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Clinical Notes

Represents narrative patient data relevant to the respective 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 18842-5)
    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.

    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)

    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 18842-5)
    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)

    Comment

    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.

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