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Product Brief - HL7 V3 Domain: Medical Records

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Product Name

HL7 V3: Medical Records/Information Management

Topics

  • Document Management
  • Document Query
  • Data Consent
    • ANSI/HL7 V3 MRDACM, R1-2008: HL7 Version 3 Standard: Medical Records; Data Access Consent, Release 1 - 11/10/2008
    • Composite Privacy Consent Directive, R2 (Informative)

Standard Category

  • Health Information Exchange Standards

Integration Paradigm

  • Messaging

Type

  • Normative, ANSI Standard (Release 1)
  • DSTU (Release 2, expired May 2008)

Releases

  • ANSI/HL7 V3 RCMR, R1-2006; HL7 Version 3 Standard: Medical Records/Information Management, Release 1 - 11/3/2006
  • HL7 V3 RCMR, R2-2006 - HL7 Version 3 Standard: Medical Records/Information Management, Release 2; 2006
  • ANSI/HL7 V3 MRDACM, R1-2008: HL7 Version 3 Standard: Medical Records; Data Access Consent, Release 1 - 11/10/2008; Composite Privacy Consent Directive, R2

Summary

The Medical Records standard defines the messages used to manage, organize, exchange and query documents.

Description

The Medical Records domain currently supports clinical document management, and document querying. In the future, it is intended also to support the data exchange needs of applications supporting other medical record functions, including chart location and tracking, deficiency analysis, consents, and release of information. The main purpose of the medical record is to produce an accurate, legal, and legible clinical document that serves as a comprehensive account of healthcare services provided to a patient, and which has the following characteristics:

Persistence: A clinical document continues to exist in an unaltered state, for a time period defined by local and regulatory requirements.

Stewardship: A clinical document is maintained by an organization entrusted with its care.

Potential for authentication: A clinical document is an assemblage of information that is intended to be legally authenticated.

Wholeness: Authentication of a clinical document applies to the whole and does not apply to portions of the document without the full context of the document.

Human readability: A clinical document is human readable.

These interactions are mainly associated with documents that will be or have been transcribed. The types and appearance of the transcribed documents can vary greatly within a healthcare organization and between organizations. However, the main purpose of the transcription process is to document patient care or diagnostic results in a legible manner; these documents then become part of the legal medical record.

Business Case (Intended Use, Customers)

Healthcare Providers, Healthcare IT Vendors, EHR Systems, Transcription Systems, Departmental Systems

Benefits

Provides a standards means of communicating clincial documents between transcription systems ad medical record systems. Also enables querying clinical document support from EHR systems for various use cases.

Implementations/ Case Studies (Actual Users)

Canada Health Infoway (CHI), UK National Health Service (NHS)

Resources

Work Groups

Structured Documents

Education

Presentations

Relationship to/ Dependencies on, other standards

Links to current projects in development



Product Name- HL7 Version 3 Standard: Medical Records; Data Access Consent, Release 1

Topics

Data Access Consent, Release 1

Standard Category

  • Health Information Exchange Standards

Integration Paradigm

  • Messaging

Type

  • Normative, ANSI Standard (Release 1)

Releases

  • ANSI/HL7 V3 MRDACM, R1-2008: HL7 Version 3 Standard: Medical Records; Data Access Consent, Release 1 - 11/10/2008; Composite Privacy Consent Directive, R2

Summary

The Data Consent topic CMET and messages will allow patients to consent to their health information being collected, accessed, used or disclosed, or to rescind such consent. There is support for health care providers to gain emergency access and support for patients to utilize a 'shared secret' in managing their consents. Used in conjunction with the masking messages from the Shared Message Domain, the Data Consent messages will provide patients the appropriate tools to manage their health information. This version of the document includes improved documentation, vocabulary, business name changes for the Shared secret as agreed in reconciliation.

Description

Business Case (Intended Use, Customers)

Healthcare Providers, Healthcare IT Vendors, EHR Systems, Transcription Systems, Departmental Systems

Benefits

Implementations/ Case Studies (Actual Users)

Resources

Work Groups

Community Based Collaborative Care (CBCC)

Education

Relationship to/ Dependencies on, other standards

Links to current projects in development

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