Clinical Data in the Chart

Clinical data displayed in the Patient Chart Viewer is derived from clinical documents retrieved through national networks and connected data sources. Documents are parsed, normalized where possible, and presented as structured entries within the chart.

Key characteristics of chart data include:

• Data may be document-derived, normalized, or both.
• Entries reflect what is available in source documents and may vary in completeness.
• Multiple documents from different organizations may contribute to the same section.
• Sections are conceptual groupings, not direct representations of document sections.

Chart Sections

The Patient Chart Viewer organizes clinical information into multiple sections, each representing a specific type of healthcare data. The sections described below represent the primary normalized clinical data views commonly used for review and filtering. Additional sections may appear in the chart depending on the availability and content of source documents.

Procedures

The Procedures section displays surgical and non-surgical procedures that represent ordered or performed clinical actions. Procedures are distinct from diagnostic results and remain listed regardless of whether related results are available elsewhere in the chart.

Procedure entries may include information such as the procedure name, associated provider or organization, start and end date/time, procedure status, notes, and indications, depending on source data availability.

Selecting a procedure displays additional details, such as body sites, specimens, and source document context, when available.

Diagnostic Results (Labs and Imaging)

Diagnostic Results display the outputs of clinical procedures, such as laboratory findings and imaging interpretations. Results represent observations, measurements, reports, or interpretations generated as part of patient care.

Results appear independently of procedures and may be associated with one or more procedures, but they are not embedded within the Procedures section. A procedure may have no results, a single result, or multiple results over time.

Medications

The Medications section displays medications that have been prescribed, administered, or documented for the patient. Entries may originate from medication orders, administration records, or medication lists found in clinical documents.

Medication records may include drug name, dosage, route, status, start and end dates, and prescribing information, depending on source data.

Encounters

The Encounters section represents patient interactions with healthcare organizations, such as inpatient stays, outpatient visits, or emergency encounters. Encounter entries provide contextual information such as dates, locations, and participating providers.

Encounters may serve as context for other data types but do not directly contain procedures, results, or medications.

Problems and Conditions

The Problems section displays documented diagnoses, conditions, or problem list entries associated with the patient. These entries reflect clinical assessments rather than procedures or results and may persist across multiple encounters.

Documents

The Documents section provides access to the underlying clinical documents from which chart data is derived. Documents include metadata such as document type, source organization, author, and creation date, and may be previewed when available.

Documents serve as provenance for chart entries but are displayed separately from normalized clinical sections.

Additional Sections

Depending on available source data, the chart may also include sections such as Allergies, Immunizations, Vital Signs, Social History, Functional Status, Advance Directives, or Care Plans. These sections follow the same document-derived and normalization principles as the primary sections described above.

Procedures and Results Relationship

Procedures and diagnostic results are treated as separate clinical data streams in the Patient Chart Viewer.

• Procedures represent clinical actions that were ordered or performed.
• Results represent findings or interpretations generated from those actions.

A procedure remains visible even after related results are posted. Results do not replace or remove procedures from the chart.

This separation allows users to distinguish between what was done and what was observed or reported as a result.

Categorization and Terminology

Clinical entries are categorized using a combination of resolved terminology mappings and source code system information.

For procedures:

• Certain procedure categories are resolved across multiple code systems through terminology harmonization work, including: laboratory, radiology, surgery, anesthesia.
• For other procedure types, category labels may be derived from CPT category groupings.
• Procedures that cannot be confidently categorized using available mappings may appear as Undefined.

“Undefined” indicates that the procedure was captured but does not yet map to a resolved category. It does not indicate missing or invalid data.

Filtering Behavior

Each section of the Patient Chart Viewer supports filtering appropriate to the data it displays.

Filtering behavior may include:

• Date range filtering
• Category-based filtering
• Status or type-based filtering, depending on the section

Filters apply only within the active section and reflect the categorization logic described above. Filter availability and behavior depend on how data is represented in source documents and resolved through terminology mappings.

Source Data and Provenance

Every chart entry is linked to one or more source documents and organizations. Users can review document metadata and, where supported, preview the original document to understand the clinical context in which the data was recorded.

Source provenance is preserved even when data is normalized or aggregated across multiple documents.

Summary

The Patient Chart Viewer organizes clinical information into distinct sections that represent different types of healthcare activity. Procedures and diagnostic results are intentionally separated, categorization reflects current terminology resolution, and filtering behavior depends on available source data. Original documents remain accessible to support validation and clinical context.