Medical record documents are clinical documents associated with a specific patient. This documentation classifies these documents into two categories:
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Clinical patient documents are medical record documents not attached to charts. They are part of a patient record, but not in the context of a chart. Examples might include x-rays or advance directives.
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Chart documents are medical record documents attached to charts. A patient may have multiple charts, each containing chart documents. In OnBase, when a document is attached to a chart, it also is attached to the corresponding patient. Examples of chart documents might include history and physicals or discharge summaries.
As shown in the following diagram, chart documents are attached to a chart, an MRN, and an MPI. Clinical patient documents are attached to an MRN (if available) and an MPI, but not to any charts.
Non-medical record documents can also be associated with patient records, but they do not belong to a medical record Document Type. For information about associating non-medical record documents with patients, see Medical Records Custom Query Configuration.