Representing Clinical/Nursing Assessments

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Type Standard Implementation/Specification Standards Process Maturity Implementation Maturity Adoption Level Federally required Cost Test Tool Availability
Standard for observations
Final
Production
Rating 1
No
Free
N/A
Standard for observation values
Final
Production
Rating 1
No
Free
N/A
Limitations, Dependencies, and Preconditions for Consideration Applicable Value Set(s) and Starter Set(s)
  • Assessments are represented as question/answer (name/value) pairs.
  • Codes should generally be chosen from two axes: Clinical finding and Situation with explicit context.
  • When representing validated scales, LOINC should be used for the question and LOINC answers (LA Codes) should be used for the answers
  • See LOINC projects in the Interoperability Proving Ground.
  • For more information about observations and observation values, see Appendix II for an informational resource developed by the Health IT Standards Committee. 
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