Clinical

Records the precise time of day when a patient medical record chart was last updated or amended in the EHR. Combined with chart modified date, enables full timestamp audit trails for clinical documentation changes and regulatory compliance purposes.

The human-readable label assigned to a patient medical record chart in the EHR, typically reflecting the chart type or clinical encounter category. Used to identify and display the chart in clinical workflows, reporting dashboards, and documentation management systems.

Free-text or structured annotation entered by a clinician or staff member within a patient medical record chart in the EHR. Captures clinical observations, follow-up instructions, care plan details, or documentation clarifications associated with a specific patient encounter or condition.

A unique alphanumeric identifier assigned to a patient medical record chart within an EHR or HIS. Used to consistently reference, retrieve, and track the chart across clinical systems, billing workflows, and health information exchanges throughout the patient care continuum.

Records the calendar date when a patient's symptoms, condition, or clinical episode first began as documented in the medical record chart. Used in clinical decision support, disease management tracking, and retrospective analysis of condition progression and treatment timelines.

Records the patient's peripheral oxygen saturation percentage (SpO2) as measured by pulse oximetry and documented in the medical record chart. A critical vital sign used to monitor respiratory function, guide oxygen therapy decisions, and assess patient acuity across care settings.

Captures the dollar amount paid against a medical record chart encounter, reflecting reimbursements from payers or patient payments. Used in revenue cycle management to reconcile expected versus actual payments and track financial performance at the chart or encounter level.

Records the calendar date on which payment was received or processed for services associated with a medical record chart encounter. Used in revenue cycle management and accounts receivable reporting to track payment timelines and monitor outstanding balances.

Identifies the higher-level medical record chart to which a subordinate or child chart is linked in an EHR hierarchical structure. Used to associate related encounters, episodes of care, or sub-charts under a primary chart for cohesive clinical documentation and reporting.

A calculated ratio or percentage value associated with a patient medical record chart, such as completion rate, documentation compliance score, or a clinical metric expressed as a proportion. Used in quality reporting, clinical analytics, and care management performance tracking.

Defines the date range or time interval covered by a patient medical record chart, such as an episode of care, billing period, or reporting cycle. Used to bound clinical documentation, define coverage windows for chronic condition management, and align encounters with reporting periods.

Records the telephone number associated with a patient medical record chart, typically the patient's preferred contact number or the facility contact linked to the chart. Used to support appointment scheduling, care coordination outreach, and patient communication workflows.

Captures the name by which a patient prefers to be addressed, as documented in their medical record chart. Supports patient-centered care by ensuring clinical staff use the patient's preferred identity in communications, labels, and care interactions across the health system.

Represents the standard or negotiated cost associated with services or encounters documented in a patient medical record chart. Used in healthcare revenue cycle management, charge capture workflows, and financial reporting to establish expected reimbursement or patient responsibility amounts.

A flag or boolean indicator designating whether a medical record chart is the primary chart for a patient encounter, diagnosis, or care episode. Used to distinguish principal records from supplementary or secondary charts in clinical documentation and claims processing workflows.

Designates the urgency or importance level assigned to a patient medical record chart, such as urgent, routine, or stat. Used in clinical workflow management to sequence chart review, documentation completion, and care team responses based on patient acuity or operational needs.

Records the calendar date on which a clinical procedure or treatment was performed, as documented in the patient medical record chart. Used in surgical scheduling, clinical outcome tracking, claims adjudication, and quality measure reporting to anchor procedure timelines.

Records the patient's heart rate in beats per minute as measured and documented in the medical record chart during a clinical encounter. A fundamental vital sign used to assess cardiovascular status, monitor patient response to treatment, and support clinical decision-making across care settings.

The numeric count of discrete items documented within a patient medical record, such as the number of medications, procedures, diagnoses, or lab results recorded. Used in clinical data analysis to measure documentation volume and completeness across patient encounters.

The patient-reported or administratively recorded racial identity captured within the medical record, following standard classifications such as OMB categories. Used in population health analytics, health equity reporting, and identifying disparities in clinical outcomes and care utilization.