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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 Standards(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)

Comment

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.”

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.

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.

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