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Clinical Encounter Notes

In April and June of 2008, the American Health Information Community (AHIC) approved a recommendation to develop documents that address extensions/gaps from the use cases published between 2006 and 2008. One of the extensions/gaps prioritized for subsequent processing in the national health agenda activities in 2009 was Clinical Encounter Note Details. AHIC specifically requested that the Clinical Encounter Note Details Extension/ Gap address the development, completion, and exchange of interoperable clinical encounter notes and reports. A clinical encounter note or report can be structured and/or unstructured information exchanged between electronic health records (EHRs) and other systems.

This extension/gap document is being developed by the Office of the National Coordinator for Health Information Technology (ONC) to represent the AHIC priorities and provide context for the national agenda activities, beginning with the selection of harmonized standards by the Health Information Technology Standards Panel (HITSP). Components that need to be considered during the standards identification and harmonization activities include standardized datasets, data elements, vocabularies, naming conventions, capabilities, and technical standards that support the information needs and processes to support exchange of clinical encounter notes to support consultations and transfers of care.

There will be one opportunity for review and feedback by interested stakeholders within both the private and public sectors. This public feedback period will last approximately 4 weeks and will close on September 16th, 2008. The feedback will be analyzed, dispositioned, and will be utilized in the development of the final Clinical Encounter Notes Extension/Gap Document.

The Draft Clinical Encounter Notes Extension/Gap and instructions for providing public feedback are available for download:

  • Draft Extension/Gap – Clinical Encounter Notes [PDF - 393KB]
  • Feedback Instructions – Clinical Encounter Notes [DOC - 39KB]

Please send your feedback regarding Clinical Encounter Notes by 5pm on September 16th, 2008 to: Please send any overall requests for additional information and/or inquiries by email to: (

You may also send your requests and/or inquiries to:

Office of the National Coordinator for Health Information Technology
Attention: Use Case Team
Mary Switzer Building
330 C Street, S.W. Suite 1200
Washington, DC 20201

Thank you again for your sharing your views and/or the views of your organization.


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