Submitted by yale-coredQMRoadmap on 2023-04-17
CMS-CCSQ USCDIv4 Priority: Emergency Department Note
Emergency Department Notes should be a distinct clinical note data element to distinguish data from other Progress Notes, for the purposes of coordination of care and care continuity. This ensures capture of a critically unique encounter type that represents a key interface between and across acute and outpatient care settings. A separate Emergency Department Notes data element will also ensure patient access to this information. As historically vulnerable and underserved populations disproportionately use Emergency Departments for primary care, these clinical notes may be particularly useful in supporting the ONC USCDI v4 goals of addressing needs of underserved communities and public health interoperability needs related to emergency response.
Maturity:
- Current standards:
- LOINC codes, Emergency department|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain, LOINC Group Code LG41825-7 or at a minimum, Emergency department Discharge summary note, LOINC 59258-4.
- Current uses, exchange, and use cases: Emergency department notes are exchanged and used routinely throughout the course of care. Emergency Departments can be fully integrated within a healthcare system, fully independent and administratively distinct from a nearby healthcare or hospital system, or some intermediate state between these extremes. They represent a unique and critical connection between inpatient and outpatient care settings and are therefore an important component of both acute and chronic disease management. The information is particularly important to reflect a patient’s health status to support transitions of care.
Submitted by yale-coredQMRoadmap on 2023-09-19
CMS-CCSQ Support for Emergency Department Notes for USCDI v5
CMS-CCSQ recommends this Level 2 data element be added to USCDI v5. Emergency Department Notes should be a distinct clinical note data element to distinguish data from other Progress Notes, for the purposes of coordination of care and care continuity for routine exchange throughout the course of care. Emergency Departments can be fully integrated within a healthcare system, fully independent and administratively distinct from a nearby healthcare or hospital system, or some intermediate state between these extremes. This ensures capture of a critically unique encounter type that represents a key interface between and across acute and outpatient care settings and therefore an important component of both acute and chronic disease management. A separate Emergency Department Notes data element will also ensure patient access to this information and will support transitions of care. This data element is currently classified with LOINC Group Code LG41825-7 or at the Emergency Department Discharge Summary Note LOINC 59258-4, at a minimum. This aligns with the ISWG Recommendations on Draft USCDI v4 (April 12, 2023) to include LOINC 59258-4 Emergency Department Discharge Summary as the generic or minimum Emergency Department Note codes.