Health Story: Integrating Narrative Notes and the EHR (formerly CDA4CDT)

Wiki page supporting collaborative work on CDA to produce data standards for the flow of information between common types of healthcare documents and electronic health records.

The project is currently focusing on development of a Discharge Summary for the September 2009 ballot cycle. The purpose of this phase will be to issue a Discharge Summary-specific CRS updated for compliance with the current approach to CDA templates in CCD and the HL7 Health Story implementation guides. The resulting specification will be consistent with IHE XDS-MS for Discharge Summary and HITSP C48 and will not introduce conflicting requirements.

Recurring meeting: Tuesday @ 11:00 AM EST - 12:30 PM EST

Conference line: Phone Number: 770-657-9270 Participant Passcode: 310940

Goto Meeting: Discharge Summary Goto Meeting ID: 694-590-139

Development

Header Review

-- In Progress

Body Review

• DS Section title analysis courtesy of M*Modal

Reference Material

• Project Scope Statement

IHE

• Wiki page for IHE Discharge Summary
• PCC Technical Framework Volume 1, Revision 4.0 (use case)
• PCC Technical Framework Volume 2, Revision 4.0 (details of Discharge Summary)

HITSP

• HITSP C48

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)

Sample Files

• Sample IHE Discharge Summaries from NIST

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).

Meeting Minutes

• Project Kick-off 6/16/2009