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

HL7 Implementation Guide for CDA® R2: Consult Notes, Release 1

DESCRIPTION

This implementation guide (IG) (currently a DSTU) describes how HL7 Version 3 Clinical Document Architecture (CDA) Release 2 is used to record information for a Consult Note. The Consult Note may contain both narrative and coded data. For the purpose of this IG a consultation visit is defined by the evaluation and management guidelines for a consultation established by the Centers for Medicare and Medicaid Services.

ALTERNATIVE NAMES

HL7 Implementation Guide for CDA® R2: Consult Notes, Release 1 may also go by the following names or acronyms:

"HL7 IG for CDA R2: Consult Notes, Release 1",CDAR2

TARGETS

  • Those charged with implementation of electronic health record (EHR) systems, electronic medical record (EMR) systems, personal health record (PHR) systems, dictation/transcription systems, document management applications, and departmental systems
  • Local, regional and national health information exchange networks who wish to create and/or process HL7 CDA documents created according to this specification
  • Healthcare Providers
  • Healthcare IT Vendors

BENEFITS

  • Integrates narrative notes and the EHR
  • Supports meaningful use
  • Minimal change to current practice

IMPLEMENTATIONS/CASE STUDIES

  • In development

DEVELOPMENT BACKGROUND

A sample Consultation Note was provided by the Association for Healthcare Documentation Integrity (AHDI) and used as a test against the design of this HL7 Draft Standard for Trial Use. 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: Consult Notes, Release 1

ADDITIONAL DETAILS

For more information visit: http://www.healthstory.com/standards/sec/consult_note.htm.

 

The Consolidated CDA Templates guide includes new releases for Consultation Notes (Release 1.1), where release 1.1 documents supersede existing release 1 publications.

TOPIC

  • Patient Referral

BALLOT TYPE

  • DSTU

STATUS DATE

2012-10-22

RESPONSIBLE WORK GROUP

Structured Documents

FAMILY

  • CDA

CURRENT STATE

  • Retired

REALM

  • US Realm