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[COAS-List] SGML Thread on Report Types

There was a very interesting thread on the HL7 mail list about
categories (and dimensions of information) found in a patient record.  I
have attached the whole thread (as of this moment) to this message. 
Sorry about the size - I think there are some relevent issues to COAS.

Tim

-- BEGIN included message

And then there are those of other sectors:

Nursing
Physiotherapist,
Mensendieck and Ceasar therapists
Dentist
preventive medicine

and many more I forgot.

Listing the whole variety of all possible documents won't bring us verry much further.
Listing the all possible collections of medical information stored in a structured way won't bring us verry much further.

Gerard
At 22:07 +0100 29-10-1998, Jason Williams wrote:
>Angelo, here are some specific note types you may wish to consider for the
>CEN report, if you are going to be going into detail regarding specific
>types of documents.
>
>
>
>Cardiology Consult Note
>Care Manager Note
>Communication Note
>Consult Note
>Dobutamine Echo Interpretation
>Dobutamine Echo Report
>Echocardiogram Report
>ED Note
>ED Procedure Note
>ED Triage
>Encounter Summary
>Health Maintenance Update
>History & Physical
>Nursing Communication Note
>Nursing Outpatient Note
>Nutrition SOAP Note
>Operative Note
>Orders
>Outpatient Progress Note
>Patient Information Update
>Patient Profile Update
>Pediatric Care Manager Note
>Pediatric Nursing Note
>Pediatric Progress Note
>Procedure & Progress Note
>Procedure Note
>Referral Note
>SOAP Note
>Stress Echo Interpretation
>Stress Echocardiogram Report
>
>Thanks.
>
>--
>Jason P. Williams
>Clinical Data Engineering
>Oceania, Inc.
>650-813-4505
>
>
>
>> -----Original Message-----
>> From: Angelo Rossi Mori [SMTP:rossi@COLOR.IRMKANT.RM.CNR.IT]
>> Sent: Wednesday, October 28, 1998 5:35 AM
>> To:   SGML-HL7@listserv.duhc.duke.edu
>> Subject:      types of documents
>>
>> Dear colleagues,
>> I'm preparing a list of kinds of documents that could appear in an
>> Electronic Heath Care Record, for a CEN standard on the topic.
>>
>>
>> Here is my starting point, in arbitrary order:
>>
>> Problem list
>> Discharge summary
>> Referral letter
>> Diagnostic report
>>         (it includes a lot of specialized reports)
>> Abstract of the record
>> Report of second opinion
>> Activity report
>>         Report of surgical procedure
>> Clinical journal
>> Instructions to patient
>>
>>
>> Do you have more ideas ?
>> I'm interested also in nursing and allied professions.
>>
>> Thanks
>>
>> Angelo
>>
>>
>>
>>
>> ---------------------------------
>> Angelo Rossi Mori, Reparto Informatica Medica,
>> Istituto Tecnologie Biomediche, CNR
>> viale Marx 15, I-00137, Roma, Italy
>> http://gift.irmkant.rm.cnr.it/termhome.htm
>>
>>
>> NOTE NEW NUMBERING SYSTEM IN ITALY:
>> tel. + 39 - 06 827 71 01; fax + 39 - 06 827 36 65


ProRec- Nederland
Gerard Freriks,huisarts, MD
C. Sterrenburgstr 54
3151JG Hoek van Holland
the Netherlands
Telephone: (+31) (0)174-384296/ Fax: -386249
Mobile   : (+31) (0)6-54792800
ARS LONGA, VITA BREVIS

-- END included message

-- BEGIN included message

Dear colleagues,
I'm preparing a list of kinds of documents that could appear in an
Electronic Heath Care Record, for a CEN standard on the topic.


Here is my starting point, in arbitrary order:

Problem list
Discharge summary
Referral letter
Diagnostic report
(it includes a lot of specialized reports)
Abstract of the record
Report of second opinion
Activity report
Report of surgical procedure
Clinical journal
Instructions to patient


Do you have more ideas ?
I'm interested also in nursing and allied professions.

Thanks

Angelo




---------------------------------
Angelo Rossi Mori, Reparto Informatica Medica,
Istituto Tecnologie Biomediche, CNR
viale Marx 15, I-00137, Roma, Italy
http://gift.irmkant.rm.cnr.it/termhome.htm


NOTE NEW NUMBERING SYSTEM IN ITALY:
tel. + 39 - 06 827 71 01; fax + 39 - 06 827 36 65

-- END included message

-- BEGIN included message

Angelo--

I would propose adding a Registration/Admission Report.  This is the point
at which the encounter/visit ID is created, patient identification is
established based on whatever information or evidence the patient presents,
and at which any documents furnished by the patient are received.

Documentation of this event is spotty, which is one reason, I believe, why
patient identification errors are so troublesome to track down and correct.
Is anybody presently documenting these events?  I would welcome discussion
of its appropriateness.

--Fred


At 02:34 PM 10/28/98 +0100, you wrote:
>Dear colleagues,
>I'm preparing a list of kinds of documents that could appear in an
>Electronic Heath Care Record, for a CEN standard on the topic.
>
>
>Here is my starting point, in arbitrary order:
>
>Problem list
>Discharge summary
>Referral letter
>Diagnostic report
>        (it includes a lot of specialized reports)
>Abstract of the record
>Report of second opinion
>Activity report
>        Report of surgical procedure
>Clinical journal
>Instructions to patient
>
>
>Do you have more ideas ?
>I'm interested also in nursing and allied professions.
>
>Thanks
>
>Angelo
>
>
>
>
>---------------------------------
>Angelo Rossi Mori, Reparto Informatica Medica,
>Istituto Tecnologie Biomediche, CNR
>viale Marx 15, I-00137, Roma, Italy
>http://gift.irmkant.rm.cnr.it/termhome.htm
>
>
>NOTE NEW NUMBERING SYSTEM IN ITALY:
>tel. + 39 - 06 827 71 01; fax + 39 - 06 827 36 65
>
>
__________________________________________________________________

Fred M. Behlen, Ph.D.
Assistant Professor of Radiology
The University of Chicago, MC2026
5841 South Maryland Avenue
Chicago, Illinois 60637

Phone: (773)702-7418
Fax: (773)702-1161
E-Mail: f-behlen@uchicago.edu

-- END included message

-- BEGIN included message

Greetings Angelo,


I would not restrict "Lists" to just problem lists. You might have  a "list"
of current medications, previous medications, recent hospitalizations or
allergies.

Same for letter -- they could be referral or letters to employers or insurers.

What about demographic and registration information?

At 02:34 PM 10/28/98 +0100, Angelo Rossi Mori wrote:
>Dear colleagues,
>I'm preparing a list of kinds of documents that could appear in an
>Electronic Heath Care Record, for a CEN standard on the topic.
>
>
>Here is my starting point, in arbitrary order:
>
>Problem list
>Discharge summary
>Referral letter
>Diagnostic report
>        (it includes a lot of specialized reports)
>Abstract of the record
>Report of second opinion
>Activity report
>        Report of surgical procedure
>Clinical journal
>Instructions to patient
>
>
>Do you have more ideas ?
>I'm interested also in nursing and allied professions.
>
>Thanks
>
>Angelo
>
>
>
>
>---------------------------------
>Angelo Rossi Mori, Reparto Informatica Medica,
>Istituto Tecnologie Biomediche, CNR
>viale Marx 15, I-00137, Roma, Italy
>http://gift.irmkant.rm.cnr.it/termhome.htm
>
>
>NOTE NEW NUMBERING SYSTEM IN ITALY:
>tel. + 39 - 06 827 71 01; fax + 39 - 06 827 36 65
>
>
________________________________________________________________________

Rachael Sokolowski
Chief Scientist and Vice President of Research
iTRUST
Co-chair, HL7 SGML/XML SIG
8 Central St
Arlington MA 02474
VOICE: 781 646 8877
FAX:   781 646 5377

-- END included message

-- BEGIN included message

Angelo,
   How long do you want the list to be?  We (at IHC) have several
hundred report types that we are actively using in our system.  Do you
want just major categories, or the more specific reports.  For
example, at the general category level, we have:

Initial Visit
Progress Notes
Phone Notes (notes from phone calls from patients)
Discharge Summary
Radiology Report
Surgery Operative Note
etc.

At the detail level we have:

Psychiatric Consult
Cardiac Catherization Report
Chest XRay - 2 views
CT Scan Abdomen

So what level of detail are you interested in?  -Stan

>>> Angelo Rossi Mori <rossi@COLOR.IRMKANT.RM.CNR.IT> 10/28/98
06:34AM >>>
Dear colleagues,

I'm preparing a list of kinds of documents that could appear in an
Electronic Heath Care Record, for a CEN standard on the topic.

Here is my starting point, in arbitrary order:

Problem list
Discharge summary
Referral letter
Diagnostic report
        (it includes a lot of specialized reports)
Abstract of the record
Report of second opinion
Activity report
        Report of surgical procedure
Clinical journal
Instructions to patient

Do you have more ideas ?

I'm interested also in nursing and allied professions.

Thanks


Angelo

-- END included message

-- BEGIN included message

Question is to what level of detail such a list must encompass?
Our current medical record has over 300 approved page types or categories
used in a paper record framework that has been in place for over 60 years.
We are replicating much of the same in the electronic environment., taking
advantage of the cross-referencing and indexing the electronic environment
offers.

Paul C Carpenter MD
Mayo Clinic
Rochester MN 55905
Pccarp@mayo.edu

        -----Original Message-----
        From:   Angelo Rossi Mori [SMTP:rossi@COLOR.IRMKANT.RM.CNR.IT]
        Sent:   Wednesday, October 28, 1998 7:35 AM
        To:     SGML-HL7@listserv.duhc.duke.edu
        Subject:        types of documents

        Dear colleagues,
        I'm preparing a list of kinds of documents that could appear in an
        Electronic Heath Care Record, for a CEN standard on the topic.


        Here is my starting point, in arbitrary order:

        Problem list
        Discharge summary
        Referral letter
        Diagnostic report
                (it includes a lot of specialized reports)
        Abstract of the record
        Report of second opinion
        Activity report
                Report of surgical procedure
        Clinical journal
        Instructions to patient


        Do you have more ideas ?
        I'm interested also in nursing and allied professions.

        Thanks

        Angelo




        ---------------------------------
        Angelo Rossi Mori, Reparto Informatica Medica,
        Istituto Tecnologie Biomediche, CNR
        viale Marx 15, I-00137, Roma, Italy
        http://gift.irmkant.rm.cnr.it/termhome.htm


        NOTE NEW NUMBERING SYSTEM IN ITALY:
        tel. + 39 - 06 827 71 01; fax + 39 - 06 827 36 65

-- END included message

-- BEGIN included message

Carpenter, Paul C., M.D. wrote:
> 
> Question is to what level of detail such a list must encompass?
> Our current medical record has over 300 approved page types or categories
> used in a paper record framework that has been in place for over 60 years.


Stan Huff wrote:
> 
> Angelo,
>    How long do you want the list to be?  We (at IHC) have several
> hundred report types that we are actively using in our system.  Do you
> want just major categories, or the more specific reports.  


Stan, Paul, others,

Do you know of any (preferably publicly available) coding schemes that
have codes for these?  It seems I have seen an entry in the DICOM SNOMED
Microglosary that listed patient record catagories but never found where
they showed up as indivivual codes.  Then again I don't have access to
the full SNOMED.

Tim Brinson
begin:          vcard
fn:             Tim Brinson
n:              Brinson;Tim
org:            Protocol Systems, Inc.
adr:            8500 SW Creekside Place;;;Beaverton;Oregon;97008-7107;USA
email;internet: tim@protocol.com
title:          Systems Software Lead
tel;work:       503 526 4392
tel;fax:        503 526 4200
note:           <img src=http://aco.protocol.com/pids/tbrinson.jpg>
x-mozilla-cpt:  ;0
x-mozilla-html: TRUE
version:        2.1
end:            vcard

-- END included message

-- BEGIN included message

Tim Brinson wrote:

> Do you know of any (preferably publicly available) coding schemes that
> have codes for these?  It seems I have seen an entry in the DICOM SNOMED
> Microglosary that listed patient record catagories but never found where
> they showed up as indivivual codes.  Then again I don't have access to
> the full SNOMED.



        This is the AMA's CPT system (proprietary five digit numeric codes)
currently mandated by HCFA and shown in its proposed 1999 format as a
heirarchial document architecture:-

        http://www.ama-assn.org/emupdate/guidelin.htm

        For those non-US subscribers to this list, the interesting thing about
this is that dollar value is attached to each separate heading. In our
fee-for-service system, more headings = more money.


                                        John Totten MD
                                        Sitka AK

-- END included message

-- BEGIN included message

This amount of lists is unwieldy.

It will leed to chaos.

Names of lists (names of slices through data space)  are user dependent.
I hope we / you  don't want to include all this in one standard model?

The right way , I think, is to provide basic names to label information and let each user make as much Names of Lists as he wants.

Perhaps a basic primitive selection must be provided.
(Summary, Problem List, Lab result list, History, etc)


Gerard
At 18:54 +0100 28-10-1998, Stan Huff wrote:
>Angelo,
>   How long do you want the list to be?  We (at IHC) have several
>hundred report types that we are actively using in our system.  Do you
>want just major categories, or the more specific reports.  For
>example, at the general category level, we have:
>
>Initial Visit
>Progress Notes
>Phone Notes (notes from phone calls from patients)
>Discharge Summary
>Radiology Report
>Surgery Operative Note
>etc.
>
>At the detail level we have:
>
>Psychiatric Consult
>Cardiac Catherization Report
>Chest XRay - 2 views
>CT Scan Abdomen
>
>So what level of detail are you interested in?  -Stan
>
>>>> Angelo Rossi Mori <rossi@COLOR.IRMKANT.RM.CNR.IT> 10/28/98
>06:34AM >>>
>Dear colleagues,
>
>I'm preparing a list of kinds of documents that could appear in an
>Electronic Heath Care Record, for a CEN standard on the topic.
>
>Here is my starting point, in arbitrary order:
>
>Problem list
>Discharge summary
>Referral letter
>Diagnostic report
>        (it includes a lot of specialized reports)
>Abstract of the record
>Report of second opinion
>Activity report
>        Report of surgical procedure
>Clinical journal
>Instructions to patient
>
>Do you have more ideas ?
>
>I'm interested also in nursing and allied professions.
>
>Thanks
>
>
>Angelo


ProRec- Nederland
Gerard Freriks,huisarts, MD
C. Sterrenburgstr 54
3151JG Hoek van Holland
the Netherlands
Telephone: (+31) (0)174-384296/ Fax: -386249
Mobile   : (+31) (0)6-54792800
ARS LONGA, VITA BREVIS

-- END included message

-- BEGIN included message

Tim,
    As far as I know, clinical report types are not included in
SNOMED.  However, they might be there and I am just unaware.  I will
forward this message to Kent Spackman and see if he has additional
information.  -Stan

>>> Tim Brinson <tim@PROTOCOL.COM> 10/28/98 04:04PM >>>
Carpenter, Paul C., M.D. wrote:
>
> Question is to what level of detail such a list must encompass?
> Our current medical record has over 300 approved page types or
categories
> used in a paper record framework that has been in place for over 60
years.


Stan Huff wrote:
>
> Angelo,
>    How long do you want the list to be?  We (at IHC) have several
> hundred report types that we are actively using in our system.  Do
you
> want just major categories, or the more specific reports.


Stan, Paul, others,

Do you know of any (preferably publicly available) coding schemes
that
have codes for these?  It seems I have seen an entry in the DICOM
SNOMED
Microglosary that listed patient record catagories but never found
where
they showed up as indivivual codes.  Then again I don't have access
to
the full SNOMED.

Tim Brinson

-- END included message

-- BEGIN included message

Stan,

I just found the document (printout) I was thinking of.  It is a set of
tables 16 pages long. It says "SNOMED DICOM MICROGLOSSARY CONTEXT GROUPS
-- Version 1.01" at the top of the first few pages.  The columns of the
table of interest say CID, CONTEXT CONCEPT, VALUE SET, SOURCE, TAG,
etc.   The two rows of interest here have CID 51 and 52.

51 | Patient record information  | {See Section C.6.8.1.1 for
   | categories, except physical | furhter definition. TPSQ=
   | observation categories      | PRI-SQ. Context Identifier#
   |                             | SDM102 includes the following
   |                             | terms (and others) } <then it
   |                             | lists 50 or so>


52 | Patient record information  | <lists ~100 categories>
   | categories, comprehensive   | 

Does this ring a bell with anyone?

Tim


Stan Huff wrote:
> 
> Tim,
>     As far as I know, clinical report types are not included in
> SNOMED.  However, they might be there and I am just unaware.  I will
> forward this message to Kent Spackman and see if he has additional
> information.  -Stan
> 
> >>> Tim Brinson <tim@PROTOCOL.COM> 10/28/98 04:04PM >>>
> Stan, Paul, others,
> 
> Do you know of any (preferably publicly available) coding schemes
> that
> have codes for these?  It seems I have seen an entry in the DICOM
> SNOMED
> Microglosary that listed patient record catagories but never found
> where
> they showed up as indivivual codes.  Then again I don't have access
> to
> the full SNOMED.

-- BEGIN included message

Dear colleagues,
I'm preparing a list of kinds of documents that could appear in an
Electronic Heath Care Record, for a CEN standard on the topic.


Here is my starting point, in arbitrary order:

Problem list
Discharge summary
Referral letter
Diagnostic report
(it includes a lot of specialized reports)
Abstract of the record
Report of second opinion
Activity report
Report of surgical procedure
Clinical journal
Instructions to patient


Do you have more ideas ?
I'm interested also in nursing and allied professions.

Thanks

Angelo




---------------------------------
Angelo Rossi Mori, Reparto Informatica Medica,
Istituto Tecnologie Biomediche, CNR
viale Marx 15, I-00137, Roma, Italy
http://gift.irmkant.rm.cnr.it/termhome.htm


NOTE NEW NUMBERING SYSTEM IN ITALY:
tel. + 39 - 06 827 71 01; fax + 39 - 06 827 36 65

-- END included message

-- BEGIN included message

Angelo,
   How long do you want the list to be?  We (at IHC) have several
hundred report types that we are actively using in our system.  Do you
want just major categories, or the more specific reports.  For
example, at the general category level, we have:

Initial Visit
Progress Notes
Phone Notes (notes from phone calls from patients)
Discharge Summary
Radiology Report
Surgery Operative Note
etc.

At the detail level we have:

Psychiatric Consult
Cardiac Catherization Report
Chest XRay - 2 views
CT Scan Abdomen

So what level of detail are you interested in?  -Stan

>>> Angelo Rossi Mori <rossi@COLOR.IRMKANT.RM.CNR.IT> 10/28/98
06:34AM >>>
Dear colleagues,

I'm preparing a list of kinds of documents that could appear in an
Electronic Heath Care Record, for a CEN standard on the topic.

Here is my starting point, in arbitrary order:

Problem list
Discharge summary
Referral letter
Diagnostic report
        (it includes a lot of specialized reports)
Abstract of the record
Report of second opinion
Activity report
        Report of surgical procedure
Clinical journal
Instructions to patient

Do you have more ideas ?

I'm interested also in nursing and allied professions.

Thanks


Angelo

-- END included message

-- BEGIN included message

Question is to what level of detail such a list must encompass?
Our current medical record has over 300 approved page types or categories
used in a paper record framework that has been in place for over 60 years.
We are replicating much of the same in the electronic environment., taking
advantage of the cross-referencing and indexing the electronic environment
offers.

Paul C Carpenter MD
Mayo Clinic
Rochester MN 55905
Pccarp@mayo.edu

        -----Original Message-----
        From:   Angelo Rossi Mori [SMTP:rossi@COLOR.IRMKANT.RM.CNR.IT]
        Sent:   Wednesday, October 28, 1998 7:35 AM
        To:     SGML-HL7@listserv.duhc.duke.edu
        Subject:        types of documents

        Dear colleagues,
        I'm preparing a list of kinds of documents that could appear in an
        Electronic Heath Care Record, for a CEN standard on the topic.


        Here is my starting point, in arbitrary order:

        Problem list
        Discharge summary
        Referral letter
        Diagnostic report
                (it includes a lot of specialized reports)
        Abstract of the record
        Report of second opinion
        Activity report
                Report of surgical procedure
        Clinical journal
        Instructions to patient


        Do you have more ideas ?
        I'm interested also in nursing and allied professions.

        Thanks

        Angelo




        ---------------------------------
        Angelo Rossi Mori, Reparto Informatica Medica,
        Istituto Tecnologie Biomediche, CNR
        viale Marx 15, I-00137, Roma, Italy
        http://gift.irmkant.rm.cnr.it/termhome.htm


        NOTE NEW NUMBERING SYSTEM IN ITALY:
        tel. + 39 - 06 827 71 01; fax + 39 - 06 827 36 65

-- END included message

begin:          vcard
fn:             Tim Brinson
n:              Brinson;Tim
org:            Protocol Systems, Inc.
adr:            8500 SW Creekside Place;;;Beaverton;Oregon;97008-7107;USA
email;internet: tim@protocol.com
title:          Systems Software Lead
tel;work:       503 526 4392
tel;fax:        503 526 4200
note:           <img src=http://aco.protocol.com/pids/tbrinson.jpg>
x-mozilla-cpt:  ;0
x-mozilla-html: TRUE
version:        2.1
end:            vcard

-- END included message

-- BEGIN included message

Tim,
    As far as I know, clinical report types are not included in
SNOMED.  However, they might be there and I am just unaware.  I will
forward this message to Kent Spackman and see if he has additional
information.  -Stan

>>> Tim Brinson <tim@PROTOCOL.COM> 10/28/98 04:04PM >>>
Carpenter, Paul C., M.D. wrote:
>
> Question is to what level of detail such a list must encompass?
> Our current medical record has over 300 approved page types or
categories
> used in a paper record framework that has been in place for over 60
years.


Stan Huff wrote:
>
> Angelo,
>    How long do you want the list to be?  We (at IHC) have several
> hundred report types that we are actively using in our system.  Do
you
> want just major categories, or the more specific reports.


Stan, Paul, others,

Do you know of any (preferably publicly available) coding schemes
that
have codes for these?  It seems I have seen an entry in the DICOM
SNOMED
Microglosary that listed patient record catagories but never found
where
they showed up as indivivual codes.  Then again I don't have access
to
the full SNOMED.

Tim Brinson

-- END included message

-- BEGIN included message

Angelo,

I can almost visualize the paper record and try to list the sections found in a U.S. record.

Admitting data document: Demographic, Insurance, Next of Kin

Physician Orders

Nursing Notes

Admission History and Physical

Progress Notes

Laboratory Reports

Radiology Reports

Procedures: Surgery, Endoscopy, etc. depending on which department generates the study ophthalmology, pulmonary, urology, cardiology etc.

Consulations:

One can add to this: Correspondance, Discharge Summaries, Problem Lists.



At 02:34 PM 10/28/98 +0100, you wrote:
>>>>
Dear colleagues,
I'm preparing a list of kinds of documents that could appear in an
Electronic Heath Care Record, for a CEN standard on the topic.


Here is my starting point, in arbitrary order:

Problem list
Discharge summary
Referral letter
Diagnostic report
(it includes a lot of specialized reports)
Abstract of the record
Report of second opinion
Activity report
Report of surgical procedure
Clinical journal
Instructions to patient


Do you have more ideas ?
I'm interested also in nursing and allied professions.

Thanks

Angelo




---------------------------------
Angelo Rossi Mori, Reparto Informatica Medica,
Istituto Tecnologie Biomediche, CNR
viale Marx 15, I-00137, Roma, Italy
http://gift.irmkant.rm.cnr.it/termhome.htm


NOTE NEW NUMBERING SYSTEM IN ITALY:
tel. + 39 - 06 827 71 01; fax + 39 - 06 827 36 65


<<<<

-- END included message

-- BEGIN included message

Some more examples:

"Temp curve" (often including a graph of vital signs, but also medications
and perhaps other important observations)
Specialist data summary
  e.g. diabetes data summary
Data collection sheet
  e.g. maternity care data collection sheet
ECG (a kind of diagnostic report, but very common and sometimes without
interpretation)

/Anders Thurin

-- END included message

-- BEGIN included message

My recent field research with health care providers at Sequoia software
has indicated that the important clinical reports (in order of
importance) are

diagnosis list (ICD9)- or problem list
current medications OR medications dispensed
allergies and adverse reactions
procedures (CPT)
lab report list & radiology list


Any additional reports are nice, but these are the critical ones that
will meet the needs of most health care providers 80% of the time.

Just my 2 cents.

George Moutsiakis, Ph.D.
georgem@sequoiasw.com <mailto:georgem@sequoiasw.com>
Usability Engineer
Sequoia Software Corporation
(410) 715-0206 x 273

-- END included message

-- BEGIN included message

At 12.46 28/10/98 -0600, Carpenter, Paul C., M.D. wrote:
>Question is to what level of detail such a list must encompass?
>Our current medical record has over 300 approved page types or categories
>used in a paper record framework that has been in place for over 60 years.
>We are replicating much of the same in the electronic environment., taking
>advantage of the cross-referencing and indexing the electronic environment
>offers.

thanks to all for the quick feedback.


I have urgent needs and a long term plan.

For the urgent needs in CEN, I'm looking for a compromise around 10-20
very general typologies of documents.

For the long term plan (in CEN, but I believe also in HL7),
I volunteer to work with other people
to develop a long list of hundreds of "page types".
We could start by collecting the available material and by
putting that on some web page, in the original heterogeneous formats.



Just to clarify another issue:

I feel naively that there are three groups of titles
(still partially overlapping in my mind),
each with many levels of granularity:

- kinds of documents (e.g. discharge summary)
- headings of the record (e.g. family history)
- views (e.g. laboratory orders in progress).

Perhaps my distinction is artificial, and difficult to apply.
Someone could assist me ?


Angelo


---------------------------------
Angelo Rossi Mori, Reparto Informatica Medica,
Istituto Tecnologie Biomediche, CNR
viale Marx 15, I-00137, Roma, Italy
http://gift.irmkant.rm.cnr.it/termhome.htm


NOTE NEW NUMBERING SYSTEM IN ITALY:
tel. + 39 - 06 827 71 01; fax + 39 - 06 827 36 65

-- END included message

-- BEGIN included message

At 03:30 PM 10/29/98 +0100, Angelo wrote:
>Just to clarify another issue:
>
>I feel naively that there are three groups of titles
>(still partially overlapping in my mind),
>each with many levels of granularity:
>
>- kinds of documents (e.g. discharge summary)
>- headings of the record (e.g. family history)
>- views (e.g. laboratory orders in progress).
>
>Perhaps my distinction is artificial, and difficult to apply.
>Someone could assist me ?
>

I believe there are four groups: categories of documents first (report,
summary, note, letter, list, etc.) and then kinds (perhaps specific
instances?) of documents under each category (pathology report, discharge
summary, nurse's notes, referral letter, current medications list, etc.).
Then each category would have specific headings (letters would have
salutations where as reports would not) and views which could be further
specialized by the kind of document (pathology laboratory orders in progress) .

I don't know if this helps or not, but this recommendation comes from a
previous project where we defined  different types of documents for health care.

________________________________________________________________________

Rachael Sokolowski
Chief Scientist and Vice President of Research
iTRUST
Co-chair, HL7 SGML/XML SIG
8 Central St
Arlington MA 02474
VOICE: 781 646 8877
FAX:   781 646 5377

-- END included message

-- BEGIN included message

If you include Problem list, how about these other lists:
Medications (list of active medications)
Allergies/ADRs
Immunizations
We also sometimes use:
Health Factors (really a subset of problems, but specifically includes
psychosocial and other factors which are disease risks but not diseases)

Does Diagnostic report include consultations, progress notes, etc? If
so, why a separate category for a second opinion? Do you want to combine
laboratory and ancillary testing reports with clinical notes?

Some lump Surgical procedures and minor procedures (LP, I&D,
paracentesis, thoracentesis, etc) together, some have separate
"operative notes" and "procedure notes"

Angelo Rossi Mori wrote:
>
> Dear colleagues,
> I'm preparing a list of kinds of documents that could appear in an
> Electronic Heath Care Record, for a CEN standard on the topic.
>
> Here is my starting point, in arbitrary order:
>
> Problem list
> Discharge summary
> Referral letter
> Diagnostic report
> (it includes a lot of specialized reports)
> Abstract of the record
> Report of second opinion
> Activity report
> Report of surgical procedure
> Clinical journal
> Instructions to patient
>
> Do you have more ideas ?
> I'm interested also in nursing and allied professions.
>
> Thanks
>
> Angelo
>
> ---------------------------------
> Angelo Rossi Mori, Reparto Informatica Medica,
> Istituto Tecnologie Biomediche, CNR
> viale Marx 15, I-00137, Roma, Italy
> http://gift.irmkant.rm.cnr.it/termhome.htm
>
> NOTE NEW NUMBERING SYSTEM IN ITALY:
> tel. + 39 - 06 827 71 01; fax + 39 - 06 827 36 65

--
Edwin B. George, M.D., Ph.D.                    Wayne State Neurology
Assistant Professor                             University Health Center 6E
Voice: 313-577-1249                             4201 St. Antoine
Fax:   313-577-4216                             Detroit, MI 48201

-- END included message

-- BEGIN included message

Angelo, here are some specific note types you may wish to consider for the
CEN report, if you are going to be going into detail regarding specific
types of documents.



Cardiology Consult Note
Care Manager Note
Communication Note
Consult Note
Dobutamine Echo Interpretation
Dobutamine Echo Report
Echocardiogram Report
ED Note
ED Procedure Note
ED Triage
Encounter Summary
Health Maintenance Update
History & Physical
Nursing Communication Note
Nursing Outpatient Note
Nutrition SOAP Note
Operative Note
Orders
Outpatient Progress Note
Patient Information Update
Patient Profile Update
Pediatric Care Manager Note
Pediatric Nursing Note
Pediatric Progress Note
Procedure & Progress Note
Procedure Note
Referral Note
SOAP Note
Stress Echo Interpretation
Stress Echocardiogram Report

Thanks.

--
Jason P. Williams
Clinical Data Engineering
Oceania, Inc.
650-813-4505



> -----Original Message-----
> From: Angelo Rossi Mori [SMTP:rossi@COLOR.IRMKANT.RM.CNR.IT]
> Sent: Wednesday, October 28, 1998 5:35 AM
> To:   SGML-HL7@listserv.duhc.duke.edu
> Subject:      types of documents
>
> Dear colleagues,
> I'm preparing a list of kinds of documents that could appear in an
> Electronic Heath Care Record, for a CEN standard on the topic.
>
>
> Here is my starting point, in arbitrary order:
>
> Problem list
> Discharge summary
> Referral letter
> Diagnostic report
>         (it includes a lot of specialized reports)
> Abstract of the record
> Report of second opinion
> Activity report
>         Report of surgical procedure
> Clinical journal
> Instructions to patient
>
>
> Do you have more ideas ?
> I'm interested also in nursing and allied professions.
>
> Thanks
>
> Angelo
>
>
>
>
> ---------------------------------
> Angelo Rossi Mori, Reparto Informatica Medica,
> Istituto Tecnologie Biomediche, CNR
> viale Marx 15, I-00137, Roma, Italy
> http://gift.irmkant.rm.cnr.it/termhome.htm
>
>
> NOTE NEW NUMBERING SYSTEM IN ITALY:
> tel. + 39 - 06 827 71 01; fax + 39 - 06 827 36 65

-- END included message

-- BEGIN included message

As another lurker on this list server, I've been following this discussion
with some interest.  I'd like to suggest that the work done in the Medical
Record Technical Committee may have some value in defining the issues here.
In turn, I believe the discussion will help extend the standard.

Chapter 9 of the HL7 2.3 Standard deals with Medical Record documents.  Our
starting point was the types of documents retained permanently in a
healthcare setting in the U.S.  Since many of these are transcribed and
placed into electronic storage, the document metadata was developed into a
TXA , "Transcription Header" segment.  A message about a document may
include the TXA segment only, or the TXA segment with the document content
in an OBX segment.  The committee's expectation was that the definition of
"documents" would extend well beyond transcribed documents.

The TXA metadata include individuals involved with the creation of the
document, such as document originator and authenticator, and a
differentiated legal authenticator.  The TXA also carries status
information about the document, including the confidentiality of the
document, and its maturity in an organization's processing of the document,
both of which determine if a document can be viewed, and by whom.  These
are the kinds of data which were discussed in the thread started by Sandy
Boyer a couple of weeks ago.

In response to Angelo's comments, below, I would suggest that Chapter 9
defines his categories of document "kinds", and "headers".  The Order
Communication committee has been dealing with Angelo's third category of
"views", and the same OBX segment is used for text in the context of an
order or result.

My hope is that the SGML group can use the existing definitions as a
starting point for the new process of applying a markup language to medical
documents, and in turn, suggest places where the definitions are not
adequate.

There is a Medical Record - SGML joint working group session scheduled for
the January meeting in Orlando.  We will be meeting on Wednesday morning,
January 27, location TBA.  I look forward to this continuing dialogue, and
to meeting as many of you as attend.

Best regards,

Anne Shanney
Co-chair, Medical Record/Information Mgmt Committee


IDX Systems, Inc
1001 Fourth Avenue Plaza, Suite 1500
Seattle, WA 98154
phone: (206)689-1102
e-mail: anne_shanney@idx.com






Rachael Sokolowski <rsokolowski@ITRUST.NET> on 10/29/98 02:21:53 AM

Please respond to SGML special interest group of HL7
      <SGML-HL7@listserv.duhc.duke.edu>

To:   SGML-HL7
cc:    (bcc: Anne Shanney/SEA/IDX1)
Subject:  Re: types of documents
Body:



At 03:30 PM 10/29/98 +0100, Angelo wrote:
>Just to clarify another issue:
>
>I feel naively that there are three groups of titles
>(still partially overlapping in my mind),
>each with many levels of granularity:
>
>- kinds of documents (e.g. discharge summary)
>- headings of the record (e.g. family history)
>- views (e.g. laboratory orders in progress).
>
>Perhaps my distinction is artificial, and difficult to apply.
>Someone could assist me ?
>

I believe there are four groups: categories of documents first (report,
summary, note, letter, list, etc.) and then kinds (perhaps specific
instances?) of documents under each category (pathology report, discharge
summary, nurse's notes, referral letter, current medications list, etc.).
Then each category would have specific headings (letters would have
salutations where as reports would not) and views which could be further
specialized by the kind of document (pathology laboratory orders in
progress) .

I don't know if this helps or not, but this recommendation comes from a
previous project where we defined  different types of documents for health
care.

________________________________________________________________________

Rachael Sokolowski
Chief Scientist and Vice President of Research
iTRUST
Co-chair, HL7 SGML/XML SIG
8 Central St
Arlington MA 02474
VOICE: 781 646 8877
FAX:   781 646 5377

-- END included message

-- BEGIN included message

At 15:30 +0100 29-10-1998, Angelo Rossi Mori wrote:
I have urgent needs and a long term plan.

For the urgent needs in CEN, I'm looking for a compromise around 10-20
very general typologies of documents.

For the long term plan (in CEN, but I believe also in HL7),
I volunteer to work with other people
to develop a long list of hundreds of "page types".
We could start by collecting the available material and by
putting that on some web page, in the original heterogeneous formats.



Just to clarify another issue:

I feel naively that there are three groups of titles
(still partially overlapping in my mind),
each with many levels of granularity:

- kinds of documents (e.g. discharge summary)
- headings of the record (e.g. family history)
- views (e.g. laboratory orders in progress).

Perhaps my distinction is artificial, and difficult to apply.
Someone could assist me ?


Life is simple.
But thats hard to see.

Question: a document (e.g. discharge summary) is this a View?
(discharge summary: list with all important history, findings, diagnosis, plans, treatments, etc of one patient during a stay, episode of care)
Answer: When a View is nothing but a selection of recorded information then this document=view.

So this leaves it to a group of two.

Heading , like family history, is a label put on a selection of stored information.
(All diagnosis belonging to 'family', not being the patient)
Hence Heading is a kind of View.

Now we have only one group consisting of Views. !

Now what's missing?
What is missing is the distinction between:
- Document as a physical container, with a name,
- Consisting of time-stamped entries with a name and each with its proper Context's and names and
- A complete logical container ( e.g. Health Care Record) with a name and
- A 'Document' as a logical container , Heading (e.g. family history) like a section or paragraph in a text, but then published, with a name and
- Context as part of Medical Narrative like : Reason for Encounter, Complaint, Finding, Diagnosis, Plan, Action, etc with a name. And
- Names of 'things' like : Blood Pressure, Weight, Lung, Liver, Pain. And
- Names of attributes like: owner, subject, time start-end, negation, severity, laterality, etc
- Names of lists used in atributes: severity: none-very, Laterality: Left, Right, etc

Gerard

ps:

Life is simple.
But thats hard to believe.








ProRec- Nederland
Gerard Freriks,huisarts, MD
C. Sterrenburgstr 54
3151JG Hoek van Holland
the Netherlands
Telephone: (+31) (0)174-384296/ Fax: -386249
Mobile : (+31) (0)6-54792800
ARS LONGA, VITA BREVIS

-- END included message

-- BEGIN included message

At 13.40 29/10/98 -0800, Anne Shanney wrote:
>As another lurker on this list server, I've been following this discussion
>with some interest. I'd like to suggest that the work done in the Medical
>Record Technical Committee may have some value in defining the issues here.
(snip)
>There is a Medical Record - SGML joint working group session scheduled for
>the January meeting in Orlando. We will be meeting on Wednesday morning,
>January 27, location TBA. I look forward to this continuing dialogue, and
>to meeting as many of you as attend.


I'm not willing to monopolize the joint meeting.
Nevertheless, I would appreciate if we put aside some time
for the issue of headings and types of documents.



I'm the Project Leader of a Project Team in CEN (the European Standardization Body),
to prepare a CEN prestandard (ENV) about:
"Electronic Heath Care Record Communication - Part 2: Domain Termlist".

The standard deals with various mechanisms to organize,
annotate and structure the clinical content of the record.
A part of the draft (clause 4.1 and Annex A1) deals with
very general "organizing terms", i.e. headings such as "family history" or "allergies".

The goal is to allow the receiver to "have an idea" of what a section of a record is about,
to facilitate browsing of the received message and to support the user
in extracting the suitable information from the message to include it in the local record.

We believe that record systems are too disparate
to ask for an "automatic" processing of names of sections.
Therefore we aim at a list of 10-20 very general kinds of documents,
just to provide a first-approximation organization to the received information.

In a recent CEN meeting, there was a long discussion on this topic.
During that discussion, I recognized that an important table
was missing from the draft, namely the one about the kinds of documents.
The principle will be the same:
to provide a short list of the most general kinds of documents,
just to assist the receiver in understanding the context of the received information.

The standard concept do not replace the original "document type",
but is attached to it in the message.



I'm putting in the next message two documents in rtf
with the motivations and the current status of my understanding,
that includes the following short list:

Summaries
Discharge summary
Summary made on request
Report of healthcare activity
Report of diagnostic procedure
Pathology report
Laboratory report
Imaging report
Report of consultation
Report of major surgical procedure
Registration/admission report
Notes
Clinical journal
Nursing note
Phone notes
Letters/Correspondance
Referral letter
Instructions to patient
Letter to employer/insurer
Views
current overview
problem list
laboratory orders in progress
list of laboratory results
list of current medications
list of previous medications


You can also download them from:
ftp://gift.irmkant.rm.cnr.it/PT27termlist/PT27N35typesOfDoc03.doc
ftp://gift.irmkant.rm.cnr.it/PT27termlist/PT27r01tableA1v1.4.doc

Thanks


Angelo Rossi Mori






---------------------------------
Angelo Rossi Mori, Reparto Informatica Medica,
Istituto Tecnologie Biomediche, CNR
viale Marx 15, I-00137, Roma, Italy
http://gift.irmkant.rm.cnr.it/termhome.htm


NOTE NEW NUMBERING SYSTEM IN ITALY:
tel. + 39 - 06 827 71 01; fax + 39 - 06 827 36 65

-- END included message

-- BEGIN included message

How about prescription(s)?

-- END included message

-- BEGIN included message

XML taxonomy distinguishes among content, structure, and presentation, but:
I think we should attempt to nail the taxonomy before we generate the "list of types".  However, by inpecting the "type" lists already in existence, we can check the robustness of the taxonomy.  I would suggest that we all stop saying "type" as soon as we can agree on at least a few dimensions.   I distinguish among the following "type" dimensions:
 
Composition model ("composition format" in writing terms) - e.g. letters reports.  (Writing= content, style, and mechanics.  This is style)
Interface specification (Patient Record Archtiecture artifacts) - the machine-addressible operations and properties
Problem Domain Content, or functional area - healthcare words go here and only here, with categories ad subcategories
Functional Workflow status (completed, revised, etc)
Storage integrity and existence status (logical deletes, validity of pointers, identifier states)
-----Original Message-----
From: Rachael Sokolowski <rsokolowski@ITRUST.NET>
To: SGML-HL7@listserv.duhc.duke.edu <SGML-HL7@listserv.duhc.duke.edu>
Date: Thursday, October 29, 1998 10:59 AM
Subject: Re: types of documents

At 03:30 PM 10/29/98 +0100, Angelo wrote:
>Just to clarify another issue:
>
>I feel naively that there are three groups of titles
>(still partially overlapping in my mind),
>each with many levels of granularity:
>
>- kinds of documents (e.g. discharge summary)
>- headings of the record (e.g. family history)
>- views (e.g. laboratory orders in progress).
>
>Perhaps my distinction is artificial, and difficult to apply.
>Someone could assist me ?
>

I believe there are four groups: categories of documents first (report,
summary, note, letter, list, etc.) and then kinds (perhaps specific
instances?) of documents under each category (pathology report, discharge
summary, nurse's notes, referral letter, current medications list, etc.).
Then each category would have specific headings (letters would have
salutations where as reports would not) and views which could be further
specialized by the kind of document (pathology laboratory orders in progress) .

I don't know if this helps or not, but this recommendation comes from a
previous project where we defined  different types of documents for health care.

________________________________________________________________________

Rachael Sokolowski
Chief Scientist and Vice President of Research
iTRUST
Co-chair, HL7 SGML/XML SIG
8 Central St
Arlington MA 02474
VOICE: 781 646 8877
FAX:   781 646 5377

-- END included message

-- BEGIN included message

Hi Anne,

I just wanted to let you know that we have reviewed and drawn from Chapter 9
(and corresponding RIM objects and attributes) extensively in the creation
of the HL7 Document Patient Record Architecture header. We hope to have
material suitable for distribution some time in November. I'm looking
forward to your comments as to how well we represented the intent of Chapter
9.

Take care,
Bob

Bob Dolin, MD
Kaiser Permanente


> ----------
> From:         Anne Shanney[SMTP:Anne_Shanney@IDX.COM]
> Reply To:     SGML special interest group of HL7
> Sent:         Thursday, October 29, 1998 1:40 PM
> To:   SGML-HL7@listserv.duhc.duke.edu
> Subject:      Re: types of documents
>
> As another lurker on this list server, I've been following this discussion
> with some interest.  I'd like to suggest that the work done in the Medical
> Record Technical Committee may have some value in defining the issues
> here.
> In turn, I believe the discussion will help extend the standard.
>
> Chapter 9 of the HL7 2.3 Standard deals with Medical Record documents.
> Our
> starting point was the types of documents retained permanently in a
> healthcare setting in the U.S.  Since many of these are transcribed and
> placed into electronic storage, the document metadata was developed into a
> TXA , "Transcription Header" segment.  A message about a document may
> include the TXA segment only, or the TXA segment with the document content
> in an OBX segment.  The committee's expectation was that the definition of
> "documents" would extend well beyond transcribed documents.
>
> The TXA metadata include individuals involved with the creation of the
> document, such as document originator and authenticator, and a
> differentiated legal authenticator.  The TXA also carries status
> information about the document, including the confidentiality of the
> document, and its maturity in an organization's processing of the
> document,
> both of which determine if a document can be viewed, and by whom.  These
> are the kinds of data which were discussed in the thread started by Sandy
> Boyer a couple of weeks ago.
>
> In response to Angelo's comments, below, I would suggest that Chapter 9
> defines his categories of document "kinds", and "headers".  The Order
> Communication committee has been dealing with Angelo's third category of
> "views", and the same OBX segment is used for text in the context of an
> order or result.
>
> My hope is that the SGML group can use the existing definitions as a
> starting point for the new process of applying a markup language to
> medical
> documents, and in turn, suggest places where the definitions are not
> adequate.
>
> There is a Medical Record - SGML joint working group session scheduled for
> the January meeting in Orlando.  We will be meeting on Wednesday morning,
> January 27, location TBA.  I look forward to this continuing dialogue, and
> to meeting as many of you as attend.
>
> Best regards,
>
> Anne Shanney
> Co-chair, Medical Record/Information Mgmt Committee
>
>
> IDX Systems, Inc
> 1001 Fourth Avenue Plaza, Suite 1500
> Seattle, WA 98154
> phone: (206)689-1102
> e-mail: anne_shanney@idx.com
>
>
>
>
>
>
> Rachael Sokolowski <rsokolowski@ITRUST.NET> on 10/29/98 02:21:53 AM
>
> Please respond to SGML special interest group of HL7
>       <SGML-HL7@listserv.duhc.duke.edu>
>
> To:   SGML-HL7
> cc:    (bcc: Anne Shanney/SEA/IDX1)
> Subject:  Re: types of documents
> Body:
>
>
>
> At 03:30 PM 10/29/98 +0100, Angelo wrote:
> >Just to clarify another issue:
> >
> >I feel naively that there are three groups of titles
> >(still partially overlapping in my mind),
> >each with many levels of granularity:
> >
> >- kinds of documents (e.g. discharge summary)
> >- headings of the record (e.g. family history)
> >- views (e.g. laboratory orders in progress).
> >
> >Perhaps my distinction is artificial, and difficult to apply.
> >Someone could assist me ?
> >
>
> I believe there are four groups: categories of documents first (report,
> summary, note, letter, list, etc.) and then kinds (perhaps specific
> instances?) of documents under each category (pathology report, discharge
> summary, nurse's notes, referral letter, current medications list, etc.).
> Then each category would have specific headings (letters would have
> salutations where as reports would not) and views which could be further
> specialized by the kind of document (pathology laboratory orders in
> progress) .
>
> I don't know if this helps or not, but this recommendation comes from a
> previous project where we defined  different types of documents for health
> care.
>
> ________________________________________________________________________
>
> Rachael Sokolowski
> Chief Scientist and Vice President of Research
> iTRUST
> Co-chair, HL7 SGML/XML SIG
> 8 Central St
> Arlington MA 02474
> VOICE: 781 646 8877
> FAX:   781 646 5377
>

-- END included message

-- BEGIN included message

Stan et al:

An interesting thread.  Here's my 2 cents worth:

In SNOMED 3.5, the closest thing to a "report type" that you will find is a
rather large (and widely scattered) set of procedures that (implicitly or
explicitly)  include a report as part of the procedure. 
E.g. "History and physical examination", "Progress note by physician",
"preparation of discharge summary", "preparation of disability evaluation
report", "health hazard appraisal", "spirometry including recording and report",
"evaluation of cardiac catheterization data and report", etc. etc. etc.

In order to create full logic-based definitions of these procedures in SNOMED
RT, we might consider creating a list of types of report (history, physical,
progress note, discharge summary, disability evaluation report, etc).
However, it seems much more logical to me to categorize the *action* or
*procedure* that is being performed, and index (code) reports based on that. 
Any report can then be encoded with a simple composition (report-of
procedure-x).

One might, in addition, create categories of reports of similar *structure*, and
of course certain procedures tend to be reported by a very scripted structure,
and the *content* of reports is something that may lend itself to
standarization.  Still, I think the *procedure* or *action* determines what
should be the content of the report (rather than the report type per se).  So a
codification of procedures makes a much more logical and useful starting point
than a codification of report types.  And of course SNOMED has a very
comprehensive (and growing) set of procedures and their definitions and
inter-relationships.

--Kent

>>> "Stan Huff" <COSHuff@ihc.com> 10/28/98 04:24pm >>>
Tim,
    As far as I know, clinical report types are not included in
SNOMED.  However, they might be there and I am just unaware.  I will
forward this message to Kent Spackman and see if he has additional
information.  -Stan

>>> Tim Brinson <tim@PROTOCOL.COM> 10/28/98 04:04PM >>>
Carpenter, Paul C., M.D. wrote:
>
> Question is to what level of detail such a list must encompass?
> Our current medical record has over 300 approved page types or
categories
> used in a paper record framework that has been in place for over 60
years.


Stan Huff wrote:
>
> Angelo,
>    How long do you want the list to be?  We (at IHC) have several
> hundred report types that we are actively using in our system.  Do
you
> want just major categories, or the more specific reports.


Stan, Paul, others,

Do you know of any (preferably publicly available) coding schemes
that
have codes for these?  It seems I have seen an entry in the DICOM
SNOMED
Microglosary that listed patient record catagories but never found
where
they showed up as indivivual codes.  Then again I don't have access
to
the full SNOMED.

Tim Brinson

-- END included message

-- BEGIN included message

Tim:
These are part of the SNOMED-DICOM microglossary *draft*. The values of Context
groups 51 and 52 have not yet been integrated into SNOMED.  They also are not
report types, with perhaps a few exceptions. 
--Kent

>>> Tim Brinson <tim@protocol.com> 10/28/98 05:17pm >>>
Stan,

I just found the document (printout) I was thinking of.  It is a set of
tables 16 pages long. It says "SNOMED DICOM MICROGLOSSARY CONTEXT GROUPS
-- Version 1.01" at the top of the first few pages.  The columns of the
table of interest say CID, CONTEXT CONCEPT, VALUE SET, SOURCE, TAG,
etc.   The two rows of interest here have CID 51 and 52.

51 | Patient record information  | {See Section C.6.8.1.1 for
   | categories, except physical | furhter definition. TPSQ=
   | observation categories      | PRI-SQ. Context Identifier#
   |                             | SDM102 includes the following
   |                             | terms (and others) } <then it
   |                             | lists 50 or so>


52 | Patient record information  | <lists ~100 categories>
   | categories, comprehensive   | 

Does this ring a bell with anyone?

Tim


Stan Huff wrote:
> 
> Tim,
>     As far as I know, clinical report types are not included in
> SNOMED.  However, they might be there and I am just unaware.  I will
> forward this message to Kent Spackman and see if he has additional
> information.  -Stan
> 
> >>> Tim Brinson <tim@PROTOCOL.COM> 10/28/98 04:04PM >>>
> Stan, Paul, others,
> 
> Do you know of any (preferably publicly available) coding schemes
> that
> have codes for these?  It seems I have seen an entry in the DICOM
> SNOMED
> Microglosary that listed patient record catagories but never found
> where
> they showed up as indivivual codes.  Then again I don't have access
> to
> the full SNOMED.

-- END included message

-- BEGIN included message

Folks,
   Here is a response from Kent Spackman that many of you may not
have recieved.  -Stan

>>> Kent Spackman <spackman@ohsu.edu> 10/28/98 06:08PM >>>
Stan et al:

An interesting thread.  Here's my 2 cents worth:

In SNOMED 3.5, the closest thing to a "report type" that you will
find is a
rather large (and widely scattered) set of procedures that
(implicitly or
explicitly)  include a report as part of the procedure. 
E.g. "History and physical examination", "Progress note by
physician",
"preparation of discharge summary", "preparation of disability
evaluation
report", "health hazard appraisal", "spirometry including recording
and report",
"evaluation of cardiac catheterization data and report", etc. etc.
etc.

In order to create full logic-based definitions of these procedures
in SNOMED
RT, we might consider creating a list of types of report (history,
physical,
progress note, discharge summary, disability evaluation report,
etc).
However, it seems much more logical to me to categorize the *action*
or
*procedure* that is being performed, and index (code) reports based
on that. 
Any report can then be encoded with a simple composition (report-of
procedure-x).

One might, in addition, create categories of reports of similar
*structure*, and
of course certain procedures tend to be reported by a very scripted
structure,
and the *content* of reports is something that may lend itself to
standarization.  Still, I think the *procedure* or *action*
determines what
should be the content of the report (rather than the report type per
se).  So a
codification of procedures makes a much more logical and useful
starting point
than a codification of report types.  And of course SNOMED has a
very
comprehensive (and growing) set of procedures and their definitions
and
inter-relationships.

--Kent

>>> "Stan Huff" <COSHuff@ihc.com> 10/28/98 04:24pm >>>
Tim,
    As far as I know, clinical report types are not included in
SNOMED.  However, they might be there and I am just unaware.  I will
forward this message to Kent Spackman and see if he has additional
information.  -Stan

>>> Tim Brinson <tim@PROTOCOL.COM> 10/28/98 04:04PM >>>
Carpenter, Paul C., M.D. wrote:
>
> Question is to what level of detail such a list must encompass?
> Our current medical record has over 300 approved page types or
categories
> used in a paper record framework that has been in place for over
60
years.


Stan Huff wrote:
>
> Angelo,
>    How long do you want the list to be?  We (at IHC) have several
> hundred report types that we are actively using in our system.  Do
you
> want just major categories, or the more specific reports.


Stan, Paul, others,

Do you know of any (preferably publicly available) coding schemes
that
have codes for these?  It seems I have seen an entry in the DICOM
SNOMED
Microglosary that listed patient record catagories but never found
where
they showed up as indivivual codes.  Then again I don't have access
to
the full SNOMED.

Tim Brinson

-- END included message

-- BEGIN included message

Folks,
   Here is a response from Kent Spackman that many of you may not
have recieved.  -Stan

>>> Kent Spackman <spackman@ohsu.edu> 10/28/98 06:08PM >>>
Stan et al:

An interesting thread.  Here's my 2 cents worth:

In SNOMED 3.5, the closest thing to a "report type" that you will
find is a
rather large (and widely scattered) set of procedures that
(implicitly or
explicitly)  include a report as part of the procedure.
E.g. "History and physical examination", "Progress note by
physician",
"preparation of discharge summary", "preparation of disability
evaluation
report", "health hazard appraisal", "spirometry including recording
and report",
"evaluation of cardiac catheterization data and report", etc. etc.
etc.

In order to create full logic-based definitions of these procedures
in SNOMED
RT, we might consider creating a list of types of report (history,
physical,
progress note, discharge summary, disability evaluation report,
etc).
However, it seems much more logical to me to categorize the *action*
or
*procedure* that is being performed, and index (code) reports based
on that.
Any report can then be encoded with a simple composition (report-of
procedure-x).

One might, in addition, create categories of reports of similar
*structure*, and
of course certain procedures tend to be reported by a very scripted
structure,
and the *content* of reports is something that may lend itself to
standarization.  Still, I think the *procedure* or *action*
determines what
should be the content of the report (rather than the report type per
se).  So a
codification of procedures makes a much more logical and useful
starting point
than a codification of report types.  And of course SNOMED has a
very
comprehensive (and growing) set of procedures and their definitions
and
inter-relationships.

--Kent

>>> "Stan Huff" <COSHuff@ihc.com> 10/28/98 04:24pm >>>
Tim,
    As far as I know, clinical report types are not included in
SNOMED.  However, they might be there and I am just unaware.  I will
forward this message to Kent Spackman and see if he has additional
information.  -Stan

>>> Tim Brinson <tim@PROTOCOL.COM> 10/28/98 04:04PM >>>
Carpenter, Paul C., M.D. wrote:
>
> Question is to what level of detail such a list must encompass?
> Our current medical record has over 300 approved page types or
categories
> used in a paper record framework that has been in place for over
60
years.


Stan Huff wrote:
>
> Angelo,
>    How long do you want the list to be?  We (at IHC) have several
> hundred report types that we are actively using in our system.  Do
you
> want just major categories, or the more specific reports.


Stan, Paul, others,

Do you know of any (preferably publicly available) coding schemes
that
have codes for these?  It seems I have seen an entry in the DICOM
SNOMED
Microglosary that listed patient record catagories but never found
where
they showed up as indivivual codes.  Then again I don't have access
to
the full SNOMED.

Tim Brinson

-- END included message

-- BEGIN included message

Dear friends,
thanks again for the contribution.

You can find a summary of the discussion at:
ftp://gift.irmkant.rm.cnr.it/PT27termlist/PT27N35typesOfDoc01.htm

The original WOrd97 document is:
ftp://gift.irmkant.rm.cnr.it/PT27termlist/PT27N35typesOfDoc01.doc

Angelo





---------------------------------
Angelo Rossi Mori, Reparto Informatica Medica,
Istituto Tecnologie Biomediche, CNR
viale Marx 15, I-00137, Roma, Italy
http://gift.irmkant.rm.cnr.it/termhome.htm


NOTE NEW NUMBERING SYSTEM IN ITALY:
tel. + 39 - 06 827 71 01; fax + 39 - 06 827 36 65

-- END included message

-- BEGIN included message

Dear friends,
the interested people can find a revised proposal for the list
(trying to merge contributions up to know) at:
ftp://gift.irmkant.rm.cnr.it/PT27termlist/PT27r01tableA1v1.3.doc
ftp://gift.irmkant.rm.cnr.it/PT27termlist/PT27r01tableA1v1.3.htm

The involved table is AA2.
If you have other suggestions or can send to me detailed lists
of "page types", I'll try to refine that list.

Thanks

Angelo





---------------------------------
Angelo Rossi Mori, Reparto Informatica Medica,
Istituto Tecnologie Biomediche, CNR
viale Marx 15, I-00137, Roma, Italy
http://gift.irmkant.rm.cnr.it/termhome.htm


NOTE NEW NUMBERING SYSTEM IN ITALY:
tel. + 39 - 06 827 71 01; fax + 39 - 06 827 36 65

-- END included message

-- BEGIN included message

I am having trouble accessing these documents.  Any chance you could
email them to me?
 
Thanks.

-----Original Message-----
From: Angelo Rossi Mori [mailto:rossi@COLOR.IRMKANT.RM.CNR.IT]
Sent: Thursday, October 29, 1998 11:43 AM
To: SGML-HL7@listserv.duhc.duke.edu
Subject: Re: types of documents; revised proposal



Dear friends, 

the interested people can find a revised proposal for the list 

(trying to merge contributions up to know) at: 

ftp://gift.irmkant.rm.cnr.it/PT27termlist/PT27r01tableA1v1.3.doc 

ftp://gift.irmkant.rm.cnr.it/PT27termlist/PT27r01tableA1v1.3.htm 


The involved table is AA2. 

If you have other suggestions or can send to me detailed lists 

of "page types", I'll try to refine that list. 


Thanks 


Angelo 






--------------------------------- 

Angelo Rossi Mori, Reparto Informatica Medica, 

Istituto Tecnologie Biomediche, CNR 

viale Marx 15, I-00137, Roma, Italy 

http://gift.irmkant.rm.cnr.it/termhome.htm 



NOTE NEW NUMBERING SYSTEM IN ITALY: 

tel. + 39 - 06 827 71 01; fax + 39 - 06 827 36 65

-- END included message

-- BEGIN included message

here are the attachments.

You can download the next versions from:
ftp://gift.irmkant.rm.cnr.it/PT27termlist/

Thanks


Angelo Rossi Mori


PT27N35typesOfDoc03.doc

PT27r01tableA1v1.4.doc




---------------------------------
Angelo Rossi Mori, Reparto Informatica Medica,
Istituto Tecnologie Biomediche, CNR
viale Marx 15, I-00137, Roma, Italy
http://gift.irmkant.rm.cnr.it/termhome.htm


NOTE NEW NUMBERING SYSTEM IN ITALY:
tel. + 39 - 06 827 71 01; fax + 39 - 06 827 36 65

-- END included message

-- BEGIN included message

A thought:

What about Authorizations for Treatment?

Frank

-- END included message

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