Stream: C-CDA
Topic: Encounter Summary?
David Pyke (Oct 21 2020 at 14:14):
Can someone point me to the documentation on the C-CDA Encounter Summary template? I have someone referring to it and I can't seem to find it anywhere. IHE has one for ED Encounters but I can't seem to find a general one.
Vassil Peytchev (Oct 21 2020 at 14:23):
I think it's the CCD template, which is of dual use - overall summary and encounter summary. I think one of the MUs had some specific language defining a list of sections for such a "summary of encounter" (SOEN).
David Pyke (Oct 21 2020 at 14:24):
That's what I thought but they told me that there's a specific template because CCD doesn't fit their use case. I'm starting to think this is something custom
Brett Marquard (Oct 21 2020 at 14:52):
C-CDA Progress Note? C-CDA Discharge Summary?
Brett Marquard (Oct 21 2020 at 14:53):
...using CCD template as only covering a single encounter isn't encouraged.
David Pyke (Oct 21 2020 at 14:53):
That's what I'm going to push them to
Vassil Peytchev (Oct 21 2020 at 15:04):
...using CCD template as only covering a single encounter isn't encouraged.
That's interesting - do you know what ONC had in mind when talking about SOEN?
Brett Marquard (Oct 21 2020 at 15:29):
Do you have a reference to "summary of encounter" (SOEN). in a prior rule? I am not immediately finding it.
Vassil Peytchev (Oct 21 2020 at 15:37):
The one I can immediately find that could be related is page 44 of this slideshow (emphasis mine:
The CCD is a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters.
Joe Lamy (Oct 21 2020 at 15:41):
I've seen SOEN to mean "Summary of Episode Note" which is the LOINC code for a CCD.
Vassil Peytchev (Oct 21 2020 at 15:45):
I've seen SOEN to mean "Summary of Episode Note" which is the LOINC code for a CCD.
Bingo! That was the source of my confusion (which doesn't help David one bit)...
Joe Lamy (Oct 21 2020 at 15:45):
Dave, if you saw a reference to "Encounter Summary", from what I understand, that term was introduced by the CommonWell-Carequality Content Guide, to encompass the document types that can be used to capture an encounter. The guide currently emphasizes use of Discharge Summary for inpatient and Progress note for outpatient. And while it notes the use of CCD document type used historically for encounters (and called out by rules), it urges these more appropriate formats for encounters over the CCD.
David Pyke (Oct 21 2020 at 15:46):
THank you all, you've given me enough info to push back
Joe Lamy (Oct 21 2020 at 15:49):
https://fhir.cerner.com/soarian/dstu2/infrastructure/document-reference/
John D'Amore (Oct 21 2020 at 17:03):
@David Pyke I think I may have been the source of confusion. At one point some EHRs were sending the CCD with an encompassingEncounter to designate it as an encounter summary. @Brett Marquard is right that's now discouraged. Here's the joint document created by Commonwell + Carequality https://ceq-project.s3.amazonaws.com/wp-content/uploads/2019/04/11013830/20190201_Improve_C-CDA_Joint_Content_WG_IHE_v1.1_Final.pdf
Last updated: Apr 12 2022 at 19:14 UTC
