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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

Clinical Notes for Newborn
Clinical notes information for a newborn may include the Labor and delivery summary
record under–Infant data, and maternal progress note. Example information will include breastfeeding information at time of discharge.

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