Document Reference
Document Reference
Introduction
The Document Reference data model is a critical component of our healthcare platform, designed to provide comprehensive information regarding the status of clinical documents for patients. These documents track the handling and availability of medical records throughout a patient's healthcare journey. Leveraging the TXA HL7 segment and other relevant fields, this model offers invaluable insights into document management and patient care.
Use Case
Developers can leverage the Document Reference data model for a variety of use cases in the healthcare domain:
- Patient Record Management: Developers can use this model to access and manage patient records, including their availability status, completeness, and confidentiality. This is crucial for ensuring that healthcare providers have access to the most up-to-date and accurate patient information.
- Document Tracking: With the unique_document_number and activity_datetime fields, developers can track the movement and handling of clinical documents within the healthcare system. This information is essential for auditing and compliance purposes.
- Document Availability: The document_availability_status field allows developers to check whether specific documents are available or if they are still pending. This information can be used to trigger notifications or workflow actions when documents become accessible.
- Document Completion: Developers can query the document_completion_status field to identify incomplete documents that require further action or additional information. This helps ensure that patient records are comprehensive and accurate.
- Document Confidentiality: The document_confidentiality_status field provides insights into the confidentiality level of clinical documents. Developers can use this information to implement access controls and comply with privacy regulations.
- Document Origination: The origination_datetime field enables developers to determine when clinical documents were originally created or added to the patient's record. This information can be used to identify the age and relevance of documents.
- Transcription Management: Developers can leverage the transcription_datetime field to track when clinical documents were transcribed, helping to monitor the timeliness of data entry and document updates.
- Document Retrieval: Healthcare providers often need to retrieve specific documents quickly. Developers can build search and retrieval functionalities using the document_id and other relevant fields to facilitate efficient document access.
- Compliance and Auditing: The Document Reference model supports compliance efforts by providing a comprehensive audit trail of document activities. Developers can use this data for compliance reporting and monitoring.
Data Fields
| Field Name | Description | HL7 Mapping | Data Type | Label | Use Case |
|---|---|---|---|---|---|
| patient_id | Id of the patient | PID-3-1 | string | Patient ID | The patient ID is a unique identifier assigned to a patient within the healthcare system. It is used to accurately identify and link a patient's medical records, treatments, and history. |
| document_format | Document Format | Not Mapped | string | Document Format | "Document Format" typically refers to the format or structure used for electronic healthcare documents, such as clinical notes, reports, and other medical documents. These documents are often exchanged electronically within healthcare systems to facilitate data sharing and record-keeping. |
| document_storage_status | Document Storage Status | TXA-20 | string | Document Storage Status | "Document Storage Status" typically refers to the status or condition of a healthcare document. This status provides information about the document's current state within the healthcare system, including whether it has been stored, archived, finalised, or is in a draft or preliminary form. |
| unique_document_number | Unique Document Number | TXA-12-1 | string | Unique Document Number | This field usually contains the unique document number. It is a system-assigned identifier that distinguishes one document from another. The format and structure of this identifier can vary based on the organization's conventions and standards. |
| encounter_id | Encounter ID | PV1+MSH-10 | string | Encounter ID | This unique identifier is used to associate various HL7 messages with a specific patient encounter or visit. It ensures that data and events are accurately linked to the correct patient's healthcare journey. |
| document_availability_status | Document Availability Status | TXA-19 | string | Document Availability Status | This field often contains information about the availability status of the document. It may use codes or values to indicate whether the document is "Available," "Unavailable," "Archived," "Deleted," or in another state that reflects its accessibility. |
| document_completion_status | Document Completion Status | TXA-17 | string | Document Completion Status | This field often contains information about the completion status of the document. It may use codes or values to indicate whether the document is "Final," "Draft," "Corrected," "Preliminary," or in another state that reflects its completeness. |
| batch_id | Batch id | System Generated | string | Batch ID | "batch ID" is a unique identifier assigned to a group of messages that are logically grouped together for processing or transmission. Batching messages is a common practice in healthcare systems to efficiently manage and transmit multiple messages as a single unit |
| document_id | Id of document | TXA+MSH-10 | string | Document ID | "Document ID" typically refers to a unique identifier associated with a healthcare document. This identifier serves to uniquely distinguish one document from another and is essential for tracking, referencing, and managing documents within the healthcare system. |
| lineage | This is lineage attribute | Fixed - HL7 | string | Lineage | "lineage" refers to the information about the origin or source of a message. It helps trace the path of the message, indicating where it originated, how it was transmitted, and any intermediate systems or components it passed through before reaching its destination. |
| document_type | Type of document | TXA-2 | string | Document Type | This field contains information about the document's type or category. It helps classify the document based on its content and purpose. The content of this field may include codes or descriptive text that indicate the document's type. |
| document_content_presentation | Document Content Presentation | Not Mapped | string | Document Content Presentation | "Document Content Presentation" typically refers to information related to how the content of a healthcare document is presented or formatted. It may include details about the layout, structure, and style of the document's content. |
| document_content_raw | Document Content Raw | OBX-5 | text | Document Content Raw | This field contains the raw, unprocessed content of an observation or result. This field typically holds the actual textual information or data associated with the observation. |
| unique_document_file_name | Unique Document File Name | TXA-16 | string | Unique Document File Name | This field often contains the unique filename or identifier associated with the electronic file that stores the document. It serves as a key reference to access the document when needed for clinical decision-making, legal compliance, and other purposes. |
| activity_datetime | Activity Datetime | TXA-4 | date | Activity Datetime | This field in the TXA segment often contains the date and time when the activity or event related to the document took place. This information is valuable for tracking and auditing changes made to documents, ensuring the accuracy of timestamps, and understanding the timeline of document creation and modification. |
| description | Description of document | TXA-15 | string | Document Description | This field often contains a description of the document. The document description is valuable for healthcare professionals and users to quickly understand the nature and relevance of the document. |
| visit_number | Id of the visit | PV1-19-1 | string | Visit Number | This field contains a unique identifier for a specific patient visit or encounter within a healthcare facility. It serves as a reference number for tracking and managing patient visits. |
| transcription_datetime | Transcription Datetime | TXA-7 | date | Transcription Datetime | The transcription datetime represents the date and time when a document or observation result was transcribed or recorded. It helps establish when the document's content was captured in the system. |
| document_confidentiality_status | Document Completion Status | TXA-18 | string | Document Confidentiality Status | The document confidentiality status indicates the level of confidentiality or sensitivity of a healthcare document. It includes categorising documents as "Confidential," "Restricted," "Normal," or other levels based on organizational policies. |
| bundle_id | ID of bundle | MSH-10 | string | Bundle ID | “bundle ID" typically refers to a unique identifier assigned to a group or bundle of related messages or data elements. This identifier is used to associate multiple messages or pieces of information that are related to a specific patient, event, or transaction. |
| document_url | Document Url | OBX-5 | string | Document Url | The "document_url" represents a Uniform Resource Locator (URL) that points to the location of a document or resource, often an electronic document, in a healthcare system or external repository. |
| notes_specialty | Notes Specialty | ZTX-2 | string | Notes Specialty | Notes Specialty typically refers to a field within a healthcare record or message that specifies the particular medical specialty or category to which a clinical note or document belongs. |
| origination_datetime | Origination Datetime | TXA-6 | date | Origination Datetime | Theis field serves as a timestamp for when the clinical document was initially created or authored. It helps in tracking the timing of document creation and is useful for managing and organising clinical documents. |
| document_content_text | Document Content Text | Derived from OBX-5 | text | Document Content Text | This field is often used to convey clinical notes, such as progress notes, discharge summaries, or narrative descriptions of findings. It can be used to provide textual explanations or interpretations of numeric or structured data presented in other parts of the HL7 message. |
| alternate_visit_id | Alternative visit id | PV1-50/PID-18 | string | Alternate Visit Id | This field provides an alternate identifier for a patient's visit. It is used for tracking and cross-referencing patient visits and records, especially in scenarios requiring multiple identifiers or references. This field is recorded during patient registration and aids in accurate record linkage. |
| xc_visit_id | XC visit id | Based on alternate_visit_id followed by visit_number followed by system generated ID | string | XC visit id | The "xc_visit_id" is a unique identifier used to group together all the interactions, procedures, tests, and check-ups associated with a single patient visit in a healthcare setting. This identifier helps in organising and managing various activities and data related to that specific patient encounter. |
| edit_datetime | Edit Datetime | TXA-8 | date | Edit Datetime | This field serves as a timestamp for the most recent edit or modification made to a clinical document. It helps in tracking when changes were made to the document and who made those changes. |
| document_change_reason | Document Change Reason | TXA-21 | string | Document Change Reason | This field is used to explain why a particular change or modification was made to a clinical document. It helps in tracking and documenting the reasons behind changes to clinical documents, providing a record of justifications. |
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