Encounter Review Of Systems
Source Object: Encounter Review Of Systems
Overview and Usage: The "Encounter Review Of Systems" source object in athena EHR plays a crucial role in documenting a patient's review of systems during healthcare encounters. It captures information related to a patient's self-reported symptoms and issues in different body systems, aiding healthcare providers in understanding and addressing the patient's medical condition. Here's an overview of key fields and their usage:
- Review of Systems: "reviewofsystems" contains details of the patient's self-reported symptoms, observations, and issues related to various body systems. It allows healthcare providers to gather comprehensive information about the patient's health status.
- Last Modified By: "lastmodifiedby" specifies the user or entity responsible for the last modification of the review of systems data, facilitating tracking of changes and updates.
- Last Modified Date and Time: "lastmodifieddatetime" records the date and time when the review of systems data was last modified.
- Reported By: "reportedby" may indicate the source of the reported information, whether it was reported by the patient, a caregiver, or another healthcare provider.
- Section Note: "sectionnote" provides a space for additional notes or comments related to the review of systems, allowing for supplementary information or context.
- Section Note Last Modified By: "sectionnotelastmodifiedby" records the user or entity responsible for the last modification of the section note within the review of systems data.
- Section Note Last Modified Date and Time: "sectionnotelastmodifieddatetime" captures the date and time when the section note was last modified.
- Summary Text: "summarytext" may offer a summarized version of the patient's reported symptoms and issues, providing a concise overview of the patient's health status.
- Template Data: "templatedata" can contain structured template data related to the review of systems, ensuring consistent and standardized documentation.
- Templates: "templates" indicate the specific templates or forms used for capturing review of systems information, which may vary based on clinical specialties or encounter types.
- Well Child Review of Systems: In cases involving pediatric care, the fields with "wellchild" prefixes serve a similar purpose but specifically pertain to well child visits and the review of systems for pediatric patients.
- Replace Section Note: "replacesectionnote" may be used to specify a replacement or updated section note, allowing for the modification of section notes within the review of systems data.
- Well Child Replace Section Note: "wellchildreplacesectionnote" is the equivalent of "replacesectionnote" but applies to well child visits.
- Template IDs: "templateids" and "wellchildtemplateids" can be used to identify the specific templates or forms associated with the review of systems data.
The "Encounter Review Of Systems" source object is essential for healthcare providers to document and understand a patient's self-reported symptoms and issues across different body systems. It facilitates accurate diagnosis, treatment planning, and care coordination. Developers can utilize this source object to build features and applications that enhance the documentation and management of review of systems data within athena EHR.
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 |
|---|---|---|---|---|---|---|---|---|---|---|
| hpitoros | - | Whether ROS is as noted in HPI. | string | 0..1 | Encounter | extension.valueString | hpi-to-ros | Top Level | ||
| lastmodifiedby | - | A string representing the username of the user who last modified the review of systems section. | string | 0..1 | Encounter | extension.valueString | ros-last-modified-by | Top Level | ||
| lastmodifieddatetime | - | The last time any information in the review of systems section was modified. | string | 0..1 | Encounter | extension.valueDateTime | ros-last-modified-datetime | Top Level | ||
| reportedby | - | The type of person who reported information for the review of systems template. One of Patient, Parent, Caregiver, or Staff. | string | 0..1 | Encounter | extension.valueString | ros-reported-by | Top Level | ||
| reviewofsystems | - | The structured review of systems data. It is structured as a list of paragraphs, each containing a list of sentences, each containing a list of findings. | array | 0..1 | Encounter | extension.valueString | review-of-systems | Top Level | ||
| sectionnote | - | The structured section-level note for the review of systems section. | string | 0..1 | Encounter | extension.valueString | ros-section-note | Top Level | ||
| sectionnotelastmodifiedby | - | A string representing the username of a the user who last modified the review of systems section note. | string | 0..1 | Encounter | extension.valueString | ros-section-note-last-modified-by | Top Level | ||
| sectionnotelastmodifieddatetime | - | The last time the review of systems section note was modified. | string | 0..1 | Encounter | extension.valueDateTime | ros-section-note-last-modified-datetime | Top Level | ||
| summarytext | - | The unstructured review of systems summary. | string | 0..1 | Encounter | extension.valueString | ros-summary-text | Top Level | ||
| templatedata | - | An array of objects each containing the name and id for review of systems templates attached to the encounter. | array | 0..1 | Encounter | extension.valueString | ros-template-data | Top Level | ||
| templates | - | The comma separated list of selected review of systems templates used. | string | 0..1 | Encounter | extension.valueString | ros-templates | Top Level | ||
| wellchildlastmodifiedby | - | A string representing the username of the user who last modified the well child review of systems section. | string | 0..1 | Encounter | extension.valueString | well-child-last-modified-by | Top Level | ||
| wellchildlastmodifieddatetime | - | The last time any information in the well child review of systems section was modified. | string | 0..1 | Encounter | extension.valueDateTime | well-child-last-modified-datetime | Top Level | ||
| wellchildreportedby | - | The type of person who reported information for the well child review of systems template. One of Patient, Parent, Caregiver, or Staff. | string | 0..1 | Encounter | extension.valueString | well-child-reported-by | Top Level | ||
| wellchildros | - | The structured well child review of systems data. It is structured as a list of paragraphs, each containing a list of sentences, each containing a list of findings. This is targeted towards children but behaves the same as any other review of systems templates. | array | 0..1 | Encounter | extension.valueString | well-child-ros | Top Level | ||
| wellchildsectionnote | - | The structured section-level note for the well child review of systems section. | string | 0..1 | Encounter | extension.valueString | well-child-section-note | Top Level | ||
| wellchildsectionnotelastmodifiedby | - | A string representing the username of a the user who last modified the well child review of systems section note. | string | 0..1 | Encounter | extension.valueString | well-child-section-note-last-modified-by | Top Level | ||
| wellchildsectionnotelastmodifieddatetime | - | The last time the well child review of systems section note was modified. | string | 0..1 | Encounter | extension.valueDateTime | well-child-section-note-last-modified-datetime | Top Level | ||
| wellchildsummarytext | - | The unstructured well child review of systems summary. | string | 0..1 | Encounter | extension.valueString | well-child-summary-text | Top Level | ||
| wellchildtemplatedata | - | An array of objects each containing the name and id for well child review of systems templates attached to the encounter. | array | 0..1 | Encounter | extension.valueString | well-child-template-data | Top Level | ||
| wellchildtemplates | - | The comma separated list of selected well child review of systems templates used. | string | 0..1 | Encounter | extension.valueString | well-child-templates | Top Level | ||
| replacesectionnote | - | If true, will replace the existing section note with the new one. If false, will append to the existing note. | boolean | 0..1 | Encounter | extension.valueBoolean | ros-replace-section-note | Top Level | ||
| wellchildreplacesectionnote | - | If true, will replace the existing section note with the new one. If false, will append to the existing note. | boolean | 0..1 | Encounter | extension.valueBoolean | well-child-replace-section-note | Top Level | ||
| templateids | - | This is a JSON array of the template ids that should remain on (or be added to) the ROS. Any template ids not included in this list will be removed from the ROS. | array | 0..1 | Encounter | extension.valueString | ros-template-ids | Top Level | ||
| wellchildtemplateids | - | This is a JSON array of the well child template ids that should remain on (or be added to) the ROS. Any template ids not included in this list will be removed from the well child ROS section. | array | 0..1 | Encounter | extension.valueString | well-child-template-ids | Top Level |