Section 1a: Clinical Document Architecture (CDA®)
Section 2: Clinical and Administrative Domains
Section 3: Implementation Guides
HL7 Implementation Guide for CDA®, Release 2: Procedure Note, Release 1
This document describes constraints on the Clinical Document Architecture (CDA) Header and Body elements for Procedure Note documents. The Procedure Note or Report is created immediately following a non-operative procedure and records the indications for the procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, and the patient’s tolerance of the procedure. The report should be sufficiently detailed to justify the procedure, document the course of the procedure, and provide continuity of care.
HL7 Implementation Guide for CDA®, Release 2: Procedure Note, Release 1 may also go by the following names or acronyms:
- Healthcare Providers
- Healthcare IT Vendors
- EHR Systems
- Transcription/Dictation Systems
- Departmental Systems
- Supports meaningful use with minimal change to current practice
- In development
Procedure Note is a broad term that encompasses many specific types of non-operative procedures including interventional cardiology, interventional radiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes in that the procedures documented do not involve incision or excision as the primary act.
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.
|Expiration Jul 2012|
- Patient Care
RESPONSIBLE WORK GROUP
- US Realm