DOCS_RCVD_CLINICAL_NOTES

Description: |
This table contains metadata about clinical notes retrieved from external sources. Each row represents a discrete clinical note received in this document.

Primary Key

Column Name | Ordinal Position |
--- | --- | ---
DOCUMENT_ID | 1 |
CONTACT_DATE_REAL | 2 |
LINE | 3 |

Column Information

| Name | Type | Discontinued? |
--- | --- | --- | --- | ---
1 | DOCUMENT_ID | NUMERIC | No |
The unique identifier (.1 item) for the document record.
2 | CONTACT_DATE_REAL | FLOAT | No |
A unique contact date in decimal format. The integer portion of the number indicates the date of contact. The digits after the decimal distinguish different contacts on the same date and are unique for each contact on that date. For example, .00 is the first/only contact, .01 is the second contact, etc.
3 | LINE | INTEGER | No |
The line number for the information associated with this contact. Multiple pieces of information can be associated with this contact.
4 | CONTACT_DATE | DATETIME | No |
The date of this contact in calendar format.
5 | NOTE_REFERENCE_IDENT | VARCHAR | No |
The reference ID of the clinical note, which uniquely identifies the note.
6 | NOTE_EXTERNAL_UNIQUE_IDENT | VARCHAR | No |
The externally-assigned globally unique identifier for the clinical note.
7 | NOTE_LOCAL_UNIQUE_IDENT | VARCHAR | No |
The locally-assigned unique identifier for the clinical note.
8 | NOTE_FHIR_DOCREF_RESRC_IDENT | VARCHAR | No |
The logical ID of the FHIR Document Reference resource for the clinical note.
9 | NOTE_FHIR_DOCREF_ATTACHT_URL | VARCHAR | No |
The URL containing the content of the clinical note.
10 | NOTE_SOURCE_ORG_ID | NUMERIC | No |
The unique ID of the organization record that represents the original source of this clinical note.
11 | NOTE_SOURCE_ORG_ID_EXTERNAL_NAME | VARCHAR | No |
Organization's external name used as the display name on forms and user interfaces.
12 | NOTE_STATUS_C_NAME | VARCHAR | No |
The current status of the clinical note.
May contain organization-specific values: Yes
Category Entries:
Incomplete
Signed
Addendum
Deleted
Revised
Cosigned
Finalized
Unsigned
Cosign Needed
Incomplete Revision
Cosign Needed Addendum
Shared
13 | NOTE_SHARED_WITH_PAT_YN | VARCHAR | No |
Indicator of whether the clinical note was allowed to be shared with the patient at the source organization for the note. A Yes value does not imply the patient has actually viewed the note.
May contain organization-specific values: No
Category Entries:
No
Yes
14 | NOTE_UCN_TYPE_C_NAME | VARCHAR | No |
The mapped type of the clinical note in the Unified Clinical Notes framework.
May contain organization-specific values: Yes
Category Entries:
Progress Notes
Consults
Procedures
H&P
Discharge Summary
ED Notes
Initial Assessments
ED Triage Notes
Case Communication
OR Nursing
OR Surgeon
OR PreOp
OR PostOp
OR Anesthesia
Ambulatory Progress Notes
Ambulatory H&P Notes
Ambulatory Procedure Notes
Discharge Instructions
ED Provider Notes
Decision
Note to Patient via Portal
Anesthesia Preprocedure Evaluation
Anesthesia Postprocedure Evaluation
H&P (View-Only)
Interval H&P Note
Anesthesia Procedure Notes
Addendum Note
Care Plan
Hospital Course
Subjective & Objective
L&D Delivery Note
Telephone Encounter
Patient Instructions
Assessment & Plan Note
Communication Body
ED AVS Snapshot
Letter
Lactation Note
Committee Review
IP AVS Snapshot
MR AVS Snapshot
Pharmacy Enrollment Note
Pre-Procedure Assessment
Discharge Instr - Supplementary Instructions
Discharge Instr - AVS First Page
Discharge Instr - Meds
Discharge Instr - Pharmacy
Discharge Instr - Activity
Discharge Instr - Diet
Discharge Instr - Appointments
Discharge Instr - Lab
Discharge Instr - Other Orders
Discharge Instr - Other Info
CAA (Care Area Assessment)
Nursing Note
ACP (Advance Care Planning)
ERAS
Organ Offer
Result Encounter Note
Radiation Planning Notes
Radiation Completion Notes
Radiation Therapy Simulation Directive
Radiation Treatment Planning Directive
Radiation Treatment Management
Radiation Treatment Summary
Home Infusion
Form
BH Treatment Plan
Group Note
Video Visit Routing Comment
E-Visit Routing Comment
Claim Note
Multi-Disciplinary Team Discussion
Dialysis Plan of Care Note
Home Health Plan of Care Certification Statement
Home Health Plan of Care
Dialysis Monthly Comprehensive Note
Dialysis Rounding Note
SMD Notes
Unmapped External Note
Filtered External Note
Code Documentation
Sedation Documentation
JDT PCOD
Dental Procedure Details
Performed Procedure
Appeal Review
Appeal MD Review
Appeal Intake
Appeal Creation
Appeal External Review
Grievance Review
Grievance Resolution
Grievance Intake
Grievance Creation
Home Health
LTC Provider Review
Chart Abstraction
MR Safety Technologist Evaluation
MR Safety Medical Physics Exam Customization
MR Safety Implant Electronics Preparation
MR Safety Implant Positioning and Immobilization
Inpatient Self-Administration Sheet
Outpatient Self-Administration Sheet
Inpatient Medication Chart
Outpatient Medication Chart
Hospice
Hospice Plan of Care
Hospice Non-Covered
Hard Deleted Note
15 | NOTE_TYPE_NAME | VARCHAR | No |
The free-text description of the type of the clinical note.
16 | NOTE_LAST_FILED_UTC_DTTM | DATETIME (UTC) | No |
The instant the clinical note was last meaningfully modified at the note's source organization.
17 | NOTE_CREATION_UTC_DTTM | DATETIME (UTC) | No |
The instant the clinical note was originally created at the note's source organization.
18 | NOTE_LAST_SIGNED_UTC_DTTM | DATETIME (UTC) | No |
The instant the clinical note was most recently signed or co-signed.
19 | NOTE_LAST_SIGNER_NAME | VARCHAR | No |
The name of the individual that most recently signed or co-signed the clinical note.
20 | NOTE_AUTHOR_NAME | VARCHAR | No |
The name of the author of the clinical note.
21 | NOTE_AUTHOR_TYPE | VARCHAR | No |
The free-text description of the type of provider that authored the clinical note.
22 | NOTE_AUTHOR_SERVICE | VARCHAR | No |
The free-text description of the service associated with the authorship of the clinical note.
23 | NOTE_AUTHOR_SPECIALTY_C_NAME | VARCHAR | No |
The mapped provider specialty of the author of the clinical note.
May contain organization-specific values: Yes
24 | NOTE_AUTHOR_SPECIALTY_NAME | VARCHAR | No |
The free-text description of the provider specialty of the author of the clinical note.
25 | AUTORECONCILED_UCN_NOTE_ID | VARCHAR | No |
The unique ID of the note record automatically created in the local chart from this received clinical note.
26 | NOTE_FILTER_REASON_C_NAME | VARCHAR | No |
Stores the reason this external clinical note should be filtered and thus not auto-reconciled into the local chart. Calculated at the time the note is received and saved.
May contain organization-specific values: No
Category Entries:
Claim Derivation: Procedure Code Inclusion/Exclusion List
Claim Derivation: Missing Provider
Claim Derivation: Sensitive Diagnosis
Claim Derivation: Missing Procedure Start Date
Claim Derivation: Excluded Procedure Modifier
Source Organization Unknown
Source Organization Mismatch
Source Organization Is Self
Clinical Note Type Exclusion List
Clinical Note Missing Service Instant
Clinical Note Missing Last Filed Instant
Clinical Note Missing Author Name
Dispense Cancellation
Same Day as Internal Encounter
Missing or Invalid Binary URL
Filtered or Missing Source Note
DocumentReference Status not Current
Claim Derivation: Excluded Linked Diagnoses
Claim Derivation: Missing Encounter Start Date
Entered In Error
FHIR resource contained an invalid category
Condition verification status is no longer confirmed
Condition is no longer valid for this patient due to age or sex
FHIR resource has an invalid start date
Encounter FHIR resource is missing the type element
FHIR resource is missing the status element
Encounter FHIR resource is missing the class element
Encounter FHIR resource contained an unrecognized status code
Encounter FHIR resource contained a status code for a future encounter
Encounter FHIR resource contained a class code for a future encounter
FHIR resource has a future start date
FHIR resource does not have a status of completed
FHIR resource is missing the code element
Diagnosis is missing a link to an encounter
FHIR resource contains a reference to encounter not in the system
FHIR resource contained a patient reference not matching the searched for patient
Immunization FHIR Resource is missing the vaccineCode element or did not contain a CVX code
FHIR Resource is missing an effective date/time
FHIR resource contained an invalid status
Observation FHIR resource is linked to a filtered Condition FHIR resource
SDOH Assessment contains no questions
Missing required data for data type
FHIR resource does not have a status of confirmed
Claim Derivation: Missing face-to-face services
Condition marked invalid in external data
Condition missing from subsequent bulk flat file load
Data invalidated by delete utility
LDA Added in Error
27 | NOTE_ASSOC_EVENT_IDENT | VARCHAR | No |
The reference ID of the encounter associated with the clinical note. Is associated with a value from I DXR 8010.
28 | NOTE_SERVICE_START_UTC_DTTM | DATETIME (UTC) | No |
The instant of service associated with the clinical note.
29 | NOTE_SRC_DOCREF_RESRC_IDENT | VARCHAR | No |
The ID of the FHIR Document Reference resource for the source note of the clinical note. Populated when the clinical note is an interval note.
30 | NOTE_REMOVED_YN | VARCHAR | No |
Indicates whether the note is no longer in the received note list
The category values for this column were already listed for column: NOTE_SHARED_WITH_PAT_YN
31 | NOTE_ASSOC_PROB_IDENT | VARCHAR | No |
The reference ID of the external problem linked to a clinical note.
32 | NOTE_AUTHOR_TYPE_C_NAME | VARCHAR | No |
The internal category value of the type of provider that authored the clinical note.
May contain organization-specific values: Yes
Category Entries:
Resource
Physician
33 | NOTE_SRC_DXR_CSN | NUMERIC | No |
This item will store the contact serial number of the DXR record that owns the instance of this note.
34 | NON_UCN_NOTE_TEXT_HNO_NOTE_ID | VARCHAR | No |
The ID of the note record that store the text from a note received for Professional Billing Exchange
35 | NOTE_AUTHOR_NPI | VARCHAR | No |
The National Provider Identifier for the provider that authored the clinical note.