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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

Referral note
Documentation sent to a consultant, for example, by a primary care provider, summarizing the patient’s clinical history and reason for consult.

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