Condition, diagnosis, or reason for seeking medical attention.

Data Element
Date of First Noted/Documented
Description

Date of first noted/documented by a qualified professional of the presence of a problem or condition affecting a patient.
Submitted By: Tayler Williams / American Medical Informatics Association (AMIA)
Data Element Information
Use Case Description(s)
Use Case Description Date of Diagnosis and Resolution does not account for the history of the problem/diagnosis/concern. Date of first noted/documented to show historical care would assist in cleaning up the data for reconciliation process.
Estimate the breadth of applicability of the use case(s) for this data element To understand the journey of a diagnosis for a patient, knowing not just when a patient was diagnosed but when the symptoms were first noted can assist in reconciliation and providing a comprehensive timeline.
ONC Priority
  • Mitigate health and health care inequities and disparities
  • Address the needs of underserved communities
  • Address public health interoperability needs of reporting, investigation, and emergency response
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) Standard Date/Time formats
Additional Specifications N/A
Current Use (Level 1) Captured, stored, or accessed in at least one production EHR or HIT module
Extent of exchange N/A
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) There could be restrictions on the standardization of this data element and class with potential use of proprietary code used by an EHR.
Restrictions on Use (e.g. licensing, user fees) We are not aware of any restrictions on the use of this data element.
Privacy and Security Concerns Medical data used by an individual and health care organization contains sensitive information and should be held to a standard of privacy for health care and only securely transferred.
Estimate of Overall Burden There could be a burden of time for health systems that do not currently capture notes from care team members that are prior to the later initial diagnosis. The EHR systems could be burdened in developing software to allow the ability to capture this information.
ONC Evaluation Details
Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1
Maturity - Current Standards		 Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2
Maturity - Current Use 		Level 1 - Data element is captured, stored, or accessed in at least one production EHR or HIT module.
Criterion #3
Maturity - Current Exchange		 Level 0 - Data element is electronically exchanged in limited environments, such as connectathons or pilots.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 0 - Use cases apply to a limited number of care settings or specialties, or data element represents a specialization of other, more general data elements.
Evaluation Comment This data element represents a concept similar to the published data element Date of Diagnosis in the Problems data class in USCDI v4.

Comment

Log in or register to post comments