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

Data Element

Applicable Vocabulary Standard(s)

Consultation Note

Contains the response to request from a clinician for an opinion or advice from another clinician.

    Logical Observation Identifiers Names and Codes (LOINC®) version 2.67
    • Consult Note (LOINC® code 11488-4)
    Discharge Summary Note

    A synopsis of a patient’s admission and course in a hospital or post-acute care setting.

    Logical Observation Identifiers Names and Codes (LOINC®) version 2.67
    • Discharge Summary (LOINC® code 18842-5)
    History & Physical

    Documents the current and past conditions and observations of the patient.

    Logical Observation Identifiers Names and Codes (LOINC®) version 2.67
    • Discharge Summary (LOINC® code 34117-2)
    Procedure Note

    Encompasses non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and other specialty’s procedures.

    Logical Observation Identifiers Names and Codes (LOINC®) version 2.67
    • Procedure Note (LOINC® code 28570-0)
    Progress Note

    Represents a patient’s interval status during a hospitalization, outpatient visit, treatment with a post-acute care provider, or other healthcare encounter.

    Logical Observation Identifiers Names and Codes (LOINC®) version 2.67
    • Progress Note (LOINC® code 11506-3)
    Imaging Narrative

    Contains a consulting specialist’s interpretation of diagnostic imaging data.

    Logical Observation Identifiers Names and Codes (LOINC®) version 2.67
    • Diagnostic Imaging Study (LOINC® code 18748-4
    Laboratory Report Narrative

    Contains a consulting specialist’s interpretation of the laboratory report.

    Pathology Report Narrative

    Contains a consulting specialist’s interpretation of the pathology report.

    Data Element

    Applicable Vocabulary Standard(s)

    Consultation Note

    Contains the response to request from a clinician for an opinion or advice from another clinician.

    Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
    • Consult Note (LOINC® code 11488-4)
    Discharge Summary Note

    A synopsis of a patient’s admission and course in a hospital or post-acute care setting.

    Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
    • Discharge Summary (LOINC® code 18842-5)
    History & Physical

    Documents the current and past conditions and observations of the patient.

    Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
    • Discharge Summary (LOINC® code 34117-2)
    Procedure Note

    Encompasses non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and other specialty’s procedures.

    Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
    • Procedure Note (LOINC® code 28570-0)
    Progress Note

    Represents a patient’s interval status during a hospitalization, outpatient visit, treatment with a post-acute care provider, or other healthcare encounter.

    Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
    • Progress Note (LOINC® code 11506-3)

    Data Element

    Applicable Vocabulary Standard(s)

    Consultation Note

    Response to request from a clinician for an opinion, advice, or service from another clinician.

    • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72
      • Consult Note (LOINC® code 11488-4)
    Discharge Summary Note

    Synopsis of a patient’s admission and course in a hospital or post-acute care setting. Must contain admission and discharge dates and locations, discharge instructions, and reason(s) for hospitalization.

    • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72
      • At minimum: Discharge Summary (LOINC® code 18842-5)
    History & Physical

    Summary of current and past conditions and observations used to inform an episode of care. (e.g. admission, surgery, or other procedure)

    • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72
      • At minimum: Discharge Summary (LOINC® code 34117-2)
    Procedure Note

    Synopsis of non-operative procedures.  (e.g., interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation)

    • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72
      • At minimum: Procedure Note (LOINC® code 28570-0)
    Progress Note

    Summary of a patient’s interval status during an encounter (e.g., hospitalization, outpatient visit, treatment with a post-acute care provider, or other healthcare encounter)

    • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72
      • At minimum: Progress Note (LOINC® code 11506-3)

    Comment

    AOTA's Comment on Clinical Notes

    The American Occupational Therapy Association (AOTA) encourages USCDI to consider how notes from non-physician specialties, such as those created by occupational therapy practitioners, can be included in data exchange. AOTA believes the information captured by an occupational therapy practitioner is vital for holistic care. Occupational therapy documentation is typically captured in evaluation, progress, and discharge notes.  This field is for general comments on this specific data class. To submit new USCDI data classes and/or data elements, please use the USCDI ONDEC system: https://healthit.gov/ONDEC

    USCDI 2022 Comments 9.22_1.pdf

    Additional Clinical Notes

    I recommend the next phase of clinical notes should include:  Emergency Department Reports as a separate item from progress notes to make it easier to discern for the individual requesting their records.  Having as part of the progress notes creates confusion. Back to school / Back to work notes Rehabilitation Services records. The recommendations are based on a survey completed by AHIMA in 2021 of their members requesting feedback on items most requested by patients, payers and providers.  

    Occupational History

    Occupational exposure to disease risk factors is part of the clinical information that needs to be regularly collected during clinical encounters. Having the occupational history available as part of the clinical notes helps with the clinical investigation and decision making for diagnosis of disease conditions.   The details recommended to be part of the occupational history are:
    • Employment Status
    • Jobs taken (Past and Present) and Voluntary Work done
    • Retirement Dates
    • Worked in Combat Zone (Periods, if any)
    Work of Household Member(s), if a Minor

    LOINC provides an ontology…

    • LOINC provides an ontology of clinical reports which includes more than 3000 report names that can distinguish setting, e.g. Hospital, nursing home discharge, specialty, and other dictions at varying levels of specificity. These codes are currently called out in HL7’s CDA and HL7’s FHIR US Core as alternative codes to the few common ones that are enumerated. These are described as alternatives in an ONC guidance published in December 2020 (https://www.healthit.gov/sites/default/files/2020-08/2015EdCures_Update_CCG_USCDI.pdf). ONC should put a short statement or foot note on the clinical report section that calls attention to this larger set of LOINC code from the LOINC document ontology and provide a link to the December 2020 ONC guidance that says so.  For interested parties, the LOINC document ontology can be downloaded from: https://loinc.org/file-access/download-id/8994/
    • This section lists general codes for five important kinds of reports. We presume procedure note code is meant to cover surgical operative notes. If not, LOINC 11504-8  Surgery Operation note should be included in the short list.
    • Users should be aware of “11504-8 Surgical operation note panel” which includes most of the sections, e.g. blood loss, pre-op diagnosis, etc., and includes most of the sections defined in C-CDA for surgical notes.

    Lab, Path, and Imaging narrative

    The LOINC Document Ontology Subcommittee recommends removing the 3 rows for Laboratory narrative, Pathology narrative, and Imaging narrative. These three concepts represent narrative text from Clinical Reports, which capture information related to a lab test or imaging procedure (i.e., in response to an “order”) versus Clinical Notes, which are written by providers during the course of providing clinical care, and not in response to an order.

    Value sets for each note type

    Currently only the most generic LOINC term for each note type is listed, e.g., 11506-3 Progress note. However, for each note type, there is a larger set of more specific LOINC terms available, such as the following for progress notes: https://search.loinc.org/searchLOINC/search.zul?query=progress+note+scale%3Adoc. The LOINC Document Ontology Subcommittee recommends adding information about how to access the value set of more specific LOINC terms available for each note type to the Applicable Standard(s) column for each note type. The Regenstrief LOINC team can provide FHIR ValueSets with associated OIDs and/or webpages with downloadable content for each note type. Both of these resources would include the same set of LOINC terms. These resources do not exist yet but can easily be created if approved as additions to the USCDI. The benefit of hosting these resources on the LOINC website or providing them via LOINC FHIR terminology services compared to VSAC or other value set repositories is that the resources will be updated automatically with every LOINC release and would not require a separate process.

    Clinical notes explanatory text

    The LOINC Document Ontology Subcommittee recommends adding the following explanatory text below the Clinical Notes header, following the existing explanatory text: “LOINC document codes represent expected collections of information regardless of format (e.g., structured versus unstructured, electronic format versus PDF document). For each note type, there is a generic LOINC concept as well as more specific concepts that vary by setting, specialty, etc. In most clinical situations, use of a more specific code is encouraged.”

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