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Clinical Notes

Composed of both structured (i.e. obtained via pick-list and/or check the box) and unstructured (free text) data. A clinical note may include the history, Review of Systems (ROS), physical data, assessment, diagnosis, plan of care and evaluation of plan, patient teaching and other relevant data points.

Data Element

Applicable Standard(s)

Consultation Note
  • Consult Note (LOINC® code 11488-4)
Discharge Summary Note
  • Discharge Summary (LOINC® code 18842-5)
History & Physical
  • History and Physical Note (LOINC® code 34117-2)
Imaging Narrative
  • Diagnostic Imaging Study (LOINC® code 18748-4)
Laboratory Report Narrative
Pathology Report Narrative
Procedure Note
  • Procedure Note (LOINC® code 28570-0)
Progress Note
  • Progress Note (LOINC® code 11506-3)

Data Element

Applicable Standard(s)

Consultation Note
  • Consult Note (LOINC® code 11488-4)
Discharge Summary Note
  • Discharge Summary (LOINC® code 18842-5)
History & Physical
  • History and Physical Note (LOINC® code 34117-2)
Procedure Note
  • Procedure Note (LOINC® code 28570-0)
Progress Note
  • 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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