xCaliber healthCare Data Mesh

Interpretation Document

Source Object: Interpretation Document

Overview and Usage: The "Interpretation Document" source object in athena EHR is designed to capture and manage documents related to medical interpretations and findings. This data is critical for documenting clinical interpretations, lab results, and other diagnostic information. Key data fields include:

  • Appointment ID: Contains the unique identifier of the associated appointment.
  • Assigned To: Specifies the individual or entity responsible for the interpretation.
  • Clinical Provider ID: Identifies the healthcare provider involved in the interpretation.
  • Created Date and Time: Records when the document was created.
  • Deleted Date and Time: Indicates when the document was deleted, if applicable.
  • Department ID: Identifies the department or healthcare facility where the document was generated.
  • Document Class, Description, Route, Source, Subclass: Categorize and describe the document for easy reference.
  • Document Type and Type ID: Define the type of document and its unique identifier.
  • Encounter ID: Links the document to a specific patient encounter.
  • External Accession ID: Provides an external reference for the document.
  • External Note: Contains additional notes or information for external use.
  • Internal Accession ID: Offers an internal reference for the document.
  • Internal Note: Stores internal comments or annotations.
  • Interpretation ID: A unique identifier for the interpretation document.
  • Last Modified Date and Time: Indicates when the document was last modified.
  • Observation Date and Time: Records the date and time of the observation.
  • Patient ID: Contains the unique identifier of the patient.
  • Priority: Specifies the document's priority level.
  • Provider ID: Identifies the healthcare provider associated with the document.
  • Receive Note: Captures notes related to receiving the document.
  • Status: Describes the current status of the interpretation.
  • Subject: Contains a subject or title for the document.
  • Tieto Order ID: An identifier for the document associated with a specific order.

Developers can leverage the "Interpretation Document" source object to build applications that streamline the management of medical interpretations and findings. These applications can facilitate the creation, storage, retrieval, and sharing of interpretation documents, ensuring that clinical information is accurately documented and readily accessible within the athena EHR system. This is vital for healthcare professionals and organizations to provide quality care and maintain comprehensive patient records.

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
appointmentid-The appointment ID for this document.integer0..1DocumentReferencecontext.related.reference
assignedto-Person the document is assigned to.string0..1DocumentReferenceextension.valueStringassigned-to
clinicalproviderid-The ID of the clinical provider associated with this clinical document. Clinical providers are a master list of providers throughout the country. These include providers as well as radiology centers, labs and pharmacies.integer0..1DocumentReferencecustodian.reference
createddatetime-Date/Time (ISO 8601) the document was created.string0..1DocumentReferencedate
deleteddatetime-Date/time (ISO 8601) the document was deleted.string0..1DocumentReferenceextension.valueDateTimedeleted-datetime
departmentid-Department for the document.string0..1DocumentReferenceextension.valueStringdepartment-id
documentclass-Class of document.string0..1DocumentReferencecategory.coding.code
documentdescription-Description of the document type.string0..1DocumentReferencedescription
documentroute-Explains method by which the document was entered into the athenaNet (INTERFACE (digital), FAX, etc.).string0..1DocumentReferenceextension.valueStringdocument-route
documentsource-Explains where this document originated.string0..1DocumentReferenceextension.valueStringdocument-source
documentsubclass-Specific type of document.string0..1DocumentReferencecategory.extension.valueStringdocument-subclass
documenttype-The description for this document.string0..1DocumentReferenceextension.valueStringdocument-type
documenttypeid-The ID of the description for this document.integer0..1DocumentReferenceextension.valueStringdocument-type-id
encounterid-Encounter ID.string0..1DocumentReferencecontext.encounter.reference
externalaccessionid-The external accession ID for this document. Format depends on the system the ID belongs to.string0..1DocumentReferenceextension.valueStringexternal-accession-id
externalnote-External note for the patient.string0..1DocumentReferenceextension.valueStringexternal-note
internalaccessionid-The internal accession ID for this document. Format depends on the system the ID belongs to.string0..1DocumentReferenceextension.valueStringinternal-accession-id
internalnote-The 'Internal Note' attached to this document.string0..1DocumentReferenceextension.valueStringinternal-note
interpretationid-The primary key for interpretation class of documents.number0..1DocumentReferenceid
lastmodifieddatetime-Date/time (ISO 8601) the document was last modified.string0..1DocumentReferenceextension.valueDateTimelast-modified-datetime
observationdatetime-Date/time (ISO 8601) the observation was taken.string0..1DocumentReferenceextension.valueDateTimeobservation-datetime
patientid-The athenaNet patient ID.integer0..1DocumentReferencesubject.reference
priority-Document priority, when available. 1 is high, 2 is normal. Some labs use other numbers or characters that are lab-specific.string0..1DocumentReferenceextension.valueStringpriority
providerid-Provider ID for this document.integer0..1DocumentReferenceauthor.reference
receivernote-The external note sent to the receiving facility.string0..1DocumentReferenceextension.valueStringreceiver-note
status-Status of the document.string0..1DocumentReferencestatus
subject-Subject of the document.string0..1DocumentReferenceextension.valueStringsubject
tietoorderid-Order ID of the order this document is tied to, if any.integer0..1DocumentReferencecontext.related.reference