Table 1.

Classification, definition and examples of new clinical information.

Category	Code	Definition	Example
Clinical	Additional history	New information on patient’s medical history occurring prior to hospitalization including prior diagnoses, surgeries, labwork/imaging, immunizations, medications, allergies/reactions, family history, and social history (e.g. sexual history, drug use, intake, work history, hobbies, marital status)	Recently admitted elsewhere for a pneumonia.
	Assessment	Changes in the medical diagnosis or differential diagnosis regarding patient’s hospitalizing condition as assessed by the note’s author	I am thinking this was all related to RF and CHF exacerbation.
	Changes in symptoms	Changes in patient reported symptoms including new complaints or improvement or worsening of existing concerns.	He says he is breathing better.
	Medications	Changes in medication, dosage, or route of administration including returns to pre-hospitalization usage. Also includes changes in fluids/electrolytes/nutrition administration and immediate post-administration clinical status.	Metoprolol 100 mg po bid changed to carvedilol 25 mg po bid
	New imaging and diagnostic studies	Results of imaging previously unmentioned during hospitalization such as X-rays, computerized tomography (CT scans), and solography.	TTE shows grade III diastolic dysfunction with elevated RSVP indicating pulmonary hypertension
	New labwork	Results of labwork previously unmentioned during hospitalization such as the basic metabolic panel, liver function tests, and blood glucose levels. Also includes fluid intake and output.	Wound cx: Gram + cocciUA shows a protein level of 300
	New plan	Changes in clinical care plan for patient care	Send sample for C. Diff studies
	Patient status	Changes in the patient’s condition as reported by any healthcare provider	Perhaps a little improved today
	Physical exam	Daily physical examination as performed by clinician	Constitutional: Awake, alert, cooperative, no apparent distress
	Procedure	Procedures performed during hospitalization and related post-operative concerns	C2-4 laminectomy
	Vitals	Daily vitals including temperature, blood pressure, heart rate, and respiratory rate.	Temp: [98.1 F (36.7 C)-99F (37.2 C)] 98.2 F (36.8 C)
Non-clinical	Author	Name and degree of the note’s author if previously unmentioned	LastName, FirstName, MD
	Change in service	Patient transfer to other hospital services or clinical sites	Patient will go to 6A for close Neuro-surgical monitoring.
	Date and time	Date and time of note signing by the original author	08/03/12 1148
	Social context	Changes in social history and situation relevant to the patient’s condition and care including patient’s preference to management	Dialysis discussed with patient, he prefers to wait until July.