How to document a consultation

Decision Status: Completed

Background

One of the core documented activities in the health system is when a physician is asked to provide a consultation on a patient.

These documents need to be classified so they can be found easily.  

Options

1. Classify the document using a minimal amount of information to enable distinguishing consultation documents
2. Classify the document using all the available attributes of the LOINC ontology

 

Discussion

The the definition section of website for the definition of Consultation

ToS = Consultation

Role: Consultations are practically 100% done by physicians.  The group decided that adding the Role = Physician is not necessary because it is expected by the readers.  Additionally, there are very few LOINC codes with Physician specified.  Lastly, the word physician would be removed from the display name.

Setting:  The setting doesn't change the content of the consultation document, so it can be suppressed.   

Decision

Type of Service = Consultation

SMD:  Most of those available

Role: Suppressed 

Setting: Suppressed

NS:5

MK: 5

ML: 5

IB: 5

MKa: 5

Guideline

Type of Service = Consultation

SMD:  Most of those available

Role: Suppressed 

Setting: Suppressed