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 2
No
Free
N/A
Standard for observation values
Final
Production
Rating 2
No
Free
N/A
Limitations, Dependencies, and Preconditions for Consideration Applicable Value Set(s) and Starter Set(s)
  • Concepts for observation values from SNOMED-CT 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.
  • Question/Answer (name/value) pairs are a valuable representation of assessments, but best practices indicate the full question with answer should be included in communication. 
  • 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. 
  • For related LOINC and SNOMED codes, refer to CMS DEL HITWG.
  • 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.  

Regenstrief - Comment

We concur with the recommended standards here (LOINC and SNOMED CT). The second sentence in Limitations, Dependencies, and Preconditions for Consideration should be amended because it only applies to SNOMED: Concepts for observation values from SNOMED CT should generally be chosen from two axes: Clinical finding and Situation with explicit context.

May be underestimating the…

May be underestimating the adoption level. Vital signs are nursing variables and they are required by Meaningful Use. Other nursing variables like Braden scores are also common - so maybe two bubbles.