HL7 Implementation Guide for CDA® R2: Progress Note

DESCRIPTION

A Progress Note documents a patient’s clinical status during a hospitalization or outpatient visit, thus is associated with an encounter. The method used to develop the HL7 Implementation Guide for CDA Release 2: Progress Note, Release 1 (US Realm) included a review of industry precedents and requirements. The Progress Note is built on CDA templates as the reusable unit of standards-based exchange and interoperability.

ALTERNATIVE NAMES

HL7 Implementation Guide for CDA® R2: Progress Note may also go by the following names or acronyms:

TARGETS

• Healthcare Providers,
• Healthcare IT Vendors,
• EHR Systems,
• Transcription/Dictation Systems,
• Departmental Systems  

BENEFITS

• Integrating narrative notes and the EHR is a key benefit as is the fact that it supports meaningful use of electronic medical record technology with minimal change to current practice.

IMPLEMENTATIONS/CASE STUDIES

• The audience for this document includes software developers, consultants, and clinicians responsible for implementation of Electronic Health Record (EHR) systems, Personal Health Record (PHR) systems, dictation/transcription systems, and document management applications, and local, regional, and national health information exchange networks that wish to create and/or process CDA documents developed according to this specification.

DEVELOPMENT BACKGROUND

Progress Note (Release 1.1) documents contained in the CDA Consolidation Guide supersede existing release 1 publications.

 

This Draft Standard for Trial Use (DSTU) was produced and developed through the Health Story Project. The project was initiated by the Association for Healthcare Documentation Integrity (AHDI), Medical Transcription Industry Association (now the Clinical Documentation Industry Association or CDIA) American Health Information Management Association (AHIMA), and M*Modal and is being managed by Lantana Consulting Group and Optimal Accords, LLC.

RELATED DOCUMENTS

HL7 Implementation Guide for CDA® R2: Progress Note

STU DOCUMENTS

HL7 Implementation Guide for Clinical Document Architecture, Release 2: Progress Note, Release 1

Expiration Feb 2013

(Download) (1.22 MB)

TOPIC

• Patient Referral

BALLOT TYPE

• DSTU

STATUS DATE

2011-02-04

RESPONSIBLE WORK GROUP

FAMILY

• CDA

CURRENT STATE

• Retired

REALM

• US Realm