Any chart, form or CH10 Vital Signs Chart document used to vital 823611000000107 signs Any chart, form or CH11 Weight document used to record 820441000000103 weight Not specified or for bulk CH99 Observation 823621000000101 scanning CL Clinical Notes Any inpatient information CL03 Inpatient medical note 820221000000109 recorded by medical staff Any inpatient information CL04 Inpatient nursing note 829201000000105 recorded by nursing staff Any information recorded CL05 Medical note 820451000000100 by medical staff Any information recorded CL06 Multidisciplinary note 820461000000102 by multiple staff groups Any information recorded CL07 Nursing note by nursing staff including 820471000000109 community notes Any information recorded CL08 OOH note 823631000000104 by Out of Hours service Any outpatient CL09 Outpatient nursing note information recorded by 820481000000106 nursing staff Any outpatient CL10 Outpatient medical note information recorded by 820491000000108 medical staff Any information recorded CL11 AHP note by an AHP e.g.. Dietetic 823641000000108 Record Card Any clinical information CL13 Telephone Consultation pertaining to a telephone 24681000000104 consultation Any clinical information CL14 Consultation pertaining to a video 325921000000107 consultation Any clinical summary CL15 Summary record 824321000000109 noted at a point in time Emergency department CL16 ED Card clinical note e.g.. AE 445300006 Card Not Specified or for bulk scanning and remote CL99 Clinical note notes including patient 823651000000106 contacts by telephone and email. CO Correspondence Created as a result of an out patient clinic CO02 Outpatient Letter 823681000000100 attendance e.g.. clinic letter
CH10 Vital Signs Chart Any chart, form or document used to vital signs 823611000000107 CH11 Weight Any chart, form or document used to record weight 820441000000103 CH99 Observation Not specified or for bulk scanning 823621000000101 CL Clinical Notes CL03 Inpatient medical note Any inpatient information recorded by medical staff 820221000000109 CL04 Inpatient nursing note Any inpatient information recorded by nursing staff 829201000000105 CL05 Medical note Any information recorded by medical staff 820451000000100 CL06 Multidisciplinary note Any information recorded by multiple staff groups 820461000000102 CL07 Nursing note Any information recorded by nursing staff including community notes 820471000000109 CL08 OOH note Any information recorded by Out of Hours service 823631000000104 CL09 Outpatient nursing note Any outpatient information recorded by nursing staff 820481000000106 CL10 Outpatient medical note Any outpatient information recorded by medical staff 820491000000108 CL11 AHP note Any information recorded by an AHP e.g.. Dietetic Record Card 823641000000108 CL13 Telephone Consultation Any clinical information pertaining to a telephone consultation 24681000000104 CL14 Consultation Any clinical information pertaining to a video consultation 325921000000107 CL15 Summary record Any clinical summary noted at a point in time 824321000000109 CL16 ED Card Emergency department clinical note e.g.. AE Card 445300006 CL99 Clinical note Not Specified or for bulk scanning and remote notes including patient contacts by telephone and email. 823651000000106 CO Correspondence CO02 Outpatient Letter Created as a result of an out patient clinic attendance e.g.. clinic letter 823681000000100
2018-04-27-CDI-Standard-v3-3-FINAL.docx