Classifying documents that are typically referenced by where the patient was seen

Decision Status: Completed

Background

We often refer to writing an admission document for the ICU or for a psychiatric unit.  

Our Canadian ontology has decided that admission is defined as entry only into a hospital, and that documents are classified by the author's credentials and the type of service, not by the location where the patient was seen.  

Options

1. Create exceptions to our 'SMD' primary axis rule and admission definition
2. Keep the rules and expect health systems to classify documents in a way that is different then how clinicians talk about the document.  E.g.  An "ICU Admission" is a "Critical Care Transfer Note"; 

Discussion

Choosing Admission and Discharge documents to be only for admission and discharges from whole facilities, not units ensures that the document type will include what is expected by the reader (a summary of a whole hospital stay or whole evaluation before admission), no semantic overlap with the patient going in and out of a ward. It also allows for markers of hospital encounters when there isn't other encounter information (the date of the admission and discharge documents always form the date of the hospital encounter). For 'admission to ICU' or 'Admission to Psych" use Transfer document with the SMD the receiving discipline.

Decision

1. Keep the rules that SMD is primary way to classify a document and Admission notes are for hospitals, not wards.      E.g.  An "ICU Admission" is a "Critical Care Transfer Note"

Guideline

SMD is primary way to classify a document and Admission notes are for hospitals, not wards.      E.g.  An "ICU Admission" is a "Critical Care Transfer Note".  i.e  ToK = 'Transfer Summary' with SMD = the receiving discipline