Negation Requirements Project Minutes 4 May 2016
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|HL7 PC-CIMI-POC Meeting Minutes
Location: PC call line
Time: 11:00-12:00 ET
|Facilitator||Jay Lyle||Note taker(s)||Jay Lyle|
|y||Jay Lyle||JP Systems|
|Ron Van Duyne|
- Quality case
- Continue with classification
- No quorum; information only
- PSS delivered to DESD
- Principles moved from minutes to a wiki page
- Glossary started
- CQI: if an action is not recorded as done, this is not clinically sufficient evidence it wasn't done. You still have to ask about aspirin before assuming it was or was not given. But when calculating a measure, there is no one to ask. One has to assume it was not done. (The measure may be sophisticated enough to identify exceptions, but it may not.)
- Charting by exception is a critical topic
- Assume things are normal unless stated otherwise
- Radiology does this explicitly: report is pre-populated with negative findings appropriate to modality & site (e.g., CXR: no mediastinal widening). Radiologists modify those elements found and need not record the negatives.
- Other contexts may not be so explicit: Review of Systems normal may imply several absent pathologies, but unless you know the ROS protocol for the location, you can't tell what they are.
- Open question of what to do with this.
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