Product CDA R2 IG CommonClinDocs

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Product Brief - CDA R2 Implementation Guides for Common Clinical Documents

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Other CDA R2 Implementation Guides at Product CDA R2 IG



Product Name - CDA R2 IG Consult Note

  • HL7 Implementation Guide for CDA Release 2: Consult Notes, Release 1; DSTU ending August 2010

Type

DSTU

Releases

Release 1

Summary

This DSTU describes how CDA is used to record information for a Consult Note. The Consult Note may contain both narrative and coded data.

See http://www.healthstory.com/standards/sec/consult_note.htm

Business Case (Intended Use, Customers)

  • Healthcare Providers,
  • Healthcare IT Vendors,
  • EHR Systems,
  • Transcription/Dictation Systems,
  • Departmental Systems

Benefits

Integrating narrative notes into the EHR is a key benefit as is the fact that it supports meaningful use with minimal change to current practice.

Implementations/ Case Studies (Actual Users)

coming soon

Resources

Work Groups

Relationship to/ Dependencies on, other standards

  • CDA

Links to current projects in development

  • none



Product Name - CDA R2 IG H&P

  • HL7 Implementation Guide for CDA Release 2: History and Physical (H&P) Notes, Release 1; DSTU ending August 2010

Type

DSTU

Releases

Release 1

Summary

This DSTU describes how CDA is used to record information for a History and Physical Note. The History and Physical Note may contain both narrative and coded data.

See http://www.healthstory.com/standards/sec/history_physical.htm

Business Case (Intended Use, Customers)

  • Healthcare Providers,
  • Healthcare IT Vendors,
  • EHR Systems,
  • Transcription/Dictation Systems,
  • Departmental Systems

Benefits

Integrating narrative notes into the EHR is a key benefit as is the fact that it supports meaningful use with minimal change to current practice.

Implementations/ Case Studies (Actual Users)

coming soon

Resources

Work Groups

Relationship to/ Dependencies on, other standards

  • CDA

Links to current projects in development

  • none


Product Name - CDA R2 IG Operative Note

  • HL7 Implementation Guide for CDA Release 2: Operative Notes, Release 1; DSTU ending Mar 2011

Type

DSTU

Releases

Release 1

Summary

This DSTU describes how CDA is used to record information for an Operative Note. The Operative Note may contain both narrative and coded data.

See http://www.healthstory.com/standards/sec/op_note.htm

Business Case (Intended Use, Customers)

  • Healthcare Providers,
  • Healthcare IT Vendors,
  • EHR Systems,
  • Transcription/Dictation Systems,
  • Departmental Systems

Benefits

Integrating narrative notes into the EHR is a key benefit as is the fact that it supports meaningful use with minimal change to current practice.

Implementations/ Case Studies (Actual Users)

coming soon

Resources

Work Groups

Relationship to/ Dependencies on, other standards

  • CCD, CDA

Links to current projects in development

  • none




Product Name - CDA R2 IG Procedure Note

  • HL7 Implementation Guide for Clinical Document Architecture, Release 2: Procedure Note, Release 1; DSTU ending July 2012

Type

DSTU

Releases

Release 1

Summary

This project is to design a basic procedure note in XML as a constraint on HL7 v3 CDA r2. The note is basic enough to be used for all procedures and has developed a sample note for endoscopy. To promote standardization and acceptance, it is closely modeled on the current HL7 CDA Operative Note. CMS and JCAHO requirements, with specialty group input, were used to choose the contents.

Business Case (Intended Use, Customers)

The audience for this document includes software developers, consultants, and clinicians responsible for implementation of Electronic Health Record (EHR) systems, Personal Health Record (PHR) systems, dictation/transcription systems, and document management applications, and local, regional, and national health information exchange networks that wish to create and/or process CDA documents developed according to this specification.

  • Healthcare Providers,
  • Healthcare IT Vendors,
  • EHR Systems,
  • Transcription/Dictation Systems,
  • Departmental Systems

Benefits

Integrating narrative notes into the EHR is a key benefit as is the fact that it supports meaningful use with minimal change to current practice.

Implementations/ Case Studies (Actual Users)

coming soon

Resources

Work Groups

Relationship to/ Dependencies on, other standards

  • CDA R2

Links to current projects in development



Product Name - CDA R2 IG Progress Note

  • HL7 Implementation Guide for CDA Release 2: Progress Note, Release 1 (US realm)


Type

DSTU balloted 2010Sept cycle

Releases

Release 1

Summary

A Progress Note documents a patient’s clinical status during a hospitalization or outpatient visit, thus is associated with an encounter. The method used to develop the Progress Note included a review of industry precedents and requirements. The Progress Note is built on CDA templates as the reusable unit of standards-based exchange and interoperability.

Business Case (Intended Use, Customers)

The audience for this document includes software developers, consultants, and clinicians responsible for implementation of Electronic Health Record (EHR) systems, Personal Health Record (PHR) systems, dictation/transcription systems, and document management applications, and local, regional, and national health information exchange networks that wish to create and/or process CDA documents developed according to this specification.

  • Healthcare Providers,
  • Healthcare IT Vendors,
  • EHR Systems,
  • Transcription/Dictation Systems,
  • Departmental Systems

Benefits

Integrating narrative notes into the EHR is a key benefit as is the fact that it supports meaningful use with minimal change to current practice.

Implementations/ Case Studies (Actual Users)

This Draft Standard for Trial Use (DSTU) was produced and developed through the Health Story Project. The project was initiated by the Association for Healthcare Documentation Integrity (AHDI), Medical Transcription Industry Association (MTIA), American Health Information Management Association (AHIMA), and M*Modal and is being managed by Alschuler Associates, LLC and Optimal Accords, LLC.

Resources

Work Groups

Education: see www.healthstory.com.


Relationship to/ Dependencies on, other standards

  • CDA R2

Links to current projects in development