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 |
Applicable Standards(s) |
|---|---|
| Consultation Note |
|
| Discharge Summary Note |
|
| History & Physical |
|
| Imaging Narrative |
|
| Procedure Note |
|
| Progress Note |
|
Comment