Patient Record
Source Object: Patient Record
Overview and Usage The "Patient Record" source object contains essential data related to patient records, including details of clinical documents, appointments, and medical history.
- Appointment ID: Unique identifier for the associated appointment.
- Assigned To: The healthcare provider or entity responsible for the patient's record.
- Clinical Provider ID: Identifier for the clinical provider involved in the record.
- Contraindication Reason: Reason for any contraindications, including code, codeset, and description.
- Declined Reason: Reason for any declined actions, including code, codeset, and description.
- Created Date and Time: Date and time when the record was created.
- Deleted Date and Time: Date and time when the record was deleted or marked for deletion.
- Department ID: Identifier for the department associated with the record.
- Document Class: The class of the document related to the record.
- Document Description: Description of the document.
- Document Route: The route used for the document.
- Document Source: The source of the document.
- Document Subclass: The subclass of the document.
- Document Type: Type of the document.
- Document Type ID: Identifier for the document type.
- Encounter ID: Identifier for the patient encounter.
- External Accession ID: External identifier for accessing the record.
- External Note: Additional notes or comments for external reference.
- Internal Accession ID: Internal identifier for accessing the record.
- Internal Note: Internal notes or comments associated with the record.
- Last Modified Date and Time: Date and time of the last modification to the record.
- Observation Date and Time: Date and time of observations or events within the record.
- Patient ID: Unique identifier for the patient.
- Priority: Priority level or status of the record.
- Provider ID: Identifier for the healthcare provider.
- Receive Note: Notes or comments related to the receipt of the record.
- Status: The status of the record (e.g., active, deleted).
- Subject: The subject or main topic of the record.
- Tieto Order ID: Identifier for Tieto orders associated with the record.
The "Patient Record" source object is central to maintaining patient records and ensuring the proper documentation of patient healthcare information. It helps facilitate patient care, record-keeping, and data management.
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 | - | The code indicating why the order was contraindicated. | string | 0..1 | DocumentReference | extension.valueCodeableConcept.code | contraindication-reason | Top Level | ||
contraindicationreason.codeset | - | The codeset that the code belongs to. | string | 0..1 | DocumentReference | extension.valueCodeableConcept.system | Top Level | |||
contraindicationreason.description | - | The plaintext description of the contraindication reason. | string | 0..1 | DocumentReference | extension.valueCodeableConcept.display | Top Level | |||
createddatetime | - | Date/Time (ISO 8601) the document was created | string | 0..1 | DocumentReference | date | Top Level | |||
declinedreason.code | - | The code indicating why the order was contraindicated. | string | 0..1 | DocumentReference | extension.valueCodeableConcept.code | declined-reason | Top Level | ||
declinedreason.codeset | - | The codeset that the code belongs to. | string | 0..1 | DocumentReference | extension.valueCodeableConcept.system | Top Level | |||
declinedreason.description | - | The plaintext description of the contraindication reason. | string | 0..1 | DocumentReference | extension.valueCodeableConcept.display | 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 | ||
patientrecordid | - | The primary key for patientrecord class of documents | number | 0..1 | DocumentReference | id | 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 | ||
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 |