Domain
EHR, ICD-10, LOINC, SNOMED CT, patient care and clinical documentation
16,101 clinical terms
Represents the fully aggregated numeric value derived from all components of a composite clinical finding or assessment instrument. Used in clinical scoring systems such as pain scales, fall risk tools, and mental health assessments to produce a single summary score for clinical decision making.
Stores the cumulative number of discrete clinical finding instances recorded for a patient or within a specific assessment context. Used in clinical data warehouses to quantify finding frequency, support chronic condition monitoring, and generate population-level reporting on finding occurrence rates.
Classifies a clinical finding into a defined category such as symptom, diagnosis, observation, laboratory result, or imaging result. Used in EHR and clinical data systems to organize findings by clinical domain, enabling targeted retrieval, workflow routing, and structured reporting across care settings.
The timestamp recording when a clinical finding record was last modified in the EHR or clinical data system. Used to track changes to diagnostic observations, assessment results, or clinical documentation, supporting audit trails and longitudinal patient care management.
The clinician-assigned time sensitivity classification for acting on a clinical finding, such as routine, urgent, or critical. Drives downstream workflows including care team notifications, escalation protocols, and prioritization of follow-up actions within clinical information systems.
The sequential version number assigned to a clinical finding record each time it is revised or amended. Enables tracking of changes to diagnostic observations over time, supports audit compliance, and allows retrieval of prior versions within EHR and clinical data warehouse systems.
The postal zip code associated with the location where a clinical finding was recorded or the patient resided at time of documentation. Used in population health analytics, geographic disease surveillance, and care coordination to identify regional health patterns and access to care.
The date a patient was transferred or admitted to a specific inpatient hospital floor or nursing unit. Distinct from the overall hospital admission date, this field tracks movement across care units and is used in inpatient capacity management and length-of-stay analysis.
The date a patient was discharged or transferred out of a specific inpatient hospital floor or nursing unit. Used alongside floor admission date to calculate unit-level length of stay, supporting hospital capacity planning, staffing analysis, and inpatient care coordination workflows.
The human-readable display name assigned to a specific inpatient hospital floor or nursing unit, such as 'Cardiac Step-Down Unit' or '3 North ICU'. Used in clinical documentation, patient tracking systems, and hospital reporting to identify where care was delivered.
The date a clinical procedure was performed on a patient while assigned to a specific inpatient hospital floor or nursing unit. Used to correlate procedural activity with unit-level care episodes, supporting clinical documentation, billing workflows, and inpatient quality reporting.
The date a surgical procedure was performed on a patient associated with a specific inpatient hospital floor or nursing unit. Used to link operative events to unit assignments for post-surgical monitoring, inpatient care tracking, and hospital utilization reporting.
The hospital inpatient entry date recorded on standardized healthcare claim forms such as UB-04. Critical in claims processing and EHR systems for calculating length of stay, validating DRG assignments, and ensuring accurate reimbursement timelines across inpatient encounter records.
The date a patient was formally released from an inpatient facility as recorded on standardized healthcare claim forms such as UB-04. Used in claims processing and EHR systems to calculate length of stay, validate DRG billing periods, and support accurate post-acute care coordination and reimbursement workflows.
A binary flag on a structured clinical form indicating the encounter or documentation was associated with an emergency situation. Triggers expedited processing workflows, affects regulatory reporting classifications, and distinguishes emergency from routine clinical documentation in EHR systems.
The free-text or structured narrative field on a clinical form capturing the chronological description of the patient's current medical complaint. Documents symptom onset, duration, severity, and context as recorded by the clinician during the encounter, forming a core component of clinical documentation.
The human-readable display name assigned to a structured clinical data collection form, such as 'Initial Assessment' or 'Pre-Operative Checklist'. Used in EHR navigation, clinical workflow routing, and reporting to identify and distinguish form types across care settings.
The date a clinical procedure was documented or performed as recorded on a structured clinical form. Links procedural activity to its associated form-based documentation, supporting claims processing, clinical audit trails, and quality reporting within healthcare information systems.
Defines the minimum and maximum allowable value span for a standardized data collection instrument in healthcare systems. Used in EHR and clinical data warehouses to validate field inputs, enforce data quality rules, and flag out-of-range clinical or administrative values during ingestion pipelines.
The outcome measurement or response value recorded on a standardized clinical form in EHR or care management systems, such as lab results, assessment outcomes, or screening findings. Data engineers use this field to populate result tables and support clinical quality reporting pipelines.