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Clinical Notes

Composed of both structured (i.e. obtained via pick-list and/or check the box) and unstructured (free text) data. A clinical note may include the history, Review of Systems (ROS), physical data, assessment, diagnosis, plan of care and evaluation of plan, patient teaching and other relevant data points.

Data Element

Information from the submission form

Cause of Death Information
"This may include summary of death note, and/or death information that may be captured within discharge summary note or other cause of death documentation within the clinical notes section.

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