Reference to the patient who is the subject of this clinical note. This establishes the primary relationship between the documentation and the individual receiving care, enabling all clinical notes to be retrieved and organized by patient for comprehensive record review.

Example: "Patient/patient-67890"

Reference to the clinical encounter during which this note was created. Links the documentation to a specific episode of care, visit, or admission, providing temporal and contextual association for the clinical narrative within the broader care timeline.

Example: "Encounter/encounter-12345"

Classification of the clinical note type indicating its purpose and clinical context. Different note types follow specific documentation standards and serve distinct roles in the care process, from routine progress tracking to formal consultation responses and comprehensive discharge planning.

Values: progress-note, admission-note, discharge-summary, consultation-note, procedure-note, operative-note, nursing-note, history-physical, assessment-plan

Example: "progress-note"

Current lifecycle status of the clinical note indicating whether it is still being composed, finalized and active in the medical record, replaced by a newer version, or marked as erroneous. Status management ensures proper version control and legal validity of clinical documentation.

Values: draft, active, superseded, entered-in-error

Example: "active"

Date and time when the clinical documentation was created or the clinical observations were recorded. This timestamp establishes the temporal context for all clinical findings, assessments, and plans documented in the note, which is critical for understanding the patient's clinical trajectory.

Example: "2025-11-28T14:30:00Z"

Reference to the healthcare practitioner who composed and documented the clinical note. Establishes authorship and clinical responsibility for the documented observations, assessments, and care plans, which is essential for accountability and medicolegal purposes.

Example: "Practitioner/practitioner-45678"

Reference to the healthcare practitioner who reviewed, verified, and officially authenticated the clinical note by signing or approving it. Authentication transforms a draft document into an official legal medical record, confirming the accuracy and completeness of the documentation.

Example: "Practitioner/practitioner-45678"

Date and time when the clinical note was officially authenticated or signed by the authenticator. This timestamp marks when the documentation became a verified and legally valid component of the permanent medical record.

Example: "2025-11-28T15:45:00Z"

Human-readable title or heading for the clinical note that provides quick identification of the document's purpose and content. Titles help clinicians rapidly locate and distinguish between multiple notes in the medical record.

Example: "Cardiology Follow-up Progress Note"

The complete clinical narrative text containing all observations, findings, assessments, clinical reasoning, and care plans documented by the author. This is the primary field containing the substantive medical documentation that forms the legal clinical record.

Example: "Patient presents for follow-up of chronic heart failure. Reports improved exercise tolerance and decreased dyspnea. Physical exam shows clear lung fields, no peripheral edema. Continue current medications."

Brief statement of the primary reason for the patient's visit or the main symptom or concern expressed by the patient in their own words. The chief complaint provides immediate context for understanding the clinical focus of the encounter and subsequent documentation.

Example: "Shortness of breath and fatigue for 3 days"

Detailed chronological narrative describing the development and progression of the patient's current illness or presenting problem. The HPI section elaborates on the chief complaint with specific details about onset, duration, severity, aggravating and relieving factors, and associated symptoms.

Example: "67-year-old male with known CHF reports gradual onset of dyspnea starting 3 days ago. Initially only with exertion, now present at rest. Associated with bilateral lower extremity swelling. No chest pain or fever. Admits to dietary indiscretion over the weekend."

Clinical evaluation and interpretation of the patient's condition based on subjective and objective findings. The assessment section synthesizes all available clinical information to formulate diagnoses, differential diagnoses, and clinical impressions that guide treatment decisions.

Example: "Acute on chronic systolic heart failure exacerbation, likely secondary to dietary indiscretion and medication non-adherence. Volume overloaded on exam."

Detailed description of the therapeutic interventions, diagnostic workup, monitoring strategies, patient education, and follow-up arrangements planned to address the patient's clinical conditions. The plan section documents the clinical decision-making and care strategy moving forward.

Example: "1) Increase furosemide to 80mg daily 2) Strict fluid restriction 1.5L/day 3) Daily weights 4) Low sodium diet counseling 5) Follow-up in 1 week 6) Return precautions discussed"

References to other clinical notes that are clinically related to this document, such as prior versions being superseded, previous notes being referenced for comparison, or related documentation from other providers. These links establish document relationships that support comprehensive clinical review and care coordination.

Example: ["ClinicalNote/note-11111","ClinicalNote/note-22222"]

Calculated indicator showing whether the clinical note has been officially authenticated by having an authenticator assigned. Authenticated notes have been reviewed and signed, making them official legal medical records, while unauthenticated notes may still be in draft or pending review status.

Example: true

Calculated count of words in the clinical note content. Word count provides a quantitative measure of documentation thoroughness and can be used for quality metrics, billing support, and identifying potentially incomplete or excessive documentation.

Example: 247