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
Summarization of encounter note narrative
Description

A clinical note which narratively summarizes the patient encounter. LOINC code = 67781-5.
Submitted By: Nedra Garrett / Centers for Disease Control and Prevention
Data Element Information
Use Case Description(s)
Use Case Description "Monitoring disease and making decisions about public health threats depends on accessible and accurate data. EHRs are a data source with potential to provide timely and relevant data beyond its use by health care providers. EHR data, if made more available for public health professionals and researchers, can lead to new innovations and more rapid disease detection. Clinical notes are important for public health and research uses to ""get the whole story"" that structured EHR text entry cannot always provide.

The eight note types in USCDI V1 were a good start to capturing the most common clinal notes exchanged but the National Health Care Surveys have identified Summarization of encounter note narrative, Initial evaluation note and Outpatient note as three types of ambulatory notes as both commonly exchanged and important to data collection for the National Ambulatory Medical Care Survey.
Estimate the breadth of applicability of the use case(s) for this data element Approximately 620,000 physicians in the US are active and have at least some component of ambulatory practice and thus are annually eligible for sampling and recruitment into the National Ambulatory Medical Care Survey (NAMCS), one of the two Health Care Surveys in the MedMorph Health Care Surveys Use Case. NAMCS, samples from between 3,500 to 20,000 of these physicians annually. Presently each sampled physician submits one weeks' worth of patient encounters to NAMCS.
Link to use case project page https://www.cdc.gov/nchs/dhcs/nhcs_registry_landing.htm
Healthcare Aims
  • None of the above
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) LOINC
https://loinc.org/67781-5/ https://loinc.org/28636-9/ https;//loinc.org/34108-1/
https://loinc.org/67781-5/
Additional Specifications N/A
Current Use Extensively used in production environments
Supporting Artifacts N/A
https://www.cdc.gov/nchs/dhcs/nhcs_registry_landing.htm
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 N/A
https://www.cdc.gov/nchs/dhcs/nhcs_registry_landing.htm
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 If this data is already in the EHR, then the burden to implement should be minimal because it does not require the creation of a new data element or modifying an existing one.
Other Implementation Challenges When using FHIR there may be associated costs with development of tools needed to access specific data. Often these costs may be a limitation for states who need to develop tools to access certain data.
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.

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