Submitted by hswmin on
THIA Support for Emergency Department Note
The Texas Health Informatics Alliance (THIA) Policy and Standards Working Group are in support of an emergency department (ED) note as a separate encounter-specific clinical note. This would facilitate ambulatory practices contacting patients with a recent ED visit to report on follow-ups with their PCP. The records are already there, so additional work from clinicians would not be required.
Additionally, we would like to emphasize our support for the automation of reporting and homogenization of requests to remove some of the reporting burden on hospitals. Replication of the same data is often asked for by multiple government agencies, including the trauma registry. This is a requirement for safe reporting and certification. Information could be pulled in part from the ER record.
Submitted by nedragarrett_CDC on
CDC's Comment for draft USCDI v5
This lacks clarity regarding its contents and purpose. Is this the progress notes in the ed, transfer notes when the patient is admitted to inpatient, some other clinical notes? If the encounter type is already defined, stating "ED" may not be necessary. Clarifying whether an ED note refers to progress notes, transfer notes, or a summary of all ED-related documentation can help mitigate ambiguity and ensure accurate data capture.