Catalogue reference
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HCIR-0001 · NHS number
National patient identifier used to associate information with the correct person.
Patient identity & demographics · Critical
HCIR-0002 · Local hospital number
Trust-assigned patient identifier used within local operational systems.
Patient identity & demographics · Critical
HCIR-0003 · Legal name
Current legal or formally recorded name used to identify the person.
Patient identity & demographics · High
HCIR-0004 · Preferred name
Name by which the person wishes to be addressed in care interactions.
Patient identity & demographics · Medium
HCIR-0005 · Date of birth
Recorded date of birth used for identity matching, clinical interpretation and age-dependent care.
Patient identity & demographics · Critical
HCIR-0006 · Administrative sex
Administrative sex value required for identity, administration or specified clinical use.
Patient identity & demographics · High
HCIR-0007 · Gender identity
Recorded gender identity where relevant to respectful and clinically appropriate care.
Patient identity & demographics · Medium
HCIR-0008 · Address
Current usual address and relevant address history for contact, identity and service planning.
Patient identity & demographics · High
HCIR-0009 · Postcode
Postcode associated with the relevant patient address.
Patient identity & demographics · High
HCIR-0010 · Ethnic category
Recorded ethnic category used where relevant to care, equality monitoring and population analysis.
Patient identity & demographics · Medium
HCIR-0011 · Preferred language
Language preferred by the person for spoken or written communication.
Patient identity & demographics · High
HCIR-0012 · Communication support need
Need for interpreter, signing, accessible format or other communication support.
Patient identity & demographics · High
HCIR-0013 · Telephone number
Current telephone contact details for the person.
Contacts, relationships & support · High
HCIR-0014 · Email address
Current email address authorised for care-related communication.
Contacts, relationships & support · Medium
HCIR-0015 · Emergency contact
Person to contact in an emergency, including relationship and contact details.
Contacts, relationships & support · High
HCIR-0016 · Next of kin
Recorded next-of-kin details, distinct from legal decision-making authority unless separately established.
Contacts, relationships & support · Medium
HCIR-0017 · Carer details
Details of an informal or formal carer relevant to current care.
Contacts, relationships & support · High
HCIR-0018 · Primary care organisation
Usual general practice or primary care organisation responsible for ongoing care.
Contacts, relationships & support · High
HCIR-0019 · Usual GP
Usual general practitioner where known and relevant.
Contacts, relationships & support · Medium
HCIR-0020 · Advocate or representative
Authorised advocate, representative or proxy involved in care or communication.
Contacts, relationships & support · High
HCIR-0021 · Encounter identifier
Identifier for the attendance, visit or admission to which clinical information relates.
Encounter, attendance & episode · Critical
HCIR-0022 · Encounter type
Classification of the encounter such as emergency, inpatient, outpatient, day case or virtual.
Encounter, attendance & episode · High
HCIR-0023 · Arrival date and time
Date and time the person arrived at the care setting.
Encounter, attendance & episode · High
HCIR-0024 · Admission date and time
Date and time an inpatient or day-case admission commenced.
Encounter, attendance & episode · High
HCIR-0025 · Discharge date and time
Date and time the episode or attendance ended.
Encounter, attendance & episode · High
HCIR-0026 · Admitting specialty
Clinical specialty under which the patient is admitted.
Encounter, attendance & episode · High
HCIR-0027 · Responsible consultant
Consultant responsible for the relevant episode or period of care.
Encounter, attendance & episode · High
HCIR-0028 · Current ward or location
Current clinical location of the patient within the trust.
Encounter, attendance & episode · Critical
HCIR-0029 · Bed or treatment space
Allocated bed, bay, cubicle or treatment space where operationally relevant.
Encounter, attendance & episode · High
HCIR-0030 · Reason for attendance
Primary stated or recorded reason for the current encounter.
Encounter, attendance & episode · High
HCIR-0031 · Admission method
Method by which the patient was admitted, such as elective, emergency or transfer.
Encounter, attendance & episode · High
HCIR-0032 · Discharge destination
Destination to which the patient is discharged or transferred.
Encounter, attendance & episode · High
HCIR-0033 · Presenting complaint
Clinical problem or symptom that prompted the current presentation.
Clinical history & problems · Critical
HCIR-0034 · History of presenting complaint
Narrative and structured history describing the current problem, its onset and progression.
Clinical history & problems · High
HCIR-0035 · Active problem list
Current clinically relevant problems requiring awareness or management.
Clinical history & problems · Critical
HCIR-0036 · Past medical history
Relevant previous diagnoses, illnesses and long-term conditions.
Clinical history & problems · High
HCIR-0037 · Past surgical history
Relevant previous operations and procedures.
Clinical history & problems · High
HCIR-0038 · Family history
Clinically relevant conditions and risks recorded in biological relatives.
Clinical history & problems · Medium
HCIR-0039 · Social history
Relevant social circumstances including occupation, living situation and support.
Clinical history & problems · Medium
HCIR-0040 · Smoking status
Current and historical tobacco smoking status relevant to clinical care.
Clinical history & problems · High
HCIR-0041 · Alcohol use
Recorded alcohol consumption and clinically relevant pattern of use.
Clinical history & problems · Medium
HCIR-0042 · Substance use
Clinically relevant use of recreational or non-prescribed substances.
Clinical history & problems · Medium
HCIR-0043 · Functional baseline
Usual level of mobility, activities of daily living and independence before the current episode.
Clinical history & problems · High
HCIR-0044 · Frailty status
Recorded frailty assessment or clinical frailty status where applicable.
Clinical history & problems · High
HCIR-0045 · Allergy status
Statement confirming known allergy status, including explicit absence where recorded.
Allergies, sensitivities & clinical alerts · Critical
HCIR-0046 · Allergen or causative agent
Substance, product or class associated with a recorded allergy or intolerance.
Allergies, sensitivities & clinical alerts · Critical
HCIR-0047 · Allergic reaction
Nature of the reaction associated with an allergy or intolerance.
Allergies, sensitivities & clinical alerts · Critical
HCIR-0048 · Allergy severity
Recorded severity of an allergic or intolerance reaction.
Allergies, sensitivities & clinical alerts · High
HCIR-0049 · Critical clinical alert
High-priority clinical warning that must be visible before specified care activities.
Allergies, sensitivities & clinical alerts · Critical
HCIR-0050 · Infection prevention alert
Current infection prevention, isolation or organism-related alert affecting care delivery.
Allergies, sensitivities & clinical alerts · Critical
HCIR-0051 · Current medication list
Medicines currently taken or intended to be taken by the patient.
Medication & pharmacy · Critical
HCIR-0052 · Medication reconciliation status
Status showing whether medicines have been reconciled against an appropriate source.
Medication & pharmacy · High
HCIR-0053 · Prescribed medication order
Authorised medication order specifying medicine, dose, route, frequency and instructions.
Medication & pharmacy · Critical
HCIR-0054 · Dose
Amount of medicine to be administered or taken on each occasion.
Medication & pharmacy · Critical
HCIR-0055 · Route of administration
Route by which a medicine is to be administered.
Medication & pharmacy · Critical
HCIR-0056 · Medication frequency
Frequency or schedule for medicine administration.
Medication & pharmacy · Critical
HCIR-0057 · Medication indication
Clinical reason for prescribing or administering a medicine.
Medication & pharmacy · High
HCIR-0058 · Medication administration record
Record of medicine administrations, omissions and relevant administration details.
Medication & pharmacy · Critical
HCIR-0059 · Medication omission reason
Reason a scheduled medicine was not administered.
Medication & pharmacy · High
HCIR-0060 · Adverse drug reaction
Suspected or confirmed harmful response associated with a medicinal product.
Medication & pharmacy · Critical
HCIR-0061 · Discharge medication list
Medicines intended to continue, stop or change following discharge.
Medication & pharmacy · Critical
HCIR-0062 · Pharmacy intervention
Clinical pharmacy recommendation, action or intervention affecting medication management.
Medication & pharmacy · High
HCIR-0063 · Heart rate
Measured heart rate for clinical assessment and monitoring.
Observations, scores & assessments · Critical
HCIR-0064 · Blood pressure
Measured systolic and diastolic blood pressure.
Observations, scores & assessments · Critical
HCIR-0065 · Respiratory rate
Measured respiratory rate.
Observations, scores & assessments · Critical
HCIR-0066 · Peripheral oxygen saturation
Measured oxygen saturation including oxygen therapy context where relevant.
Observations, scores & assessments · Critical
HCIR-0067 · Temperature
Measured body temperature including measurement method where relevant.
Observations, scores & assessments · Critical
HCIR-0068 · Level of consciousness
Recorded consciousness or responsiveness assessment.
Observations, scores & assessments · Critical
HCIR-0069 · NEWS2 score
National Early Warning Score 2 value and component observations.
Observations, scores & assessments · Critical
HCIR-0070 · Pain assessment
Assessment of pain intensity, site, character and related features where relevant.
Observations, scores & assessments · High
HCIR-0071 · Weight
Measured or reported body weight.
Observations, scores & assessments · High
HCIR-0072 · Height
Measured or reported height.
Observations, scores & assessments · Medium
HCIR-0073 · Body mass index
Calculated body mass index derived from height and weight.
Observations, scores & assessments · Medium
HCIR-0074 · Fluid balance
Recorded intake and output used to assess hydration and fluid management.
Observations, scores & assessments · High
HCIR-0075 · Urine output
Measured urine output over a defined period.
Observations, scores & assessments · High
HCIR-0076 · Nutritional assessment
Assessment of nutritional status and nutrition-related risk.
Observations, scores & assessments · High
HCIR-0077 · Falls risk assessment
Assessment of the patient's current risk of falling.
Observations, scores & assessments · High
HCIR-0078 · Pressure ulcer risk assessment
Assessment of risk of pressure damage and related prevention needs.
Observations, scores & assessments · High
HCIR-0079 · Venous thromboembolism risk assessment
Recorded assessment of VTE and bleeding risk used to guide prevention.
Observations, scores & assessments · Critical
HCIR-0080 · Delirium or cognitive assessment
Assessment of cognition, delirium or acute confusion where indicated.
Observations, scores & assessments · High
HCIR-0081 · Laboratory test request
Order for one or more laboratory investigations including clinical context.
Laboratory & pathology · High
HCIR-0082 · Specimen identifier
Identifier assigned to the specimen used for a laboratory investigation.
Laboratory & pathology · Critical
HCIR-0083 · Specimen type
Type and source of specimen submitted for investigation.
Laboratory & pathology · High
HCIR-0084 · Specimen collection date and time
Date and time at which the specimen was collected.
Laboratory & pathology · High
HCIR-0085 · Laboratory result
Quantitative, qualitative or textual result produced by a laboratory investigation.
Laboratory & pathology · Critical
HCIR-0086 · Reference range
Reference interval or interpretive range relevant to a laboratory result.
Laboratory & pathology · High
HCIR-0087 · Abnormal or critical result flag
Indicator that a result is outside expected limits or meets critical escalation criteria.
Laboratory & pathology · Critical
HCIR-0088 · Pathology report status
Status of a pathology result or report including preliminary, final, corrected or amended.
Laboratory & pathology · High
HCIR-0089 · Histopathology report
Diagnostic report resulting from histological examination of tissue.
Laboratory & pathology · Critical
HCIR-0090 · Microbiology organism and susceptibility
Identified organism and antimicrobial susceptibility information.
Laboratory & pathology · Critical
HCIR-0091 · Imaging request
Order for an imaging investigation including indication, priority and requested examination.
Imaging & diagnostics · High
HCIR-0092 · Imaging clinical indication
Clinical question or indication supplied to support imaging protocol and interpretation.
Imaging & diagnostics · High
HCIR-0093 · Imaging study identifier
Identifier linking images and report to the performed study.
Imaging & diagnostics · Critical
HCIR-0094 · Imaging report
Formal diagnostic interpretation of an imaging examination.
Imaging & diagnostics · Critical
HCIR-0095 · Imaging report status
Status showing whether the report is preliminary, final, corrected or otherwise amended.
Imaging & diagnostics · High
HCIR-0096 · Critical imaging finding
Imaging finding meeting defined urgent or critical communication criteria.
Imaging & diagnostics · Critical
HCIR-0097 · Diagnostic test report
Report from a non-imaging diagnostic investigation such as ECG, endoscopy or physiological measurement.
Imaging & diagnostics · High
HCIR-0098 · Diagnostic waveform or media reference
Reference to clinically relevant waveform, image, trace or other diagnostic media.
Imaging & diagnostics · Medium
HCIR-0099 · Working diagnosis
Provisional diagnosis guiding current assessment and treatment.
Diagnosis, decisions & clinical reasoning · Critical
HCIR-0100 · Confirmed diagnosis
Diagnosis established with sufficient clinical certainty for the relevant care context.
Diagnosis, decisions & clinical reasoning · Critical
HCIR-0101 · Differential diagnosis
Alternative diagnoses under active consideration.
Diagnosis, decisions & clinical reasoning · High
HCIR-0102 · Diagnosis onset date
Date or period when a diagnosed condition began or became clinically apparent.
Diagnosis, decisions & clinical reasoning · High
HCIR-0103 · Diagnosis verification status
Status describing clinical certainty or confirmation of a diagnosis.
Diagnosis, decisions & clinical reasoning · High
HCIR-0104 · Clinical assessment
Clinician's synthesis of findings, history, investigations and context.
Diagnosis, decisions & clinical reasoning · High
HCIR-0105 · Clinical decision
Recorded decision selecting or rejecting a course of action based on available information.
Diagnosis, decisions & clinical reasoning · Critical
HCIR-0106 · Decision rationale
Recorded reasoning or evidence supporting an important clinical decision.
Diagnosis, decisions & clinical reasoning · High
HCIR-0107 · Escalation decision
Decision to obtain senior review, higher-acuity care or urgent intervention.
Diagnosis, decisions & clinical reasoning · Critical
HCIR-0108 · Treatment limitation decision
Recorded decision about limits of treatment, escalation or resuscitation, with appropriate authority and context.
Diagnosis, decisions & clinical reasoning · Critical
HCIR-0109 · Procedure planned
Procedure or intervention that has been proposed or scheduled.
Procedures & interventions · High
HCIR-0110 · Procedure performed
Procedure or intervention actually undertaken.
Procedures & interventions · Critical
HCIR-0111 · Procedure date and time
Date and time or period during which a procedure was undertaken.
Procedures & interventions · High
HCIR-0112 · Procedure performer
Clinician or team responsible for undertaking the procedure.
Procedures & interventions · High
HCIR-0113 · Procedure outcome
Recorded outcome of the procedure including immediate success, failure or complication.
Procedures & interventions · High
HCIR-0114 · Procedure complication
Complication or adverse event associated with a procedure.
Procedures & interventions · Critical
HCIR-0115 · Clinical device used
Device, implant or consumable used during the procedure where traceability is required.
Procedures & interventions · High
HCIR-0116 · Post-procedure instructions
Clinical instructions and restrictions following a procedure.
Procedures & interventions · High
HCIR-0117 · Procedure consent status
Status and evidence of consent for the procedure where consent is required.
Procedures & interventions · Critical
HCIR-0118 · Operation planned
Planned surgical operation, laterality and relevant operative detail.
Surgery, anaesthesia & perioperative care · Critical
HCIR-0119 · WHO surgical safety checklist status
Completion status of required surgical safety checklist stages.
Surgery, anaesthesia & perioperative care · Critical
HCIR-0120 · Anaesthetic assessment
Pre-operative assessment relevant to anaesthesia and perioperative risk.
Surgery, anaesthesia & perioperative care · Critical
HCIR-0121 · ASA physical status
Anaesthetic risk classification using the ASA Physical Status system.
Surgery, anaesthesia & perioperative care · High
HCIR-0122 · Anaesthetic technique
Technique and agents used to provide anaesthesia or sedation.
Surgery, anaesthesia & perioperative care · High
HCIR-0123 · Operative note
Authoritative record of the operation performed, findings, technique and immediate plan.
Surgery, anaesthesia & perioperative care · Critical
HCIR-0124 · Estimated blood loss
Estimated volume of blood lost during an operation or procedure.
Surgery, anaesthesia & perioperative care · High
HCIR-0125 · Post-anaesthetic recovery status
Clinical status and recovery assessment following anaesthesia.
Surgery, anaesthesia & perioperative care · High
HCIR-0126 · Care plan
Structured plan describing intended care, goals, activities and responsible roles.
Orders, care plans & tasks · High
HCIR-0127 · Clinical order
Authorised request for a clinical service, investigation or intervention.
Orders, care plans & tasks · High
HCIR-0128 · Clinical task
Assignable work item with owner, status, due time and completion evidence.
Orders, care plans & tasks · High
HCIR-0129 · Monitoring plan
Planned observations, tests or review required to monitor a condition or treatment.
Orders, care plans & tasks · High
HCIR-0130 · Treatment goal
Target outcome or objective against which care can be reviewed.
Orders, care plans & tasks · Medium
HCIR-0131 · Review date or interval
Planned date, interval or trigger for clinical review.
Orders, care plans & tasks · High
HCIR-0132 · Escalation plan
Documented conditions and actions for escalation if the patient's status deteriorates.
Orders, care plans & tasks · Critical
HCIR-0133 · Multidisciplinary team plan
Agreed multidisciplinary assessment, decision and actions for ongoing care.
Orders, care plans & tasks · High
HCIR-0134 · Referral request
Request for assessment, advice, investigation or treatment by another service.
Referral, transfer & coordination · High
HCIR-0135 · Referral reason
Clinical reason and question associated with a referral.
Referral, transfer & coordination · High
HCIR-0136 · Referral priority
Priority or urgency assigned to a referral.
Referral, transfer & coordination · High
HCIR-0137 · Receiving service
Service or organisation to which responsibility or work is being referred.
Referral, transfer & coordination · High
HCIR-0138 · Transfer of care status
Status showing progress of a transfer between teams, locations or organisations.
Referral, transfer & coordination · Critical
HCIR-0139 · Clinical handover
Structured information communicated when responsibility for care passes between professionals or teams.
Referral, transfer & coordination · Critical
HCIR-0140 · Advice and guidance response
Specialist advice returned without necessarily transferring responsibility for care.
Referral, transfer & coordination · Medium
HCIR-0141 · Inter-provider transfer document
Information package supporting safe transfer to another provider.
Referral, transfer & coordination · Critical
HCIR-0142 · Discharge diagnosis
Diagnoses considered relevant at the end of the episode of care.
Discharge & follow-up · Critical
HCIR-0143 · Discharge summary
Structured summary of the episode, key findings, treatment, medicines and follow-up requirements.
Discharge & follow-up · Critical
HCIR-0144 · Discharge destination
Destination or care setting to which the person is discharged.
Discharge & follow-up · High
HCIR-0145 · Discharge medication
Medication information to be continued, changed or stopped after discharge.
Discharge & follow-up · Critical
HCIR-0146 · Follow-up requirement
Clinical review, investigation, appointment or action required after discharge.
Discharge & follow-up · Critical
HCIR-0147 · Follow-up owner
Professional or service responsible for completing or coordinating a follow-up action.
Discharge & follow-up · High
HCIR-0148 · Patient discharge instructions
Information and advice provided to the patient for care after leaving the trust.
Discharge & follow-up · High
HCIR-0149 · Pending result at discharge
Investigation result not yet available at discharge and requiring assigned follow-up responsibility.
Discharge & follow-up · Critical
HCIR-0150 · Result acknowledgement after discharge
Evidence that a pending or subsequently amended result has been reviewed and acted upon.
Discharge & follow-up · Critical
HCIR-0151 · Consent to treatment
Evidence of valid consent for treatment or intervention where required.
Consent, capacity, legal & safeguarding · Critical
HCIR-0152 · Consent to information sharing
Recorded consent or preference relevant to sharing information beyond routine lawful care use.
Consent, capacity, legal & safeguarding · High
HCIR-0153 · Mental capacity assessment
Assessment of decision-specific capacity where capacity is in question.
Consent, capacity, legal & safeguarding · Critical
HCIR-0154 · Best interests decision
Decision and rationale made in the person's best interests where the person lacks relevant capacity.
Consent, capacity, legal & safeguarding · Critical
HCIR-0155 · Advance decision or advance statement
Relevant advance decision, advance statement or comparable planning information.
Consent, capacity, legal & safeguarding · Critical
HCIR-0156 · Lasting power of attorney
Recorded authority of a health and welfare attorney where relevant.
Consent, capacity, legal & safeguarding · Critical
HCIR-0157 · Safeguarding concern
Recorded concern that a child or adult may be at risk of abuse, neglect or exploitation.
Consent, capacity, legal & safeguarding · Critical
HCIR-0158 · Safeguarding plan or action
Agreed safeguarding response, referral or action required to manage identified risk.
Consent, capacity, legal & safeguarding · Critical
HCIR-0159 · Deprivation of liberty status
Relevant legal status, authorisation or application affecting care and restrictions.
Consent, capacity, legal & safeguarding · Critical
HCIR-0160 · Resuscitation decision
Current recorded cardiopulmonary resuscitation decision and associated documentation.
Consent, capacity, legal & safeguarding · Critical
HCIR-0161 · Implanted device
Device implanted in the patient and requiring ongoing traceability or clinical awareness.
Devices, implants & products · Critical
HCIR-0162 · Device identifier
Manufacturer or unique identifier required to identify a device or implant.
Devices, implants & products · High
HCIR-0163 · Implant date
Date on which an implantable device was inserted.
Devices, implants & products · High
HCIR-0164 · Device status
Current status of a device, including active, removed, replaced or inactive.
Devices, implants & products · High
HCIR-0165 · Blood product administration
Record of blood component or product administered, including traceability information.
Devices, implants & products · Critical
HCIR-0166 · Triage category
Urgency category assigned at emergency presentation.
Emergency & critical care · Critical
HCIR-0167 · Time-critical condition flag
Indicator that the patient may have a condition requiring immediate time-dependent intervention.
Emergency & critical care · Critical
HCIR-0168 · Sepsis assessment
Assessment information used to recognise, stratify and manage suspected sepsis.
Emergency & critical care · Critical
HCIR-0169 · Resuscitation event
Record of a cardiopulmonary or other emergency resuscitation event.
Emergency & critical care · Critical
HCIR-0170 · Critical care admission
Admission to an intensive or high-dependency care setting.
Emergency & critical care · Critical
HCIR-0171 · Organ support
Type and duration of respiratory, cardiovascular, renal or other organ support.
Emergency & critical care · Critical
HCIR-0172 · Ventilation status
Current respiratory support and ventilation mode where applicable.
Emergency & critical care · Critical
HCIR-0173 · Critical care outcome
Outcome of a critical care episode including transfer, discharge or death.
Emergency & critical care · High
HCIR-0174 · Physiotherapy assessment
Assessment of movement, respiratory function, mobility or rehabilitation need by physiotherapy.
Therapies, rehabilitation & discharge support · High
HCIR-0175 · Occupational therapy assessment
Assessment of function, cognition, environment and activities of daily living by occupational therapy.
Therapies, rehabilitation & discharge support · High
HCIR-0176 · Speech and language assessment
Assessment of communication and/or swallowing by speech and language therapy.
Therapies, rehabilitation & discharge support · High
HCIR-0177 · Dietetic assessment
Assessment of nutritional needs, intake and nutrition support requirements.
Therapies, rehabilitation & discharge support · High
HCIR-0178 · Mobility status
Current ability to transfer and mobilise, including assistance or equipment required.
Therapies, rehabilitation & discharge support · High
HCIR-0179 · Equipment requirement
Equipment or adaptation required to support safe care or discharge.
Therapies, rehabilitation & discharge support · High
HCIR-0180 · Rehabilitation goal
Agreed rehabilitation objective used to guide therapy and review progress.
Therapies, rehabilitation & discharge support · Medium
HCIR-0181 · Home support requirement
Health, social care or informal support required following discharge.
Therapies, rehabilitation & discharge support · High
HCIR-0182 · Clinical note
Authored clinical documentation recording assessment, findings, decisions or actions.
Clinical documentation & communication · High
HCIR-0183 · Consultation note
Record of a clinical consultation including reason, findings, decisions and plan.
Clinical documentation & communication · High
HCIR-0184 · Patient communication record
Evidence of clinically relevant communication with the patient or representative.
Clinical documentation & communication · High
HCIR-0185 · Professional communication
Clinically relevant communication between professionals or teams.
Clinical documentation & communication · High
HCIR-0186 · Clinical letter
Formal clinical correspondence such as outpatient, referral response or follow-up letter.
Clinical documentation & communication · High
HCIR-0187 · Document author
Person or system responsible for authoring the clinical document.
Clinical documentation & communication · High
HCIR-0188 · Document date and time
Date and time at which the clinical document was authored, issued or finalised.
Clinical documentation & communication · High
HCIR-0189 · Document status
Status of the clinical document including draft, final, amended or entered-in-error.
Clinical documentation & communication · High
