Official Website of The Office of the National Coordinator for Health Information Technology (ONC)
Activity performed for or on a patient as part of the provision of care.
Data Element |
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Procedures
Applicable Vocabulary Standard(s) Applicable Standards
Optional:
Optional for technology which records dental procedures:
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Submitted by maria.michaels… on
To delineate the element name from the class name, MedMorph suggests renaming the Procedures element to Procedure Code. This modification will more closely align with the USCDI definition of a Data Element ("A USCDI “Data Element” is the most granular level at which a piece of data is exchanged") as well as with US Core.
Submitted by Lantana Consul… on
Lantana Consulting Group Comment
The Procedures data class is a broad category that captures medical and dental procedures and interventions that impact the physical person as captured by CDT, CPT, ICD-10-PCS and includes SDOH interventions and Reason for Referral. We recommend clarifying the scope of the Procedures data class and considering the creation of an SDOH Data Class.
Another gap in USCDI that is closely related to a Referral is a Transition of Care Summary. ONC’s 360X Project is testing the exchange of both referrals and a transition summary. Lantana recommends including both referrals and transition summaries under a Care and Treatment Plan data class.