Clinical Notes

Contains the response to request from a clinician for an opinion or advice from another clinician.

A synopsis of a patient’s admission and course in a hospital or post-acute care setting.

Documents the current and past conditions and observations of the patient.

Encompasses non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and other specialty’s procedures.

Represents a patient’s interval status during a hospitalization, outpatient visit, treatment with a post-acute care provider, or other healthcare encounter.

Response to request from a clinician for an opinion, advice, or service from another clinician.

Synopsis of a patient’s admission and course in a hospital or post-acute care setting. Must contain admission and discharge dates and locations, discharge instructions, and reason(s) for hospitalization.

Summary of current and past conditions and observations used to inform an episode of care. (e.g. admission, surgery, or other procedure)

Synopsis of non-operative procedures.  (e.g., interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation)

Summary of a patient’s interval status during an encounter (e.g., hospitalization, outpatient visit, treatment with a post-acute care provider, or other healthcare encounter)

Response to request from a clinician for an opinion, advice, or service from another clinician. Examples include but are not limited to dermatology, dentistry, and acupuncture.

Synopsis of a patient’s admission and course in a hospital or post-acute care setting. Usage note: Must contain admission and discharge dates and locations, discharge instructions, and reason(s) for hospitalization. Examples include but are not limited to dermatology discharge summary, hematology discharge summary, and neurology discharge summary. 

Summary of current and past conditions and observations used to inform an episode of care. Examples include but are not limited to admission, surgery, and other procedure.

Synopsis of non-operative procedure. Examples include but are not limited to interventional cardiology, gastrointestinal endoscopy, and osteopathic manipulation.

Summary of a patient’s interval status during an encounter. Examples include but are not limited to hospitalization, outpatient visit, and treatment with a post-acute care provider, or other healthcare encounter.