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

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  • Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name. 

Data Element
Transfer summary note
Description

A synopsis of a patient’s admission and clinical course in one setting when being transferred to another setting.
Submitted By: Swapna Abhyankar / Regenstrief Institute, LOINC Document Ontology Subcommittee
Data Element Information
Data Element Description A synopsis of a patient’s admission and clinical course in one setting when being transferred to another setting.
Rationale for Separate Consideration There are related data elements (e.g., Discharge summary note, History and Physical note), but none that capture the information in a transfer summary.
Use Case Description(s)
Use Case Description The set of proposed data elements are complementary to the existing Clinical Notes data elements in USCDI v1 and together, they better represent the broad scope of clinical documentation that occurs each day in the U.S. Healthcare system.
Estimate the breadth of applicability of the use case(s) for this data element These data elements are broadly used every day across healthcare systems, settings, and specialties and would be used by a large proportion of USCDI stakeholders.
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Reducing the cost of care
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) LOINC.
We recommend adding the new data elements with a LOINC term representing the most generic term for that particular data element, along with information about how to access the value set of more specific LOINC terms available 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.
https://loinc.org
Additional Specifications There are HL7 C-CDA implementation guides for several of these data elements (Transfer summary, Plan of care, Referral note). In addition, the FHIR DocumentReference and other resources across versions, including the US Core, utilize these data elements.
Current Use Extensively used in production environments
Supporting Artifacts These data elements are broadly used every day across healthcare systems, settings, and specialties and would be used by a large proportion of USCDI stakeholders.
Extent of exchange 5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.
Supporting Artifacts These data elements are broadly used every day across healthcare systems, settings, and specialties and would be used by a large proportion of USCDI stakeholders.
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) None
Restrictions on Use (e.g. licensing, user fees) None
Privacy and Security Concerns None
Estimate of Overall Burden Minimal - already being used
ASTP Evaluation Details
Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1
Maturity - Current Standards		 Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2
Maturity - Current Use 		Level 2 - Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
Criterion #3
Maturity - Current Exchange		 Level 2 - Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 2 - Use cases apply to most care settings or specialties.

Comment

Submitted by Katherine.Lusk… on

Transfer Summary Note Content Recommendations

1.Transfer Reason – Course of care

2.Medications, last dose and schedule

3.Allergies

4.Admission Diagnosis

5.Discharge Diagnosis

6.Procedures:  including Interventional Radiology, Cardiac Cath, operative procedures

7.Diagnostic Imaging – Advanced imaging for example:  MRI, CT, PET, Nuclear Imaging, Ultrasound, Echo, & Venous Doppler

8.Laboratory – Recommend 1st and last laboratory result for every test.  On those rare tests – they are only done once so would be included (ANA Rheumatoid)

9.Consultations

10.Assessment 

11.Active Problem List

Submitted by Katherine.Lusk… on

Behavioral Health Transitions of Care

The following elements should be included:  

·Medications given and discharged on

·History & Physical

·Discharge Summary

·Test and studies that are pending

·Basic labs (hemoglobin)

·When is the next appointment

·Who is going to follow up with them – PCP or psychiatrist

·Education on Medication and Diagnoses

·Safety plan & crisis number

·Psychiatrist Evaluation

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