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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 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 patientYes - the team previously agreed that 
  • This extension's value url has the same meaning as the LOINC 99501-9 (Sex parameter for clinical use) and uses the same Sex Parameter for Clinical Use ValueSet answer list as the LOINC.
  • See this guidance on the US Core Patient Profile

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 ProfileNAMedication Order: RxNorm - Yes - see Medication Clinical Drug @ MedicationRequest.medication

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

19-Nov-24: Yes

Laboratory OrderUS Core ServiceRequest ProfileNA (Note Table of Additional Bindings provided: Common LOINC Lab Codes)

Laboratory Order - Planned Procedure

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

Diagnositic Imaging OrderUS Core ServiceRequest ProfileNA (Note Table of Additional Bindings provided: Radiology Procedures

Diagnostic Imaging Order - Planned Procedure

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

Clinical Test OrderUS Core ServiceRequest ProfileNA (Note Table of Additional Bindings provided: Clinical Tests

Clinical Test Order - Planned Procedure

NA (Note "AdditonalAdditional" 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.

11/22/202: Gay and Al Taylor revised set to remove codes not considered clinical tests


Procedure OrderUS Core ServiceRequest ProfileNA (Note Procedure.code bound to same set as Procedure: US Core Procedure Codes)

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 NeededUS Core Interpreter Needed Extension in US Core Encounter Profile and US Core Patient Profile

Yes - LOINC or SNOMED:

  • LOINC 54588-9 Interpreter needed
    • Based on the decision aruond SPCU. the same type of guidance wrt to URL meaning = the LOINC code was added to the extension description
  • Answer Set with Yes No and Unknowns (SCT and DAR values)

Interpreter Needed Observation

Yes - LOINC or SNOMED:



Pronouns Individual Pronouns in US Core Patient Profile

NA


Individual Pronoun Observation

NA

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




Name to Use

Guidance in US Core Patient Profile

  • Name to Use is represented by setting Patient.name.use to "usual".


NA
US Realm Patient Name (PTN.US.FIELDED)

NA


Provenance







AuthorSee New Provenance Guidance NA
Provenance - Author Participation NA

Author Role

NA

Healthcare Provider Taxonomy use to represent Practitioner role


Provenance - Author Participation (author.code)

NA

Additional Bindings: