Evidentiary Medical Records

Project Summary

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

The intent of this project is to create and maintain one generic Detailed Clinical Model that defines the main concepts of using medical device related data safely and traceably in for patient care. This DCM is intended to be reused in other domains where devices play a role in assessment and treatment. 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.

Project Team

• Beth Acker
• Harry Rhodes
• Nancy LeRoy
• Don Mon
• Michelle Dougherty
• Ioana Singureanu

Meeting Information

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Template for Meeting Minutes (Evidentiary Medical Records Project)