Information about a condition, diagnosis, or other event, situation, issue, or clinical concept that is documented.

Data Element

Additional Information

Date of Diagnosis
Description
Date of first determination by a qualified professional of the presence of a problem or condition affecting a patient.

Comment

As noted elsewhere, …

As noted elsewhere, “diagnosis” needs to be better defined. For instance, will ONC allow more than one diagnosis to be reported? A physician may diagnose a patient with X, Y, and Z; the patient then sees a physical therapist, and the physical therapist identifies several musculoskeletal diagnoses. In this instance, are all diagnoses reported including all co-morbidities? We also suggest that ONC clarify that more than one clinician is eligible to populate this field. ONC also should clarify how comorbidities should be tracked and whether these diagnoses/conditions are reported. Finally, we suggest that ONC address how “errors” will be resolved, for instance, when the date of diagnosis may vary between the date of diagnosis in an EHR and the date that the patient reports that they were diagnosed.

Comments to Date of Diagnosis Data Element

As APTA noted previously, “diagnosis” needs to be better defined. For instance, will ONC allow more than one diagnosis to be reported? A physician may diagnose a patient with X, Y, and Z; the patient then sees a physical therapist, and the physical therapist identifies several musculoskeletal diagnoses. In this instance, are all diagnoses reported including all comorbidities? APTA also suggest that ONC clarify that more than one clinician is eligible to populate this field. ONC also should clarify how comorbidities should be tracked and whether these diagnoses/conditions are reported. Finally, we suggest that ONC address how “errors” will be resolved, for instance, when the date of diagnosis may vary between the date of diagnosis in an EHR and the date that the patient reports that they were diagnosed.

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