Chapter 09: Medical Records/Information Management
This chapter covers clinical documents and their status. It defines the messages for a note or a summary that is created, edited, signed or replaced.
This chapter covers clinical documents, such as a discharge summary or a dictated note. It covers the events in a document's life: the document is created, edited, signed, replaced or made obsolete. The main message type is MDM. The TXA segment carries the document's status. The text of the document travels in OBX segments.
What is in this chapter
- 12 trigger eventsthe real-world things that cause one of these messages to be sent
- 2 segmentsthe lines these messages are built from, and the fields on each
- 14 code tablesthe value sets the fields in this chapter draw from
- 2 message typesDOC, MDM
Message types defined here
DOCDocument response1 structure, fired by 1 trigger event.
MDMMedical document management2 structures, fired by 11 trigger events.
Segments defined here
These 2 segments are defined in chapter 09. Messages in other chapters may still carry them.
Trigger events
A trigger event is the thing that happens in the hospital and causes a message to be sent. Chapter 09 defines 12 of them.
T01Original Document NotificationT02Original Document Notification and ContentT03Document Status Change NotificationT04Document status change notification and contentT05Document Addendum NotificationT06Document Addendum Notification and ContentT07Document Edit NotificationT08Document Edit Notification and ContentT09Document Replacement NotificationT10Document Replacement Notification and ContentT11Document Cancel NotificationT12Document Query