-Finished reordering ED medication data: Last week, the ED Procedure list was arranged:

  1. ED Procedure:
    1. ED Procedure Indication
    2. ED procedure name
    3. Date/Time ED procedure ordered
    4. Date/Time ED procedure starts
    5. Date/Time ED procedure ends
    6. ED procedure Practitioner type
    7. ED Procedure Practitioner ID
    8. ED Procedure Assistant type
    9. ED Procedure Assistant ID
    10. Procedure anesthesia used
    11. Procedure description
    12. Procedure description
    13. Procedure specimens obtained
    14. Procedure closure type
    15. Procedure estimated blood loss
    16. Wound Irrigation/Cleaning fluid (LOINC code issue)
    17. Procedure complications
    18. Procedure findings
    19. Date/Time ED diagnostic procedure result reported
    20. ED procedure result type (LOINC code issue)
    21. ED procedure result

Question: are these surgical procedures? Asking because the LOINC codes line up with surgical.

Note: In EHRs the procedures are usually CPT codes/ ICD procedure codes- not a LOINC code. But CPT codes can’t be used here because CPT codes are licensed by the AMA.

  • Problem: found that the procedure codes are dipping into the surgery area.
  • We don’t know if procedures that aren’t surgeries, exist in LOINC.

Emergency Department procedure note is the same as the Procedure Description 78316-7.

Note: A Level 2 document has the separate sections for each letter, but a CDA document (Level 1) would not have these separate sections.

Section O/Procedure estimated blood loss and Section P/Wound Irrigation/Cleaning fluid are both not needed as a separately coded items and therefore can be mentioned in the notes (procedure description Section K).

  1. RESULTS and FINDINGS: Grouped by Bedside and Imaging Results until there is a better way to group them.