’Definitions

Good definitions are what hold an ontology together. Definitions are required for the functions and intention of the ontology, the parts of the ontology and the terms within the ontology.   Defining the terms within the ontology anchors each concept to a stable, shared meaning—so that the same term means the same thing whether it's used by a different team, a different system, or a different jurisdiction. There is no single definitive source for many of these terms, so we have collected definitions from a variety of references and, where appropriate, blended them into a single amalgamated definition or chosen the best wording the sources offered.  We have added comments on how the definition affects document coding.

Functions of the Ontology   

  • Preferred - The concept is felt to meet the goals of the Canadian Ontology the best.  Typically, it balances specificity with the variety of typical documents.  Multiple preferred concepts are used to clearly delineate the various approaches to achieve the goals.
  • Allowable - The concept is necessary to include the variety of health system’s needs.  
  • Roll up Term - If a system receives a preferred or allowable concept that it does not utilize, then it can substitute the Roll up concept for the received document.  
  • Suppressed - The axis is intentionally excluded from that document type. Concepts should not populate that axis
  • Unspecified - it signals that the axis is deliberately left open — any value within that axis is considered valid. For example, a Discharge Summary with Role = Unspecified may have been authored by a physician, nurse, physician assistant, or other clinician

    • Note on practical usage: Because physicians author the majority of clinical documents, Role = Unspecified implicitly reflects physician authorship in most cases. The ontology uses this convention to avoid redundant specification of "Physician" across a large number of concepts. Implementers should not infer that Role = Unspecified means Physician — only that a physician author is the most common scenario.  

Document Ontology Axes/Part Types

  • Subject Matter Domain - The general focus or domain of knowledge represented within the content of the document. Each document type is defined with at least one Subject Matter Domain. Examples include Audiology, Neurology, Cardiac Surgery, Nephrology.
  • Role - The general function, responsibility, or capabilities of the author in relation to a document. Each document type is optionally defined with a Role. Examples include Physician, Nurse, Social worker, Device.
  • Setting - The health care environment or context in which the document was generated. Each document type is optionally defined with a Setting. Examples include Patient's home, Emergency department, Hospital, Outpatient, Nursing facility.
  • Type of Service - The health care service or action provided to the patient as describe in the document. Each document type is defined with one Type of Service. Examples include Referral, Consultation, Discharge summary, Communication, Disability examination, Procedure.
  • Kind of Document - The purpose or structure of the document. Each document type is defined with one Kind of Document. Examples include flowsheet, discharge plan, consent, surgical report.

Adapted from: https://loinc.org/kb/users-guide/document-ontology/ 

Type of Service

  • Admission Note - An admission note is a clinical document that provides a clear, comprehensive overview of a patient’s condition and care needs at the time of entry into a hospital or similar institution that requires documentation of admission. It typically includes the reason for admission, presenting symptoms, relevant medical history, physical examination findings, initial diagnostic impressions, and the immediate plan for investigation and treatment. Completed by the admitting physician or other qualified clinician at the start of an inpatient stay, the admission note establishes the baseline clinical picture and supports coordinated, continuous care throughout hospitalization. Although sometimes referred to as an 'Admission H&P', its modern form goes much beyond a history and physical.
  • Consultation Note - A consultation note is a clinical document that provides a comprehensive account of a provider's assessment in response to a referral from another health care provider. It typically includes the reason for referral, relevant history, examination findings, investigations reviewed or ordered, the consultant’s clinical impression, and recommendations for diagnosis, treatment, or ongoing management. It is typically completed by an RCPSC physician. Occasionally, FPSC physicians, particularly those with extra qualifications, can perform consultations. Nurse
  • Practitioners can also complete consultation notes.


  • Discharge Summary - A discharge summary is a clinical document that provides a clear, comprehensive overview of a patient's hospital stay along with the information required to support safe, continuous care after discharge. It signifies the end of a hospital or long-term care stay and typically includes the reason for admission, key diagnoses, significant events and interventions, treatments provided, the patient's condition at discharge, and instructions or plans for follow-up care. The discharge summary is usually completed by the most responsible provider (MRP) at the end of an inpatient stay, but since it can summarize medical events relating to multiple disciplines, it is often misleading to assign the discharge summary to a specific discipline. When a patient has been seen by multiple services during their hospitalization, the summary is generally written by the service responsible for the patient at the time of discharge and documented with a non-specified SMD. Other services then typically use a Transfer note or Progress note to signify the end of their consultation or care period. If a person is admitted and discharged by the same service, then it is appropriate to add an SMD to the discharge note type. In rare cases, two discharge summaries may be produced when two services are closely involved in care at discharge, and each has community care instructions to convey — although in this situation, it is generally more appropriate for the non-MRP service to write a Plan of Care document instead.


  • Emergency Department Note - An emergency department note is a clinical document that records a patient’s assessment, clinical reasoning, interventions, and disposition during an unscheduled presentation to an emergency department. It typically includes the chief complaint, history of presenting illness, relevant past medical history, physical examination findings, investigations ordered and reviewed, the clinician’s clinical impression and differential diagnosis, treatments provided, and the plan for disposition or follow-up. Completed by the treating clinician at or near the conclusion of the encounter, the emergency department note serves as the primary medicolegal record of the visit and supports continuity of care by communicating the events of an acute, unscheduled encounter to subsequent care providers.


  • Progress notes in Hospital - Clinical document(s) that are written by the clinician charged with overall care or by a clinician that was asked to consult on a particular medical issue.  Written after an initial comprehensive assessment (that was either an admission note or a consult) it records a patient's interval clinical status, the clinician's ongoing assessment, and the plan for continued management during an acute hospital admission. It typically includes changes since the previous entry, relevant examination findings and investigation results, the clinician's updated impression of the active problem (or single issue that the consultant is addressing), any adjustments to the management plan. 
  • Progress notes in community referral clinic (private or hospital run) - Clinical document(s) that Records a specialist assessment of a patient during a scheduled follow-up visit. It typically includes the interval of history since the last encounter, relevant examination findings, results of investigations reviewed, the clinician's updated impression, and the plan for ongoing management or further follow-up. Written by the clinician responsible for the patient's ongoing ambulatory care, the clinic note represents the continuation of a clinical relationship established by initial consult that typically occurred in the same clinic but might have occurred in the hospital. 
  • Referral Note - A referral note is a clinical document that provides a clear, comprehensive summary of a patient’s condition and the specific clinical question prompting a request for specialist assessment. It typically includes the reason for referral, relevant medical history, current concerns or findings, prior investigations or treatments, and the referring provider’s clinical impression and objectives for consultation. Completed by a primary care provider or other treating clinician when seeking additional expertise, the referral note initiates the consultation process and supports continuity of care by ensuring the consulting specialist receives the information needed for an informed assessment. The SMD assigned to the referral note is the SMD of the person receiving the referral.

References

From HL7 CCDA:

  • Consultation Note – Generated by a request from a clinician for an opinion or advice from another clinician. Consultations may involve face-to-face time with the patient or may fall under the auspices of telemedicine visits. Consultations may occur while the patient is inpatient or ambulatory. The Consultation Note should also be used to summarize an Emergency Room or Urgent Care encounter.
  • Discharge Summary – A document which synopsizes a patient's admission to a hospital, LTPAC provider, or other setting. It provides information for the continuation of care following discharge.
  • History and Physical Note – A medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status.
  • Operative Note – A frequently used type of procedure note with specific requirements set forth by regulatory agencies. It is created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.
  • Procedure Note – Encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act. It is created immediately following a non-operative procedure. It records the indications for the procedure and, when applicable, postprocedure diagnosis, pertinent events of the procedure, and the patient's tolerance for the procedure. It should be detailed enough to justify the procedure, describe the course of the procedure, and provide continuity of care.
  • Progress Note – An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note.
  • Referral Note – Communicates pertinent information about a provider who is requesting services of another provider of clinical or non-clinical services. The information in this document includes the reason for the referral and additional information that would augment decision making and care delivery.
  • Transfer Summary – Standardizes critical information for exchange of information between providers of care when a patient moves between health care settings.

HL7 International. (2026, March 17). Consolidated CDA (C-CDA). https://build.fhir.org/ig/HL7/CDA-ccda/

Consultation Note - Variety of sources

Discharge Summary - Variety of sources

  • Discharge summary is a synopsis of a patient's admission to a hospital; it provides pertinent information for the continuation of care following discharge. The summary may include the reason for hospitalization, procedures performed, the care, treatment and services provided, the patient's condition and disposition at discharge, information provided to the patient and family, and provisions for follow-up care.
  • A discharge summary is a medical document that summarizes a patient's hospital stay and treatment plan after they have been discharged from the hospital
  • A discharge summary is a written form of communication that generally contains a description of the hospital stay, diagnoses, interventions performed, and recommended action steps. Discharge summaries accompany patients after discharge from hospital and are written for care providers who will provide follow-up care. Created by the most responsible physician (MRP) from the inpatient stay, discharge summaries should be available to the primary care provider (PCP) within 48 hours of hospital discharge. This communication is critical to a patient’s transition because it is relied upon to make ongoing clinical recommendations in their care.
  • Patient discharge summaries serve as a critical bridge between the hospital environment and the subsequent care settings, ensuring that the continuum of patient care remains unbroken. These documents encapsulate the essence of a patient’s hospital stay, providing a concise yet comprehensive overview of the medical journey from admission to release. The discharge summary is not merely a record; it is a narrative that weaves together the salient points of diagnosis, treatment, and post-discharge care instructions, acting as a guide for healthcare providers who will continue the patient’s care beyond the hospital walls.
  • A discharge summary is an important clinical document that summarizes a patient’s clinical information and relevant events that occurred during hospitalization. It serves as a detailed handover of the patient’s most recent and updated medical case records to general practitioners, who continue longitudinal follow-up with patients in the community and future medical care providers.