Product MR
Contents
- 1 Product Brief - HL7 V3: Medical Records, Release 1
- 1.1 Product Name
- 1.2 Topics
- 1.3 Standard Category
- 1.4 Integration Paradigm
- 1.5 Type
- 1.6 Releases
- 1.7 Summary
- 1.8 Description
- 1.9 Business Case (Intended Use, Customers)
- 1.10 Benefits
- 1.11 Implementations/ Case Studies (Actual Users)
- 1.12 Resources
- 1.13 Relationship to/ Dependencies on, other standards
- 1.14 Links to current projects in development
Product Brief - HL7 V3: Medical Records, Release 1
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Product Name
HL7 V3: Medical Records, Release 1
Topics
Standard Category
- Health Information Exchange Standards
Integration Paradigm
- Messaging
Type
Normative, ANSI Standard
Releases
ANSI/HL7 V3 RCMR, R1-2006;
Summary
The Medical Records standard defines the messages used to manage, organize, exchange and query documents.
Description
The Medical Records domain currently supports clinical document management, and document querying. In the future, it is intended also to support the data exchange needs of applications supporting other medical record functions, including chart location and tracking, deficiency analysis, consents, and release of information. The main purpose of the medical record is to produce an accurate, legal, and legible clinical document that serves as a comprehensive account of healthcare services provided to a patient, and which has the following characteristics:
Persistence: A clinical document continues to exist in an unaltered state, for a time period defined by local and regulatory requirements.
Stewardship: A clinical document is maintained by an organization entrusted with its care.
Potential for authentication: A clinical document is an assemblage of information that is intended to be legally authenticated.
Wholeness: Authentication of a clinical document applies to the whole and does not apply to portions of the document without the full context of the document.
Human readability: A clinical document is human readable.
These interactions are mainly associated with documents that will be or have been transcribed. The types and appearance of the transcribed documents can vary greatly within a healthcare organization and between organizations. However, the main purpose of the transcription process is to document patient care or diagnostic results in a legible manner; these documents then become part of the legal medical record.
Business Case (Intended Use, Customers)
Healthcare Providers, Healthcare IT Vendors, EHR Systems, Transcription Systems, Departmental Systems
Benefits
Provides a standards means of communicating clincial documents between transcription systems ad medical record systems. Also enables querying clinical document support from EHR systems for various use cases.
Implementations/ Case Studies (Actual Users)
Canada Health Infoway (CHI), UK National Health Service (NHS)
Resources
Work Groups
Education
- See more at http://www.hl7.org/implement/training.cfm
Certification Available
- none
