CDAQuickStartWord文件下载.docx
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WhoShouldReadThisQuickStartGuide5
Introduction5
AboutThisQuickStartGuide7
DocumentNotationalConventions7
AuthoritativeSources7
Assumptions8
ReferenceInformation8
BeforeYouBegin–UseofIDsandCodes9
DocumentDesign11
CDAMinimumRequiredElements12
ClinicalDocument12
typeID12
id12
code13
effectiveTime13
confidentialityCode14
recordTarget14
author15
custodian15
CDAOptionalHeaderElements17
relatedDocument17
setId:
:
versionNumber17
componentOf:
encompassingEncounter17
legalAuthenticator17
templateId17
documentationOf:
serviceEvent18
CDABodyandNarrativeBlock19
CDAEntriesandClinicalStatements21
AppendixA–SampleCDAInstance–structuredBody23
AppendixB–AdditionalInformationonISO8601–TimeandDateStamps26
RevisionHistory
Date
Version
Comments
October17,2005
1.0
Initialrelease
November1,2005
1.1
Clarifiedtimeinformation
fixedstylesheetreferenceinexamplesandrelatedinfoCreatedbrowserversionofdocandreadme.txtforinclusionduetobuginWordthatpreventslinksfromworkingcorrectly.
Addednewsupportemailaddress.
September2,2006
1.2
Minorupdatesandcorrections
August31,2007
1.3
Minorupdatesandcorrections(typo’s,links)
October9-21,2007
1.4
Editsperthemeetingnotesof10/9/2007–BobYencha
November15,2007
1.5
AcceptedBobYencha’schanges
Added“WhoShouldReadThisDoc”
Introrewritten
AddeddefforcomponentOf/encompassingEncounter
WhoShouldReadThisQuickStartGuide
Thisdocumentisintendedforapplicationdesigners,developers,andimplementersofstandards-based,interoperablehealthcareinformationsystems.ReadersmusthaveaccesstothespecificationsreferencedinthisQuickStartGuide(QSG).(SeeReferenceInformationforfullinformationonhowtoaccessHL7specifications.)
CDAutilizesExtensibleMarkupLanguage(XML).ReadersandimplementersmustbeversedinXMLandshouldreadXPathsyntaxaswell.Whilenotrequired,manyapplicationsuseXSLTtodisplayCCDandasampleXSLTstylesheetisavailablewiththespecification.FormoreinformationontheserecommendationsfromtheWorldWideWebConsortium,seewww.W3.org.
CDAisderivedfromtheHL7ReferenceInformationModel(RIM)anduser-controlledterminologysuchasSNOMEDCT,LOINC,CPT,ICD,andRxNorm.KnowledgeoftheRIMisnotnecessaryforCDAimplementers.Somefamiliaritywithterminologysystemsisrequired.
ThisQSGpresupposesnoconsensusoncontentorcodingbeyondtheCDAspecificationitself.ItismerelyaninformativeaidtoimplementersandappliestoallimplementationsofCDA,althoughoptionalaspectsofCDAmayberequiredthroughlocal,regional,ornationalguidelinesandagreements.
IfthroughanerrorthisQSGdeviatesinanywayfromtheCDARelease2.0specification,thespecificationshouldbefollowed.
Introduction
TheHL7CDAisadocumentmarkupstandardthatspecifiesthestructureandsemanticsofclinicaldocumentsforthepurposeofexchange.
ThegoalsofCDAare:
∙Giveprioritytodeliveryofpatientcare.
∙Allowcosteffectiveimplementationacrossaswideaspectrumofsystemsaspossible.
∙Supportexchangeofhuman-readabledocumentsbetweenusers,includingthosewithdifferentlevelsoftechnicalsophistication.
∙Promotelongevityofallinformationencodedaccordingtothisarchitecture.
∙Enableawiderangeofpost-exchangeprocessingapplications.
∙Becompatiblewithawiderangeofdocumentcreationapplications.
∙Promoteexchangethatisindependentoftheunderlyingtransferorstoragemechanism.
∙Preparethedesignreasonablyquickly.
∙Enablepolicy-makerstocontroltheirowninformationrequirementswithoutextensiontothisspecification.
Akeytothisacceptanceisthe“A”forarchitectureinCDA,whichpromotesreusabilityacrossasufficientlywiderangeofdocumentstocoverclinicalinformationsharing,publichealth,qualityreporting,andclinicaltrials.
Sinceitsissuancein2005,severalimplementationguidesdescribingspecifictypesofCDAdocumentshavebeendeveloped,ballotedandpublished.TheContinuityofCareDocument(CCD)isajointprojectbyHL7andASTMInternationalthatimplementstheclinicalrequirementsspecifiedintheContinuityofCareRecord(CCR)usingtheCDAarchitecture.CCDwasballotedbyHL7in2006andpublishedinApril2007.
Startingin2007,theCDAforCommonDocumentTypes(CDA4CDT)projectdevelopedandballotedimplementationguidesfortheHistory&
PhysicalandConsultNotethatreusetemplatesdefinedinCCD,ensuringconsistencyacrossthesedocumenttypes.CDA4CDTwasinitiatedbytheprimaryplayersinthedictation/transcriptionindustrytorapidlyincreasetheavailabilityofCDAdocumentsforimportationintoelectronichealthrecordsandutilizationintheemerginghealthinformationexchanges.
Alsoin2007,theHL7AttachmentsSpecialInterestGroup(ASIG)reviseditsimplementationguidesforHIPAAclaimsattachmentstoconformtoRelease2,andIntegratingtheHealthcareEnterprise(IHE)expandeditsguidanceonCDAthroughaseriesofpatientcareprofiles.ProjectsareunderwaytodevelopguidanceontheuseofCDAforpublichealthandqualityreportingandtomeetthespecializedrequirementsoflong-termcare.InformationonhowtoobtaineachoftheseguidesisincludedintheReferenceInformationsection.
ThisQuickStartGuidewillhelpimplementerscreateasimpleCDAdocumentandthenastheyincreasetheirknowledgeofCDA,goontocreatemorecomplexversionsusingtheresourcescitedinthisQSGandtheirownexperience.
AboutThisQuickStartGuide
DocumentNotationalConventions
NarrativetextwillappearinTimesNewRomanfont,plainface.
elementwhenanXMLelementisdiscussedinnarrativetext
attributewhenanXMLattributeisdiscussedinnarrativetext
CodingexampleswillappearasCourierfontwithcolorforclaritywhereapplicable.
<
requiredElementrequired=”fixedValue”optional=”variableValue”>
optionalElementrequired=”variableValue”optional=”variableValue”>
ReferencesaremadethroughoutthisdocumenttothenormativeHL7ClinicalDocumentArchitecture(CDA),Release2.0.Toimprovereadability,allreferencestothisdocumentwillappearattheendofeachtopicas
[CDARelease2.0,SectionX.x.x.x–SectionTitle]
Additionalreferencestootherpartsofthespecificationwillincludethetitleofthedocumentinaddtiontothesectionnumberandtitle,i.e.:
[HL7ReferenceInformationModel,Section3.4.1.3–InfrastructureRoot.typeId]
NOTE:
Referencestolocationsontheinternetareactivelinks.
ThereaderofthisdocumentshouldhaveacopyoftheHL7ClinicalDocumentArchitecture(CDA),Release2.0specification.,availablefromHL7atwww.hl7.org/memonly/downloads.PleasenotethatyoumustbeanHL7membertoaccessanddownloadthespecification.
AuthoritativeSources
PortionsofthisdocumentareabstractedfromthenormativeeditionoftheHL7ClinicalDocumentArchitecture(CDA),Release2.0specification.ThisQSGisnotacompletereferencetotheCDAschemasandshouldbeusedinconjunctionwiththefullnormativespecificationforimplementationanddevelopment.PleaserefertothenormativeeditionforacompletedescriptionoftheCDAanditsusage.Anydeviationfromthespecificationisanerrorandthespecificationshouldbefollowedinallcases.
ThisQSGisbasedontheHL7ClinicalDocumentArchitecture2.0,May2005.ItdescribeshowtoimplementabasicCDAthatwillfacilitatethecollectionofpatientinformationasaseriesofCDAdocumentsorinamixedarchivewithothertypesofstandards-basedpersistentobjects.TheresultingCDAinstancewillbecomprisedofanXML-encodedheaderandabodywhichiseithernon-XMLorthesimpleXMLoftheCDAnarrativeblock.
TheQSGcoversallrequiredelementsoftheCDAHeaderandgivesguidanceonsomeoptionalelements,suchasthosethatidentifyrelatedordersandprocedures.
[CDARelease2.0,Section1.2.2-The"
A"
in"
CDA"
]
[CDARelease2.0,Section4.3.5-SectionNarrativeBlock]
Assumptions
ThisdocumentassumesthatthereaderhasathoroughunderstandingofXMLandtheW3CRecommendation.AsanXMLapplicationsdeveloper,thereadershouldbefamiliarwithW3Cschemas,XMLvalidation(parsing),andmethodsofconstructinganddeconstructingXMLfiles.
KnowledgeoftherelevantHL7standardsandapproachesarehelpful.Additionalinformationtofurtherthereader’sunderstandingcanbefoundinthefollowingsection.
ReferenceInformation
HL7ClinicalDocumentArchitecture(CDA),Release2.0–TheCDASpecificationisavailablefromhl7.org.
TheHL7StructuredDocumentsTechnicalCommitteemaintainsalistservthathostsongoingdiscussionsontheimplementationofCDAandrelatedspecifications.Implementersshouldsubscribetothelistwheretheycanpostimplementationquestionsandstaycurrentwithissuesraisedbyothers.
ASIG
HAI
QRDA
CDA4CDT
BeforeYouBegin–UseofIDsandCodes
TheCDAallowsmorethanonetypeof