Submitted by cgrote@aota.org on 2022-09-30
Narrative patient data relevant to the context identified by note types.
Data Element |
Applicable Vocabulary Standard(s) |
|---|---|
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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
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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
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History & Physical
Documents the current and past conditions and observations of the patient. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.67
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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
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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
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Imaging Narrative
Contains a consulting specialist’s interpretation of diagnostic imaging data. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.67
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Laboratory Report Narrative
Contains a consulting specialist’s interpretation of the laboratory report. |
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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
|
|
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
|
|
History & Physical
Documents the current and past conditions and observations of the patient. |
Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
|
|
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
|
|
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
|
Data Element |
Applicable Vocabulary Standard(s) |
|---|---|
|
Consultation Note
Response to request from a clinician for an opinion, advice, or service from another clinician. |
|
|
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. |
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|
History & Physical
Summary of current and past conditions and observations used to inform an episode of care. (e.g. admission, surgery, or other procedure) |
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|
Procedure Note
Synopsis of non-operative procedures. (e.g., interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation) |
|
|
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) |
|
Data Element |
Applicable Vocabulary Standard(s) |
|---|---|
|
Consultation Note
Response to request from a clinician for an opinion, advice, or service from another clinician. Examples include but are not limited to dermatology, dentistry, and acupuncture. |
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Discharge Summary Note
Synopsis of a patient’s admission and course in a hospital or post-acute care setting. Usage note: Must contain admission and discharge dates and locations, discharge instructions, and reason(s) for hospitalization. Examples include but are not limited to dermatology discharge summary, hematology discharge summary, and neurology discharge summary. |
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History & Physical
Summary of current and past conditions and observations used to inform an episode of care. Examples include but are not limited to admission, surgery, and other procedure. |
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|
Procedure Note
Synopsis of non-operative procedure. Examples include but are not limited to interventional cardiology, gastrointestinal endoscopy, and osteopathic manipulation. |
|
|
Progress Note
Summary of a patient’s interval status during an encounter. Examples include but are not limited to hospitalization, outpatient visit, and treatment with a post-acute care provider, or other healthcare encounter. |
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Data Element |
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Data Element |
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Comment
Submitted by Katherine Lusk on 2022-04-29
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.Submitted by ravi.kafle@doh… on 2022-04-28
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)
Submitted by cmcdonald on 2021-02-22
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.
Submitted by sabhyankar on 2020-10-23
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.Submitted by sabhyankar on 2020-10-23
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.Submitted by sabhyankar on 2020-10-23
Submitted by LisaRNelson on 2023-02-21
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