CODED CLINICAL ENTRY

An entry in an ELECTRONIC HEALTH RECORD, recorded by a CARE PROFESSIONAL, PATIENT or Patient Proxy, or other authorised PERSON, relating to ACTIVITIES for the care and treatment of a PATIENT.

Description

An entry in an ELECTRONIC HEALTH RECORD, recorded by a CARE PROFESSIONAL, PATIENT  or Patient Proxy, or other authorised PERSON, relating to ACTIVITIES  for the care and treatment of a PATIENT

CODED CLINICAL ENTRIES  may describe:

A CODED CLINICAL ENTRY  in an ELECTRONIC HEALTH RECORD  should include the recording of relevant   CLINICAL TERMINOLOGY CODES  and/or CLINICAL CLASSIFICATION CODES.  Where information to complete the CODED CLINICAL ENTRY  is missing, a DATA ABSENT REASON  should be recorded.

Where Used

Type Link How used
NHS Business Definition ABO System references in description CODED CLINICAL ENTRY
Attribute CLINICAL CLASSIFICATION CODE references in description CODED CLINICAL ENTRY
Attribute CLINICAL TERMINOLOGY CODE references in description CODED CLINICAL ENTRY
Class CODED CLINICAL ENTRY references in description CODED CLINICAL ENTRY
Attribute CODED CLINICAL ENTRY SEQUENCE NUMBER references in description CODED CLINICAL ENTRY
Data Element CODED FINDING (CODED CLINICAL ENTRY) references in description CODED CLINICAL ENTRY
Attribute DATA ABSENT REASON references in description CODED CLINICAL ENTRY
Data Element DATA ABSENT REASON (FHIR R4) references in description CODED CLINICAL ENTRY
Data Element DIAGNOSIS (CODED CLINICAL ENTRY) references in description CODED CLINICAL ENTRY
Attribute DIAGNOSIS SCHEME IN USE references in description CODED CLINICAL ENTRY
Data Element DM+D CODE references in description CODED CLINICAL ENTRY
Attribute FINDING SCHEME IN USE references in description CODED CLINICAL ENTRY
Data Element ICD-10 CODE references in description CODED CLINICAL ENTRY
Data Element ICD-O CODE references in description CODED CLINICAL ENTRY
NHS Business Definition Intended Patient Procedure references in description CODED CLINICAL ENTRY
Attribute LOCAL TREATMENT CATEGORY CODE references in description CODED CLINICAL ENTRY
Attribute LOCAL TREATMENT CODE references in description CODED CLINICAL ENTRY
Data Element LONG TERM PHYSICAL HEALTH CONDITION (CODED CLINICAL ENTRY) references in description CODED CLINICAL ENTRY
Data Element NICIP CODE references in description CODED CLINICAL ENTRY
Data Element OPCS-4 CODE references in description CODED CLINICAL ENTRY
Class OPERATING THEATRE references in description CODED CLINICAL ENTRY
Data Element PRESENTING COMPLAINT (CODED CLINICAL ENTRY) references in description CODED CLINICAL ENTRY
Data Element PREVIOUS DIAGNOSIS (CODED CLINICAL ENTRY) references in description CODED CLINICAL ENTRY
Data Element PRIMARY DIAGNOSIS (CODED CLINICAL ENTRY) references in description CODED CLINICAL ENTRY
Attribute PROCEDURE SCHEME IN USE references in description CODED CLINICAL ENTRY
Data Element PROVISIONAL DIAGNOSIS (CODED CLINICAL ENTRY) references in description CODED CLINICAL ENTRY
Data Element READ CODE references in description CODED CLINICAL ENTRY
NHS Business Definition Rh System references in description CODED CLINICAL ENTRY
Data Element SECONDARY DIAGNOSIS (CODED CLINICAL ENTRY) references in description CODED CLINICAL ENTRY
Attribute SITUATION SCHEME IN USE references in description CODED CLINICAL ENTRY
Data Element SNOMED CT CODE references in description CODED CLINICAL ENTRY

Also Known As

This class is also known by these names:

Context Alias
Plural CODED CLINICAL ENTRIES