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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

Additional Information

Discharge Summary Note

Applicable Standard(s)

  • Discharge Summary (LOINC® code 18842-5)

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