Domain
EHR, ICD-10, LOINC, SNOMED CT, patient care and clinical documentation
16,101 clinical terms
Indicates the hierarchical tier or complexity level assigned to a clinical evaluation or diagnostic assessment, such as levels used in E&M coding (1-5). Used to determine appropriate billing codes, resource utilization, and care intensity in clinical documentation systems.
The state-issued professional license number of the clinician performing a diagnostic evaluation or assessment. Used to verify credentials, satisfy regulatory documentation requirements, and link the assessment to a licensed practitioner in clinical and claims records.
Records the patient's marital status at the time of a clinical evaluation or diagnostic assessment. Captured as part of the patient's social history, this data element supports psychosocial screening, care planning, and eligibility determinations within clinical documentation workflows.
The enterprise-level unique identifier assigned to a clinical evaluation or diagnostic assessment record, enabling consistent cross-system tracking. Used to link evaluation data across EHRs, care management platforms, and data warehouses without duplication or ambiguity.
The upper boundary value defined for a clinical evaluation metric, scoring scale, or assessment instrument. Used to establish valid ranges for scoring tools such as pain scales, cognitive assessments, or functional tests, supporting data validation and clinical interpretation.
The middle name or initial of the patient associated with a clinical evaluation or diagnostic assessment record. Used to support accurate patient matching and identity verification, reducing duplicate records and improving data integrity in clinical documentation systems.
The lower boundary value defined for a clinical evaluation metric, scoring scale, or assessment instrument. Used to establish valid ranges for scoring tools such as pain scales, cognitive assessments, or functional tests, supporting data validation and clinical interpretation.
The mobile telephone number of the patient or responsible contact associated with a clinical evaluation or diagnostic assessment. Used to facilitate appointment reminders, follow-up communications, and care coordination outreach related to evaluation results or next steps.
The unique identifier of the system user or clinician who last updated a clinical evaluation or diagnostic assessment record. Captured as part of the audit trail to support data governance, compliance tracking, and accountability within clinical information systems.
The calendar date on which a clinical evaluation or diagnostic assessment record was most recently updated or amended. Captured as part of the audit trail to support data governance, regulatory compliance, and historical tracking of record changes in clinical systems.
The timestamp recording the exact time a clinical evaluation or diagnostic assessment record was last updated or amended. Combined with the modified date, supports precise audit trail documentation, concurrent update detection, and compliance reporting in clinical data systems.
The human-readable name or label assigned to a clinical evaluation or diagnostic assessment, such as PHQ-9, Mini-Mental State Exam, or Braden Scale. Used for display in clinical interfaces, reporting outputs, and care documentation to clearly identify the type of assessment performed.
Free-text or structured annotation entered by a clinician in association with a clinical evaluation or diagnostic assessment. Captures qualitative observations, clinical reasoning, patient responses, or contextual details that supplement scored or coded evaluation data in the medical record.
A system-assigned or operationally defined numeric identifier for a clinical evaluation or diagnostic assessment instance. Used to uniquely reference and retrieve a specific evaluation encounter across clinical workflows, reporting systems, and data integration processes.
The date on which the symptoms, condition, or clinical concern being evaluated first appeared, as reported by the patient or determined by the clinician. Used in diagnostic assessments to establish disease timeline, support coding accuracy, and inform treatment planning.
The peripheral oxygen saturation (SpO2) measurement recorded as part of a clinical evaluation or diagnostic assessment, typically expressed as a percentage. Used as a vital sign indicator of respiratory function and tissue oxygenation, supporting clinical decision-making and acuity determination.
The dollar amount reimbursed or paid by a payer for a clinical evaluation or diagnostic assessment service. Captured in claims and remittance data to support revenue cycle reconciliation, financial reporting, and contract performance analysis for evaluation and management services.
The date on which payment was issued by a payer for a clinical evaluation or diagnostic assessment claim. Used in revenue cycle management to track reimbursement timing, measure days in accounts receivable, and reconcile payments against submitted evaluation claims.
The higher-level evaluation, assessment category, or organizational entity to which a subordinate evaluation record belongs. Used to represent hierarchical relationships between evaluations in structured assessment frameworks, care plans, or data classification systems within clinical platforms.
A proportional value expressed as a percentage associated with a clinical evaluation or diagnostic assessment, such as a disability rating, functional capacity score, or test result threshold. Used to quantify assessment outcomes and support clinical, financial, or administrative decision-making.