Domain
EHR, ICD-10, LOINC, SNOMED CT, patient care and clinical documentation
16,101 clinical terms
A structured or free-text clinical evaluation documenting the patient's capacity and understanding at the time of consent execution. Used in EHR systems to record whether a patient demonstrated decision-making competency, supporting legal defensibility of informed consent and compliance with clinical ethics and regulatory standards.
The date of birth of the individual granting or associated with a consent document. Used to verify patient identity, confirm legal capacity to consent, and link consent records to the correct patient in clinical and administrative systems.
The systolic and diastolic arterial pressure reading documented at the time a patient consent was obtained. Captures the patient's clinical state during consent, supporting documentation of patient condition and capacity at the moment of agreement.
The date on which a previously granted patient consent was formally revoked or cancelled. Critical for compliance tracking, ensuring downstream clinical workflows, data sharing agreements, and treatment authorizations reflect the patient's current consent status.
A classification grouping that identifies the type or purpose of a patient consent document, such as treatment authorization, research participation, data sharing, or release of information. Drives routing, retention rules, and regulatory compliance workflows.
The primary symptom or reason for the clinical encounter documented at the time the patient consent was obtained. Contextualizes the consent record within a specific visit or episode of care, linking the permission to the relevant clinical circumstance.
An identifier or reference linking a consent record to a subordinate or dependent consent document in a hierarchical consent structure. Used when a broad consent contains nested sub-consents for specific procedures, data uses, or treatment components.
The municipality or city name associated with the location where a patient consent document was executed or where the consenting individual resides. Supports geographic jurisdiction determinations and regulatory compliance with location-specific consent laws.
A hierarchical tier or classification level assigned to a patient consent document, indicating its scope, legal weight, or applicability. Used to distinguish between general, procedure-specific, or research-level consents and to apply appropriate handling rules.
A standardized coded value identifying the specific type or nature of a patient consent document, drawn from a defined vocabulary or internal code set. Used to categorize, retrieve, and process consent records consistently across clinical and administrative systems.
Free-text notation entered by a clinician, administrator, or patient representative providing additional context, exceptions, or clarifications regarding the terms or circumstances of a patient consent document. Supplements structured consent data with narrative detail.
The date on which all required elements of a patient consent document were finalized and the consent was considered fully executed. Marks the point at which the authorized activity, treatment, or data use may proceed under the terms of the consent.
A flag indicating whether a patient consent document or its associated information is designated as confidential, restricting access to authorized personnel only. Enforces privacy controls for sensitive consent types such as behavioral health or substance use treatment.
A numeric value representing the total number of consent documents or consent instances associated with a patient, encounter, or consent type. Used for reporting, auditing, and tracking consent coverage across a patient population or care episode.
The nation in which a patient consent document was executed or to which the consenting individual's address belongs. Determines applicable legal and regulatory frameworks governing consent validity, data use, and cross-border information sharing requirements.
The user identifier of the individual who initially created or entered the patient consent record into the system. Provides an audit trail for accountability, tracking which staff member or clinician initiated the consent documentation process.
The calendar date on which a patient consent record was first entered into the system. Establishes the administrative timeline of the consent document, distinct from the date the consent was signed or became effective in clinical workflows.
The time of day at which a patient consent record was initially created in the system. Combined with the created date, provides a precise timestamp for audit purposes, sequencing of consent events, and resolution of documentation discrepancies.
The serum or urine creatinine laboratory value recorded at the time a patient consent was obtained. Documents the patient's kidney function status during consent, relevant for consents involving contrast agents, nephrotoxic medications, or renal procedures.
The date on which a patient formally granted consent for a specified treatment, procedure, data use, or research participation. Serves as the legal and clinical reference point for the validity period of the consent and compliance with authorization requirements.