Medical records contain many pieces of clinical data on the patient’s health. To help identify and organize the patient’s data, Data Elements are used to capture the data.
Reference the below table for Data Elements:
| Data Element | Definition | Identifiers |
| Allergies | An abnormal reaction in response to otherwise harmless substances | Allergy, Allergy List, Allergens, Allergic |
| Assessment/Plan | The synthesis of findings of presenting conditions that inform the treatment plan. |
Impression, Evaluation, Treatment Plan |
| Chief Complaint/Reason for Visit | The primary complaint for which the patient seeks medical care. | CC, Reason for Visit, Reason for Encounter |
| Diagnosis/Problem | The medical condition(s) experienced by the patient. This clinical information can be evident in multiple sections of a medical record. |
DX, DS, Problem, Active Problems, Problem List, Patient Active Problem List, Final Diagnosis.
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| Facility *Capture one time per Encounter date |
The name of the location where the patient received care. | |
| History of Present Illness (HPI) |
The progression of the complaints/ problems that a patient conveys to the healthcare provider. It narrates how the complaints started, their progression and their associated factors.
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HPI, Hx of Present Illness, H&P |
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Immunization *No need to currently Capture |
Protection from disease through a vaccine | Vax, Vaccine |
| Medication | Any Drug/Remedy. Medications or drugs advised to the patient. | Meds, prescriptions, MAR |
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Objective *No need to currently Capture |
Medical information gained through direct observation and testing of the patient applying objective or standard methods. This is typically used in SOAP structure | |
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Past Medical History *Capture once per chart unless there is new info, always capture new info |
History consists of information related to medical conditions/ diseases that the patient suffered or suffering from |
PMHx, Medical History, Problem List, Patient History, History, PMH.
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Physical Examination *No need to currently Capture |
The evaluation of the patient done to identify the signs of a disease. Physical Examination can contain medical conditions/ diseases or symptoms that are elicited as part of examination. | MSE, Examination, Mental Exam |
| Provider Name *Capture one time per Encounter date |
The Primary Healthcare Provider/ Physician who treated the patient | |
| Review of Systems (ROS) *No need to currently Capture | Complete examination of a patient's organ systems. | |
| Sex/Gender *Capture one time per RP# |
Female/Male | |
| Subjective | Captures all the information said by the patient. Perceived only by the patient and not evident to the examiner. This is typically used in SOAP structure | |
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Surgical History *Capture once per chart unless there is new info, always capture new info |
The surgery(s) performed on the patient | Surgical History, Past Surgical History, PSHx, Procedure History |
These Data Elements will have multiple Data Points
| Data Element | Definition | Data Points | ||||||||||||||||
| Diagnostic Testing | Procedure performed on a patient for diagnostic, measurement, screening, or rating that might have a resulting value. This includes any procedure, process, evaluation, or rating to determine a diagnosis, to rule out or find a condition, or to scale or score a patient. This includes tests like X-ray, Ultrasound, MRI, Pathology/Biopsy, Sleep studies, Eye Exam, Mental Exam and other relevant diagnostic procedures. |
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Family History *Capture once per chart unless there is new info, always capture new info |
Record of diseases and health conditions in the patient’s family |
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| Lab (Out of Range) |
Abnormal test results. This includes test from Blood, Urine, Stool, Sputum, and Swab/Culture. |
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| Operative Procedure | Procedures carried out for the diagnosis and cure of certain diseases, repair of injuries or the correction of deformities and defects |
1. Procedure Name 2. Procedure Notes |
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Social History *Capture once per chart unless there is new info, always capture new info
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Identifies a patient’s lifestyle practices that may be clinically significant
N/A: is the default -we will capture every time- even when 0 Alcohol, substance or smoker status is present Yes: If any indication that they currently use Substance, Alcohol or Smoker No: If there any indication they DO NOT or never used Substance, Alcohol or Smoker Former: is any indication of previous use of Substance, Alcohol or Smoker |
What to capture/avoid capture:
*Smoker= any use of nicotine or tobacco products including but not limited to vaping, smoking, cigarettes, smokeless tobacco, or nicotine. |
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| Vitals |
These are clinical parameters objectively measured of body’s basic functions. These measurements are taken to help assess the general physical health of the patient and can give clues to possible diseases and show progress towards recovery.
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A medical record may contain a variety of Vital signs, so use these identifiers:
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Only on INPATIENT and EMERGENCY Document Types
| Data Element | Definition | Identifiers |
| Date – Admission | • Only Seen on Emergency, Hospital, Home Health. Indicates the Admission and Discharge Date. The Admission and Discharge Notes display the general information a provider adds regarding the patient’s Admission or Discharge. | • Admission Date |
| Date – Discharge | • Discharge Date | |
| Notes – Admission | • Admission Summary • Admission Notes |
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| Notes – Discharge | • Discharge Summary • Discharge Notes |