Outpatient Note

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

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

Outpatient Note

Description

Documentation of a clinical encounter that takes place in an outpatient setting. Reason to consider separately (including this here because the "Reason" field for additional elements is truncating my text): This data element has some overlap with other existing and proposed Clinical Notes data elements Outpatient is a setting versus a type of service (Consultation, History & Physical, Discharge Summary, Transfer Summary, etc.). For example, Outpatient consultation notes span the “Consultation Note” and “Outpatient Note” data elements. However, we feel it is important to specify this particular setting because the vast majority of LOINC terms representing outpatient clinical notes aren’t captured in the data elements that represent particular types of service.

Submitted By: Swapna Abhyankar / Regenstrief Institute, LOINC Document Ontology Subcommittee
Data Element Information
Rationale for Separate Consideration	See data element description
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.

Clinical Notes

Data Element

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