CDA4CDT Coalition Submits Public Comment on Clinical Encounter Note
The American Health Information Community (AHIC), an advisory board which makes recommendations to the Office of the National Coordinator for Health Information Technology, recently requested feedback related to standards development in the area of Clinical Encounter Note Details. AHIC has drafted a list of gaps and extensions to be addressed in order to develop nationally recognized standards for the completion and exchange of clinical encounter notes (including transcribed notes). The standardization work in this area of the electronic health record will directly impact the future of the dictation-transcription process. The AHIC document recognized the work already accomplished by CDA4CDT, an alliance of organizations formed nearly two years ago, with AHDI and MTIA as founding members, to develop and publish document exchange standards for narrative reports in electronic clinical documents. The CDA4CDT workgroup submitted comments to AHIC that fully support the work of medical transcriptionists and the vital role of narrative clinical information in quality patient care. Specifically, the comments "suggest that the report address directly the integration of dictation/transcription workflow. The information within the approximately 600,000,000 reports dictated each year is critical to care and must become fully integrated into EHRs and accessible to PHRs." References and Links:Feedback on Clinical Encounter Note Details: Draft AHIC Extension/Gap Draft of August 15, 2008http://www.hhs.gov/healthit/usecases/cen.html Comments submitted by members of the CDA4CDT Initiative can be viewed here.
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