Billing |
Coded data recorded primarily for billing and administrative purposes. Includes Current Procedural Terminology (CPT) codes, Diagnosis-Related Group (DRG) codes, and International Classification of Diseases (ICD) codes. |
Descriptive |
Demographic detail, admission and discharge times, and dates of death. |
Dictionary |
Look-up tables for cross referencing concept identifiers (for example, International Classification of Diseases (ICD) codes) with associated labels. |
Interventions |
Procedures such as dialysis, imaging studies, and placement of lines. |
Laboratory |
Blood chemistry, hematology, urine analysis, and microbiology test results. |
Medications |
Administration records of intravenous medications and medication orders. |
Notes |
Free text notes such as provider progress notes and hospital discharge summaries. |
Physiologic |
Nurse-verified vital signs, approximately hourly (e.g., heart rate, blood pressure, respiratory rate). |
Reports |
Free text reports of electrocardiogram and imaging studies. |