CDA R3 Legal Authentication

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Submitted by: Calvin Beebe	Revision date: Jul7 27, 2009
Submitted date: July 27, 2009	Change request ID: <<Change Request ID>>

Issue

Need to clarify the scope of Legal Authentication.

1. Section 4.3.4.2 on entry The narrative of each Section, together with the multimedia content referenced in the narrative, comprises the complete authenticated content of the Section.

2. Section 4.4.1 Overview of CDA Context Where we indicate the Legal Authenticator's participation spans the whole document.

How can the section.text comprises the complete authenticated content of the Section, when the Legal Authentication spans into the section.entry clinical statement model?

Recommendation

Two alternative proposals to consider:

Proposal A: Have a Constraint note on the Section.entry indicating that Legal Authentication is not propagated to the clinical statement model.

Proposal B: Add text to the standard, indicating that to turn off legal authentication to clinical statements, one must assign a NULL value to the legal authentication participation of clinical statements.

Rationale

I'm inclined towards proposal A, as I see no rational way that a user would review XML (source) clinical statements, logically users see a presentation (transform) of structures into tables, lists, paragraphs, i.e. narrative text.

What they see, is the what they authenticate, is what the sender is required to place in the Narrative Block.

Resolution

(Resolution is to be recorded here and in the referenced minutes, which are the authoritative source of resolution).