Submitted By: Leslie Kelly Hall / Engaging Patient Strategy | |
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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 |
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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 |
Narrative patient data relevant to the context identified by note types.
Data Element |
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Operative Note
Description
All operative notes should be included in USCDI. https://loinc.org/LG38755-1/ |
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