Unique Agenda Items
1) Check -in with everyone and goal of the initiative
2) Update on Provincial engagement, CIHI and Health Canada
3) Do we specify Setting = Hospital for Admission, Discharge, Consult?
4) Isabelle's document ontology design
| Preferred | Allowable | Roll Up Term | Summary | |
|---|---|---|---|---|
| Kind of Document | Note | Note | Note | Note |
| Type of Service | Admission Evaluation | Admission Evaluation | Admission Evaluation | Admission Evaluation |
| Subject Matter Domain | Any | Any | Suppressed | Must |
| Role | Suppressed | Restricted to any except physician roles such as Medical Student, Attending, Physician, Fellow, Resident | Suppressed | May - if non-physician |
| Setting | =Hospital or any facility that requires an admission and discharge. Excluding units within the hospital, such as: ICU, Emergency Dept, Observation unit, Pharmacy, Recovery Room | =Hospital or any facility that requires an admission and discharge. Excluding units within the hospital, such as: ICU, Emergency Dept, Observation unit, Pharmacy, Recovery Room | Hospital | Hospital typically |
| LOINC | Many | Many | 67852-4 | Many |
| Display Guideline | Remove 'Evaluation Note' and "Hospital" | Remove 'Evaluation Note' and "Hospital" | Remove 'Evaluation Note' and "Hospital" | Remove 'Evaluation Note' and "Hospital" |
| Note | This would be used for NP/PA and others who do admissions. | Most likely a hospital admission. Even if it is a nursing/subacute facility, Hospital is reasonably accurate. This gives a consistent roll-up code. |
| Preferred | Allowable | Roll Up Term | Summary | |
|---|---|---|---|---|
| Kind of Document | Note | Note | Note | Note |
| Type of Service | Discharge Summary | Discharge Summary | Discharge Summary | Discharge Summary |
| Subject Matter Domain | Suppressed | Any | Suppressed | May |
| Role | Suppressed | Suppressed | Suppressed | Never |
| Setting | =Hospital or any facility that requires an admission and discharge. Excluding units within the hospital, such as: ICU, Emergency Dept, Observation unit, Pharmacy, Recovery Room | =Hospital or any facility that requires an admission and discharge. Excluding units within the hospital, such as: ICU, Emergency Dept, Observation unit, Pharmacy, Recovery Room | Hospital | Usually 'Hospital' |
| LOINC | 34105-7 | Many | 34105-7 | 34105-7 |
| Display Guideline | Remove 'Note' and "Hospital" | Remove 'Note' and "Hospital" | Remove 'Note' and "Hospital" | Remove 'Note' and "Hospital" |
| Note | Only use SMD if one discipline/SMD cared for the patient during the hospitalization, but this is not required. NP/PA does not need to be specified. | Most likely hospital discharge. Even if it is a nursing/subacute facility, 'Hospital' is reasonably accurate. This gives a consistent code. |
| Preferred | Preferred | Roll Up Term | Summary | |
|---|---|---|---|---|
| Kind of Document | Note | Note | Note | Note |
| Type of Service | Consultation Note | Consultation Note | Consultation Note | Consultation Note |
| Subject Matter Domain | Any | Any | Suppressed | Must |
| Role | Suppressed | Restricted to Any except physician roles such as Medical Student, Attending, Physician, Fellow, Resident | Suppressed | May - if non-physician |
| Setting | =Hospital or =Outpatient. Excluding units within the hospital, such as: ICU, Emergency Dept, Observation unit, Pharmacy, Recovery Room | =Hospital or =Outpatient. Excluding units within the hospital, such as: ICU, Emergency Dept, Observation unit, Pharmacy, Recovery Room | Suppressed | Must |
| LOINC | Asked for more to be created | Some | 11488-4 | Many |
| Display Guideline | Remove Outpatient Remove Note. e.g 'Cardiology Hospital Consult', 'Cardiology Consult' | Remove Outpatient Remove Note | Remove 'Note' from name | Remove Outpatient Remove Note |
| Note | Role of physician is most likely so not specified. When allied health is the author, see notes on how to construct the concept. | This option is for authors such as NPs or PA's When allied health is the author, see notes on how to construct the concept. |
| Preferred - Hospital | Preferred - Not hospital | Explicit for Primary Community Care | Roll Up Term | Summary | ||
|---|---|---|---|---|---|---|
| Kind of Document | Note | Note | Note | Note | Note | |
| Type of Service | Progress | Progress | Progress | Progress | Progress | |
| Subject Matter Domain | Any | Any | Primary Care | Suppressed | Any | |
| Role | Restricted to Any except physician roles such as: Medical Student, Attending, Physician, Fellow etc... | Restricted to Any except physician roles such as: Medical Student, Attending, Physician, Fellow etc... | Restricted to Any except physician roles such as: Medical Student, Attending, Physician, Fellow etc... | Suppressed | Restricted | |
| Setting | =Hospital or = LTC for when a patient is an 'inpatient' or has been 'admitted' | = Outpatient for when the patient is not an 'inpatient'. | = Outpatient or = Urgent Care | = Outpatient, = Hospital, or is Suppressed | = Outpatient, = Hospital, =LTC or is Suppressed | |
| LOINC | 330 terms | 315 terms | 34131-3, 34130-5, or 11506-3 | Many | ||
| Display Guideline | Remove "Hospital" | Change "Outpatient Progress Note" to "Clinic Note" | Change "Outpatient Progress Note" to "Clinic Note" | Use "Progress Note" or "Clinic Note" | Change "Outpatient Progress Note" to "Clinic Note" | |
| Note | When allied health is the author, see other notes on how to construct the concept | When allied health is the author, see other notes on how to construct the concept | All types use modified Display Names |
| Preferred | Allowable (Quebec) | Allowable | Roll Up Term | Summary | ||
|---|---|---|---|---|---|---|
| Kind of Document | Note | Note | Note | Note | Note | |
| Type of Service | Note | Progress Note | Note | Note | Note | |
| Subject Matter Domain | Emergency Medicine | Emergency Medicine | Emergency Medicine or Suppressed | Emergency Medicine | Emergency Medicine | |
| Role | Suppressed | Suppressed | Restricted to Any except physician roles such as: Medical Student, Attending, Physician, Fellow etc... | Suppressed | Restricted to non-physician Roles | |
| Setting | Suppressed | Emergency Department | Emergency Department or Suppressed | Suppressed | Prefer to have suppressed. | |
| LOINC | 34878-9 | 97669-6 |
| 34878-9 | Typically 34878-9 | |
| Display Guideline | ||||||
| Note | This is for NP/PA | Even if Setting = Emergency Department, or Role = non-physician, we convert to SMD = Emergency Medicine. | When allied health is the author, see other notes on how to construct the concept |
Vote:
DL:5
ML: 5
MB:5
DS: 5
DC:5
MK:5