Revision Details of Coded Values

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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: Victor Brodsky Revision date: 11/19/2009
Submitted date: 11/19/2009 Change request ID:

Issue

For pre-coded reports there is no way to document revisions of code values, who made the revisions and when

Recommendation

Add a tag similar to content tag for the code block, or provide another way to keep previous code values along with revisedBy= and timestamp attributes

Rationale

If the entire document is mostly a check list of pre-coded structured data values, as it should be in pathology, and is first filled out by a resident and subsequently changed by an attending physician, this would allow to maintain a trail array of previous values for codes (which along with revisedBy="" and timestamps above would give an editing trail for a structured document. These trails can be maintained for tracking resident performance, internal audits and reports and be stripped out before the CDA document instance is sent out.

Discussion

Recommended Action Items

Resolution

June 8, 2010 SDWG: Agree with requirement to track entry-level revisions. Will be covered by change in right hand side of model, so no additional action required here.

For narrative revision tracking, where there is the ability to show revision markup that spans versions (e.g. similar to what can be done in a commercial word processor with revision tracking), our sense is that the modeling will be complex. We'd like to put this in the category of "consider for future use", where we'd embark on the detailed design once we have a better sense of where and by whom it would be used.

opposed: 0; abstain: 0; in favor: 9

Note on disposition from Grahame: in CDA R3, it will be possible to track narrative revisions by the provision of multiple copies of the narrative in the entries - the note above concerns internal revision tracking in the narrative.