Clinical

The integer ordering number assigned to a clinical documentation entry within an encounter or episode record in EHR systems. Used by data engineers to reconstruct chronological documentation order, deduplicate addenda, and maintain proper note lineage in clinical data warehouse ETL pipelines.

The coded or categorical value representing the clinical seriousness of a condition or finding documented within an EHR note entry. Used by data engineers to classify and filter documentation records by acuity level, supporting clinical analytics, risk stratification, and quality reporting workflows.

The patient's biological sex recorded within a clinical note, distinct from gender identity. Used in clinical decision support rules, sex-specific lab reference ranges, medication dosing calculations, and demographic reporting across care delivery and population health management systems.

Identifies the originating system or author type for a clinical documentation entry in EHR platforms such as Epic or Cerner. Values may include physician, nurse, transcription service, or imported external system, enabling data lineage tracking and audit compliance.

Records the calendar date when a clinical note's documentation period begins in EHR systems. Distinct from note creation date, this field supports encounter-aligned reporting, longitudinal care timeline analysis, and clinical data warehouse date-range partitioning across inpatient and outpatient settings.

The specific time at which a clinical encounter, procedure, or documented event began, as recorded within a clinical note. Used alongside start dates to establish precise encounter timelines, support operative recordkeeping, measure care duration, and ensure accurate clinical documentation sequencing.

The US state or Canadian province associated with a clinical note entry in the EHR. Used to identify the geographic jurisdiction where the note was authored or the patient was located, supporting regional compliance, care coordination, and cross-state clinical documentation audits.

Captures the workflow state of a clinical documentation entry in EHR systems such as Epic, Cerner, or Meditech. Common values include Draft, Signed, Amended, Addended, or Retracted, and is critical for filtering authoritative clinical records in downstream analytics pipelines.

The concentration or potency of a medication documented within a clinical note, expressed as a numeric value and unit such as mg/mL or mcg. Captures the specific drug strength referenced in prescriber notes, medication reconciliation records, or pharmacist annotations within clinical documentation systems.

The intermediate or partial sum calculated within a clinical note, such as a subtotaled charge amount, partial lab result aggregate, or grouped item count. Used in clinical documentation workflows to represent running totals before final values are computed, supporting billing reconciliation and care summary reporting.

The scheduled or actual date on which a surgical procedure was performed, as recorded within a clinical note entry. Captured in operative notes, pre-surgical assessments, and post-operative documentation to establish a temporal anchor for surgical care episodes and support procedure outcome tracking.

Identifies the intended recipient, care team role, or destination system for a clinical documentation entry in EHR and care coordination platforms. Used in referral notes, consult requests, and care transition workflows to route clinical content to the appropriate provider or department.

The NUCC Health Care Provider Taxonomy Code recorded within a clinical note, identifying the specialty classification of the clinician who authored the note. Used to categorize clinical documentation by provider specialty for care coordination, credentialing validation, and specialty-specific clinical workflow routing.

The body temperature measurement recorded within a clinical note, typically expressed in Fahrenheit or Celsius. Captured as part of vital sign documentation during patient encounters to support clinical decision-making, fever detection, sepsis screening, and longitudinal monitoring of patient physiological status.

The date on which a clinical note record is marked inactive, expired, or no longer clinically relevant within the EHR system. Used in document lifecycle management to retire superseded notes, close episode-specific documentation, and maintain accurate active note rosters for ongoing patient care workflows.

Stores the time-of-day component for a clinical documentation entry in EHR systems, typically formatted as HH:MM:SS in UTC or local timezone. Used alongside note date to reconstruct precise clinical event sequences for audit trails, medication administration records, and care timeline analysis.

Stores the full datetime value indicating when a clinical note was created, signed, or last modified in EHR systems such as Epic or Cerner. Used for audit logging, event sequencing, SLA compliance reporting, and reconciling documentation timing in clinical data warehouses.

The formal descriptive name assigned to a clinical note entry, such as 'Discharge Summary,' 'Progress Note,' or 'Consultation Report.' Identifies the note type and clinical purpose within the EHR, enabling clinicians to quickly locate, categorize, and retrieve relevant documentation across patient encounters and care episodes.

Represents an aggregated count or cumulative numeric value associated with a clinical documentation entry, such as total number of note lines, observation values, or linked diagnoses in EHR or clinical data repository systems. Supports documentation completeness validation and volume-based analytics.

The cumulative number of clinical note entries associated with a patient, encounter, episode, or defined reporting period. Used in clinical data analytics and quality reporting to measure documentation volume, track clinician productivity, assess care coordination completeness, and monitor patient engagement across care settings.