Evidentiary Medical Records
The Evidentiary Medical Records Projects is intended to establish a solid foundation/framework for legal health records using standard-based management and interchange. The project will define
- Reusable framework for a variety of care settings
- Metadata regarding the clinical context of medical records
- Management of records rather than individual data elements; records that may be maintained for legal and disclosure purposes
- “Closed records” must have the following elements
- Records passed from one organization to another
- Historical/longitudinal records
- Analyzed the EHRS Functional Model to identify any missing information or metadata
This project will produce an informative Conceptual/Domain Analysis Model focused on the set of information required for evidentiary purposes. The initial informative ballot will be followed by a DSTU Platform Independent Specification and a CDA R2 Implementation Guide DSTU. After a trial period the CDA IG will be balloted as a normative specification.
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