodeableConcept.codedeclined-reasonTop Level
declinedreason.description-The codeset that the code belongs to.string0..1DocumentReferenceextension.valueCodeableConcept.displayTop Level
declinedreason.codeset-The plaintext description of the reason the order was not given.string0..1DocumentReferenceextension.valueCodeableConcept.systemTop Level
contraindicationreason.code-The code indicating why the order was contraindicated.String0..1DocumentReferenceextension[*].valueCodableConcept.coding[1].code--contraindication-reasonTop Level
contraindicationreason.codeset-The codeset that the code belongs to.String0..1DocumentReferenceextension[*].valueCodableConcept.coding[1].system--contraindication-reasonTop Level
contraindicationreason.description-The plaintext description of the contraindication reason.String0..1DocumentReferenceextension[*].valueCodableConcept.coding[1].display--contraindication-reasonTop Level