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. 
  • Feedback requested

Comment

Agree with use of name/value pairs

The Joint Commission agrees with the use of name/value pairs to represent clinical assessments.  This is the current structure used in electronic clinical quality measures (eCQMs).

Question / Answer Pairs

Question / Answer pairs are valuable, supporting context of the assessment.  The assessment should not be limited to Q/A pairs. Full question with answer must be included in communication.

We strongly approve of Nursing practice being included in ISA.