NOTE

Table Description

The NOTE table captures unstructured information that was recorded by a provider about a patient in free text (in ASCII, or preferably in UTF8 format) notes on a given date. The type of note_text is CLOB or varchar(MAX) depending on RDBMS.

ETL Conventions

HL7/LOINC CDO is a standard for consistent naming of documents to support a range of use cases: retrieval, organization, display, and exchange. It guides the creation of LOINC codes for clinical notes. CDO annotates each document with 5 dimensions:

• Kind of Document: Characterizes the general structure of the document at a macro level (e.g. Anesthesia Consent)
• Type of Service: Characterizes the kind of service or activity (e.g. evaluations, consultations, and summaries). The notion of time sequence, e.g., at the beginning (admission) at the end (discharge) is subsumed in this axis. Example: Discharge Teaching.
• Setting: Setting is an extension of CMS’s definitions (e.g. Inpatient, Outpatient)
• Subject Matter Domain (SMD): Characterizes the subject matter domain of a note (e.g. Anesthesiology)
• Role: Characterizes the training or professional level of the author of the document, but does not break down to specialty or subspecialty (e.g. Physician) Each combination of these 5 dimensions rolls up to a unique LOINC code.

According to CDO requirements, only 2 of the 5 dimensions are required to properly annotate a document; Kind of Document and any one of the other 4 dimensions. However, not all the permutations of the CDO dimensions will necessarily yield an existing LOINC code. Each of these dimensions are contained in the OMOP Vocabulary under the domain of ‘Meas Value’ with each dimension represented as a Concept Class.

CDM Field	User Guide	ETL Conventions	Datatype	Required	Primary Key	Foreign Key	FK Table	FK Domain
note_id	A unique identifier for each note.		integer	Yes	Yes	No
person_id			integer	Yes	No	Yes	PERSON
note_date	The date the note was recorded.		date	Yes	No	No
note_datetime		If time is not given set the time to midnight.	datetime	No	No	No
note_type_concept_id	The provenance of the note. Most likely this will be EHR.	Put the source system of the note, as in EHR record. Accepted Concepts. A more detailed explanation of each Type Concept can be found on the vocabulary wiki.	integer	Yes	No	Yes	CONCEPT	Type Concept
note_class_concept_id	A Standard Concept Id representing the HL7 LOINC Document Type Vocabulary classification of the note.	Map the note classification to a Standard Concept. For more information see the ETL Conventions in the description of the NOTE table. Accepted Concepts. This Concept can alternatively be represented by concepts with the relationship ‘Kind of (LOINC)’ to 706391 (Note).	integer	Yes	No	Yes	CONCEPT
note_title	The title of the note.		varchar(250)	No	No	No
note_text	The content of the note.		varchar(MAX)	Yes	No	No
encoding_concept_id	This is the Concept representing the character encoding type.	Put the Concept Id that represents the encoding character type here. Currently the only option is UTF-8 (32678). It the note is encoded in any other type, like ASCII then put 0.	integer	Yes	No	Yes	CONCEPT
language_concept_id	The language of the note.	Use Concepts that are descendants of the concept 4182347 (World Languages).	integer	Yes	No	Yes	CONCEPT
provider_id	The Provider who wrote the note.	The ETL may need to make a determination on which provider to put here.	integer	No	No	Yes	PROVIDER
visit_occurrence_id	The Visit during which the note was written.		integer	No	No	Yes	VISIT_OCCURRENCE
visit_detail_id	The Visit Detail during which the note was written.		integer	No	No	Yes	VISIT_DETAIL
note_source_value		The source value mapped to the NOTE_CLASS_CONCEPT_ID.	varchar(50)	No	No	No
note_event_id	If the Note record is related to another record in the database, this field is the primary key of the linked record.	Put the primary key of the linked record, if applicable, here.	integer	No	No	No
note_event_field_concept_id	If the Note record is related to another record in the database, this field is the CONCEPT_ID that identifies which table the primary key of the linked record came from.	Put the CONCEPT_ID that identifies which table and field the NOTE_EVENT_ID came from.	integer	No	No	Yes	CONCEPT