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:
Thank you again for your sharing your views and/or the views of your organization.
Use Case Team - ONC
Office of the National Coordinator for Health Information Technology
The Department of Health and Human Services
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"We have hospitals in Afghanistan and Iraq, and many of the soldiers would arrive without records in Germany, with no record of the CAT scans or what happened in surgery in Afghanistan or Iraq. The clinicians in Germany would have to re-operate on the patient, would have to redo all their x-ray evaluations, CAT scans, etc...." ~ Colonel John Holcomb