Submitted by cgrote@aota.org on
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
Submitted by LisaRNelson on
Clinical Notes data class needs clarification
The Clinical Notes data class needs to include Encounter Summaries and Patient Summaries.
Along the way, something got lost in translations for this data class. The Consolidation CDA standard defines Clinical Note Templates for the document types named in the Clinical Notes Data Class. It needs to be clarified that this data class covers support for Clinical Notes including support for “note activity” as well as wholly formed encounter summaries which are Clinical Notes of these types. Specifically, the Clinical Notes data class needs to call out Clinical Notes, Clinical Note Encounter Documents, and Patient Summary Documents. Patient Summary Documents are also known as Continuity of Care Documents (CCDs) they are a type of Clinical Note which covers a span of time which may cover multiple encounters.
Lisa Nelson Comments 20230221.pdf