Data Elements for EHR Documentation

Health records contain a wide range of information, but most information within a health record can be grouped into two main categories: administrative or demographic data and clinical data. Although EHRs are primarily data-centric rather than document-centric, the issue remains with regard to how information is displayed for the purposes of patient care, information exchange, and so on. As a result, this resource focuses on defining clinical data content for EHR systems.

Document Headers

Section Subsection Data Element Description
Header N/A Patient name
Previously registered name/maiden name
Individual identifier/medical record number
Universal patient health number
Gender
Race
Address
Telephone number
Date of birth
Organization
Admission date
Discharge date
Legal authenticator
Authentication date
Transcriptionist/data enterer
Transcription date
The header provides the general demographic information.

History and Physical Report

Section Subsection Data Element Description
Reason for visit/chief complaint N/A Chief complaint
Reason for visit
The reason for the visit in the patient’s own words (or those of the patient’s representative); the principal reason the patient is seeking care. Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
History of present illness N/A Symptom(s)
Onset of symptom(s)
Duration of symptom(s)
Over-the-counter (OTC) treatment
This section describes the history related to the chief complaint. It contains the historical details leading up to and pertaining to the patient’s current complaint or reason for seeking medical care.
Past medical history Conditions Condition type
Date diagnosed
Age of onset
Treatment
Condition status
The past medical history for the patient, including illnesses that might have an impact on the patient’s current condition.
Medications N/A Drug
Dosage
Route
Quantity number
Quantity form
Frequency
Start date
Stop date
Prescribed by
Prescription date
Prescription number
Pharmacy
Allergic reaction
Source of medication list
The patient’s current medications and pertinent medication history. The section may also include a patient’s prescription history and enables the determination of the source of a medication list (e.g., from a pharmacy system versus from the patient, spouse, etc.).
Allergies   Allergy or sensitivity type
Reaction
Severity
Date last occurred
Treatment
This section is used to list and describe any allergies, adverse reactions, and alerts that are pertinent to the patient’s current or past medical history. At a minimum, current and any relevant historical allergies and adverse reactions should be listed.
Social history   Marital status
Occupation
Home environment
Daily routine
Dietary patterns
Sleep patterns
Exercise patterns
Coffee consumption
Tobacco use
Alcohol use
Drug use
This section contains data defining the patient’s occupational, personal (i.e., lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity, and religious affiliation. Social history can have significant influence on a patient’s physical, psychological, and emotional health and well being, so it should be considered in the development of a complete record.
Family history N/A Child health history
Adult health history
Hereditary diseases
Mother health status
Mother age of death
Mother cause of death
Father health status
Father age of death
Father cause of death
Sibling(s) health status
Sibling(s) age of death
Sibling(s) cause of death
This section contains data defining the patient’s genetic relatives in terms of relevant health risk factors that have a potential impact on the patient’s healthcare profile.
Review of systems N/A General
Skin
Head
Eyes
Ears
Nose and sinuses
Mouth and throat
Neck
Breasts
Respiratory
Cardiac
Gastrointestinal
Genitourinary
Gynecologic
Musculoskeletal
Peripheral vascular
Neurologic
Hematologic
Endocrine
Psychiatric
A review of systems is the physician’s summary of a patient’s main and general body systems for basic functioning purposes. The physician will identify any problem areas in the respective sections if needed.
Physical examination Vital signs Pulse
Respiratory rate
Systolic blood pressure
Diastolic blood pressure
Body temperature
Height
Weight
Body mass index
Head circumference
Crown-to-rump length
Pulse oximetry
Vital signs are the indicators of a patient’s general physical condition. It identifies a patient’s level of physical functions based on elements such as heart rate, pulse, blood pressure, and body temperature.
General appearance Appearance
Body build
Demeanor
Hygiene
The general appearance section describes general observations and readily observable attributes of the patient, including affect and demeanor, apparent age compared to actual age, ethnicity, body build and habitus (e.g., muscular, cachectic, obese), developmental or other deformities, gait and mobility, personal hygiene, evidence of distress, voice quality, and speech.
Physical findings Skin
Head
Eyes
Ears
Nose and sinus
Mouth and throat
Neck
Thorax, anterior, and posterior
Breasts
Lungs
Cardiovascular
Abdomen
Male genitourinary
Female reproductive organs
Ano-rectal
Musculoskeletal system
Extremities
Lymphatics
Peripheral vascular
Neurologic
Mental status
The physical findings section describes direct observations made by the clinician, divided by organ system.
Diagnostic findings Laboratory
Pathology
Imaging
Cardiovascular
Test
Result/finding
Result/finding date
Interpretation
This section contains the results of observations generated by laboratories, imaging procedures, and any other procedures that aid in defining treatment.
Assessment and plan Assessment Diagnoses
Disposition
A history and physical contains either discrete sections for assessment and plan or a single section combining the two. The assessment (also dictated impression or diagnoses) represents the physician’s conclusions and working assumptions that will guide treatment of the patient. The assessment is used to formulate a specific plan or set of recommendations. The assessment may be a list of specific disease entities or a narrative block.
Plan Treatment goals
Procedures
The plan section contains all active, incomplete, or pending orders, appointments, referrals, procedures, and services. Any other pending events of clinical significance to the current and ongoing care of the patient should be listed unless constrained due to issues of privacy. The plan section also contains information regarding goals and clinical reminders. Clinical reminders are placed here for purposes of providing prompts that may be used for disease prevention and management, patient safety, and healthcare quality improvements, including widely accepted performance measures.
Procedure history (optional) N/A Procedure
Date
Physician
Institution/location
Result
This section is optional and will include any past procedures or surgeries that the patient has had to include information such as what was done, where it was done, by whom it was done, and the results of it.
Immunizations (optional) Childhood immunizations Vaccine
Vaccine type
Dose
Age administered
Date administered
Lot number
Physician
The immunizations section defines a patient’s current immunization status and pertinent immunization history.
Adult immunizations Vaccine
Vaccine type
Dose
Date administered
Lot number
Physician
Problems (optional) N/A Problem
Date of onset
This section lists and describes all relevant clinical problems at the time the summary is generated. At a minimum, all pertinent current and historical problems should be listed.
Payers (optional) N/A Source of payment The entity responsible for the financial aspects of the patient’s care.

Consultation Report

Section Subsection Data Element Description
Request for consultation N/A Requesting provider
Consulting provider
Reason for consultation
This section identifies to the consulting provider the focal point of the reason for the consultation request.
Chief complaint N/A Chief complaint The reason for the visit in the patient’s own words (or those of the patient’s representative); the principal reason the patient is seeking care. Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
History of present illness N/A Symptom(s)
Onset of symptom(s)
Duration of symptom(s)
Over-the-counter (OTC) treatment
This section describes the history related to the chief complaint. It contains the historical details leading up to and pertaining to the patient’s current complaint or reason for seeking medical care.
Past medical history Conditions Condition type
Date diagnosed
Age of onset
Treatment
Condition status
The past medical history for the patient, including illnesses that might have an impact on the patient’s current condition.
Medications N/A Drug
Dosage
Route
Quantity number
Quantity form
Frequency
Start date
Stop date
Prescribed by
Prescription date
Prescription number
Pharmacy
Allergic reaction
Source of medication list
The patient’s current medications and pertinent medication history. The section may also include a patient’s prescription history and enables the determination of the source of a medication list (e.g., from a pharmacy system versus from the patient, spouse, etc.).
Allergies   Allergy or sensitivity type
Reaction
Severity
Date last occurred
Treatment
This section is used to list and describe any allergies, adverse reactions, and alerts that are pertinent to the patient’s current or past medical history. At a minimum, current and any relevant historical allergies and adverse reactions should be listed.
Social history   Marital status
Occupation
Home environment
Daily routine
Dietary patterns
Sleep patterns
Exercise patterns
Coffee consumption
Tobacco use
Alcohol use
Drug use
This section contains data defining the patient’s occupational, personal (i.e., lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity, and religious affiliation. Social history can have significant influence on a patient’s physical, psychological, and emotional health and well being, so it should be considered in the development of a complete record.
Family history N/A Child health history
Adult health history
Hereditary diseases
Mother health status
Mother age of death
Mother cause of death
Father health status
Father age of death
Father cause of death
Sibling(s) health status
Sibling(s) age of death
Sibling(s) cause of death
This section contains data defining the patient’s genetic relatives in terms of relevant health risk factors that have a potential impact on the patient’s healthcare profile.
Review of systems N/A General
Skin
Head
Eyes
Ears
Nose and sinuses
Mouth and throat
Neck
Breasts
Respiratory
Cardiac
Gastrointestinal
Genitourinary
Gynecologic
Musculoskeletal
Peripheral vascular
Neurologic
Hematologic
Endocrine
Psychiatric
A review of systems is the physician’s summary of a patient’s main and general body systems for basic functioning purposes. The physician will identify any problem areas in the respective sections if needed.
Physical examination Vital signs Pulse
Respiratory rate
Systolic blood pressure
Diastolic blood pressure
Body temperature
Height
Weight
Body mass index
Head circumference
Crown-to-rump length
Pulse oximetry
Vital signs are the indicators of a patient’s general physical condition. It identifies a patient’s level of physical functions based on elements such as heart rate, pulse, blood pressure, and body temperature.
General appearance Appearance
Body build
Demeanor
Hygiene
The general appearance section describes general observations and readily observable attributes of the patient, including affect and demeanor, apparent age compared to actual age, ethnicity, body build and habitus (e.g., muscular, cachectic, obese), developmental or other deformities, gait and mobility, personal hygiene, evidence of distress, voice quality, and speech.
Physical findings Skin
Head
Eyes
Ears
Nose and sinus
Mouth and throat
Neck
Thorax, anterior, and posterior
Breasts
Lungs
Cardiovascular
Abdomen
Male genitourinary
Female reproductive organs
Ano-rectal
Musculoskeletal system
Extremities
Lymphatics
Peripheral vascular
Neurologic
Mental status
The physical findings section describes direct observations made by the clinician, divided by organ system.
Procedure history (optional) N/A Procedure
Date
Physician
Institution/location
Result
This section is optional and will include any past procedures or surgeries that the patient has had to include information such as what was done, where it was done, by whom it was done, and the results of it.
Diagnostic findings Laboratory
Pathology
Imaging
Cardiovascular
Test
Result/finding
Result/finding date
Interpretation
This section contains the results of observations generated by laboratories, imaging procedures, and any other procedures that aid in defining treatment.
Assessment and plan Assessment Diagnoses
Disposition
A history and physical contains either discrete sections for assessment and plan or a single section combining the two. The assessment (also dictated impression or diagnoses) represents the physician’s conclusions and working assumptions that will guide treatment of the patient. The assessment is used to formulate a specific plan or set of recommendations. The assessment may be a list of specific disease entities or a narrative block.
Plan Treatment goals
Procedures
The plan section contains all active, incomplete, or pending orders, appointments, referrals, procedures, and services. Any other pending events of clinical significance to the current and ongoing care of the patient should be listed unless constrained due to issues of privacy. The plan section also contains information regarding goals and clinical reminders. Clinical reminders are placed here for purposes of providing prompts that may be used for disease prevention and management, patient safety, and healthcare quality improvements, including widely accepted performance measures.

Discharge Summary

Section Subsection Data Element Description
Reason for visit N/A Admitting diagnosis
Other diagnoses
Principal operation/procedure
This section describes why the patient presented for treatment
History of present illness N/A Symptom(s)
Onset of symptom(s)
Duration of symptom(s)
Over-the-counter (OTC) treatment
This section describes the history related to the chief complaint. It contains the historical details leading up to and pertaining to the patient’s current complaint or reason for seeking medical care.
Diagnostic findings Laboratory
Pathology
Imaging
Cardiovascular
Result/finding
Result/finding date
This section contains significant findings and observations generated by laboratories, imaging procedures, and other procedures.
Procedures N/A Procedures performed
Date procedure performed
Physician
Institution/location
Result
This sections lists all procedures that were preformed on the patient, the date they were performed, by who, and where. This section will also provide a summary of those findings.
Medications at discharge N/A Drug
Dosage
Route
Quantity number
Quantity form
Frequency
Start date
Stop date
Prescribed by
Prescription date
Prescription number
Pharmacy
This section is a detailed section of the medications a patient is going to be discharged with including prescription instructions. This section may or may not include pharmacy information and prescription number.
Patient’s condition on discharge N/A Final diagnosis
Condition on discharge
Reason for discharge
This section provides the status of the patient before leaving the facility or practice. This section will also identify final diagnosis and why the patient is ready for discharge.
Discharge instructions N/A Disposition patient instructions
Follow-up action
Follow-up target date
This section is usually a listing of instructions to the patient for a healthy recovery or ongoing treatment beyond the facility. A follow-up date or action must be included.

Operative Report


Section
Subsection Data Element Description
Operative staff N/A Surgeon
Assistant
Anesthesiologist
This section identifies the clinicians who were present for the procedure such as who performed the surgery and who assisted.
Operative diagnoses N/A Preoperative diagnoses
Postoperative diagnoses
This section provides the diagnoses of the patient prior to the surgery and can include the diagnoses after the surgery.
Operation N/A Operation/procedures performed
Operation description
Findings
Sedation/anesthesia
Complications
Drains
Estimated blood loss
Packs
Sutures
This section describes in detail how the surgery was performed, what equipment was used/implanted including bandages and sutures, and what was concluded about patient diagnoses based on findings. This section will also identify and complications during surgery.
Patient condition N/A Patient condition
Discharge from recovery care
This section describes the patient’s status after surgery and any precautions that need to be taken for recovery.

References

ASTM International. Standard Practice for Content and Structure of the Electronic Health Record (EHR): E1384-02a. Available online at www.astm.org/cgi-bin/SoftCart.exe/database.cart/redline_pages/E1384.htm?L+mystore+hwat7244.

ASTM International. Standard Specification for Healthcare Document Formats: E2184-02. Available online at www.astm.org/cgi-bin/SoftCart.exe/database.cart/redline_pages/E2184.htm?L+mystore+vjmw7203.

Health Level 7 (HL7). HL7 Clinical Document Architecture, Release 2.0.Available online at www.hl7.org.

Health Level 7 (HL7). Implementation Guide for CDA Release 2.0 History and Physical (H&P) Reports. May 2007.Available online at www.hl7.org/ctl.cfm?action=ballots.home.

Health Level 7 (HL7). HL7 Implementation Guide: CDA Release 2 – Continuity of Care Document (CCD). Available online at www.hl7.org.

LaTour, Kathleen, and Shirley Eichenwald. Health Information Management: Concepts, Principles, and Practice, 2nd Edition. Chicago, IL: AHIMA, 2006.

This web extra was created to be used in conjunction with the AHIMA Practice Brief, "Data Content for EHR Documentation."


Article citation:
Kallem, Crystal; Burrington-Brown, Jill; Dinh, Angela K. "Data Elements for EHR Documentation." Journal of AHIMA 78, no.7 (July-August 2007): web extra.