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Section 1a: Clinical Document Architecture (CDA®)
Section 2: Clinical and Administrative Domains
Section 3: Implementation Guides

HL7 Standard for CDA® Release 2: Imaging Integration; Basic Imaging Reports in CDA and DICOM, Release 1

DESCRIPTION

This HL7 implementation guide describes how the HL7 Version 3 Clinical Document Architecture (CDA) Release 2 is used to record information for a Diagnostic Imaging Report. A Diagnostic Imaging Report contains a consulting specialist’s interpretation of image data. It is intended to convey the interpretation to the referring (ordering) physician and become part of the patient’s medical record.

ALTERNATIVE NAMES

HL7 Standard for CDA® Release 2: Imaging Integration; Basic Imaging Reports in CDA and DICOM, Release 1 may also go by the following names or acronyms:

"HL7 CDA: Imaging Integration; Basic Imaging Reports in CDA and DICOM, Release 1",DICOM,CDA,DIR

TARGETS

  • Medical imaging service providers, equipment vendors and information systems implementers
  • Software developers and consultants responsible for implementation of radiology information systems, radiology reporting systems, picture archiving and communications systems (PACS), other image and imaging management systems, and dictation/transcription and document management systems
  • Developers of specifications for health information networks, both governmental and non-governmental, who may specify use of this Implementation Guide for Diagnostic Imaging Reports

BENEFITS

  • Integrates narrative notes and the electronic health record (EHR)
  • Supports meaningful use
  • Minimal change to current practice

IMPLEMENTATIONS/CASE STUDIES

  • Health Story Project
  • The American Health Information Management Association (AHIMA)
  • The Association for Healthcare Documentation Integrity (AHDI), formerly the American Association for Medical Transcription (AAMT), now affiliated with the Medical Transcription Industry Association (MTIA)

DEVELOPMENT BACKGROUND

The implementation guide for this informative document was developed by DICOM, with support from the HL7 International Imaging Integration Work Group and the Health Story Project. It is consistent with a companion guide for transforming DICOM Structured Reports to CDA Release 2 and is suitable for use with both structured and narrative data capture. The purpose of guide is to describe constraints on the CDA Header and Body elements for Diagnostic Imaging Reports. It is intended for use in radiology, endoscopy, cardiology and other imaging specialties and is consistent with the DICOM guide for transforming DICOM Structured Reports to CDA. The report may contain both narrative and coded data.

RELATED DOCUMENTS

HL7 Standard for CDA® Release 2: Imaging Integration; Basic Imaging Reports in CDA and DICOM, Release 1

(Download)

ADDITIONAL DETAILS

For additional background visit: http://www.healthstory.com/standards/sec/dir.htm.

TOPIC

  • Patient Care

BALLOT TYPE

  • Informative

STATUS DATE

2007-03-16

RESPONSIBLE WORK GROUP

Imaging Integration

STAKEHOLDERS

  • Equipment Vendors
  • Medical Imaging Service Providers

FAMILY

  • CDA

CURRENT STATE

  • Stable

REALM

  • Universal