Emergency Department Note

Operative Note

US Core Observation ADI Documentation Profile

US Core ADI DocumentReference Profile

• Advance Directives Section
  • Advance Directive Existence Observation
    • Advance Directive Observation

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.

• 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

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

And THO set Sex Parameter for Clinical Use

• Planned Medication Activity
  • Medication Information

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

Laboratory Order - Planned Procedure

Diagnostic Imaging Order - Planned Procedure

Clinical Test Order - Planned Procedure

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 Order - Planned Procedure

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)

Yes - LOINC or SNOMED:

• LOINC 54588-9 Interpreter needed
• Answer Set with Yes No and Unknowns (SCT and DAR values)

NA

• Answer Set LOINC  THO Set:  Personal Pronouns

NA

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

Guidance in US Core Patient Profile: 

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

NA

• callMe in EntityPersonNamePartQualifier

NA

Healthcare Provider Taxonomy use to represent Practitioner role

NA

• CDA Role Code (HL7 V3 RoleCode System)

Additional Bindings:

• • (Providers) Healthcare Provider Taxonomy (HealthCareProvider Taxonomy code system)
  • (Non-Clinicians) PersonalAndLegalRelationshipRoleType (HL7 Role Code codeSystem)