Clinical

The language in which a clinical assessment was administered or in which the patient or member prefers to receive the assessment. Supports health equity initiatives, CMS language access requirements, and care management workflows for diverse member populations.

The family surname of the patient, member, or clinician associated with a clinical assessment record. Used in identity verification, record matching, and reporting across care management systems to ensure assessments are accurately attributed to the correct individual.

The official government-registered name of the patient or member as recorded on a clinical assessment. Used for identity verification, insurance eligibility matching, and compliance purposes where legal name alignment is required across health plan and clinical systems.

A classification indicating the intensity, complexity, or tier of a clinical assessment, such as a brief screening versus a comprehensive evaluation. Used in care management programs to determine appropriate resource allocation, billing codes, and clinical follow-up protocols.

The professional state license number of the clinician or practitioner who administered or certified a clinical assessment. Used to validate credentialing, meet regulatory documentation requirements, and attribute assessment records to a licensed healthcare professional in clinical systems.

The marital status of the patient at the time of the clinical assessment. Captured during intake or health risk evaluations to support care planning, social determinants of health screening, and population health stratification in clinical and care management workflows.

The enterprise-wide unique identifier assigned to a clinical assessment record, enabling consistent tracking and linking of the evaluation across EHR, care management, and data warehouse systems. Used for deduplication and longitudinal patient record matching.

The upper boundary value defined for a clinical assessment scoring scale or measurement range. Used to validate scored responses, flag out-of-range results, and normalize scores across standardized tools such as PHQ-9, GAD-7, or functional status assessments.

The middle name or initial of the patient associated with the clinical assessment record. Used for identity verification and matching the assessment to the correct patient record within EHR and care management systems, reducing misidentification risk.

The lower boundary value defined for a clinical assessment scoring scale or measurement range. Used to validate scored responses, flag out-of-range results, and anchor normalization for standardized tools such as PHQ-9, GAD-7, or functional status evaluations.

The mobile phone number associated with the patient or contact person linked to the clinical assessment record. Used to facilitate follow-up outreach, care coordination communication, and patient engagement activities following completion of the assessment.

The system user identifier of the clinician, care manager, or administrator who last updated the clinical assessment record. Supports audit trail requirements, accountability tracking, and compliance with documentation standards in EHR and care management systems.

The calendar date on which the clinical assessment record was most recently updated or amended. Used for audit trail documentation, version control, and identifying the most current assessment data when multiple updates exist within a longitudinal patient record.

The timestamp indicating the exact time at which the clinical assessment record was last updated. Combined with the modified date, this supports precise audit trail reconstruction and sequencing of concurrent documentation changes in clinical data systems.

The human-readable title or label assigned to a clinical assessment instrument or evaluation record, such as PHQ-9 Depression Screening or Fall Risk Assessment. Used to identify and display the assessment type across clinical workflows, reporting dashboards, and care plans.

Free-text narrative or structured annotation entered by a clinician or care manager in association with a clinical assessment record. Captures supplemental observations, patient-reported context, or clinical rationale that extends beyond discrete scored fields in the assessment tool.

A system-generated or manually assigned sequential reference number that uniquely identifies a specific clinical assessment instance. Used to retrieve, reference, and link the assessment across clinical documentation, reporting workflows, and care coordination records.

The date on which the patient's symptoms, condition, or concern being evaluated in the clinical assessment first began. Captured to establish clinical timeline, support diagnosis coding accuracy, and inform care planning decisions based on condition duration and progression.

The peripheral blood oxygen saturation percentage (SpO2) recorded as part of a clinical assessment, typically measured via pulse oximetry. Used to evaluate respiratory status, monitor chronic conditions such as COPD or heart failure, and trigger clinical escalation protocols.

The dollar amount reimbursed or paid for the clinical assessment service, reflecting adjudicated payment from a payer or patient responsibility collected. Used in revenue cycle reporting, cost analysis, and reconciling assessment-related charges against expected reimbursement rates.