Documentation of Clinical Notes

Discharge C-CDA Content Needs

The Texas Health Services Authority Standardizing C-CDA content workgroup completed a community survey to understand the clinician needs with a Discharge C-CDA.  The goal of the workgroup is to recommend clinical content to be included in the C-CDA that will benefit transitions of care.  The complete document was shared in a previous post but it is believed the survey may help inform other initiatives.     Discharge C-CDA Minimum Data-Set Content  

1. Discharge Summary Narrative (aka Hospital Course)
2. Discharge Medications
3. Allergies
4. Admission Diagnosis
5. Discharge Diagnosis
6. Procedures:  including Interventional Radiology, Cardiac Cath, operative procedures
7. Diagnostic Imaging – Advanced imaging for example:  MRI, CT, PET, Nuclear Imaging, Ultrasound, Echo, & Venous Doppler
8. Laboratory – Recommend first and last laboratory result for every test.  On rare tests – they are only done once so would be included (ANA Rheumatoid)
9. Consultations
10. Assessment & Plan (includes future orders for follow-up with PCP and diagnostic tests)
11. Problem List

CCDA Content Standardization Survey Results.pdf

Discharge Clinical Note

The Texas Health Services Authority supports a multi-disciplinary workgroup that focuses on improving clinical communication by standardizing C-CDA content.  “The feedback from providers is that all too often the content of the data currently being exchanged has too little or too much information. This leads to lack of trust and will lead to lower utilization. Too much information is as much a problem as too little information – providers today struggle with cognitive overload from electronic health records. It is very important to have succinct and relevant information presented to healthcare providers. Future capabilities, like FHIR, may enable the best of both worlds – a succinct summary with the ability to drill down to further details if needed.”   The workgroup has formulated a minimum dataset for the Discharge C-CDA to improve communication.  We would appreciate if this content standard could be adopted nationally, recognizing that this is a start.  The content was developed from workgroup experience and from a community survey with 119 respondents on what is important in the C-CDA.  The Survey will be attached separately.    

Discharge C-CDA Minimum Data-Set 9.28.2022.docx.pdf

USCDI formats?

Where can I access the USCDI fields, format for the patient data?  Such as Date of Birth, Medical History etc...   Darrell Calderon