Health Story: Unstructured Documents

The page will support the development of an Implementation Guide for CDA Release 2, Unstructured Documents, for the January 2010 ballot cycle.

This project will provide guidance for sending/receiving unstructured clinical documents including images, scanned documents, faxed and word processor output.

Development

Header Review

• Material to be added

Body Review

• Material to be added

Reference Material

• Project Scope Statement

IHE

IHE XDS-SD is included under ITI

• IT Infrastructure Technical Framework

Description of IHE XDS-SD section 2.2.17 and use cases in Chapter 20

• IT Infrastructure Technical Framework Vol. 1 (ITI TF-1)

XDS-SD requirements analysis spreadsheet

• XDS-SD_Requirements.xls

Pertinent CDA Guides

• Care Record Summary (CRS)
• History and Physical (H&P) Notes
• Operative Notes
• Consult Notes
• Imaging Integration; Basic Imaging Reports in CDA and DICOM (membership required)
• Continuity of Care Document (CCD) (membership required)

Education

Quick Start Guides

• CDA Quick Start Guide (v1.5)

This Quick Start Guide supports implementers working with simple CDA documents. It covers required elements in the CDA header and body and explains fundamental concepts including the CDA approach to identifiers, vocabulary and data types.

• Continuity of Care Document (CCD) Quick Start Guide (v1.0)

This Quick Start Guide is for implementers working with the Continuity of Care Document (CCD). If not already familiar with the underlying Clinical Document Architecture Release 2.0 (CDA R2) standard, readers should also take advantage of the CDA Quick Start Guide available here.

• Care Record Summary (CRS) Quick Start Guide (v1.0)

This Quick Start Guide is for implementers working with the Care Record Summary (CRS).