6.4.1 Kind of document
Characterizes the purpose or structure of the document, section, or entry. Examples include flowsheet, discharge plan, consent, surgical report.
| Part Number | Part Name |
|---|---|
| LP173387-4 | Administrative note |
| LP447691-9 | Administrative information |
| LP173388-2 | Against medical advice note |
| LP173389-0 | Agreement |
| LP412176-2 | Controlled substance agreement |
| LP173390-8 | Certificate |
| LP173391-6 | Birth certificate |
| LP173392-4 | Death certificate |
| LP173393-2 | Evaluation of mental and physical incapacity certificate |
| LP267921-7 | Proof of encounter certificate |
| LP450642-6 | Fetal death certificate |
| LP450641-8 | Recovery certificate |
| LP450640-0 | Proof of medical test certificate |
| LP450638-4 | Medical fitness certificate |
| LP450637-6 | Temporary incapacity certificate |
| LP453365-1 | Pregnancy gestational age certificate |
| LP173394-0 | Consent |
| LP173395-7 | Abortion consent |
| LP436850-4 | Organ AndOr tissue donation consent |
| LP173396-5 | Anesthesia consent |
| LP267939-9 | Blood or blood product transfusion consent |
| LP173397-3 | Hysterectomy consent |
| LP267417-6 | Long-term opioid therapy for pain consent |
| LP173398-1 | Organ donation consent |
| LP173399-9 | Procedure consent |
| LP173400-5 | Release of information consent |
| LP416139-6 | Research study consent |
| LP173401-3 | Sterilization consent |
| LP173402-1 | Surgical operation consent |
| LP193873-9 | Driver license |
| LP173404-7 | Health insurance card |
| LP173405-4 | Health insurance-related form |
| LP173407-0 | Legal document |
| LP200113-1 | Legal letter |
| LP416137-0 | Portable medical order form |
| LP173408-8 | Power of attorney |
| LP248740-5 | Medical clearance note |
| LP181089-6 | Request |
| LP181085-4 | Prescription request |
| LP173409-6 | Advance directives |
| LP173410-4 | Do not resuscitate |
| LP173412-0 | Living will |
| LP446478-2 | Advance healthcare directives |
| LP447690-1 | Treatment intervention preferences |
| LP450636-8 | Directive |
| LP200111-5 | Checklist |
| LP267279-0 | Discharge checklist |
| LP173414-6 | Diagram |
| LP173415-3 | Flowsheet |
| LP181112-6 | Form |
| LP204180-6 | Mandatory reporting form |
| LP416138-8 | Medical history screening form |
| LP416137-0 | Portable medical order form |
| LP181116-7 | Instructions |
| LP181119-1 | Action plan |
| LP173754-5 | ADHD action plan |
| LP420133-3 | Adrenal insufficiency emergency action plan |
| LP173755-2 | Anaphylaxis action plan |
| LP173756-0 | Asthma action plan |
| LP173757-8 | Autism action plan |
| LP173758-6 | Complex medical conditions action plan |
| LP173759-4 | Cystic fibrosis action plan |
| LP173765-1 | Diabetes type I action plan |
| LP173766-9 | Diabetes type II action plan |
| LP173760-2 | Heart disease action plan |
| LP173761-0 | Inflammatory bowel disease action plan |
| LP173762-8 | Multiple sclerosis action plan |
| LP173763-6 | Muscular dystrophy action plan |
| LP173764-4 | Seizure disorder action plan |
| LP173118-3 | Discharge instructions |
| LP173417-9 | Letter |
| LP200113-1 | Legal letter |
| LP436846-2 | End of treatment letter |
| LP448213-1 | Screening reminder letter |
| LP448685-0 | Invitation letter |
| LP450751-5 | Progress letter |
| LP204161-6 | List |
| LP181534-1 | Prescription list |
| LP173418-7 | Note |
| LP173419-5 | Adverse event note |
| LP436851-2 | Repository initial evaluation note |
| LP173420-3 | Alert |
| LP434808-4 | Appointment reminder |
| LP436848-8 | Comprehensive plan of care note |
| LP447692-7 | Clinical note |
| LP448671-0 | Screening invitation letter |
| LP450051-0 | Implanted device note |
| LP450749-9 | Progress note |
| LP181207-4 | Order |
| LP416137-0 | Portable medical order form |
| LP181204-1 | Prescription |
| LP181529-1 | Prescription for diagnostic or specialist care |
| LP181530-9 | Prescription for durable medical equipment attachment |
| LP181190-2 | Prescription for eyewear |
| LP181531-7 | Prescription for medical equipment or product |
| LP181532-5 | Prescription for medication |
| LP181533-3 | Prescription for rehabilitation |
| LP181534-1 | Prescription list |
| LP181231-4 | Photographic image |
| LP173421-1 | Report |
| LP183503-4 | Case report |
| LP183502-6 | Registry report |
| LP436849-6 | Laboratory report |
| LP436982-5 | Scanned Laboratory Result |
| LP450052-8 | Domestic violence screening report |
| LP450608-7 | Periodic personal health monitoring report |
| LP450644-2 | Personal health monitoring report |
| LP450606-1 | Record |
| LP439904-6 | FHIR previous cancer therapy medical record |
| LP436981-7 | FHIR resource patient medical record |
| LP449574-5 | Child health surveillance |
| LP437011-2 | Implant card |
| LP443264-9 | Authenticity information |
| LP446479-0 | Completion information |
| LP448453-3 | Warranty Coverage Information |
| LP448629-8 | Advanced explanation of benefits |
| LP448631-4 | Good faith estimate |
| LP453335-4 | Financial document |
| LP453336-2 | Social document |
| LP453337-0 | Clinical document |
6.4.2 Type of service
Describes the healthcare service or action provided to/for the patient (or other subject of the service) as described in the note. Examples include Referral, Consultation, Discharge summary, Communication, Disability examination, Procedure.
| Part Number | Part Name |
|---|---|
| LP173099-5 | Conference |
| LP173110-0 | Consultation |
| LP173111-8 | Confirmatory consultation |
| LP418143-6 | Coronavirus Disease 2019 (COVID-19) |
| LP173100-1 | Counseling |
| LP173113-4 | Group counseling |
| LP173112-6 | Individual counseling |
| LP173114-2 | Daily or end of shift signout |
| LP173115-9 | Diagnostic study |
| LP173117-5 | Education |
| LP173120-9 | Discharge teaching |
| LP173122-5 | Evaluation and management |
| LP173129-0 | Care |
| LP437010-4 | Goals, preferences, and priorities for care experience |
| LP310260-7 | Care management |
| LP173130-8 | Crisis intervention |
| LP263715-7 | Suicide prevention |
| LP173131-6 | Disease staging |
| LP173132-4 | Disability examination |
| LP173134-0 | Compensation and pension examination |
| LP173124-1 | Evaluation |
| LP173123-3 | Annual evaluation |
| LP173125-8 | Functional status assessment |
| LP173198-5 | History and physical |
| LP173200-9 | Admission history and physical |
| LP173202-5 | Labor and delivery admission history and physical |
| LP173201-7 | Comprehensive history and physical |
| LP173203-3 | Targeted history and physical |
| LP173204-1 | Initial evaluation |
| LP173205-8 | Admission evaluation |
| LP428833-0 | Pain assessment |
| LP173126-6 | Readiness for military duty assessment |
| LP270301-7 | Reevaluation |
| LP173127-4 | Risk assessment and screening |
| LP173128-2 | Fall risk assessment |
| LP204157-4 | Safety issue assessment |
| LP173192-8 | Evaluation and management of a specific problem |
| LP173193-6 | Evaluation and management of anticoagulation |
| LP173194-4 | Evaluation and management of hyperlipidemia |
| LP173195-1 | Evaluation and management of hypertension |
| LP267443-2 | Evaluation and management of radiation exposure |
| LP173197-7 | Evaluation and management of smoking cessation |
| LP208913-6 | Evaluation and management of workers compensation |
| LP269262-4 | Fluid management |
| LP204160-8 | Medical equipment or product |
| LP173206-6 | Plan |
| LP173209-0 | Plan of care |
| LP173211-6 | Restraint |
| LP427038-7 | Stroke prevention |
| LP173214-0 | Surgical operation |
| LP173215-7 | Postoperative evaluation and management |
| LP173216-5 | Preoperative evaluation and management |
| LP173103-5 | Summary |
| LP173218-1 | Antepartum summary |
| LP173221-5 | Discharge summary |
| LP450488-4 | Newborn discharge summary |
| LP222264-6 | Immunization summary |
| LP173223-1 | Labor and delivery summary |
| LP175732-9 | Population summary |
| LP173225-6 | Summary of death |
| LP200117-2 | Summary of encounters |
| LP173224-9 | Summary of episode |
| LP173226-4 | Transfer summary |
| LP189614-3 | Weight management summary |
| LP438240-6 | Appointment summary |
| LP451462-8 | Postpartum summary |
| LP173227-2 | Transplant candidate evaluation |
| LP173228-0 | Transplant donor evaluation |
| LP173229-8 | Well child visit |
| LP263510-2 | Immunization |
| LP450643-4 | Immunization reminder |
| LP204160-8 | Medical equipment or product |
| LP173231-4 | Medication management |
| LP207306-4 | Medication administration |
| LP266264-3 | Parenteral therapy |
| LP173232-2 | Medication reconciliation |
| LP203673-1 | Notification |
| LP203034-6 | Admission notification |
| LP428837-1 | Departure notification |
| LP203035-3 | Discharge notification |
| LP204130-1 | Visit notification |
| LP450482-7 | Birth notification |
| LP428834-8 | Arrival notification |
| LP173233-0 | Outreach |
| LP173234-8 | Procedure |
| LP267418-4 | Cardiopulmonary resuscitation |
| LP269244-2 | Conscious sedation procedure |
| LP410764-7 | Emergency procedure |
| LP411573-1 | Mechanical circulatory support |
| LP173235-5 | Interventional procedure |
| LP418371-3 | Intubation |
| LP173236-3 | Pathology procedure |
| LP173237-1 | Autopsy |
| LP421048-2 | Quality |
| LP421047-4 | Gaps in care |
| LP173238-9 | Referral |
| LP173240-5 | Respite |
| LP173104-3 | Supervisory |
| LP173242-1 | Triage |
| LP450622-8 | Rehabilitation |
6.4.3 Setting
The healthcare environment or context in which the document was generated. Examples include Patient’s home, Emergency department, Hospital, Outpatient, Nursing facility.
| Part Number | Part Name |
|---|---|
| LP173041-7 | Ambulance |
| LP173043-3 | Emergency department |
| LP173065-6 | Hospital |
| LP173045-8 | Intensive care unit |
| LP173046-6 | Long term care facility |
| LP173047-4 | Custodial care facility |
| LP173048-2 | Nursing facility |
| LP173049-0 | Skilled nursing facility |
| LP222061-6 | Observation unit |
| LP173051-6 | Outpatient |
| LP266261-9 | Adult day care center |
| LP173054-0 | Outpatient hospital |
| LP173055-7 | Urgent care center |
| LP173056-5 | Patient’s home |
| LP220237-4 | Pharmacy |
| LP248736-3 | Recovery room |
| LP173058-1 | Telehealth |
| LP248737-1 | Teleimaging |
| LP173059-9 | Telephone encounter |
6.4.4 Subject matter domain
Characterizes the general focus or domain of knowledge represented within the content of the note. Typically values represent medical specialties but there is no requirement that the author have licensure or registration in that field. Examples include Audiology, Neurology, Cardiac Surgery, Nephrology.
| Part Number | Part Name |
|---|---|
| LP263512-8 | Addiction medicine |
| LP172912-0 | Addiction psychiatry |
| LP172915-3 | Aerospace medicine |
| LP345051-9 | Allergy |
| LP172918-7 | Anesthesiology |
| LP172981-5 | Pain medicine |
| LP248728-0 | Sleep medicine |
| LP172919-5 | Audiology |
| LP439903-8 | Child life |
| LP172923-7 | Chiropractic medicine |
| LP172933-6 | Critical care medicine |
| LP172934-4 | Dentistry |
| LP172935-1 | Dermatology |
| LP172987-2 | Pediatric dermatology |
| LP172940-1 | Emergency medicine |
| LP172957-5 | Medical toxicology |
| LP173027-6 | Sports medicine |
| LP183499-5 | Trauma |
| LP265794-0 | Polytrauma |
| LP173035-9 | Undersea and hyperbaric medicine |
| LP172942-7 | Ethics |
| LP172943-5 | Family medicine |
| LP172913-8 | Adolescent medicine |
| LP172947-6 | Geriatric medicine |
| LP248728-0 | Sleep medicine |
| LP173027-6 | Sports medicine |
| LP172894-0 | Forensic medicine |
| LP172946-8 | General medicine |
| LP433455-5 | Hospitalist |
| LP431539-8 | Hospice care |
| LP345043-6 | Immunology |
| LP342846-5 | Integrative medicine |
| LP172911-2 | Acupuncture |
| LP172952-6 | Internal medicine |
| LP172913-8 | Adolescent medicine |
| LP172921-1 | Cardiovascular disease |
| LP172927-8 | Clinical cardiac electrophysiology |
| LP269425-7 | Heart failure |
| LP172953-4 | Interventional cardiology |
| LP269424-0 | Transplant cardiology |
| LP172941-9 | Endocrinology |
| LP172938-5 | Diabetology |
| LP172945-0 | Gastroenterology |
| LP172950-0 | Hepatology |
| LP172947-6 | Geriatric medicine |
| LP175685-9 | Hematology |
| LP417851-5 | Bone Marrow Transplant |
| LP172951-8 | Infectious disease |
| LP183500-0 | HIV |
| LP175686-7 | Medical Oncology |
| LP172962-5 | Nephrology |
| LP263511-0 | Dialysis |
| LP418387-9 | Therapeutic apheresis |
| LP173015-1 | Pulmonary disease |
| LP173023-5 | Rheumatology |
| LP248728-0 | Sleep medicine |
| LP417852-3 | Solid organ transplant |
| LP173027-6 | Sports medicine |
| LP439901-2 | Vascular Access |
| LP172956-7 | Medical genetics |
| LP172926-0 | Clinical biochemical genetics |
| LP172929-4 | Clinical genetics |
| LP268361-5 | Pharmacogenomics |
| LP172958-3 | Mental health |
| LP345044-4 | Eating disorders |
| LP173011-0 | Psychiatry |
| LP172912-0 | Addiction psychiatry |
| LP172922-9 | Child and adolescent psychiatry |
| LP173012-8 | Psychology |
| LP248501-1 | Child and adolescent psychology |
| LP248729-8 | Neuropsychology |
| LP172960-9 | Multi-specialty program |
| LP345048-5 | Aerodigestive medicine |
| LP263714-0 | Brain injury |
| LP420041-8 | Breastfeeding |
| LP345049-3 | Cleft and Craniofacial |
| LP345044-4 | Eating disorders |
| LP417672-5 | Medical Aid in Dying |
| LP265794-0 | Polytrauma |
| LP417852-3 | Solid organ transplant |
| LP172897-3 | Multidisciplinary |
| LP172963-3 | Neurological surgery |
| LP345042-8 | Spinal surgery |
| LP172964-1 | Neurology |
| LP263714-0 | Brain injury |
| LP172931-0 | Clinical neurophysiology |
| LP248726-4 | Epilepsy |
| LP172898-1 | Neurology w special qualifications in child neuro |
| LP172981-5 | Pain medicine |
| LP248728-0 | Sleep medicine |
| LP173038-3 | Vascular neurology |
| LP172968-2 | Nuclear medicine |
| LP172899-9 | Nutrition and dietetics |
| LP345044-4 | Eating disorders |
| LP269243-4 | Obesity medicine |
| LP172971-6 | Obstetrics and gynecology |
| LP221284-5 | Gynecology |
| LP202989-2 | Gynecologic oncology |
| LP172955-9 | Maternal and fetal medicine |
| LP221283-7 | Obstetrics |
| LP173020-1 | Reproductive endocrinology and infertility |
| LP172973-2 | Occupational therapy |
| LP172901-3 | Oncology |
| LP202989-2 | Gynecologic oncology |
| LP175686-7 | Medical Oncology |
| LP172991-4 | Pediatric hematology-oncology |
| LP173016-9 | Radiation oncology |
| LP207940-0 | Surgical oncology |
| LP172974-0 | Ophthalmology |
| LP172975-7 | Optometry |
| LP172902-1 | Oral and maxillofacial surgery |
| LP434806-8 | Orthopaedic surgery |
| LP345042-8 | Spinal surgery |
| LP173029-2 | Surgery of the hand |
| LP434870-4 | Orthopaedic |
| LP172979-9 | Orthotics prosthetics |
| LP434767-2 | Osteopathic medicine |
| LP172980-7 | Otolaryngology |
| LP172994-8 | Pediatric otolaryngology |
| LP248728-0 | Sleep medicine |
| LP172982-3 | Palliative care |
| LP172983-1 | Pastoral care |
| LP172984-9 | Pathology |
| LP208907-8 | Anatomic pathology |
| LP208906-0 | Clinical pathology |
| LP172920-3 | Blood banking and transfusion medicine |
| LP418387-9 | Therapeutic apheresis |
| LP208902-9 | Chemical pathology |
| LP208903-7 | Pathology – Medical microbiology |
| LP173002-9 | Pediatrics |
| LP172913-8 | Adolescent medicine |
| LP345048-5 | Aerodigestive medicine |
| LP172922-9 | Child and adolescent psychiatry |
| LP248501-1 | Child and adolescent psychology |
| LP172937-7 | Developmental-behavioral pediatrics |
| LP172950-0 | Hepatology |
| LP172957-5 | Medical toxicology |
| LP172961-7 | Neonatal perinatal medicine |
| LP192135-4 | Birth defects |
| LP172985-6 | Pediatric cardiology |
| LP172986-4 | Pediatric critical care medicine |
| LP172987-2 | Pediatric dermatology |
| LP172989-8 | Pediatric endocrinology |
| LP172990-6 | Pediatric gastroenterology |
| LP173000-3 | Pediatric transplant hepatology |
| LP172991-4 | Pediatric hematology-oncology |
| LP417851-5 | Bone Marrow Transplant |
| LP172992-2 | Pediatric infectious diseases |
| LP172993-0 | Pediatric nephrology |
| LP172994-8 | Pediatric otolaryngology |
| LP172995-5 | Pediatric pulmonology |
| LP172997-1 | Pediatric rehabilitation medicine |
| LP172998-9 | Pediatric rheumatology |
| LP172999-7 | Pediatric surgery |
| LP248728-0 | Sleep medicine |
| LP173027-6 | Sports medicine |
| LP173003-7 | Pharmacology |
| LP220238-2 | Clinical pharmacology |
| LP268361-5 | Pharmacogenomics |
| LP447710-7 | Clinical pharmacy |
| LP173004-5 | Physical medicine and rehabilitation |
| LP263714-0 | Brain injury |
| LP172954-2 | Kinesiotherapy |
| LP172981-5 | Pain medicine |
| LP172997-1 | Pediatric rehabilitation medicine |
| LP265794-0 | Polytrauma |
| LP173026-8 | Spinal cord injury medicine |
| LP173040-9 | Vocational rehabilitation |
| LP173005-2 | Physical therapy |
| LP173006-0 | Plastic surgery |
| LP268363-1 | Burn management |
| LP173029-2 | Surgery of the hand |
| LP173008-6 | Podiatry |
| LP433456-3 | Chiropody |
| LP173009-4 | Preventive medicine |
| LP172957-5 | Medical toxicology |
| LP172972-4 | Occupational medicine |
| LP173035-9 | Undersea and hyperbaric medicine |
| LP173010-2 | Primary care |
| LP448682-7 | Preventive care |
| LP173014-4 | Public health |
| LP204156-6 | Community health care |
| LP267441-6 | Environmental health |
| LP173018-5 | Radiology |
| LP172896-5 | Interventional radiology |
| LP173016-9 | Radiation oncology |
| LP448142-2 | Social Care |
| LP173019-3 | Recreational therapy |
| LP173021-9 | Research |
| LP173022-7 | Respiratory therapy |
| LP173025-0 | Speech-language pathology |
| LP173028-4 | Surgery |
| LP248500-3 | Bariatric surgery |
| LP268363-1 | Burn management |
| LP172932-8 | Colon and rectal surgery |
| LP172999-7 | Pediatric surgery |
| LP173029-2 | Surgery of the hand |
| LP173030-0 | Surgical critical care |
| LP207940-0 | Surgical oncology |
| LP173031-8 | Thoracic and cardiac surgery |
| LP207300-7 | Cardiac surgery |
| LP173033-4 | Transplant surgery |
| LP417852-3 | Solid organ transplant |
| LP183499-5 | Trauma |
| LP265794-0 | Polytrauma |
| LP434807-6 | Trauma Surgery |
| LP173039-1 | Vascular surgery |
| LP269976-9 | Thromboembolism |
| LP173034-2 | Tumor board |
| LP173036-7 | Urology |
| LP173001-1 | Pediatric urology |
| LP248732-2 | Womens health |
| LP185997-6 | Wound care management |
| LP268363-1 | Burn management |
| LP412351-1 | Wound, Ostomy, and Continence Care |
| LP439901-2 | Vascular Access |
| LP448293-3 | Rapid response |
| LP450620-2 | Hemodynamic |
6.4.5 Role
Characterizes the general function, responsibility, or capabilities of the author in relation to a document. The role category is a high-level classification that does not get as detailed as specialty or subspecialty so as to avoid potential overlap with the subject matter domain axis. Examples include Physician, Nurse, Social worker, Device.
| Part Number | Part Name |
|---|---|
| LP443176-5 | Worker |
| LP269965-2 | Attending |
| LP173067-2 | Case manager |
| LP269966-0 | Consultant |
| LP269967-8 | Fellow |
| LP412180-4 | Healthcare navigator |
| LP173071-4 | Hygienist |
| LP173072-2 | Interdisciplinary |
| LP173073-0 | Team |
| LP203036-1 | Rapid response team |
| LP269968-6 | Intern |
| LP221282-9 | Midwife |
| LP173075-5 | Nurse |
| LP173078-9 | Clinical nurse specialist |
| LP173080-5 | Nurse practitioner |
| LP173081-3 | Licensed practical nurse |
| LP173082-1 | Registered nurse |
| LP173083-9 | Patient |
| LP453142-4 | Patient (existing |
| LP453146-5 | Patient related individual (new) |
| LP181523-4 | Pharmacist |
| LP173084-7 | Physician |
| LP269965-2 | Attending |
| LP269966-0 | Consultant |
| LP269967-8 | Fellow |
| LP269968-6 | Intern |
| LP269969-4 | Resident |
| LP173090-4 | Physician assistant |
| LP269969-4 | Resident |
| LP269801-9 | Social worker |
| LP448143-0 | Community Health Worker |
| LP173091-2 | Student |
| LP173092-0 | Medical student |
| LP173094-6 | Technician |
| LP173095-3 | Therapist |
| LP453144-0 | Provider (new) |