CODING_CLA_NOTES

Description: |
This table contains information on queries sent during coding (including documentation queries) and clinical documentation improvement (CDI) reviews.

Primary Key

Column Name | Ordinal Position |
--- | --- | ---
NOTE_ID | 1 |

Column Information

| Name | Type | Discontinued? |
--- | --- | --- | --- | ---
1 | NOTE_ID | VARCHAR | No |
The unique ID of the notes record.
2 | PATIENT_ID | VARCHAR | No |
The patient associated with the coding query.
3 | CCR_EMP_ID | VARCHAR | No |
The user who created the coding query.
4 | CCR_EMP_ID_NAME | VARCHAR | No |
The name of the user record. This name may be hidden.
5 | CCR_NOTE_DT_TIME | DATETIME (Local) | No |
The date and time the coding query created.
6 | CCR_NOTE_SUMMARY | VARCHAR | No |
The subject line (free text) of the coding query.
7 | CCR_STATUS_C_NAME | VARCHAR | No |
The status of the coding query.
May contain organization-specific values: No
Category Entries:
Query Pending
Query Sent
Response Received
Completed
Deleted
Reassigned
Deactivated
8 | CCR_HOSP_ACCT_ID | NUMERIC | No |
The hospital account associated with the coding query.
9 | NOTE_TYPE_NOADD_C_NAME | VARCHAR | No |
The note type of the coding query.
May contain organization-specific values: Yes
Category Entries:
General
Phone Message
Letter
Message
Telephone Encounter
Provider Comments
RTF Letter
Routing Comments
Specialty Comments
Charting Text
MyChart Message
Eligibility Message
Criteria Review
AP Claim Code Edit
Patient Flag
Nurse Triage Message
Dental Soft Tissue Note
ABN INFORMATION
Progress Note
Nursing Note
Consult/Results - Findings
Consult/Results - Impression
Consult/Results - Recommendations/Plans
Chart Sync Patient Summary Report
Chart Sync Admission Summary Report
H&P Note
Procedure Note
Communication Body
Anesthesia
Department Message
Assessment & Plan Note
Problem Overview
Subjective & Objective
Care Coordination
Home Care Admit
Home Care Non-Admit
CTI Order
Bookmark
Hospice Discharge Remarks
Charge Homing Guarantor Inquiry
Patient Genomic Indicator Overview Note
Home Health Face to Face Attestation
Hospice Face to Face Attestation
Sticky Note
Coding Query
Address Verification Message
Intake Communication
Pharmacy Enrollment Note
Treatment Note
Patient Instructions
Discharge Attachment
Previous Reports
Date-Specific Sticky Note
Result Order Report
Home Care Intervention
Home Health Plan of Care Header
Dermatology Finding Description
Specimen Tracking Comments
Radiology Study Results
Translation
Auth/Cert Update
Phenotype Comment
VECOZO Authorization Update
OR Instructions
Dermatology Skin Cancer History
In Basket Conversation
Incoming Message Pend Notes
Xtenity Patient Portal Message
Outside Organization Note
Outside Organization Update
Outside Organization Document
Cosign with Attestation Text
Simple Med Note
Medication History
Electronic Authorization Information
History Overview
ED Disposition Edit Trail
Lab
Intervention Data from External System
Event Note
Treatment Summary
Rehabilitation Potential
Discharge Plans
History Event Details
Referral Transaction Record
Happy Together Result Transcription
Group Note
Care Advice Text
Infection Case
Prior Auth Decision Note
Clinical Note Summary
Transplant
Organ
Reg History Event
Interfaced Result
Outside Organization Coverage Information
10 | QUERY_WORKFLOW_C_NAME | VARCHAR | No |
The workflow type category number for the query. NULL or 0 is returned for a coding query.
May contain organization-specific values: No
Category Entries:
HB Coding Query
CDI Query
Coding Documentation Deficiency
NoteReader CDI Nudge
PB Coding Query
Pre-Visit Suggestion
Potential Condition Nudge
11 | PAT_ENC_CSN_ID | NUMERIC | No |
The unique contact serial number for the patient contact associated with this coding query. This number is unique across all patient encounters in your system. If you use IntraConnect, this is the Unique Contact Identifier (UCI).
12 | COD_QRY_HNO_TYP_C_NAME | VARCHAR | No |
The coding query type category number for the query.
May contain organization-specific values: Yes
Category Entries:
All Other
13 | CDI_QRY_HNO_TYP_C_NAME | VARCHAR | No |
The clinical documentation improvement (CDI) query type category number for the query.
May contain organization-specific values: Yes
Category Entries:
All Other
14 | CODING_DOC_DFI_ID | NUMERIC | No |
The unique ID of the deficiency which is associated with a documentation query. This column is frequently used to link to the DFI_DETAILS table.
15 | CODING_DOC_CREATE_C_NAME | VARCHAR | No |
The creation method category ID for the documentation query.
May contain organization-specific values: No
Category Entries:
Automatic Deficiency Creation
Manual Deficiency Creation
Added to Existing Deficiency
16 | CCR_ASSN_TO_POOL_ID | NUMERIC | No |
The pool to whom the documentation query was sent.
17 | CCR_ASSN_TO_POOL_ID_REGISTRY_NAME | VARCHAR | No |
The name of the In Basket registry in the HIP master file.
18 | CCR_OUTCOME_C_NAME | VARCHAR | No |
The query outcome category ID for the query. This indicates the conclusion of the query (recipient agrees, disagrees, or doesn't respond).
May contain organization-specific values: Yes
Category Entries:
Recipient Agreed – Documentation Updated
Recipient Agreed – Documentation Not Updated
Recipient Disagreed
Recipient Did Not Respond
Auto Completed - Provider Response Received
Auto Completed - Query Still Outstanding
19 | RESP_USER_ID | VARCHAR | No |
To store the provider's ID whose response to a query satisfies the query sender.
20 | RESP_USER_ID_NAME | VARCHAR | No |
The name of the user record. This name may be hidden.
21 | QRY_RESP_NOTE_ID | VARCHAR | No |
Holds the note ID of the note used to respond to a coding/CDI query.
22 | QRY_RESP_SMRTTXT_ID | VARCHAR | No |
Specifies the smart text to use to populate a new note in response to a query.
23 | QRY_RESP_SMRTTXT_ID_SMARTTEXT_NAME | VARCHAR | No |
The name of the SmartText record.
24 | DOC_QRY_REP_TYPE_C_NAME | VARCHAR | No |
Indicates the reporting workflow of the query based on the presence of an attached deficiency. Use this instead of workflow value when breaking CDI and Coding queries out by whether they are a documentation query as well.
May contain organization-specific values: No
Category Entries:
Coding Query
CDI Query
Coding Documentation Query
CDI Documentation Query
25 | CCR_UPD_INST_UTC_DTTM | DATETIME (UTC) | No |
The instant that the query was updated, in UTC time.
26 | CCR_NOTE_INST_UTC_DTTM | DATETIME (UTC) | No |
The date and time the coding query was created, in UTC time.
27 | QRY_SUGG_RESP_NOTE_CSN_ID | NUMERIC | No |
The unique contact serial number (CSN) of the suggested response note linked to the query.
28 | QRY_PEND_NOTE_CSN_ID | NUMERIC | No |
The unique contact serial number (CSN) of the note pended by the provider responding to a query.
29 | QRY_SUGG_REJECT_REASON_C_NAME | VARCHAR | No |
The reason a query suggestion was rejected and not shown to a provider.
May contain organization-specific values: No
Category Entries:
Already Documented
Disagreed With
Low Impact
Other
Not Acted On
Dismissed by System
30 | QRY_IS_AI_SUGG_YN | VARCHAR | No |
Whether this query is suggested by an AI.
May contain organization-specific values: No
Category Entries:
No
Yes
31 | PB_CODING_QUERY_TYPE_C_NAME | VARCHAR | No |
This item stores the actual type of PB coding query, which the user can choose when composing a new PB coding query.
May contain organization-specific values: Yes
Category Entries:
All Other
32 | BASE_CODING_RECORD_CSN_ID | NUMERIC | No |
The Coding/CDI review that captures the pre-query state of codes.
33 | IMPACT_CODING_RECORD_CSN_ID | NUMERIC | No |
The Coding/CDI review that captures the post-query state of codes.
34 | QRY_AI_SUGG_REASON | VARCHAR | No |
The reason the AI query was suggested.
35 | QRY_SUGG_FEEDBACK | VARCHAR | No |
User provided feedback for the query suggestion.
36 | QRY_AI_SUGG_SRC_C_NAME | VARCHAR | No |
The source of what created the reason for the AI query suggestion.
May contain organization-specific values: No
Category Entries:
AI
Epic
37 | QRY_CONDITION_C_NAME | VARCHAR | No |
The condition associated with this query.
May contain organization-specific values: No
Category Entries:
Other Condition
Acute Myocardial Infarction
Anemia
Debridement
Heart Failure
Pneumonia
Sepsis
Bronchitis
Chronic Obstructive Pulmonary Disease
Acute Kidney Injury
Attention Deficit Hyperactive Disorder
Arrhythmia
Burn
Cerebral Palsy
Chronic Kidney Disease
Dementia
Diabetes
Enteric Ulcer
Headache
Heart Disease
Hemorrhoids
Hernia
Hyperbilirubinemia
Hypertension
Respiratory Failure
Pelvic Inflammatory Disease
Phlebitis
Rheumatoid Arthritis
Stroke
Transport Injury
Varicose Veins
Vehicle Injury
Vesicoureteral Reflux
Whooping Cough
Withdrawal
Renal Failure
Malnutrition
Encephalopathy
Asthma
Depression
Cerebral Infarction
Fracture
Gastrointestinal Bleed
Colitis
Surgical Complication
Bronchiolitis
Syncope
Altered Mental Status
Pleural Effusion
Thrombosis
Embolism
Rhabdomyolysis
Seizure
Obesity
Pulmonary Embolism
Human Immunodeficiency Virus
Shock
Pancytopenia
Cor Pulmonale
Deep Vein Thrombosis
Atrial Fibrillation
Bowel Ischemia
Cachexia
Catheter Associated UTI
Central Line Associated Bloodstream Infection
Cerebral Edema
Coagulopathy and Coagulation Disorders
End Stage Liver Disease
Pulmonary Edema
Skin Ulcer
Systemic Inflammatory Response Syndrome
Urosepsis
Pressure Injury
COVID-19
Substance Use
Developmental Delay
Neonatal Drug Exposure
Neonatal Maternal Diabetes
Neonatal Necrotizing Enterocolitis
Hypernatremia
Hyponatremia
Sodium Imbalance
Coma
Hypercalcemia
Hypocalcemia
Calcium Imbalance
Hyperkalemia
Hypokalemia
Potassium Imbalance
Hypermagnesemia
Hypomagnesemia
Magnesium Imbalance
Hyperphosphatemia
Hypophosphatemia
Phosphate Imbalance
38 | QRY_AI_SUGG_INV_YN | VARCHAR | No |
Whether or not the query suggestion was invalidated by a subsequent run of the AI model. If null, then the model didn't run. If set to No, then the model ran and determined the query suggestion is still valid. If set to Yes, then the query suggestion was invalidated.
The category values for this column were already listed for column: QRY_IS_AI_SUGG_YN
39 | QRY_AI_SUGG_INV | VARCHAR | No |
The reason an existing AI query suggestion that has not been acted upon is no longer valid.