Clinical

Indicates the processing or workflow state of a patient medical record at a given point in its lifecycle, such as draft, pending review, complete, or archived. Used to manage chart progression through clinical documentation workflows and quality review stages in EHR systems.

Captures the current operational condition of a patient medical record, such as active, incomplete, closed, or suspended. Drives workflow routing, clinician alerts, and compliance tracking in EHR systems to ensure documentation is completed accurately and within required timeframes.

Records the concentration or dosage strength of a medication as documented within a patient medical record or medication administration chart. Used in clinical documentation to ensure accurate medication reconciliation, dosing verification, and pharmacy coordination across care settings.

A partial aggregated value calculated across a subset of line items or entries within a patient medical record, such as subtotaled charges, observations, or procedure counts. Used in clinical and billing workflows to support itemized summaries before final chart totals are computed.

The calendar date on which a surgical procedure documented within a patient medical record was performed. Critical for operative documentation, post-surgical care planning, quality reporting, and tracking outcomes relative to procedure timing in clinical data systems.

Identifies the intended destination, goal, or reference point associated with a patient medical record entry, such as a target clinical value, care goal, or routing destination within a clinical workflow. Supports care coordination and outcome measurement in EHR environments.

A standardized classification code, such as a NUCC taxonomy code, assigned within a patient medical record to identify the clinical specialty or provider type associated with the documented care. Supports care categorization, specialty routing, and reporting in clinical data systems.

The recorded body temperature of a patient as documented in a medical record or clinical chart, typically measured in Fahrenheit or Celsius. Used as a vital sign to monitor patient health status, detect fever or hypothermia, and track clinical trends across care encounters.

The calendar date on which a patient medical record or chart documentation period is officially closed or deactivated. Marks the end of an active chart episode, supporting records management, audit trail maintenance, and longitudinal care analysis in clinical data systems.

The specific time of day associated with a clinical event, observation, or documentation entry recorded in a patient medical record. Enables precise temporal sequencing of care activities, medication administration, and clinical observations within a patient encounter or episode of care.

The combined date and time value recorded when a clinical entry is created, modified, or finalized within a patient medical record. Provides an auditable point-in-time reference for documentation accuracy, regulatory compliance, and chronological sequencing of patient care events.

The formal name or heading assigned to a patient medical record, document section, or clinical note within an EHR system. Identifies the nature and purpose of the documentation, such as discharge summary, progress note, or operative report, supporting retrieval and clinical workflow management.

The cumulative aggregated value across all entries or line items within a patient medical record segment, such as total charges, total medications, or total observations recorded. Used in clinical and administrative reporting to summarize care activity or financial data for a chart episode.

The total number of discrete entries, occurrences, or records documented within a patient medical record or chart segment. Used in clinical data analytics and reporting to measure documentation volume, encounter frequency, or the number of clinical events captured over a defined period.

Classifies a patient medical record by its documentation category, such as inpatient, outpatient, emergency, surgical, or behavioral health chart. Determines applicable documentation requirements, workflow routing, and reporting standards applied to the record in clinical and administrative systems.

The calendar date on which a patient medical record was most recently modified, amended, or supplemented. Used to track documentation currency, support audit trails, identify records requiring review, and ensure clinical data integrity across EHR and clinical data warehouse environments.

Indicates the time-sensitivity or clinical priority level assigned to a patient medical record or documentation task, such as routine, urgent, or emergent. Drives workflow prioritization, clinician notification, and response time expectations within clinical documentation and care coordination systems.

Identifies the iteration number of a patient medical record or clinical document, incrementing each time the record is amended or updated. Supports audit trail management, version control, and retrieval of prior documentation states to maintain an accurate history of clinical record changes.

The postal ZIP code associated with a patient medical record, typically reflecting the practice or facility location where the chart was created. Used in clinical data warehouses to support geographic analysis, regional reporting, and patient population segmentation across care settings.

A binary flag indicating whether a laboratory chemistry test, panel, or result record is currently active within the clinical system. Used in lab information systems to filter valid chemistry records from discontinued, voided, or historical entries during result retrieval and clinical reporting workflows.