Evidentiary Medical Records

Project Summary

The Evidentiary Medical Records Projects is intended to establish a solid foundation/framework for legal health records using standard-based management and interchange. The project will define

• Reusable framework for a variety of care settings
• Metadata regarding the clinical context of medical records
• Management of records rather than individual data elements; records that may be maintained for legal and disclosure purposes
• “Closed records” must have the following elements
• Records passed from one organization to another
• Historical/longitudinal records
• Analyzed the EHRS Functional Model to identify any missing information or metadata

This project will produce an informative Conceptual/Domain Analysis Model focused on the set of information required for evidentiary purposes. The initial informative ballot will be followed by a DSTU Platform Independent Specification and a CDA R2 Implementation Guide DSTU. After a trial period the CDA IG will be balloted as a normative specification.

Project Team

• Beth Acker
• Harry Rhodes
• Nancy LeRoy
• Don Mon
• Michelle Dougherty
• Ioana Singureanu

Meeting Information

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Template for Meeting Minutes (Evidentiary Medical Records Project)