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CDA R2 Implementation Guide for Procedure Notes

This guide, authored by Dr. Judith R. Logan of Oregon Health & Science University, focuses on enhancing documentation quality in medical procedures. It addresses key aspects, including defining procedures, ensuring consistency with other implementation guides, and specifying coding systems. Additionally, it suggests utilizing clinical content from the Continuity of Care Document (CCD) while collaborating with the ASGE Quality Committee for endoscopic procedures. The guide aims to develop clinical content useful for quality reporting, measurement specification, and innovative research, while aligning with parallel ontology work.

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CDA R2 Implementation Guide for Procedure Notes

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  1. CDA R2 Implementation Guide for Procedure Notes Judith R. Logan, MD Department of Medical Informatics & Clinical Epidemiology Oregon Health & Science University

  2. Quality in Documentation Documentation Quality Measurement Quality in Research Research

  3. Significant issues • What is a procedure? • How to be consistent with other IGs • How to specify coding systems in a universal realm IG • How to select sections that are general enough for all types of procedures yet specific enough to be useful • Can clinical content from the CCD be suggested when that is a US-realm standard?

  4. Where now? • Continue work with the ASGE Quality Committee to develop an implementation for one or more types of endoscopic procedures • Develop clinical content which can be used for quality reporting/quality measure specification as well as documentation and in research • Merge this work with the vocabulary/ontology work that is occurring in parallel

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