Health Story: Unstructured Documents

The page will support the development of the Unstructured Document for the January 2010 ballot cycle.

This project is to design a basic procedure note as a constraint on HL7 v3 CDA r2. The note will be basic enough to be used for all procedures and will develop a sample note for endoscopy. To promote standardization and acceptance, it will be closely modeled on the current HL7 CDA Operative Note.

Development

Header Review

• Material to be added

Body Review

• Material to be added

Reference Material

• Project Scope Statement

• Project Overview Presentation

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).