Are nursing, pharmacy, or other professions’ clinical notes included in the definition of “electronic health information”?

Yes. Electronic health information (EHI), as defined in 45 CFR 171.102, does not specifically include or exclude notes or other clinical observations based on the type or specialty of the professional who authors them.

Until October 6, 2022, EHI’s scope for purposes of the information blocking definition (45 CFR 171.103) is limited to that information represented by data classes and elements within the United States Core Data for Interoperability (USCDI). Therefore, until October 6, 2022, only those notes that map to any of the eight types specified in the “Clinical Notes” data class within the USCDI would be required to be included in a response to a request for legally permissible access, exchange, or use of EHI. However, actors (health care providers, health IT developers of certified health IT, and health information networks or health information exchanges) should bear in mind that none of the eight types of clinical notes currently represented within the USCDI are limited based on the type or specialty of the professional who authors them.

Please review the other questions under this heading for more information.