Representing patient assessments in LOINC®

Abstract

Without being included in accepted vocabulary standards, the results of completed patient assessment instruments cannot be easily shared in health information exchanges. To address this important barrier, we have developed a robust model to represent assessments in LOINC through iterative refinement and collaborative development. To capture the essential aspects of the assessment, the LOINC model represents the hierarchical panel structure, global item attributes, panel-specific item attributes, and structured answer lists. All assessments are available in a uniform format within the freely available LOINC distribution. We have successfully added many assessments to LOINC in this model, including several federally required assessments that contain functioning and disability content. We continue adding to this "master question file" to further enable interoperable exchange, storage, and processing of assessment data.