- Jim McClay
- Samuel Wang
- Laura Langford
- Michelle Barry
- Post Workgroup Meeting follow up
- ED Disposition Tab
Discussion of ED Medical Decision Making Component
ED Medical Decision Making
"Narrative note written by the provider describing the medical decision making throughout the ED Visit. Beginning with the presentation of the patient, high level observations/assessments and orders, finding. Diagnoses considered and the final diagnosis determined.".
Recommend changing LOINC Code 56853-5 to narrative.
A search of LOINC did not find a medical decision making document section
Discussion of this section with references to various CMS and specialty society documents we concluded this wasn't coded well.
JCM: The difficulty we're dealing with arises from the overlap of the data elements (concepts) relevant to the ED (DEEDS) and the assumed information model for recording those concepts. An information model would include the concept with associated metadata, related attributes and there value sets. We assume an HL7 reference information model (RIM 3.0) in our thinking.
DEEDS needs to remain a set of ED related concepts important to representing the visit and reporting to secondary users. It may be best to define DEEDS in the context of a host information model. For instance, an EDIS FHIR IG built on DEEDS would define the relationships between concepts and their required attributes (author, time, etc.). In this situation DEEDS would not be overloaded with the need to record these separately.
Therefore, the discussion of ED Medical Decision Making would reduce to the narrative section of the note required to communicate the providers assessment, differential dx, approach and outcome of the encounter. The enormous variability of these portions of an ED note make modeling discrete concepts impossible.
We adjourned at 3:PM ET