Stream: argonaut
Topic: USCDI Clinical Notes
Shamil Nizamov (Jan 10 2022 at 17:29):
I'm trying to understand what USCDI Clinical Notes are. The description says that those are narrative patient data relevant to the respective note types but assigned LOINC codes are similar to corresponding C-CDA document templates.
E.g., USCDI Consultation Note (contains the response to request from a clinician for an opinion or advice from another clinician) refers to the LOINC code (11488-4) that defines the C-CDA Consultation Note (v3).
Are the USCDI Clinical Notes just true narratives (i.e., just a text) or do they represent the entire CDA document with the header, required and optional sections?
Greg Thole (Jan 10 2022 at 17:37):
I think this clarification in the ONC's USCDI Certification Companion Guide (https://www.healthit.gov/sites/default/files/2020-08/2015EdCures_Update_CCG_USCDI.pdf) addresses that question (language comes directly from the final rule preamble): "The Clinical Notes Data Elements are content exchange standard-agnostic. They should not be interpreted or associated with the specific C-CDA Document Templates that may share the same name"
Shamil Nizamov (Jan 10 2022 at 17:52):
Oh, great, that answers the question.
Last updated: Apr 12 2022 at 19:14 UTC
