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

HL7 Implementation Guide for CDA® Release 2: Patient Assessments, Release 1

DESCRIPTION

This Implementation Guide (IG) facilitates a standard electronic communication for electronic submission to CDA of their Questionnaire Assessments. These allow healthcare facilities and providers a standard way to communicate reports in an industry standard format. Questionnaire Assessments contain multiple questions with specific answers. These questions typically assess a variety of clinical domains (including the patient’s functional and disability status) and may include assessment scales to quantify the assessment. Questionnaire Assessments are instruments that have psychometric properties that contribute to the statistical adequacy of an instrument in terms of reliability, validity, and internal consistency.

ALTERNATIVE NAMES

HL7 Implementation Guide for CDA® Release 2: Patient Assessments, Release 1 may also go by the following names or acronyms:

"HL7 IG for CDA R2: CDA Framework for Questionnaire Assessments, Release 1", CDAR2

TARGETS

  • Government Agencies
  • Healthcare Facilities
  • Healthcare Providers
  • System Developers and Implementers
  • Frequently these types of assessments are used in long-term care settings (e.g., nursing facilities, home health agencies, and residential care facilities) or in outpatient settings with patients who have certain chronic physical and mental health conditions

BENEFITS

  • Enables systems for reporting patient Questionnaire Assessments in an interoperable, industry-standard format to government agencies, between healthcare facilities and providers or to personal healthcare records

IMPLEMENTATIONS/CASE STUDIES

  • ACTS Retirement-Life Communities, Inc.
  • Golden Living, Inc.

DEVELOPMENT BACKGROUND

Implementation Guide for CDA Release 2: CDA Framework for Questionnaire Assessments (Universal Realm) describes constraints on CDA Release 2 to provide a framework for patient Questionnaire Assessments that can be used internationally.

 

CDA Representation of the Minimum Data Set (MDS) Questionnaire Assessment (U.S. Realm) adds further constraints to the constraints outlined for the Universal Realm to define a specific questionnaire commonly used in the United States. These constraints can also be applied to other assessment questionnaires used in the United States, such as the Outcome and Assessment Information Set (OASIS).

RELATED DOCUMENTS

HL7 Implementation Guide for CDA® Release 2: Patient Assessments, Release 1

STU DOCUMENTS

HL7 Implementation Guide for CDA® Release 2: CDA Framework for Questionnaire Assessments, DSTU Release 2 Expiration Feb 2016

(Download) (908 KB)

HL7 Implementation Guide for CDA® Release 2: CDA Framework for Questionnaire Assessments, Release 1 Expiration Apr 2012

(Download) (2.60 MB)

TOPIC

  • Patient Care

BALLOT TYPE

  • DSTU

STATUS DATE

2021-06-17

RESPONSIBLE WORK GROUP

Structured Documents

FAMILY

  • CDA

CURRENT STATE

  • Stable

REALM

  • US Realm