What is USCDI?
In IT healthcare, It is a set of standardized health data elements established by the U.S. Department of Health and Human Services (HHS) to promote the interoperability of health information technology (IT) systems.
The USCDI includes a standardized set of data elements, such as patient demographic information, clinical notes, laboratory results, and medication lists, that must be included in certified health IT systems to improve the sharing of patient information between different healthcare providers and organizations. USCDI aims to facilitate the exchange of health information between other healthcare systems and improve patient outcomes by providing a comprehensive and consistent view of patient's health information across different providers and care settings.
Clinical Notes
What is this?
The previous field of ‘Visit Type’ has been updated to Note Type. This is in accordance with measure 170.213 which requires the adoption of USCDI v1 to replace the ‘Common Clinical Data Set’. This change was implemented to improve interoperability by creating a new and improved data set. As part of this new data standard, the Note Type drop down on the Encounter creation pop-up lists all of the required fields for the USCDI category of ‘Clinical Notes’.
What does it affect in the system?
The Note Type selected is saved on the CCD and in the Chart Summary. Its main purpose is to improve interoperability by standardizing categories for Encounters. The Note Type options Consultation Note, Discharge Summary Note, History & Physical, Procedure Note, and Progress Note contain the previous 'Visit Type' field of 'Office'.
Where is it displayed?
Once selected, a “Note Type” will appear under the ‘Clinical Notes’ section of a patient’s CCD.
It will also be displayed on the Chart Summary under the ‘Encounters’ section.
Additional Information?
Please visit HealthIT.gov Interoperability Standards Advisory (ISA)