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

HL7 Implementation Guide for CDA® Release 2 - Level 1 and 2 - Care Record Summary (US realm)

DESCRIPTION

The Implementation Guide for CDA Release 2 – Level 1 and 2 – Care Record Summary (US realm) describes constraints on the CDA Header and Body elements for Care Record Summary documents.  A Care Record Summary document contains patient's relevant health history for some time period.  It is intended for communication between healthcare providers and 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. See CDA Implementation Guide for Care Record Summary, Release 2, Discharge Summary DSTU for most recent version.

ALTERNATIVE NAMES

HL7 Implementation Guide for CDA® Release 2 - Level 1 and 2 - Care Record Summary (US realm) may also go by the following names or acronyms:

Implementation Guide for CDA R2 L1 CRS, Implementation Guide for CDA R2 L2 CRS, Implementation Guide for CDA R2 L1-2 CRS

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 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 - Level 1 and 2 - Care Record Summary (US realm)

(Download) (1.78 MB)

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

TOPICS

  • Patient Care
  • Patient Referral

BALLOT TYPE

  • Informative

STATUS DATE

2006-06-23

FAMILY

  • CDA

CURRENT STATE

  • Retired

REALM

  • US Realm