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 Field | Example Value | Source Data Field Description | Source Field Data Type | Source Data Field Cardinality | Mapped FHIR++ Resource | Mapped FHIR Data Field | Augmented Mapping | Associated Coding System | Associated FHIR Data Field Extension | Mapping Context |
---|---|---|---|---|---|---|---|---|---|---|
actionnote | - | The most recent action note for a document. | string | 0..1 | DocumentReference | extension.valueString | action-note | Top Level | ||
appointmentid | - | The appointment ID for this document. | integer | 0..1 | DocumentReference | extension.valueString | appointment-id | Top Level | ||
assignedto | - | Person the document is assigned to. | string | 0..1 | DocumentReference | extension.valueString | assigned-to | Top Level | ||
createddatetime | - | Date the document was created. Please use createddatetime instead. | string | 0..1 | DocumentReference | date | Top Level | |||
createduser | - | The user who created this document. | string | 0..1 | DocumentReference | extension.valueString | created-user | Top Level | ||
deleteddatetime | - | Date/time (ISO 8601) the document was deleted. | string | 0..1 | DocumentReference | extension.valueDatetime | deleted-datetime | Top Level | ||
departmentid | - | Department for the document. | string | 0..1 | DocumentReference | extension.valueString | department-id | Top Level | ||
description | - | Description of the document type. | string | 0..1 | DocumentReference | category.coding.display | Top Level | |||
documentdata | - | Text data associated with this document. | string | 0..1 | DocumentReference | content.attachment.data | Top Level | |||
documentsource | - | Explains where this document originated. | string | 0..1 | DocumentReference | extension.valueString | document-source | Top Level | ||
documentsubclass | - | Specific type of document. | string | 0..1 | DocumentReference | category.extension.valueString | document-subclass | Top Level | ||
encounterdate | - | Date of the encounter associated with this document. | string | 0..1 | DocumentReference | context.extension | encounter-date | Top Level | ||
encounterdocumentid | - | The primary key for encounter document class of documents. | integer | 0..1 | DocumentReference | id | Top Level | |||
encounterid | - | Encounter ID. | string | 0..1 | DocumentReference | context.encounter.reference | Top Level | |||
entitytype | - | Type of entity creating the document. Possible values are PROVIDER, PATIENT and OTHERS. | string | 0..1 | DocumentReference | extension.valueString | entity-type | Top Level | ||
internalnote | - | The 'Internal Note' attached to this document. | string | 0..1 | DocumentReference | extension.valueString | internal-note | Top Level | ||
lastmodifieddate | - | Date/time (ISO 8601) the document was last modified. | string | 0..1 | DocumentReference | extension.valueDateTime | last-modified-date | Top Level | ||
lastmodifieduser | - | The user who last modified this document. | string | 0..1 | DocumentReference | extension.valueString | last-modified-user | Top Level | ||
pages.contenttype | - | The content-type that will be returned by the page image call. | string | 0..1 | DocumentReference | content.attachment.contentType | Top Level | |||
pages.href | - | The URL to get the document image. | string | 0..1 | DocumentReference | content.attachment.url | Top Level | |||
pages.pageid | - | The ID to use in a call to get the page image. | string | 0..1 | DocumentReference | content.attachment.id | Top Level | |||
pages.pageordering | - | Within this list of pages, the ordering (starting with 1). | string | 0..1 | DocumentReference | content.attachment.extension.valueString | page-ordering | Top Level | ||
patientid | - | The athenaNet patient ID. | integer | 0..1 | DocumentReference | subject.reference | Top Level | |||
priority | - | Document priority, when available. 1 is high, 2 is normal. Some labs use other numbers or characters that are lab-specific. | string | 0..1 | DocumentReference | extension.valueString | priority | Top Level | ||
providerid | - | Provider ID for this document. | integer | 0..1 | DocumentReference | author.reference | Top Level | |||
providerusername | - | The username of the provider associated with this lab result document. | string | 0..1 | DocumentReference | author.reference.display | Top Level | |||
status | - | Status of the document. | string | 0..1 | DocumentReference | status | Top Level | |||
subject | - | Subject of the document. | string | 0..1 | DocumentReference | extension.valueString | subject | Top Level | ||
clinicalproviderid | - | The clinical provider ID of the performing provider. | number | 0..1 | DocumentReference | custodian.reference | Top Level | |||
declinedreasontext | - | The user-facing description of the reason the order was not given. | string | 0..1 | DocumentReference | extension.valueString | declined-reason-text | Top Level | ||
documentclass | - | Class of document. | string | 0..1 | DocumentReference | category.coding.code | Top Level | |||
documentdescription | - | Description of the document type. | string | 0..1 | DocumentReference | description | Top Level | |||
documentroute | - | Explains method by which the document was entered into the AthenaNet (INTERFACE (digital), FAX, etc.). | string | 0..1 | DocumentReference | extension.valueString | document-route | Top Level | ||
documenttype | - | The description for this document. | string | 0..1 | DocumentReference | extension.valueString | document-type | Top Level | ||
documenttypeid | - | The ID of the description for this document. | number | 0..1 | DocumentReference | extension.valueString | document-type-id | Top Level | ||
externalaccessionid | - | The external accession ID for this document. Format depends on the system the ID belongs to. | string | 0..1 | DocumentReference | extension.valueString | external-accession-id | Top Level | ||
externalnote | - | External note for the patient. | string | 0..1 | DocumentReference | extension.valueString | external-note | Top Level | ||
internalaccessionid | - | The internal accession ID for this document. Format depends on the system the ID belongs to. | string | 0..1 | DocumentReference | extension.valueString | internal-accession-id | Top Level | ||
internalnote | - | The 'Internal Note' attached to this document. | string | 0..1 | DocumentReference | extension.valueString | internal-note | Top Level | ||
lastmodifieddatetime | - | Date/time (ISO 8601) the document was last modified. | string | 0..1 | DocumentReference | extension.valueDateTime | last-modified-datetime | Top Level | ||
observationdatetime | - | Date/time (ISO 8601) the observation was taken. | string | 0..1 | DocumentReference | extension.valueDateTime | observation-datetime | Top Level | ||
tietoorderid | - | Order ID of the order this document is tied to, if any. | number | 0..1 | DocumentReference | context.related.reference | Top Level | |||
receivernote | - | External note sent to the receiving facility. | string | 0..1 | DocumentReference | extension.valueString | receiver-note | Top Level | ||
declinedreason.code | - | The code indicating why the order was not given. | string | 0..1 | DocumentReference | extension.valueCodeableConcept.code | declined-reason | Top Level | ||
declinedreason.description | - | The codeset that the code belongs to. | string | 0..1 | DocumentReference | extension.valueCodeableConcept.display | Top Level | |||
declinedreason.codeset | - | The plaintext description of the reason the order was not given. | string | 0..1 | DocumentReference | extension.valueCodeableConcept.system | Top Level | |||
contraindicationreason.code | - | The code indicating why the order was contraindicated. | String | 0..1 | DocumentReference | extension[*].valueCodableConcept.coding[1].code | - | - | contraindication-reason | Top Level |
contraindicationreason.codeset | - | The codeset that the code belongs to. | String | 0..1 | DocumentReference | extension[*].valueCodableConcept.coding[1].system | - | - | contraindication-reason | Top Level |
contraindicationreason.description | - | The plaintext description of the contraindication reason. | String | 0..1 | DocumentReference | extension[*].valueCodableConcept.coding[1].display | - | - | contraindication-reason | Top Level |