Revised Event Types: Post Big Sky 2002 (16 Total)

Revised Event Types: Post Big Sky 2002 16 Total

CLASS

Event type/subtype

Event name

ETHICAL/LEGAL
/

CNS-Consent for Treatment*

CNS - Consent for Treatment

Includes patient’s informed consent for treatment and procedures.
Could be used in future re: granting permission for electronic access to records

SEN-Study Consent & Enrollment*

SEN - Study Consent & Enrollment

A note generated for the purpose of documenting an encounter with a patient where the focus of the encounter was discussion and/or signing of consent forms for patient to enter into a research protocol(s). Notes with this event type will include only a statement that a person has consented to and enrolled in a research study. They will not contain any significant clinical information. If a patient agrees to participate in a research study during the course of an examination, the care provider will create two notes: one containing the clinical information and the other containing the consent.
ADV-Advance Decisions for Treatment / ADV - Advance Decisions
for Treatment
Advance directives, code status
Includes advance directives regarding treatment, the withholding of such, and the patient’s granting of permission to another to make such decisions.
Includes directives related to the management of:
Respiratory status
Pain
Nutritional status

ETH– Ethical Emphasis

ETH – Ethical Emphasis

Includes documentation with an ethical &OR legal emphasis. May include elements of an EM &OR SV. ETH documents contain information pertinent to:
Health care proxy
Power of attorney
Court appointed guardianship
Court ordered commitments, treatment & holds
Seclude & restrain &OR other involuntary restrictions

NOTES

EM – Evaluation & Management

/ EMN – Evaluation & Management
This can be used to indicate a general type of service. It can can be used as the event type for a comprehensive H&P, for example (which would be further specified in the Focus part of the component axis.) Also, EM can be used when ambiguity exists in the evaluation &OR management aspect of the document. For example, if the original name is ‘Medicine Note’, or ‘Diabetes Clinic Visit, assignment of the EMN event type would be appropriate. Has sub-types ADM, SV, EDV, CON, CNF & SUP.

ADM - Admission

ADM – Admission

This event type is associated with information about &OR obtained during the admssion process. Includes admission assessment, admission note, admission H&P, for example. For example: ADM.Assessment, AMD.Endocrinilogy.)

SV- Subsequent

Visit

SV- Subsequent Visit

An encounter that is part of a series of encounters initiated by an ADM, SV, or CON. It is used in the sense of the ‘follow-up’ visit for reassessment, summarization, completion of evaluations, or treatment planning started in an ADM or CON encounter. The SV may or may not have exam elements.

CON – Consult

This designation is used when the encounter was based on a referral from another health provider, internal or external to the current practice location - or - is a confirmatory assessment (consultation) sought by another provider, or the patient with the knowledge of the patient’s provider, i.e., second opinion, etc. It does not define the extent of the evaluation or examination elements recorded. Individual specialties will have what are deemed to be required elements for quality or business purposes to define a comprehensive evaluation for that specialty. CON will often imply a comprehensive examination was done but need not be exclusively that.

EDV- Educational

Visit

EDV – Educational Visit

This event type is used when a care provider meets with a patient solely to educate him or her. An example would be a session in which a nurse teaches a patient how to manage asthma or how to use a blood pressure cuff. Other types of patient encounters may include an educational component, but EDV indicates that the visit was devoted entirely to education.

CNF - Conference

encounter

CNF - Conference encounter

Encounter where patient is seen by more than one provider for the purpose of gathering more than one opinion about diagnosis or management options. A single author is responsible for the document but the other participants names should be included.

SUP –

Supervisory

/ SUP – Supervisory
Event type used by supervising staff for their note which they generate when serving a supervisory role while working with resident, PA, CNP, student or other practitioner. The event type is designed to be used when two documents are created for a single patient encounter

SUM – Episode Summary

A summarization of one or more encounters which describes the assessment and care of the patient over a period of time. It can be focused on:
-the traditional inpatient care process - a hospitalization and the Hospital Dismissal Summary;
-summarizing the patient’s health status for the purpose of hospital transfer of care to another provider team, transfer to extended care facility, transfer from remote facility to the hospital, etc.
-discharge from out-patient care, for example: from ambulatory surgery or if released from a provider`s ambulatory care in general, for example.

THP- Therapy**

/ THP - Therapy
This event_type is used when documenting an encounter in which the primary focus of the visit is for a non-invasive therapeutic intervention. E.g., respiratory therapy, physical therapy, occupational therapy, etc.

Procedure Report

RPT – Report

This is the documentation of finding(s) &OR observations with associated interpretation regarding a specific patient in the context of a test or procedure. It may also include certain information derived during or from the procedure or test.
CMO – Communication Other /

IDC- Indirect Communication

/ IDC - Indirect Communication
Designation given to documentation of discrete information about a patient’s care without a face-to-face encounter. The note content can concern reporting to the patient, or their agent, test or other results via non-direct contact modalities, e.g., phone, FAX, e-mail, etc. Also, this event type can be used when obtaining informatation from the patient, or their agent. This can include documentation of telephone triage and CAPD by phone, for example.

LTR – Letter /Correspondence

/ LTR – Letter /correspondence
A document generated for the purpose of communications with patient, their families or other providers external to the care facility. The form is usually the traditional “letter” with or without suitable informational attachments. One of the most common uses is communication of summary or evaluation and/or management to external parties.

REF - Referral

/ REF- Referral
A document generated for the purpose of requesting care for a patient from a provider/type of provider.

*Not using CNS or SEN in current set of names. Instead using old type, CEN, which includes both CNS and SEN as defined in this doument. Please comment on the proposed use of CNS and SEN vs. CEN.

**THP (Therapy) type is not meant to be a sub-type of Notes, couldn’t get anything to insert into that cell-a snafu. Furthermore, still figuring out a good name for a super-type for THP &OR RPT (Report.)