Representing Clinical Notes

Type	Standard / Implementation Specification	Standards Process Maturity	Implementation Maturity	Adoption Level	Federally required	Cost	Test Tool Availability
Standard for observations	LOINC®	Final	Production		Yes	Free	N/A
Standard for observations	IHE FormatCode Vocabulary	Final	Production	Feedback Requested	No

Limitations, Dependencies, and Preconditions for Consideration	Applicable Value Set(s) and Starter Set(s)
LOINC: A Consultation note is generated as part of a request from a clinician for an opinion or advice from another clinician. A Discharge Summary note is a synopsis of a patient’s admission and course in a hospital or post-acute care setting. A History & Physical note documents the current and past conditions of the patient. A Progress Note represents a patient's interval status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. IHE: See also Integrating the Healthcare Enterprise (IHE) IT Infrastructure White Paper: Enabling Document Sharing Health Information Exchange Using IHE Profiles.	LOINC: Consultation note (LOINC code 11488-4) Discharge Summary note (LOINC code 18842-5) History and Physical note (LOINC code 34117-2) Progress Note (LOINC code 11506-3) IHE: IHE FormatCode CodeSystem

Limitations, Dependencies, and Preconditions for Consideration

Applicable Value Set(s) and Starter Set(s)

LOINC:

A Consultation note is generated as part of a request from a clinician for an opinion or advice from another clinician.
A Discharge Summary note is a synopsis of a patient’s admission and course in a hospital or post-acute care setting.
A History & Physical note documents the current and past conditions of the patient.
A Progress Note represents a patient's interval status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter.

IHE:

See also Integrating the Healthcare Enterprise (IHE) IT Infrastructure White Paper: Enabling Document Sharing Health Information Exchange Using IHE Profiles.

LOINC:

Consultation note (LOINC code 11488-4)
Discharge Summary note (LOINC code 18842-5)
History and Physical note (LOINC code 34117-2)
Progress Note (LOINC code 11506-3)

IHE:

IHE FormatCode CodeSystem

Comment

Submitted by pwilson@ncpdp.org on 2021-09-29

NCPDP Comments

NCPDP supports ONC’s recommendations.

Submitted by John Moehrke on 2021-09-08

IHE FormatCode vocabulary

Comprehensive FormatCode Vocabulary: For use with Document Sharing (XDS, XCA, MHD, etc)

Submitted by gldickinson on 2020-10-23

Preserving Clinical Context

General Comments:

USCDI specifies lots of clinical data classes and data elements

Resolving to myriad de-coupled fragments
With vanishingly little focus on:
- Clinical context and vital inter-relationships, e.g., between problems, diagnoses, complaints, symptoms, encounters, allergies, medications, vaccinations, assessments, clinical decisions, orders, results, diagnostic procedures, interventions, observations, treatments/therapies, referrals, consults, protocols, care plans and status...
- Elements and context + purpose of capture: e.g., blood pressure, its measurement (systolic, diastolic), its unit of measure (mm/Hg), its reason for capture, its context of capture (sampling site, sampling method, patient position, at rest/during/post exercise...

It is crucial to consider and determine/resolve how clinical content and context are bound together and preserved in USCDI. The ultimate end user (often a clinician) must be able to readily discern context and inter-relationships – otherwise USCDI places an undue (and often unresolvable) burden on this user. Only the source EHR/HIT system can structure clinical content and context properly. Once data is stuffed into the USCDI framework and related exchange artifact (e.g., FHIR resources) this opportunity is forever lost.

Submitted by gldickinson on 2020-10-22

Clinical Content and Context - See Attached Document

See attached document

USCDI-ONDEC-Submission-Context-GLD-20201023.docx