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Encounter Information

Data Element

Additional Information

Encounter Diagnosis
Represents the primary reason for a healthcare encounter and associated diagnoses, represented by a diagnosis code.

Comment

MedMorph's support of Encounter Diagnosis

The MedMorph project supports the addition of Encounter Diagnosis to USCDI V2. We propose a change to the definition to read: "The diagnoses associated with the encounter, represented by diagnoses codes." This will support implementations by identifying the respective terminologies for these diagnoses codes.

MedMorph's need for Delivery and Pregnancy Information class

Pregnancy Outcome is specific to if an infant is living at time of report.  This is relevant to noting the infant's survival when birth certification information is being documented. This item is on the national standard worksheet capturing medical information that jurisdictions use to report. As commented on other natality reporting data elements submitted to USCDI, it is important to recognize that birth and delivery events information may be captured within specific areas of a healthcare system such as labor and delivery summaries and prenatal care records. To help lessen the burden of implementations and queries of these events is the reason to propose a new Delivery and Pregnancy Information class where these specific data elements may be captured.  Another option for data class instead of 'Encounter Diagnosis' would be ‘Observation’.  However, as previously stated an ideal fit for natality reporting would be within a specific class for this specific life event. National worksheet for reporting of live birth and US standard birth certificate: https://www.cdc.gov/nchs/data/dvs/facility-worksheet-2016-508.pdf, https://www.cdc.gov/nchs/data/dvs/birth11-03final-ACC.pdf Additional relevant specification for this data element includes HL7 and IHE standards listed below. HL7 Version 2.6 Implementation Guide: Vital Records Birth and Fetal Death Reporting, Release 1 STU Release 2 - US Realm: https://www.hl7.org/implement/standards/product_brief.cfm?product_id=320 IHE Quality, Research and Public Health Technical Framework Supplement – Birth and Fetal Death Reporting-Enhanced (BFDR-E) Revision 3.1: https://www.ihe.net/uploadedFiles/Documents/QRPH/IHE_QRPH_Suppl_BFDR-E.pdf Vital Records Common Profiles Library FHIR IG: http://build.fhir.org/ig/HL7/fhir-vr-common-ig/branches/master/index.html Vital Records Birth and Fetal Death Reporting:  https://build.fhir.org/ig/HL7/fhir-bfdr/index.html Birth Defect Reporting FHIR IG: https://build.fhir.org/ig/HL7/fhir-birthdefectsreporting-ig/index.html HL7 CDA® R2 Implementation Guide: Ambulatory and Hospital Healthcare Provider Reporting to Birth Defect Registries Release 1 , STU 2 -US Realm: https://www.hl7.org/implement/standards/product_brief.cfm?product_id=428 Below lists examples of artifacts of where this data element is collected. EPIC stork module (obstetrics) for birth reporting: https://www.epic.com/software#PatientEngagement EPIC FHIR APIs for patient, vitals, obstetric details: https://fhir.epic.com/Specifications?api=932 https://fhir.epic.com/Specifications?api=968 https://fhir.epic.com/Specifications?api=966 BFDR-E in ISA: https://www.healthit.gov/isa/reporting-birth-and-fetal-death-public-health-agencies

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