Submitted by Riki Merrick APHL on 2021-04-15
Rename and change definition
- We suggest that in the Laboratory data class Laboratory Report Narrative and Pathology Report Narrative data elements be refocused to be Laboratory Report and Pathology Report:
- clearly define that each report is inclusive of the relevant/applicable narrative, numeric, and encoded data in a structured format.
- Limiting to ONLY narrative is inappropriate and counterproductive in getting more structured data be made available; a typical laboratory report often has less narrative as a pathology report, just providing narrative separately from the encoded and/or numeric data is not appropriate.
Submitted by Riki Merrick APHL on 2021-09-29
Rename and change definition - 2 optionsRename to Narrative Pathology Consultation Note - that is closer to what the definition describes If this remains a Laboratory Report, then it needs to include ALL CLIA required elements: –see here for references: Specifics on the CLIA Regulation are found at http://www.cdc.gov/clia/. Interpretative Guidelines on the elements required in a report may be found at http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Interpretive_Guidelines_for_Laboratories.html. That means all these elements MUST be in the EHR) and these elements must be clearly connected (same report) – bolded elements already exist in USCDI v2, italicized are level 2 elements in USCDI: - the full report is represented either by Laboratory Report Narrative (which should be renamed to just Laboratory Report) or Pathology Report Narrative (which should be renamed to just Patology Report), depending on the domain.