Narrative patient data relevant to the context identified by note types.

Data Element

Additional Information

Procedure Note
Description
Synopsis of non-operative procedure. Examples include but are not limited to interventional cardiology, gastrointestinal endoscopy, and osteopathic manipulation.

Applicable Vocabulary Standard(s)

Applicable Standards
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
    • At minimum: Procedure Note (LOINC code 28570-0)

Comment

CMS-CCSQ Support for Surgical Operative Note: USCDI v4

Currently, the Procedure Notes data element is limited to non-operative procedures. CMS strongly recommends either expanding these notes to also include the surgical operation note (LOINC 11504-8) or consider adding the distinct Operative Note data element to USCDI v4. Surgical notes are important to ensure patient access to data and capture interoperable information critical to patient safety, care coordination and hand-offs. This element was previously identified as a joint CMS-CDC priority, and the recommendation aligns with the ISWG recommendation for USCDI v3 to include all note types coded in the LOINC Document Ontology, or at least the Surgical Operation Note (LOINC 11504-8) and Tumor Board Notes. Existing disparities in surgical procedure rates and outcomes support that these data elements are critical additive tools to help mitigate health and health care inequities and address needs of underserved communities. Maturity: ONC already includes non-operative clinical notes in the USCDI and has classified an Operative Note data element as Level 2.
  • Current standards:
    • The Surgical Operative Note is standardized and captured by LOINC 11504-8; or the group LOINC code LG38755-1
Current uses, exchange, and use cases: Surgical Operation Notes are routinely captured in EHR systems used by hospitals and providers for care coordination, and hand-offs. These notes include critical information for assessing patient safety and include important data patients should have access to.

CMS-CCSQ Support for Surgical Operation Note: USCDI V3

USCDI Draft version 3 currently includes Procedure Notes that are limited to non-operative procedures. We strongly recommend ONC expand these notes to also include the surgical operation note (LOINC 11504-8). Surgical notes are important to ensure patient access to data, as well as interoperability of data for care coordination and hand-offs. Maturity:
  • Current standards:
    • The Surgical Operation Note is standardized and captured by LOINC 11504-8
  • Current uses, exchange, and use cases: Surgical Operation Notes are routinely captured in EHR systems used by hospitals and providers.

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