A patient authored note is generated by a patient, or a patient agent (proxy), acting in a non-clinical role to provide clinically relevant information. The information within the note is used to support planned or unplanned health care services. This document gives healthcare providers and others involved in a person's care information which the patient considers essential input during care delivery and coordination. This document enables patients and their agents to contribute to the continuity of care. The patient agent may not have a legally defined relationship with the patient (e.g. a close friend). Because a patient authored note is generated by a person acting as a non-clinician, this document may not be a complete medical summary and should be considered in context with other information routinely collected by clinicians during care delivery and coordination. This general class of patient authored notes includes information that is interoperable with data defined for clinician-generated documents. Other more specific classes of patient authored notes may include more tightly defined content. This document may be generated from a patient-, clinician-, or payer-controlled source system.
status
ACTIVE
Fully-Specified Name
component
Note
property
Find = Finding
time
Pt = Point in time: To identify measures at a point in time. This is a synonym for “spot” or “random” as applied to urine measurements.
system
{Setting}
scale
Doc = Document: A document that could be in many formats (XML, narrative, etc.)
method
Patient
Additional Names
short name
DOC.ONT; Document; Encounter; Evaluation and management; Evaluation and management note; Finding; Findings; notes; Point in time; Random; Visit note
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