Tuesday, January 10, 2017

What is in a name? CDA Document Types revisited

The CCD (Continuity of Care Document) was originally envisioned as being the HL7 version of the Continuity of Care Record, which originated from a paper form originally used in the State of Massachusessets.  Since then the name has become synonymous with Meaningful Use, and in many ways, burdensome communication.

Because after all, if what you are after is Continuity of Care, what information would you possibly omit?

Recently I'd been asked by John Moehrke what other document could be used to represent a summary of a single visit.  Providers have many names for these:

Visit Note is the most generic, and basically could mean any level of detail from a single line of text to a three page report on the patient's current condition.  It could mean any of the different kinds of notes physicians use.

History and Physical Note describes an encounter (ambulatory visit) in which a History and Physical Examination is performed.  This could represent something like what your provider would report for your annual physical examination, or prior to undertaking some specific health-related activity.  Often surgeons perform an H&P prior to surgery.  Newly expectant mothers undergo one often when they first learn of their pregnancy.  The H&P principally is describing the results of a physical examination where either something specific is being looked for (such as the reason for an undetermined illness), or where more generally an assessment of a patient's overall health is being done.  More specifically, H&P relates to a specific service performed and billed by physicians.  H&P is pretty typically used in cases where a healthy patient is having an encounter with a physician, and may also be used in other cases where nothing is obvious.  It is in some ways a fishing expedition.

A consult note represents a different kind of service.  In this case, an opinion is being sought about a specific situation.  Rendering that opinion may require a history and physical, or it may just require some very specific examinations.  When my wife was being evaluated for arthritis, the physician didn't perform all of the steps one would expect in a physical examination.  He didn't need to look at different body systems, he was just interested in two or three.  He applied a stethoscope to my wife's knee and promptly upon listening when she bent it indicated that she did indeed have arthritis,and so rendered his opinion.  After we had already gone to the trouble to procure expensive imaging of said joint which he didn't even need to look at (although fortunately it later did come in handy).

A progress note is simply an update about a patient's progress.  In ambulatory settings it is used to report on a patient's progress with particular treatment or disease that is being followed by a physician.  Often it is used in various ancillary "therapy" settings, such as Physical Therapy, Respiratory Therapy, Cardiac Rehab, et cetera.

If you want a note that summarizes what happened in an encounter, think about the principal service provided during that encounter.  The note will name it, and the provider will also bill for it.  If I had to pick just one of the three above, Consult note would be my choice, because a consultation can always include an H&P, but an H&P doesn't cover the wide variety of healthcare situations.

Then again, maybe we should stop trying to shoe-horn every healthcare visit into the same documentation template.  There's more to this world than nails, and not every problem needs a hammer.


P.S.  I think its funny that almost nine years later I'm still talking about hammers.


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