Section 1a: Clinical Document Architecture (CDA®)
Section 3: Implementation Guides
HL7 Implementation Guide for CDA® R2: History and Physical (H&P) Notes, Release 1
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.
HL7 Implementation Guide for CDA® R2: History and Physical (H&P) Notes, Release 1 may also go by the following names or acronyms:
- Healthcare providers
- Healthcare IT Vendors
- Electronic Health Record Systems
- Transcription/Dictation Systems
- Departmental Systems
- Integrates narrative notes and the electronic health record (EHR)
- Supports meaningful use with minimal change to current practice
- 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
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.
- Patient Care
RESPONSIBLE WORK GROUP
- US Realm