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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

Expanded list of clinical notes, detailed in Data Element Description
Audiometry/Audiology
Audiograms: (68635-2 Audiology Diagnostic study note)

Psychology Reports
Mental Status Evaluation: (94798-6 Psychology Diagnostic study note)
Neuropsychological Testing: (94798-6 Psychology Diagnostic study note)
Psychological Testing: (94798-6 Psychology Diagnostic study note)

Cardiac Reports
Angiogram: (75425-9 Cardiology Diagnostic study note)
Cardiac Catheterization: (75425-9 Cardiology Diagnostic study note)
Doppler Test (75425-9 Cardiology Diagnostic study note)
Electrocardiograph, electrocardiogram (EKG/ECG) result/interpretation: (75425-9 Cardiology Diagnostic study note)
EKG/ECG Tracing Image: (75425-9 Cardiology Diagnostic study note)
Echocardiogram result/interpretation: (75425-9 Cardiology Diagnostic study note)
Stress Testing (exercise, pharma): (83539-7 Cardiology Risk assessment & screening note)
Holter monitor: (83539-7 Cardiology Risk assessment & screening note)

Neurology
Electroencephalogram (EEG): (68556-0 Neurology Diagnostic study note)
Electromyogram/nerve conduction (EMG): (68556-0 Neurology Diagnostic study note)
Myelogram: (68556-0 Neurology Diagnostic study note)

Ophthalmology/Optometry
Visual Acuity: (78573-3 Ophthalmology Diagnostic study note)
Visual Fields: (78573-3 Ophthalmology Diagnostic study note)

Radiology (Interpretations Only; No Images)
CT: (68604-8 Ophthalmology Diagnostic study note)
MRI: (68604-8 Ophthalmology Diagnostic study note)
PET: (68604-8 Ophthalmology Diagnostic study note)
X-Ray: (68604-8 Ophthalmology Diagnostic study note)

Respiratory
DLCO Study: (80792-5 Pulmonary Diagnostic study note)
Pulmonary Function Study: (80792-5 Pulmonary Diagnostic study note)
Spirometry Test result/interpretation: (80792-5 Pulmonary Diagnostic study note)
Spirometry Tracing Image: (80792-5 Pulmonary Diagnostic study note)

Surgical Diagnostics
Bone Marrow (Biopsy/Aspiration): (48807-2 Bone marrow aspiration report)
Colonoscopy: (18746-8 Colonoscopy study report)
Endoscopy: (18751-8 Endoscopy study report)

Additional Procedures
Ultrasound (exclude Doppler): (59282-4 Stress cardiac echo study report)
Genetic Testing: (51969-4 Genetics analysis report)
Physical Exam: (29545-1 Physical findings narrative)

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