Clinical Notes

CMS-CCSQ Support for Surgical Notes for USCDI v5

CMS-CCSQ strongly recommends either expanding the current Procedure Notes data element that is in USCDI to include the Surgical Operation Note (LOINC 11504-8) in addition to Non-Operative Procedure Notes or consider adding the distinct Operative Note data element that is at Level 2 to USCDI v5. Surgical notes are routinely captured in EHR systems and important to ensure patient access to data and capture interoperable information critical to patient safety, care coordination, and hand-offs. This element was previously identified as a joint CMS-CDC priority, and the recommendation aligns with ISWG Recommendations on Draft USCDI v4  (April 12, 2023) to include all note types coded in the LOINC Document Ontology, or at least the Surgical Operation Note (LOINC 11504-8) and Tumor Board Notes.

CMS-CCSQ/CDC Joint USCDIv4 Priority: Surgical Operative Note

Surgical notes are important to ensure patient access to data and capture interoperable information critical to patient safety, care coordination and hand-offs. Currently, the Procedure Notes data element is limited to non-operative procedures. CMS and CDC strongly recommend either expanding these notes to also include the surgical operation note or consider adding the distinct Operative Note data element to USCDI v4.

CMS-CCSQ Support for Surgical Operative Note: USCDI v4

Currently, the Procedure Notes data element is limited to non-operative procedures. CMS strongly recommends either expanding these notes to also include the surgical operation note (LOINC 11504-8) or consider adding the distinct Operative Note data element to USCDI v4. Surgical notes are important to ensure patient access to data and capture interoperable information critical to patient safety, care coordination and hand-offs. This element was previously identified as a joint CMS-CDC priority, and the recommendation aligns with the ISWG recommendation for USCDI v3 to include all note types coded in the LOINC Document Ontology, or at least the Surgical Operation Note (LOINC 11504-8) and Tumor Board Notes. Existing disparities in surgical procedure rates and outcomes support that these data elements are critical additive tools to help mitigate health and health care inequities and address needs of underserved communities.

Maturity: ONC already includes non-operative clinical notes in the USCDI and has classified an Operative Note data element as Level 2.

• Current standards:
  • The Surgical Operative Note is standardized and captured by LOINC 11504-8; or the group LOINC code LG38755-1

Current uses, exchange, and use cases: Surgical Operation Notes are routinely captured in EHR systems used by hospitals and providers for care coordination, and hand-offs. These notes include critical information for assessing patient safety and include important data patients should have access to.

CDC-CMS Joint Priority Data Element

Proposing to extend the element to include surgical operation notes. 

CMS-CCSQ Support for Surgical Operation Note: USCDI V3

USCDI Draft version 3 currently includes Procedure Notes that are limited to non-operative procedures. We strongly recommend ONC expand these notes to also include the surgical operation note (LOINC 11504-8). Surgical notes are important to ensure patient access to data, as well as interoperability of data for care coordination and hand-offs.

Maturity:

• Current standards:
  • The Surgical Operation Note is standardized and captured by LOINC 11504-8
• Current uses, exchange, and use cases: Surgical Operation Notes are routinely captured in EHR systems used by hospitals and providers.