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US Core

QA - ONC Assessment of Ballot Design in US Core

 

C-CDA

QA - ONC Assessment of Ballot Design in C-CDA

CategoryFields

Profile

USCDI Terminology Present?

(Do Terminology bindings agree with what is declared in USCDI)

ASTP agrees Design covers USCDI Definition?

(Yes/No and Date)

Template

USCDI Terminology Present?

(Do Terminology bindings agree with what is declared in USCDI)

ASTP agees agrees Design covers USCDI Definition?

(Yes/No and Date)

Clinical Notes









Emergency Department Note

Operative Note

US Core Document Reference ProfileYes - the 2 LOINC codes added to minumum set servers SHALL support declared on the Clinical Notes Guidance page
Note ActivityYes - the LOINC codes are already present in the existing Note Types value set. Template description update to reflect USCDI Narrative Note Types19-Nov-24: Yes
Immunizations







Lot NumberUS Core Immunization ProfileNA
Immunization Medication InformationNA19-Nov-24: Yes
Observations







Advance Directive Observation

US Core Observation ADI Documentation Profile

US Core ADI DocumentReference Profile

NA
NA

19-Nov-24: Yes

Alex suggested that an Invariant be added, so that if answer is "No" to the Existence of an Advance Directive, that there are no Advance Directive Observations contained in Advance Directive Existence Observation

Gay will follow-up with the Dev Team to see if that can been done prior to ballot or via a ballot comment during the ballot process.


Sex Parameter for Clinical UseSex Parameter for Clinical Use used in US Core patient

Sex Parameter For Clinical Use Observation

Yes - LOINC: 99501-9 Sex parameter for clinical use

And THO set Sex Parameter for Clinical Use

19-Nov-24: Yes
Order







Medication OrderUS Core MedicationRequest ProfileNA

Medication Order: RxNorm - Yes - see Medication Clinical Drug in Medication Information

19-Nov-24: Yes

Laboratory Order


Laboratory Order - Planned Procedure

NA (Note "Additonal" binding provided Common LOINC Lab Codes)19-Nov-24: Yes

Diagnositic Imaging Order


Diagnostic Imaging Order - Planned Procedure

NA (Note "Additonal" binding provided Radiology Procedures19-Nov-24: Yes

Clinical Test Order


Clinical Test Order - Planned Procedure

NA (Note "Additonal" binding provided Clinical Tests

19-Nov-24: Yes

Re: Clinical Tests value set. This value set is Clinical LOINC codes minus radiology codes with multiple classes excluded for codes that do not fit the conceptual idea of clinical test. The binding is an "Additional" binding or "Preferred" type and is intended to provide an idea od what a "clinical test" is as there has been much discussion over the past year about is "fuzziness" as a type of test (or result).

Gay noted that Al and Carmela have noted codes that do not seem appropropriate in the set and is hoping that Al and Carmela will provide that feedback and she will adjust the set accordingly. Preferably this will be done before ballot.


Procedure Order


Procedure Order - Planned Procedure

NA (Note Procedure.code bound to same set as Procedure: US Core Procedure Codes)19-Nov-24: Yes
Patient Demographics/Information







Interpreter Needed


Interpreter Needed Observation

Yes - LOINC or SNOMED:



Pronouns


Individual Pronoun Observation

NA

  • LOINC 90779-2 Personal pronouns reported
  • Answer Set LOINC  THO Set:  Personal Pronouns




Name to Use


US Realm Patient Name (PTN.US.FIELDED)

NA


Provenance







Author


Provenance - Author Participation NA

Author Role


Provenance - Author Participation (author.code)

NA

Additional Bindings: