HL7 Implementation Guide for CDA® R2: History and Physical (H&P) Notes, Release 1

DESCRIPTION

This Draft Standard for Trial Use (DSTU) describes how The HL7 Version 3 Clinical Document Architecture (CDA) Release 2 is used to record information for a History and Physical Note. The History and Physical Note may contain both narrative and coded data. The purpose of the implementation guide is to describe constraints on the CDA Header and Body for these notes.

ALTERNATIVE NAMES

HL7 Implementation Guide for CDA® R2: History and Physical (H&P) Notes, Release 1 may also go by the following names or acronyms:

TARGETS

• Healthcare providers
• Healthcare IT Vendors
• Electronic Health Record Systems
• Transcription/Dictation Systems
• Departmental Systems

BENEFITS

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

IMPLEMENTATIONS/CASE STUDIES

• A sample History and Physical Note was provided by the Military Health System and used as a test against the design of this HL7 International DSTU

DEVELOPMENT BACKGROUND

The Consolidated CDA Templates guide includes new releases for History and Physical (H&P) Note (Release 1.1), where release 1.1 documents supersede existing release 1 publications.

A History and Physical (H&P) Note is a two-part medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status. The information forms the basis of most treatment plans. 

 

The project received support from the Health Story Project through an Associate Charter Agreement with HL7 to accelerate development of standards for common types of clinical documents.

RELATED DOCUMENTS

HL7 Implementation Guide for CDA® R2: History and Physical (H&P) Notes, Release 1

TOPIC

• Patient Care

BALLOT TYPE

• DSTU

STATUS DATE

2012-10-22

RESPONSIBLE WORK GROUP

FAMILY

• CDA

CURRENT STATE

• Retired

REALM

• US Realm