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 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 |
---|---|---|---|---|---|---|---|---|---|---|
appointmentid | - | The appointment ID for this document. | integer | 0..1 | DocumentReference | context.related.reference | ||||
assignedto | - | Person the document is assigned to. | string | 0..1 | DocumentReference | extension.valueString | assigned-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. | integer | 0..1 | DocumentReference | custodian.reference | ||||
createddatetime | - | Date/Time (ISO 8601) the document was created. | string | 0..1 | DocumentReference | date | ||||
deleteddatetime | - | Date/time (ISO 8601) the document was deleted. | string | 0..1 | DocumentReference | extension.valueDateTime | deleted-datetime | |||
departmentid | - | Department for the document. | string | 0..1 | DocumentReference | extension.valueString | department-id | |||
documentclass | - | Class of document. | string | 0..1 | DocumentReference | category.coding.code | ||||
documentdescription | - | Description of the document type. | string | 0..1 | DocumentReference | description | ||||
documentroute | - | Explains method by which the document was entered into the athenaNet (INTERFACE (digital), FAX, etc.). | string | 0..1 | DocumentReference | extension.valueString | document-route | |||
documentsource | - | Explains where this document originated. | string | 0..1 | DocumentReference | extension.valueString | document-source | |||
documentsubclass | - | Specific type of document. | string | 0..1 | DocumentReference | category.extension.valueString | document-subclass | |||
documenttype | - | The description for this document. | string | 0..1 | DocumentReference | extension.valueString | document-type | |||
documenttypeid | - | The ID of the description for this document. | integer | 0..1 | DocumentReference | extension.valueString | document-type-id | |||
encounterid | - | Encounter ID. | string | 0..1 | DocumentReference | context.encounter.reference | ||||
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 | |||
externalnote | - | External note for the patient. | string | 0..1 | DocumentReference | extension.valueString | external-note | |||
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 | |||
internalnote | - | The 'Internal Note' attached to this document. | string | 0..1 | DocumentReference | extension.valueString | internal-note | |||
interpretationid | - | The primary key for interpretation class of documents. | number | 0..1 | DocumentReference | id | ||||
lastmodifieddatetime | - | Date/time (ISO 8601) the document was last modified. | string | 0..1 | DocumentReference | extension.valueDateTime | last-modified-datetime | |||
observationdatetime | - | Date/time (ISO 8601) the observation was taken. | string | 0..1 | DocumentReference | extension.valueDateTime | observation-datetime | |||
patientid | - | The athenaNet patient ID. | integer | 0..1 | DocumentReference | subject.reference | ||||
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 | |||
providerid | - | Provider ID for this document. | integer | 0..1 | DocumentReference | author.reference | ||||
receivernote | - | The external note sent to the receiving facility. | string | 0..1 | DocumentReference | extension.valueString | receiver-note | |||
status | - | Status of the document. | string | 0..1 | DocumentReference | status | ||||
subject | - | Subject of the document. | string | 0..1 | DocumentReference | extension.valueString | subject | |||
tietoorderid | - | Order ID of the order this document is tied to, if any. | integer | 0..1 | DocumentReference | context.related.reference |