Official Website of the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health IT
Activity performed for or on a patient as part of the provision of care.
Data Element |
Applicable Vocabulary Standard(s) |
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Procedures
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Optional:
Optional for technology which records dental procedures:
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Data Element |
Applicable Vocabulary Standard(s) |
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Procedures
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Optional:
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SDOH Interventions
A service offered to a patient to address identified Social Determinants of Health concerns, problems, or diagnoses (e.g., Education about Meals on Wheels Program, Referral to transportation support programs). SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes. |
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Data Element |
Applicable Vocabulary Standard(s) |
|---|---|
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Procedures
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Optional:
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SDOH Interventions
Actions or services to address an identified Social Determinants of Health-related health concern, condition, or diagnosis (e.g., education about food pantry program, referral to non-emergency medical transportation program) |
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Reason for Referral
Explanation or justification for a referral or consultation. |
Data Element |
Applicable Vocabulary Standard(s) |
|---|---|
|
Procedures
|
Optional:
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SDOH Interventions
Actions or services to address an identified Social Determinants of Health-related health concern, condition, or diagnosis (e.g., education about food pantry program, referral to non-emergency medical transportation program) |
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Reason for Referral
Explanation or justification for a referral or consultation. |
Data Element |
Applicable Vocabulary Standard(s) |
|---|---|
|
Procedures
Activity performed for or on a patient as part of the provision of care. |
Optional:
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SDOH Interventions
Actions or services to address an identified Social Determinants of Health-related health concern, condition, or diagnosis. Examples include but are not limited to education about food pantry program and referral to non-emergency medical transportation program. |
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Reason for Referral
Explanation or justification for a referral or consultation. |
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Performance Time
Time and/or date a procedure is performed. Examples include but are not limited to vaccine or medication administration times, surgery start time, and time ultrasound performed. |
Data Element |
Applicable Vocabulary Standard(s) |
|---|---|
|
Procedures
Activity performed for or on a patient as part of the provision of care. |
Optional:
|
|
SDOH Interventions
Actions or services to address an identified Social Determinants of Health-related concern, condition, or diagnosis. Examples include but are not limited to education about food pantry program and referral to non-emergency medical transportation program. |
|
|
Reason for Referral
Explanation or justification for a referral or consultation. |
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|
Performance Time
Time and/or date a procedure is performed. Examples include but are not limited to vaccine or medication administration times, surgery start time, and time ultrasound performed. |
Data Element |
Applicable Vocabulary Standard(s) |
|---|---|
|
Procedures
Activity performed for or on a patient as part of the provision of care. |
Optional:
|
|
SDOH Interventions
Actions or services to address an identified Social Determinants of Health-related concern, condition, or diagnosis. Examples include but are not limited to education about food pantry program and referral to non-emergency medical transportation program. |
|
|
Reason for Referral
Explanation or justification for a referral or consultation. |
|
|
Performance Time
Time and/or date an activity is performed. Examples include but are not limited to vaccine or medication administration times, surgery start time, time ultrasound performed, and laboratory specimen collection time. |
Data Element |
Applicable Vocabulary Standard(s) |
|---|---|
|
Procedure
Activity performed for or on a patient as part of the provision of care. Examples include but are not limited to suture placement, gait training, knee replacement, and education about a food pantry program. |
Optional:
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Reason for Referral
Explanation or justification for a referral or consultation. |
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Procedure Status
The status of planned or performed activity. Examples include but are not limited to in-progress, completed, and not done. |
Data Element |
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Submitted by joshualegler on
Consider adding a data element for the date/time a procedure was performed.
This comment is submitted on behalf of the National Emergency Medical Services Information System (NEMSIS) Technical Assistance Center.
Submitted by mrallins on
The Regenstrief Institute applauds the addition of Reason for Referral as a data element in USCDI V3. We note that the association of Reason for Referral with the Procedures class can be confusing without having a clear definition for procedures as a data class. We also recommend including specific examples to clarify reason for referral concept so that the data element and the intent for its association with the procedures as a data class are clearly understood. Some examples of reason for referral include referral to social services, referral for pre-operative consultation. These examples will help the user understand the broad definition that procedures as a data class includes any type of activity that is performed with or on a patient as part of the provision of care.
Submitted by mrallins on
Logical Identifiers Names and Codes (LOINC) has an extensive set of concepts to express patient demographic data. We recommend including LOINC as a terminology standard to represent demographic data or to map to other demographic related code sets such as the CDC race and ethnicity code set.
LOINC examples include:
76458-9 Patient Email address
21112-8 Birth date
46463-6 Race or ethnicity
Submitted by cmcdonald on
A note to clarify what is meant by procedures would be helpful here because everything, lab tests, radiology studies, etc. could be considered procedures in some sense of the meaning. FHIR used “procedure” to mean surgical and similar invasive processes. It is messy because CPT, for example, considers tests of all kinds as procedures, so some distinctions would be helpful.
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Submitted by csnewman on
Overlapping data elements
If the Healthcare Information Attributes data class applied to the Procedure data class, there seems to be overlap between Indication (Sign, symptom, or medical condition that is the reason for a care activity.) and Reason for Referral (which is odd in Procedure to begin with - is it really needed given the new Referral Order data element?)