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Evidentiary Medical Records

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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

Meeting Information

Template for Meeting Minutes (Evidentiary Medical Records Project)

Meeting Agendas/Minutes

Project Scope

Use Cases

Business Requirements