1 |
Demographics |
age, sex/gender, race |
2 |
Diagnoses |
diagnosis, severity, medical history |
3 |
Problem list |
active diagnosis, resolved diagnosis |
4 |
Medical history |
past procedures, diagnoses, medication, lab, radiology |
5 |
Family history |
familial disorders, risk factors |
6 |
Allergies |
food and medication allergy |
7 |
Immunization |
DTaP, HepB |
8 |
Medications |
prescriptions written, IFA |
9 |
Procedures |
inpatient, outpatient |
10 |
Lab orders/values |
CBC results, HbA1C levels |
11 |
Vital signs |
BMI (weight and height), blood pressure, body temperature |
12 |
Radiology reports |
radiology, pathology, and other reports |
13 |
Utilization |
cost, hospitalization |
14 |
Social data |
income level, education |
15 |
Discharge summary |
inpatient summary report |