[NO/URSA-CORE] Clinical Notes

Object Description

One record per clinical note; excludes deleted notes.

Metadata

• Table Name: ursa.no_ursa_core_note_001
• Layer: NATURAL_OBJECT
• Object Type: Single Stack
• Temporal Class: Event
• Case ID: Clinical Note ID
• Event Date: Created Datetime
• Primary Key: Clinical Note ID

Published Fields

• Data Model Keys

  • Clinical Note ID -- The internal database identifier (used, e.g., for joins and primary keys) for the Clinical Note. (See also [URSA-CORE] Clinical Note)
  • Patient ID -- The internal database identifier (used, e.g., for joins and primary keys) for the patient. This value is typically mastered, i.e., all records for the same patient, regardless of the source data system from which that record originated, should have the same Patient ID value. (Note that while the mastered Patient ID value might resemble a local identifier used in one of the upstream data sources, this does not indicate any special priority of that source system in determining the characteristics of the patient.) (See also [URSA-CORE] Patient)
  • Signing Provider ID
  • Originating EMR Encounter ID -- The internal database identifier (used, e.g., for joins and primary keys) for the EMR encounter that is the originating encounter of the given document. (See also [URSA-CORE] EMR Encounter, [URSA-CORE] Originating EMR Encounter)
  • Document ID
  • Source ID -- The identifier for the original source data system from which the current record originated.

• Source Local Keys

  • Source Local Clinical Note ID
  • Source Local Patient ID -- The internal database identifier for the patient in the source data system this record originated from. (See also [URSA-CORE] Patient)
  • Source Local Signing Provider ID

• Date Fields

  • Created Date
  • Created Datetime
  • Signed Date
  • Signed Datetime

• Clinical Services Fields

  • Note Type Description
  • Note Type Operational ID
  • Note Type SNOMED CT Code
  • Note Type LOINC Code
  • Note Body Text
  • Note Status Description
  • Note Status Operational ID
  • Is Note Status Signed

• Metadata Fields

  • Other EMR Comments -- Any other annotations or comments associated with the current record entered into the EMR.
  • Record Last Updated Datetime -- The date and time the current record was last updated in the original data source.
  • Source Data Effective Datetime -- The "as of" date and time of the original source data system at the moment the current record was extracted. For example, if a snapshot of the data in a production system is taken at 12:05 AM on the first of each month and used to generate a package of flat files that are eventually loaded into the Ursa Studio client database later that month, the Source Data Effective Datetime of all records in that month's package will be 12:05 AM on the first. Not to be confused with Record Last Updated Datetime. (See also [URSA-CORE] Record Last Updated Datetime)

Terms

• Patient Observation: An instance of a documented observation about a patient, such as a lab result, imaging study, assessment tool response, flowchart entry, etc.; a Patient Observation object includes fields capturing the service that was performed to generate the observation, the type of result, and the result value; Patient Observations may also have subordinate Patient Observations representing finer-grained, component results that contribute to a higher-level result.

Foreign Keys

• parent_pat_obs_id → ursa.no_ursa_core_pat_003.pat_obs_id
• pat_id → ursa.no_ursa_core_pat_001.pat_id
• obs_report_id → ursa.no_ursa_core_pat_004.obs_report_id
• observation_generating_emr_enc_id → ursa.no_ursa_core_enc_001.emr_enc_id
• observation_generating_emr_enc_service_line_item_id → ursa.no_ursa_core_enc_002.emr_enc_service_line_item_id
• observation_generating_service_id → ursa.no_ursa_core_proc_003.service_id
• observation_generating_service_prov_id → ursa.no_ursa_core_prov_001.prov_id
• service_order_id → ursa.no_ursa_core_proc_004.service_order_id
• signing_prov_id → ursa.no_ursa_core_prov_001.prov_id
• originating_emr_enc_id → ursa.no_ursa_core_enc_001.emr_enc_id

Dedicated Precursors

• [NO/URSA-CORE] Clinical Notes, Precursor 1 (All Source Records): One record per clinical note found in a source system