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
Colonoscopy
Description

Narrative clinical assessment of the Colonoscopy results.
Submitted By: Melissa Ayres / SSA
Data Element Information
Use Case Description(s)
Use Case Description SSA-VA federal benefits determination
Estimate the breadth of applicability of the use case(s) for this data element approximately 11,000,000 individuals currently receive disability benefits from SSA with the number of applicants being higher
Supporting Attachments USCDI V3+ Prioritized-SSA-VA_FINAL 9302022.xlsx
Use Case Description entered in error
Estimate the breadth of applicability of the use case(s) for this data element entered in error
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) Please see suggestions from attached Excel document
Additional Specifications N/A
Current Use Extensively used in production environments
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 SSA and VA currently obtain these elements via record exchange over the eHealth Exchange and other partners
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 We do not believe this to be a significant burden because we are already receiving this information in our one to one exchanges.
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 0 - Use cases apply to a limited number of care settings or specialties, or data element represents a specialization of other, more general data elements.
Evaluation Comment This submission is considered a “subset” of another data element already included in USCDI or that has been previously submitted. This other data element is Procedure Note https://www.healthit.gov/isa/taxonomy/term/631/uscdi-v3. This data element is designated a Comment level.

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