CDA R2 Implementation Guides in Development

May 2008 Ballots

Operative Notes Release 1

The operative note is under ballot for the Spring 2008 working group. The Operative Note is a frequently used type of procedure note with very specific requirements set forth by regulatory agencies. The Operative Note or Report is created immediately following a surgical or other high-risk procedure and records the pre and postsurgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure.

Plan-to-Plan Personal Health Record Data (P2PPHR) Transfer Release 1

The P2PPHR implementation guide is a constraint on the Continuity of Care Document (CCD) for sharing Personal Health Records (PHR) being managed by insurance plans.

Imaging Integration; Basic Imaging Reports in CDA and DICOM, Release 1

The Diagnostic implementation guide is intended to support the exchange of Diagnostic Imaging Reports. A Diagnostic Imaging Report contains a consulting specialist’s interpretation of image data. It is intended to convey the interpretation to the referring (ordering) physician, and becomes part of the patient’s medical record. It is intended for use in Radiology, Endoscopy, Cardiology, and other imaging specialties.

Draft Standard for Trial Use (DSTU)

History and Physical

The H&P implementation guide passed DSTU ballot in January 2008. An H&P Note is a two-part medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status. The information forms the basis of most treatment plans.

Consultation Notes

The Consultation implementation guide passed DSTU ballot in January 2008. For the purpose of the Implementation Guide, a consultation visit is defined by the evaluation and management guidelines for a consultation established by the Centers for Medicare and Medicaid Services (CMS). According to those guidelines, a Consultation Note must be generated as a result of a physician or nonphysician practitioner’s (NPP) request for an opinion or advice from another physician or NPP.

Healthcare Associated Infections (HAI) (updated DSTU ballot September 2008)

The HAI implementation guide for submission of HAI reports to the National Health Safety Network (NHSN) of the Center for Disease Control and Prevention (CDC) passed DSTU ballot in January 2008. The guide includes four forms for reporting: Bloodstream Infections (BSI), Surgical Site Infections (SSI), Procedure Denominator and the ICU Denominator. The September ballot will include updates to the SSI, BSI and include the new form Multi-Drug Resistant Organisms (MDRO).