Working Group

I) Documenting Seeing the Patient Again

•  Type of Service:  Progress, LP173213-2
• Subject Mater Domain:  All SMD's that see patients
• Setting:  If patient in hospital then use Hospital (LP173065-6).  If patient is in the community as a referral service or primary care, use Outpatient (LP173051-6).  
• Role:  Any non-physician role
• Display Name:  
  • If we we use the LCN the display name will be very long e.g.:  Internal Medicine Outpatient Progress Note.  
  • Mix of words used in the community to describe a follow-up note.  
  • If we replace 'Outpatient Progress Note ' with "Clinic", then "Progress Note" can also carry the meaning of 'Hospital ', and we can remove "Hospital" from the inpatient progress notes, shortening all the display names and standardizing the terms.    Internal Medicine Progress Note is from Hospital and Internal Medicine Clinic Note is from a community clinic.   

Agreed :

BW: 5
NS: 4
DL: 5
MK:5
ML: 3

Documenting Seeing a Patient Again

II) Emergency Department Visit Note

Discussed at previous meeting

Choice:

1) SMD: Emergency Medicine
Setting: unspecified
Role: unspecified
Type: Note
LOINC: 34878-9

2) SMD: unspecified
Setting: Emergency Department
Role: unspecified
Type: Note.
LOINC: 34111-5

3) SMD: Emergency Medicine
Setting: Emergency Department
Role: unspecified
Type: Note
LOINC: not available

Choice: 1

BW: 5
NS: 4
DL: 4
MK:4
ML: 5

Note:  Although SMD is our primary coding necessity, it is only so for documents written by physicians.   Since the other roles are not so tightly trained to be regulated to work only in certain SMDs, their documents can be classified by the patient's location.  For example, if a nurse writes a note in the ED, the SMD can be suppressed, and the Setting can be used to classify the document.   

General agreement by the working group on this

Documenting an Emergency Visit