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Section 1a: Clinical Document Architecture (CDA®)
Section 3: Implementation Guides

HL7 Implementation Guide for CDA® Release 2: Care Record Summary Discharge Summary

DESCRIPTION

The CDA Implementation Guide for Care Record Summary, Release 2, Discharge Summary provides disparate hospital systems a standard format to report back to a primary care provider or other parties interested in the patient's hospital care.

ALTERNATIVE NAMES

HL7 Implementation Guide for CDA® Release 2: Care Record Summary Discharge Summary may also go by the following names or acronyms:

"HL7 IG for CDAR2: Care Record Summary R2; Discharge Summary, R1",CRS,CDAR2

TARGETS

  • Clinicians
  • Healthcare Providers
  • Healthcare IT Vendors

BENEFITS

  • Communicate discharge summary information as an image, free text or structured coded data
  • Provides a common format for narrative notes and the electronic health record (EHR)
  • Supports meaningful use with minimal change to current practice

IMPLEMENTATIONS/CASE STUDIES

  • In development

DEVELOPMENT BACKGROUND

The Consolidated CDA Templates guide includes new releases for Care Record Summary - Discharge Summary (Release 1.1), where release 1.1 documents supersede existing release 1 publications.

The HL7 Implementation Guide for CDA Release 2: Care Record Summary: Discharge Summary was supported by the Health Story Project (www.healthstory.com), a non-profit industry collaborative working to integrate narrative notes and electronic medical records.

 The Care Record Summary (CRS), issued in June 23, 2006, was the first balloted Implementation Guide for CDA R2. CRS covered CDA Levels 1, 2, however, did not specify Level 3 templates (CDA entries). CCD, meanwhile, developed a rich set of Level 3 templates, however, CCD is not a discharge summary and does not specify a hospital course. The purpose of this update was 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 is consistent with IHE XDS-MS for Discharge Summary and HITSP C48 and does not introduce conflicting requirements.

RELATED DOCUMENTS

HL7 Implementation Guide for CDA® Release 2: Care Record Summary Discharge Summary
Presentation: Overview of Care Record Summary (View Brief)

(Download) (227 KB)

ADDITIONAL DETAILS

For specifications and information about workgroups, training, projects and more, visit the
Structured Documents work group webpage on the HL7.org website or the project wiki at http://wiki.hl7.org/index.php?title=Health_Story:_Discharge_Summary for additional information.

TOPIC

  • Patient Referral

BALLOT TYPE

  • DSTU

STATUS DATE

2012-10-22

RESPONSIBLE WORK GROUP

Structured Documents

FAMILY

  • CDA

CURRENT STATE

  • Retired

REALM

  • US Realm