Eight Mandatory Medical Record Categories:
The eight (8) types of clinical notes that must be shared are outlined in the United States Core Data for Interoperability (USCDI) include:
- Consultation Notes
- Discharge Summary Notes
- History & Physical
- Imaging Narratives
- Laboratory Report Narratives
- Pathology Report Narratives
- Procedure Notes
- Progress Notes
Information Blocking Exceptions:
Information Blocking Exceptions include:
- Preventing Harm
- Privacy
- Security
- Infeasibility
- Health IT Performance
- Content and Manner
- Fees
- Licensing
