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

Data Element
Operative Note
Description

All operative notes should be included in USCDI. https://loinc.org/LG38755-1/
Submitted By: Leslie Kelly Hall / Engaging Patient Strategy
Data Element Information
Rationale for Separate Consideration Very high benefit and low risk. Known LOINC codes and current work flows and exchange in place. https://loinc.org/LG38755-1/
Use Case Description(s)
Use Case Description Consistent with Clinical notes, view download and transport and the desires of information sharing, OP notes is a necessary component for access and
Estimate the breadth of applicability of the use case(s) for this data element Approximately 51% of all hospital visits under Medicare include a procedure that includes an operative note. Cancer patients and their supporting clinical team members, count on OP notes for continuity of care and transitions.
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) https://loinc.org/LG38755-1/
https://loinc.org/LG38755-1/
Additional Specifications N/A
Current Use This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders
Supporting Artifacts Every EMR contains an OP note for every operative procedure.
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 This is commonly collected but not specifically called out in USCDI.
As a patient advocate, I do not have access to the artifacts.
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 Very little burden. Codes, creation, storage and standards are in place.
Other Implementation Challenges none
ONC 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.

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