Clinical Notes

Provide Broader Guidance on Progress Note in USCDI Clinical Note

Recommend inclusion of Antepartum Summary Progress Note in USCDI Clinical Notes to support narrative antepartum notes and structured Antepartum Summary Progress Note Documents. 

This clarification can be addressed by adding the LOINC Document Ontology term 57055-6 Antepartum Note to the C-CDA value set 

ProgressNoteDocumentTypeCode defined in the NLM Value Set AuthorityCenter: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.11.20.8.1/expansion. 

The term 57055-6 Antepartum Note also should be added to the ValueSet Note Types  2.16.840.1.113883.11.20.9.68  for narrative notes that may appear in the context of a structured document or accessed independently as a clinical note.

ONC needs to do a better job of clarifying the differences and relationships between "clinical notes" and "clinical note documents"  which can be either a structured document that includes unstructured clinical note "entries" or an unstructured document which may contain all types of information in a narrative format.

USCDI+ Comments 20240731 v2_0.pdf

Prenatal Record Request

The Texas Health Services Authority Interoperability Collaborative requests that clinical notes include the Pre-Natal Record as an encounter-specific note in an upcoming USCDI version.  There are multiple national initiatives in support of decreasing maternal and fetal morbidity. However, the exchange of this critical information is impacted due to the lack of standardization.  The Center for Medicare and Medicaid Services announced the Transforming Maternal Health Model in December 2023.  A distinct encounter-specific Pre-natal Record would support two functions: 1) availability of the information at the right time to the clinical care teams promoting clinical efficiencies during high-risk deliveries, and 2) allow the EHR vendor community to develop tools to ingest critical pieces of information needed for direct care and quality review activities.    

Feedback

Highly recommend and support the Progress Note as a required data element. Frontline clinicians report needing the Progress Note to ensure best patient care outcomes.

USCDI v2 Clinical Notes – Need for Outpatient Note

The inclusion of clinical notes that summarize encounters is a welcome addition to the USCDI.  The Discharge Summary Note is a good choice for an inpatient stay.  There needs to be an equivalent note type for an outpatient encounter, but the current choice, Progress Note, is too ambiguous.

As it is defined in the HL7 Implementation for CDA Release 2: Consolidated CDA Templates for Clinical Notes, a progress note template represents a patient’s clinical status in either an inpatient or outpatient encounter.  That is too broad for the USCDI v2.  What is needed is a clinical note type that is limited to the outpatient setting.

The LOINC code associated with Progress Note is 11506-3 which is also defined to contain both inpatient and outpatient notes.

Furthermore, in most clinical settings, the term “progress note” refers to notes written about the clinical status during a single inpatient encounter and contained in the inpatient chart.  The definitions of Progress note in Taber’s Medical Dictionary and Mosby’s Medical Dictionary do not specify the setting in which they are found, but the McGaw-Hill Concise Dictionary of Modern Medicine, copyright 2002 by The McGraw-Hill Companies, Inc., explicitly defines a progress note as “A brief summary of a hospitalized patient's current clinical status, written sequentially in the chart,reflecting information provided by physical exam, lab tests, and imaging modalities.” That is consistent with current usage in health care settings. This will cause further confusion.

The USCDI v2 must make clear that a note summarizing an outpatient encounter is what is asked for.  That could be accomplished in two ways:

1. Specify that the progress note be outpatient only and continue to use LOINC code 11506-3; or
    
2. Specify that the progress note be outpatient only by calling it an outpatient progress note.  There is a LOINC term with that exact short name and it has LOINC code 34131-3.  This would require some negotiation with the HL7 organization since there is no C-CDA template specifically designated for the outpatient progress note, even though it would be identical to the current progress note template.