NEHTA Clinical Documents: Exclusion Statements 2

Aug 15, 2012

As promised in the last post, this is a summary of the sections in the 5 main clinical documents, which sections are required to be present, and which have exclusion statements: |Section|Required?|Exclusion Statement? |SHS |Adverse Reactions|Yes|Yes |Medications|Yes|Yes |Medical History|Yes|Yes (2) |Immunisations|Yes|Yes ||| |e-Referral |Referral Detail|Yes|N/A |Medical History|Yes|No |Medications|Yes|Yes |Adverse Reactions|Yes|Yes |Diagnostic Investigations & sub-sections|No|No ||| |Specialist Letter |Response Details|Yes|N/A |Recommendations|Yes|Yes |Medications|Yes|Yes |Newly Identified Adverse Reactions|No|No |Diagnostic Investigations & sub-sections|No|No ||| |Event Summary |Event Details|No|No |Newly Identified Adverse Reactions|No|No |Medications|No|No |Diagnoses/Interventions|No|No |Immunisations|No|No |Diagnostic Investigations & sub-sections|No|No ||| |Discharge Summary |Clinical Synopsis|Yes|N/A |Problems/Diagnoses this visit|Yes|Yes |Clinical Interventions Performed|No|No |Current Medications|Yes|Yes |Ceased Medications|Yes|Yes |Adverse Reactions|Yes|Yes |Alerts|No|No |Arranged Services|No|No |Record of Recommendations|Yes|No |Diagnostic Investigations & sub-sections|No|No

Generally, mandatory sections have exclusion statements. There’s a few exceptions, where the requirements analysis has indicated that there is always (or should be always) at least one value, and so the mandatory sections don’t allow exclusion statements. For instance, a discharge summary must have at least one recommendation. And notably - e-Referral Medical History. Another kind of exception is the clinical synopsis type sections, which are free formatted text - there’s no sense having exclusion statements for them.

Generally, optional sections don’t have exclusion statements; you just leave the section out. Since this leaves a clinical message gap, I think this will be reviewed for the next release (some time next year, maybe?).

The other document types (Advance Care Directive, Consumer Documents, and the Medicare documents) don’t have exclusion statements in them - though I personally think that there should be exclusion statements for medications and adverse reactions in the Consumer Entered Health Summary.