Representing Clinical/Nursing Assessments

Type	Standard / Implementation Specification	Standards Process Maturity	Implementation Maturity	Adoption Level	Federally required	Cost	Test Tool Availability
Standard for observations	LOINC®	Final	Production		No	Free	N/A
Standard for observation values	SNOMED CT® U.S. Edition	Final	Production		No	Free	N/A

Limitations, Dependencies, and Preconditions for Consideration	Applicable Value Set(s) and Starter Set(s)
Concepts for observation values from SNOMED CT U.S. Edition should generally be chosen from two axes: Clinical finding and Situation with explicit context. When representing validated scales, LOINC should be used for the question and LOINC answers (LA Codes) should be used for the answers. Question/Answer (name/value) pairs are a valuable representation of assessments, but best practices indicate the full question with answer should be included in communication. For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee.	Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) - Version 2.0 [CMS Assessment]: LOINC 88329-8 Long-Term Care Hospital Continuity Assessment Record & Evaluation (CARE) Data Set (LCDS) v.4.0 [CMS Assessment]: LOINC 87509-6 Resident Assessment Instrument (RAI) Minimum Data Set (MDS) v.1.16 Nursing Home Comprehensive (NC) item set [CMS Assessment]: LOINC 88954-3 Outcome and Assessment Information Set (OASIS) - Version D - Start of Care [CMS Assessment]: LOINC 88373-6

Limitations, Dependencies, and Preconditions for Consideration

Applicable Value Set(s) and Starter Set(s)

Concepts for observation values from SNOMED CT U.S. Edition should generally be chosen from two axes: Clinical finding and Situation with explicit context.
When representing validated scales, LOINC should be used for the question and LOINC answers (LA Codes) should be used for the answers.
Question/Answer (name/value) pairs are a valuable representation of assessments, but best practices indicate the full question with answer should be included in communication.
For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee.

Comment

Submitted by gldickinson on 2020-10-23

Preserving Clinical Context

General Comments:

USCDI specifies lots of clinical data classes and data elements

Resolving to myriad de-coupled fragments
With vanishingly little focus on:
- Clinical context and vital inter-relationships, e.g., between problems, diagnoses, complaints, symptoms, encounters, history and physical findings, allergies, medications, vaccinations, assessments, goals/objectives, clinical decisions, orders, results, diagnostic procedures, interventions, observations, treatments/therapies, referrals, consults, outcomes, protocols, care plans and status...
- Elements and context + purpose of capture: e.g., blood pressure, its measurement (systolic, diastolic), its unit of measure (mm/Hg), its reason for capture, its context of capture (sampling site, sampling method, patient position, at rest/during/post exercise...

It is crucial to consider, determine and resolve how clinical content and context are bound together and preserved in USCDI. The ultimate end user (often a clinician) must be able to readily discern context and inter-relationships – otherwise USCDI places an undue (and often unresolvable) burden on this user. Only the source EHR/HIT system can structure clinical content and context properly. Once data is stuffed into the USCDI framework and related exchange artifact (e.g., FHIR resources) this opportunity is forever lost.

Submitted by cmcdonald on 2018-10-01

May be underestimating the…

May be underestimating the adoption level. Vital signs are nursing variables and they are required by Meaningful Use. Other nursing variables like Braden scores are also common - so maybe two bubbles.

Submitted by dvreeman on 2018-09-27

Regenstrief - Comment

We concur with the recommended standards here (LOINC and SNOMED CT). The second sentence in Limitations, Dependencies, and Preconditions for Consideration should be amended because it only applies to SNOMED: Concepts for observation values from SNOMED CT should generally be chosen from two axes: Clinical finding and Situation with explicit context.

Submitted by gdixon on 2018-09-12

Question / Answer Pairs

Question / Answer pairs are valuable, supporting context of the assessment. The assessment should not be limited to Q/A pairs. Full question with answer must be included in communication.

We strongly approve of Nursing practice being included in ISA.

Submitted by andersol on 2018-08-08

Agree with use of name/value pairs

The Joint Commission agrees with the use of name/value pairs to represent clinical assessments. This is the current structure used in electronic clinical quality measures (eCQMs).