Domain
EHR, ICD-10, LOINC, SNOMED CT, patient care and clinical documentation
16,101 clinical terms
Free-text annotation or supplementary clinical commentary attached to a patient's advance directive record, capturing specific care preferences, exceptions, or contextual details that cannot be fully expressed through structured fields in EHR or clinical documentation systems.
The unique reference number assigned to a patient's advance directive document, used to track, retrieve, and cross-reference the legally executed end-of-life care instructions across healthcare facilities, medical record systems, and legal or compliance repositories.
The date on which the conditions or circumstances specified in a patient's advance directive became clinically relevant or were formally activated, such as the onset of a terminal diagnosis that triggers the application of documented end-of-life care preferences.
The blood oxygen saturation threshold specified within a patient's advance directive, indicating the clinically defined SpO2 level at which intervention instructions take effect, such as withholding supplemental oxygen or initiating comfort measures per the patient's documented end-of-life care wishes.
The dollar amount paid for services related to advance directive documentation, counseling, or end-of-life care planning. Captured in claims processing systems to record reimbursement for advance care planning encounters billed under applicable CPT codes such as 99497 and 99498.
The date on which payment was issued for advance directive counseling or documentation services. Used in claims adjudication workflows to track reimbursement timing for end-of-life care planning encounters and reconcile payment cycles in healthcare financial systems.
The hierarchical parent record associated with an advance directive document, linking it to a broader care plan, episode of care, or patient record. Used in clinical data systems to maintain relational structure between advance directive entries and their governing legal or clinical documents.
A ratio or percentage value associated with an advance directive record, such as benefit coverage percentage or compliance rate for advance care planning documentation. Used in population health and quality reporting to measure advance directive completion rates across patient cohorts.
The defined time interval during which an advance directive is considered active and legally valid, spanning from the effective date to expiration or revocation. Used in clinical and legal systems to determine whether a patient's end-of-life wishes are currently enforceable during care delivery.
The telephone contact number associated with an advance directive record, typically belonging to the patient, healthcare proxy, or legal representative designated in the document. Used to facilitate communication regarding end-of-life care decisions when the patient is incapacitated.
The human-readable display name assigned to an advance directive document or record, used to distinguish it from other legal documents in the patient's record. Supports clinical workflow navigation and ensures staff can identify the correct end-of-life care document during care delivery.
The cost associated with advance directive counseling, documentation, or notarization services rendered to a patient. Captured in billing and claims systems to represent the charged amount for end-of-life care planning services before insurance adjudication or patient responsibility calculation.
A flag identifying whether an advance directive record is the primary or most current legally valid document on file for a patient. Used in clinical systems to ensure care teams reference the correct end-of-life care instructions when multiple advance directive versions exist in the medical record.
A ranking value indicating the precedence of an advance directive document relative to other care instructions or legal documents on file. Used in clinical decision support systems to resolve conflicts between multiple directives and ensure the highest-priority end-of-life wishes are honored.
The date on which an advance directive counseling session or documentation procedure was performed by a clinician. Used in claims and clinical records to establish the service date for billing advance care planning CPT codes and to track when end-of-life preferences were formally documented.
The patient's heart rate measurement recorded at the time of an advance directive encounter or end-of-life care planning visit. Captured as a clinical vital sign to document the patient's health status during the consultation in which advance care preferences were discussed or updated.
The count of advance directive documents, counseling units, or related service items associated with a patient record or claim. Used in billing and clinical data systems to track the number of advance care planning sessions completed or documents executed within a given timeframe.
The racial or ethnic classification of the patient associated with an advance directive record. Used in population health analytics and quality reporting to identify disparities in advance care planning documentation rates across demographic groups and support health equity initiatives.
The defined value span or boundary limits applicable to an advance directive data element, such as acceptable age ranges for execution or clinical threshold ranges referenced in the directive. Used in data validation and clinical decision support to ensure advance directive data integrity.
The per-unit reimbursement rate applied to advance directive counseling services, used in claims pricing and contract management. Also may represent the population-level rate of advance directive completion within a health plan or patient panel for quality measurement and reporting purposes.