Representing Clinical/Nursing Assessments

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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.