Medical Record
Source Object: Medical Record
Overview and Usage: The "Medical Record" source object in the athena EHR system is used for managing and storing a patient's medical records and documents. It is essential for maintaining a comprehensive patient history. Developers can utilize this object to access and update medical records. Key data fields include:
- Appointment ID: Identifies the appointment associated with the medical record.
- Assigned To: Specifies the entity or user assigned to the medical record.
- Clinical Provider ID: Represents the ID of the clinical provider associated with the record.
- Contraindication Reason (Code, Description, Code Set): Describes contraindication reasons related to the record.
- Created Date and Time: Records the date and time when the medical record was created.
- Declined Reason (Code, Description, Code Set): Indicates reasons for declining the record.
- Declined Reason Text: Provides additional text information for declined records.
- Deleted Date and Time: Specifies when the record was deleted, if applicable.
- Department ID: Identifies the department associated with the record.
- Document Class and Description: Classifies the type and description of the medical document.
- Document Route, Source, Subclass, Type, and Type ID: Details of the document's routing, source, subclass, type, and type ID.
- Encounter ID: Links the medical record to a specific patient encounter.
- External Accession ID and Note: External identifiers and notes for the record.
- Internal Accession ID and Note: Internal identifiers and notes for the record.
- Last Modified Date and Time: Records the date and time of the last modification to the record.
- Medical Record ID: A unique identifier for the medical record.
- Observation Date and Time: Indicates the date and time of the observation recorded.
- Patient ID: Identifies the patient associated with the record.
- Priority: Specifies the priority level of the medical record.
- Provider ID: Identifies the provider associated with the record.
- Receive Note: Contains additional notes related to record receipt.
- Status: Represents the status of the medical record.
- Subject: Describes the subject of the medical record.
- Tieto Order ID: Identifies the order associated with the record.
- Document Data: Stores data related to the document.
- Facility ID: Identifies the facility associated with the record.
- Original Document (Content Type, HREF): Information about the original document, including content type and HREF.
- Pages (Content Type, HREF, Page ID, Page Ordering): Details of individual pages within the document.
Developers can use the "Medical Record" source object to create applications for efficient management and retrieval of patient medical records, ensuring that healthcare providers have quick access to essential patient 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 |
|---|---|---|---|---|---|---|---|---|---|---|
| appointmentid | - | The appointment ID for this document. | number | 0..1 | DocumentReference | context.related.reference | Top Level | |||
| assignedto | - | Person the document is assigned to. | string | 0..1 | DocumentReference | extension.valueString | assigned-to | Top Level | ||
| clinicalproviderid | - | The clinical provider ID of the performing provider. | number | 0..1 | DocumentReference | custodian.reference | Top Level | |||
| contraindicationreason.code | - | List of codes indicating why the order was contraindicated (for vaccines only). If this field is not present, the order does not contain a contraindication reason. | array | 0..1 | DocumentReference | extension.valueCodeableConcept.code | contraindication-reason | Top Level | ||
| contraindicationreason.description | - | List of codes indicating why the order was contraindicated (for vaccines only). If this field is not present, the order does not contain a contraindication reason. | array | 0..1 | DocumentReference | extension.valueCodeableConcept.display | Top Level | |||
| contraindicationreason.codeset | - | List of codes indicating why the order was contraindicated (for vaccines only). If this field is not present, the order does not contain a contraindication reason. | array | 0..1 | DocumentReference | extension.valueCodeableConcept.system | Top Level | |||
| createddatetime | - | Date/Time (ISO 8601) the document was created. | string | 0..1 | DocumentReference | date | Top Level | |||
| declinedreason.code | - | List of codes indicating why the order was not given. If this field is not present, the order was not declined. If the array is empty, no reason has been chosen. | array | 0..1 | DocumentReference | extension.valueCodeableConcept.code | declined-reason | Top Level | ||
| declinedreason.description | - | List of codes indicating why the order was not given. If this field is not present, the order was not declined. If the array is empty, no reason has been chosen. | array | 0..1 | DocumentReference | extension.valueCodeableConcept.display | declined-reason | Top Level | ||
| declinedreason.codeset | - | List of codes indicating why the order was not given. If this field is not present, the order was not declined. If the array is empty, no reason has been chosen. | array | 0..1 | DocumentReference | extension.valueCodeableConcept.system | declined-reason | 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 | ||
| 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 | ||
| 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 | ||
| documentsource | - | Explains where this document originated (e.g. ENCOUNTER, PORTAL, etc.). | 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 | ||
| 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 | ||
| encounterid | - | Encounter ID. | string | 0..1 | DocumentReference | context.encounter.reference | 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 | ||
| medicalrecordid | - | The primary key for medicalrecord class of documents. | number | 0..1 | DocumentReference | id | Top Level | |||
| observationdatetime | - | Date/time (ISO 8601) the observation was taken. | string | 0..1 | DocumentReference | extension.valueDateTime | observation-datetime | Top Level | ||
| patientid | - | The athenaNet patient ID. | number | 0..1 | DocumentReference | subject.reference | Top Level | |||
| priority | - | Document priority, when available. | number | 0..1 | DocumentReference | extension.valueString | priority | Top Level | ||
| providerid | - | Provider ID for this document. | number | 0..1 | DocumentReference | author.reference | Top Level | |||
| receivernote | - | External note sent to the receiving facility. | string | 0..1 | DocumentReference | extension.valueString | receiver-note | 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 | ||
| tietoorderid | - | Order ID of the order this document is tied to, if any. | number | 0..1 | DocumentReference | context.related.reference | Top Level | |||
| deleteddatetime | - | Date/time (ISO 8601) the document was deleted. | string | 0..1 | DocumentReference | extension.valueDateTime | deleted-datetime | Top Level | ||
| documentdata | - | Text data associated with this document. | string | 0..1 | DocumentReference | extension.valueString | document-data | Top Level | ||
| facilityid | - | 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 | Top Level | |||
| originaldocument.contenttype | - | The content-type of the original document. | string | 0..1 | DocumentReference | content.attachment.contentType | Top Level | |||
| originaldocument.href | - | The URL to get the original document. | string | 0..1 | DocumentReference | content.attachment.url | 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 |