Narrative patient data relevant to the context identified by note types.

Data Element

Emergency Department Note
Description
Summary of a patient’s interval status during an emergency department encounter, including narrative and free text data. Emergency department notes typically include information related to assessment and plans of care, chief complaints, physical findings, interventions, and results.

Comment

THIA Support for Emergency Department Note

The Texas Health Informatics Alliance (THIA) Policy and Standards Working Group are in support of an emergency department (ED) note as a separate encounter-specific clinical note. This would facilitate ambulatory practices contacting patients with a recent ED visit to report on follow-ups with their PCP. The records are already there, so additional work from clinicians would not be required.

Additionally, we would like to emphasize our support for the automation of reporting and homogenization of requests to remove some of the reporting burden on hospitals. Replication of the same data is often asked for by multiple government agencies, including the trauma registry. This is a requirement for safe reporting and certification. Information could be pulled in part from the ER record.

THIA Policy & Standards WG - USCDI v5 Recommendations - Clinical Notes - Emergency Department Note.pdf

Emergency Department Note Data Element

I am a student who interviewed an Emergency Department nurse to gain their perspective on the emergency department note data element. It would be useful to add a section to input IV infusion start and end times to have that documented for when nurses switch their shifts. 

 

Support addition of Emergency Department Note with clarification

Good day, and thank you for the ability to comment.  As the Chief Medical Officer for one of the largest integrators of Emergency Medical Services and Emergency Department clinical information (www.eso.com), I write in support of the inclusion of this data element.  In order to have maximum utility, I suggest clarity around the exact nature of the Emergency Department Note.  Specifically, this should be the clinical documentation (inclusive of History/Physical/Past Medical and Surgical History/Medications/Allergies/Vital Signs/Clinical Decision Making/Diagnosis/Disposition) as recorded by the Qualified Independent Healthcare Pracitioner in the Emergency Department (e.g., Physician/Physicians Assistant/Nurse Practioner).  This is important for several reasons; three deserve specific mention.  First, this provides clarity for any continuation of the episode of care in the inpatient setting.  Second, this is important for continuity of care, as many patients receive a large portion of their care in the emergency department for a host of socioeconomic and other factors.  The inclusion of a designated note will facilitate appropriate on-going care.  Finally, this provides the opportunity for Emergency Medical Services providers to understand the outcome of their care and thus facilitate quality assurance and performance improvement activities for EMS.  This will improve community health and safety for the entire population, inclusive of those at highest risk and may have historically experienced disparities in care.

CMS-CCSQ Support for Emergency Department Notes for USCDI v5

CMS-CCSQ  recommends this Level 2 data element be added to USCDI v5. Emergency Department Notes should be a distinct clinical note data element to distinguish data from other Progress Notes, for the purposes of coordination of care and care continuity for routine exchange throughout the course of care. Emergency Departments can be fully integrated within a healthcare system, fully independent and administratively distinct from a nearby healthcare or hospital system, or some intermediate state between these extremes. This ensures capture of a critically unique encounter type that represents a key interface between and across acute and outpatient care settings and therefore an important component of both acute and chronic disease management. A separate Emergency Department Notes data element will also ensure patient access to this information and will support transitions of care. This data element is currently classified with LOINC Group Code LG41825-7 or at the Emergency Department Discharge Summary Note LOINC 59258-4, at a minimum. This aligns with the ISWG Recommendations on Draft USCDI v4  (April 12, 2023) to include LOINC 59258-4 Emergency Department Discharge Summary as the generic or minimum Emergency Department Note codes.

CMS-CCSQ USCDIv4 Priority: Emergency Department Note

Emergency Department Notes should be a distinct clinical note data element to distinguish data from other Progress Notes, for the purposes of coordination of care and care continuity. This ensures capture of a critically unique encounter type that represents a key interface between and across acute and outpatient care settings. A separate Emergency Department Notes data element will also ensure patient access to this information. As historically vulnerable and underserved populations disproportionately use Emergency Departments for primary care, these clinical notes may be particularly useful in supporting the ONC USCDI v4 goals of addressing needs of underserved communities and public health interoperability needs related to emergency response.

Maturity:

  • Current standards:
    • LOINC codes, Emergency department|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain, LOINC Group Code LG41825-7 or at a minimum, Emergency department Discharge summary note, LOINC 59258-4.
  • Current uses, exchange, and use cases: Emergency department notes are exchanged and used routinely throughout the course of care. Emergency Departments can be fully integrated within a healthcare system, fully independent and administratively distinct from a nearby healthcare or hospital system, or some intermediate state between these extremes. They represent a unique and critical connection between inpatient and outpatient care settings and are therefore an important component of both acute and chronic disease management. The information is particularly important to reflect a patient’s health status to support transitions of care.

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