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CDA R3 Legal Authentication

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Return to SDTC page; Return to CDA R3 Formal Proposals page.

See CDA R3 Formal Proposals for instructions on using this form. Failure to adhere to these instructions may result in delays. Editing of formal proposals is restricted to the submitter and SDTC co-chairs. Other changes will be undone. Comments can be captured in the associated discussion page.

Submitted by: Calvin Beebe Revision date: Jul7 27, 2009
Submitted date: July 27, 2009 Change request ID: <<Change Request ID>>


Need to clarify the scope of Legal Authentication.

1. Section on entry The narrative of each Section, together with the multimedia content referenced in the narrative, comprises the complete authenticated content of the Section.

2. Section 4.4.1 Overview of CDA Context Where we indicate the Legal Authenticator's participation spans the whole document.

How can the section.text comprises the complete authenticated content of the Section, when the Legal Authentication spans into the section.entry clinical statement model?


Proposal: Tweak the statements in Section 4.4.1 to indicate that the Legal Authenication spans the whole document's narrative representation. Look at adding additional examples of participation on the entries in the standard. These examples would clarify the proper modeling for a number of use cases related to entries. These additional use cases and types of participation represent distinct relationships to content and do not affect legal authentication.

4 use cases were proposed:

Natural Language Processing (NLP) content placed in the document.
Structured Entries from content captured via discrete entry by authors.
Summary Entries (extraction documents) examples are CCD.
Abstractor Entries where codes are added to the document. 


Revised based upon discussion.


Recommended Action Items

Recommend that we adopt this clarification for CDA R3.


Against: 0; Abstain: 1; In favor: 9 (passed, August 11, 2009)