Submitted By: Leslie Kelly Hall
/ Engaging Patient Strategy
|
Data Element Information |
Data Element Description |
All operative notes should be included in USCDI. https://loinc.org/LG38755-1/ |
Rationale for Separate Consideration |
Very high benefit and low risk. Known LOINC codes and current work flows and exchange in place. https://loinc.org/LG38755-1/ |
Use Case Description(s) |
Use Case Description |
Consistent with Clinical notes, view download and transport and the desires of information sharing, OP notes is a necessary component for access and |
Estimate the breadth of applicability of the use case(s) for this data element
|
Approximately 51% of all hospital visits under Medicare include a procedure that includes an operative note. Cancer patients and their supporting clinical team members, count on OP notes for continuity of care and transitions. |
Healthcare Aims |
- Improving patient experience of care (quality and/or satisfaction)
- Improving the health of populations
- Reducing the cost of care
- Improving provider experience of care
|
Maturity of Use and Technical Specifications for Data Element |
Applicable Standard(s) |
https://loinc.org/LG38755-1/
https://loinc.org/LG38755-1/
|
Additional Specifications |
N/A |
Current Use |
This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders |
Supporting Artifacts |
Every EMR contains an OP note for every operative procedure.
|
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 |
This is commonly collected but not specifically called out in USCDI.
As a patient advocate, I do not have access to the artifacts.
|
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 |
Very little burden. Codes, creation, storage and standards are in place. |
Other Implementation Challenges |
none |
Submitted by rbaker@cdisc.org on
Clarify the difference between a "Operative Note" and "Procedure
In hospitals, there are "Operative Notes" that occur in the "Operating Room" or "Surgery" and there are "Procedures that occur in "Interventional Radiology" and the "Cardiac Catheterization Laboratory" or the "Electrophysiology Lab". There are cases where procedures done in the operating room resemble those done in a procedure room. The notes are similar to the area. Standardly speaking, should an "Operative Note" mean there was an "incision" or "opening of a body cavity" and the "Procedure Note mean" these were done in a "non-invasive fashion"? Does the fact that "Anesthesia" was there make a difference? In most surgery cases, "Anesthesia" is involved while in the other cases the nurses administer the sedation unless there is high risk with the sedation or the procedure and airway concerns.
There are cases in the intensive care unit (ICU) where invasive surgeries and procedures occur at the bedside. They are often "free text" in the progress notes. The may have "Operative Note" as a header OR "Procedure Note" as a header. Examples, "Tracheotomy", "Insertion of Triple Lumen Catheter", "Insertion of Invasive Heart Pressure Monitoring (Swan-Ganz) Cathether", "Endotracheal intubation". How would these be categorized?
Loinc code - https://loinc.org/11504-8
These components are found in operative notes. The term "surgery" is defined as "the setting". However, as noted above there is overlap dependent on healthcare organization and hospital which may vary depending on location and both national and international definitions of these terms.
Existing Text:
Defined as:
"Summary of surgical procedure."
"Usage note: May include procedures performed, operative and anesthesia times, findings observed, fluids administered, specimens obtained, and complications identified."
Proposed Text:
Defined as:
"Summary of surgical procedure defined as involving an incision and the removal or replacement of a diseased organ or tissue"
Consider, "requiring anesthesia"?
(no change recommended to "Usage note")