Clinical Notes

Clarify the difference between a "Operative Note" and "Procedure

Currently, Procedure note is defined as:
"Summary of non-operative procedure."
"Examples include but are not limited to interventional cardiology, gastrointestinal endoscopy, and osteopathic manipulation."

Proposed Text is defined as:
"Summary of non-invasive procedure where the diagnostic or therapeutic procedure is done using tubes and catheters without incision to remove, repair or examine diseased organ or tissue."
(no change recommended to "example sentence".

Rationale (similar to the comment in Operative notes with additional text from LOINC codes.

In hospitals, there are "Operative Notes" that occur in the "Operating Room" or "Surgery" and there are "Procedures that occur in "Interventional Radiology" and the "Cardiac Catheterization Laboratory" or the "Electrophysiology Lab". There are cases where procedures done in the operating room resemble those done in a procedure room. The notes are similar to the area.  Standardly speaking, should an "Operative Note" mean there was an "incision" or "opening of a body cavity" and the "Procedure Note mean" these were done in a "non-invasive fashion"?  Does the fact that "Anesthesia" was there make a difference? In most surgery cases, "Anesthesia" is involved while in the other cases the nurses administer the sedation unless there is high risk with the sedation or the procedure and airway concerns.
There are cases in the intensive care unit (ICU) where invasive surgeries and procedures occur at the bedside. They are often "free text" in the progress notes. The may have "Operative Note" as a header OR "Procedure Note" as a header. Examples, "Tracheotomy", "Insertion of Triple Lumen Catheter", "Insertion of Invasive Heart Pressure Monitoring (Swan-Ganz) Cathether", "Endotracheal intubation". How would these be categorized?

For operative note

• Loinc code - https://loinc.org/11504-8

For procedures:

• Loinc code - https://loinc.org/28570-0
• Loinc key point - " do not involve incision or excision as the primary act."

LP74249-1   Procedure note
Procedure note is a broad term that encompasses many specific types of non-operative procedures including interventional cardiology, interventional radiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes in that the procedures documented do not involve incision or excision as the primary act. The Procedure Note is created immediately following a non-operative procedure and records the indications for the procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, and the patient's tolerance of the procedure. Source: HL7

These components are found in op notes. The term "surgery" is defined as "the setting". However, as noted above there is overlap dependent on healthcare organization and hospital which may vary depending on location and both national and international definitions of these terms
 

Synopsis of non-operative procedure.

It is odd that the "Procedure Note" is defined as "non-operative". If there was a category for "Operative Reports" this would make since, but there isn't. Where is the "Operative Report" or "OR Report" expected to be? It seems like this is the most relevant "Date Element" under the "Clinical Notes" section.  "Procedure" in the greater context of data interoperability and data structures usually includes both "non-operative" and "operative". In the paper chart world, we kept them separate but they each had a section (currently, USCDI does not have a section). the structure of these two items is the same too. Two examples are included at these links: (https://training.seer.cancer.gov/abstracting/procedures/operative/example/ex4.html) and (http://jaccjacc.cardiosource.com/DataSupp/2014_Cathlab_CathReportSample.pdf)

This link is clinical research focused but could be applied generally https://raw.githubusercontent.com/CBIIT/bridg-model/master/Documents/For%20Website/NEW%20Performing%20a%20Surgical%20Procedure.png

BRIDG was an initiative that included HL7, ISO, NIH, NCI, FDA and CDISC (maybe others). It is based on the HL7 RIM model. https://bridgmodel.nci.nih.gov/model-subset

In the diagram under FoundationClasses Subject Area Procdure is noted - https://vico.org/HL7_RIM/index.html

Thank you for considering the update to the definition of Procedure Note.

CMS-CCSQ Support for Surgical Notes for USCDI v5

CMS-CCSQ strongly recommends either expanding the current Procedure Notes data element that is in USCDI to include the Surgical Operation Note (LOINC 11504-8) in addition to Non-Operative Procedure Notes or consider adding the distinct Operative Note data element that is at Level 2 to USCDI v5. Surgical notes are routinely captured in EHR systems and important to ensure patient access to data and capture interoperable information critical to patient safety, care coordination, and hand-offs. This element was previously identified as a joint CMS-CDC priority, and the recommendation aligns with ISWG Recommendations on Draft USCDI v4  (April 12, 2023) to include all note types coded in the LOINC Document Ontology, or at least the Surgical Operation Note (LOINC 11504-8) and Tumor Board Notes.

CMS-CCSQ/CDC Joint USCDIv4 Priority: Surgical Operative Note

Surgical notes are important to ensure patient access to data and capture interoperable information critical to patient safety, care coordination and hand-offs. Currently, the Procedure Notes data element is limited to non-operative procedures. CMS and CDC strongly recommend either expanding these notes to also include the surgical operation note or consider adding the distinct Operative Note data element to USCDI v4.

CMS-CCSQ Support for Surgical Operative Note: USCDI v4

Currently, the Procedure Notes data element is limited to non-operative procedures. CMS strongly recommends either expanding these notes to also include the surgical operation note (LOINC 11504-8) or consider adding the distinct Operative Note data element to USCDI v4. Surgical notes are important to ensure patient access to data and capture interoperable information critical to patient safety, care coordination and hand-offs. This element was previously identified as a joint CMS-CDC priority, and the recommendation aligns with the ISWG recommendation for USCDI v3 to include all note types coded in the LOINC Document Ontology, or at least the Surgical Operation Note (LOINC 11504-8) and Tumor Board Notes. Existing disparities in surgical procedure rates and outcomes support that these data elements are critical additive tools to help mitigate health and health care inequities and address needs of underserved communities.

Maturity: ONC already includes non-operative clinical notes in the USCDI and has classified an Operative Note data element as Level 2.

• Current standards:
  • The Surgical Operative Note is standardized and captured by LOINC 11504-8; or the group LOINC code LG38755-1

Current uses, exchange, and use cases: Surgical Operation Notes are routinely captured in EHR systems used by hospitals and providers for care coordination, and hand-offs. These notes include critical information for assessing patient safety and include important data patients should have access to.

CDC-CMS Joint Priority Data Element

Proposing to extend the element to include surgical operation notes. 

CMS-CCSQ Support for Surgical Operation Note: USCDI V3

USCDI Draft version 3 currently includes Procedure Notes that are limited to non-operative procedures. We strongly recommend ONC expand these notes to also include the surgical operation note (LOINC 11504-8). Surgical notes are important to ensure patient access to data, as well as interoperability of data for care coordination and hand-offs.

Maturity:

• Current standards:
  • The Surgical Operation Note is standardized and captured by LOINC 11504-8
• Current uses, exchange, and use cases: Surgical Operation Notes are routinely captured in EHR systems used by hospitals and providers.