CDAQuickStartWord文件下载.docx

1、Who Should Read This Quick Start Guide 5Introduction 5About This Quick Start Guide 7Document Notational Conventions 7Authoritative Sources 7Assumptions 8Reference Information 8Before You Begin Use of IDs and Codes 9Document Design 11CDA Minimum Required Elements 12ClinicalDocument 12typeID 12id 12co

2、de 13effectiveTime 13confidentialityCode 14recordTarget 14author 15custodian 15CDA Optional Header Elements 17relatedDocument 17setId:versionNumber 17componentOf:encompassingEncounter 17legalAuthenticator 17templateId 17documentationOf:serviceEvent 18CDA Body and Narrative Block 19CDA Entries and Cl

3、inical Statements 21Appendix A Sample CDA Instance structuredBody 23Appendix B Additional Information on ISO8601 Time and Date Stamps 26Revision HistoryDateVersionCommentsOctober 17, 20051.0Initial releaseNovember 1, 20051.1Clarified time information fixed stylesheet reference in examples and relate

4、d info Created browser version of doc and readme.txt for inclusion due to bug in Word that prevents links from working correctly. Added new support email address.September 2, 20061.2Minor updates and correctionsAugust 31, 20071.3Minor updates and corrections （typos, links）October 9-21, 20071.4Edits

5、per the meeting notes of 10/9/2007 Bob YenchaNovember 15, 20071.5Accepted Bob Yenchas changesAdded “Who Should Read This Doc”Intro rewrittenAdded def for componentOf/encompassingEncounter Who Should Read This Quick Start GuideThis document is intended for application designers, developers, and imple

6、menters of standards-based, interoperable healthcare information systems. Readers must have access to the specifications referenced in this Quick Start Guide （QSG）. （See Reference Information for full information on how to access HL7 specifications.）CDA utilizes Extensible Markup Language （XML）. Rea

7、ders and implementers must be versed in XML and should read XPath syntax as well. While not required, many applications use XSLT to display CCD and a sample XSLT stylesheet is available with the specification. For more information on these recommendations from the World Wide Web Consortium, see www.

8、W3.org. CDA is derived from the HL7 Reference Information Model （RIM） and user-controlled terminology such as SNOMED CT, LOINC, CPT, ICD, and RxNorm. Knowledge of the RIM is not necessary for CDA implementers. Some familiarity with terminology systems is required.This QSG presupposes no consensus on

9、 content or coding beyond the CDA specification itself. It is merely an informative aid to implementers and applies to all implementations of CDA, although optional aspects of CDA may be required through local, regional, or national guidelines and agreements. If through an error this QSG deviates in

10、 any way from the CDA Release 2.0 specification, the specification should be followed. IntroductionThe HL7 CDA is a document markup standard that specifies the structure and semantics of clinical documents for the purpose of exchange. The goals of CDA are: Give priority to delivery of patient care.

11、Allow cost effective implementation across as wide a spectrum of systems as possible. Support exchange of human-readable documents between users, including those with different levels of technical sophistication. Promote longevity of all information encoded according to this architecture. Enable a w

12、ide range of post-exchange processing applications. Be compatible with a wide range of document creation applications. Promote exchange that is independent of the underlying transfer or storage mechanism. Prepare the design reasonably quickly. Enable policy-makers to control their own information re

13、quirements without extension to this specification.A key to this acceptance is the “A” for architecture in CDA, which promotes reusability across a sufficiently wide range of documents to cover clinical information sharing, public health, quality reporting, and clinical trials.Since its issuance in

14、2005, several implementation guides describing specific types of CDA documents have been developed, balloted and published. The Continuity of Care Document （CCD） is a joint project by HL7 and ASTM International that implements the clinical requirements specified in the Continuity of Care Record （CCR

15、） using the CDA architecture. CCD was balloted by HL7 in 2006 and published in April 2007. Starting in 2007, the CDA for Common Document Types （CDA4CDT） project developed and balloted implementation guides for the History & Physical and Consult Note that reuse templates defined in CCD, ensuring cons

16、istency across these document types. CDA4CDT was initiated by the primary players in the dictation/transcription industry to rapidly increase the availability of CDA documents for importation into electronic health records and utilization in the emerging health information exchanges. Also in 2007, t

17、he HL7 Attachments Special Interest Group （ASIG） revised its implementation guides for HIPAA claims attachments to conform to Release 2, and Integrating the Healthcare Enterprise （IHE） expanded its guidance on CDA through a series of patient care profiles. Projects are underway to develop guidance o

18、n the use of CDA for public health and quality reporting and to meet the specialized requirements of long-term care. Information on how to obtain each of these guides is included in the Reference Information section.This Quick Start Guide will help implementers create a simple CDA document and then

19、as they increase their knowledge of CDA, go on to create more complex versions using the resources cited in this QSG and their own experience.About This Quick Start GuideDocument Notational ConventionsNarrative text will appear in Times New Roman font, plain face.element when an XML element is discu

20、ssed in narrative textattribute when an XML attribute is discussed in narrative textCoding examples will appear as Courier font with color for clarity where applicable.optionalElement required=”variableValue” optional=”variableValue”References are made throughout this document to the normative HL7 C

21、linical Document Architecture （CDA）, Release 2.0. To improve readability, all references to this document will appear at the end of each topic asCDA Release 2.0, Section X.x.x.x Section TitleAdditional references to other parts of the specification will include the title of the document in addtion t

22、o the section number and title, i.e.:HL7 Reference Information Model, Section 3.4.1.3 InfrastructureRoot.typeIdNOTE: References to locations on the internet are active links.The reader of this document should have a copy of the HL7 Clinical Document Architecture （CDA）, Release 2.0 specification., av

23、ailable from HL7 at www.hl7.org/memonly/downloads. Please note that you must be an HL7 member to access and download the specification.Authoritative Sources Portions of this document are abstracted from the normative edition of the HL7 Clinical Document Architecture （CDA）, Release 2.0 specification.

24、 This QSG is not a complete reference to the CDA schemas and should be used in conjunction with the full normative specification for implementation and development. Please refer to the normative edition for a complete description of the CDA and its usage. Any deviation from the specification is an e

25、rror and the specification should be followed in all cases. This QSG is based on the HL7 Clinical Document Architecture 2.0, May 2005. It describes how to implement a basic CDA that will facilitate the collection of patient information as a series of CDA documents or in a mixed archive with other ty

26、pes of standards-based persistent objects. The resulting CDA instance will be comprised of an XML-encoded header and a body which is either non-XML or the simple XML of the CDA narrative block.The QSG covers all required elements of the CDA Header and gives guidance on some optional elements, such a

27、s those that identify related orders and procedures.CDA Release 2.0, Section 1.2.2 - The A in CDACDA Release 2.0, Section 4.3.5 - Section Narrative Block AssumptionsThis document assumes that the reader has a thorough understanding of XML and the W3C Recommendation. As an XML applications developer,

28、 the reader should be familiar with W3C schemas, XML validation （parsing）, and methods of constructing and deconstructing XML files.Knowledge of the relevant HL7 standards and approaches are helpful. Additional information to further the readers understanding can be found in the following section.Re

29、ference InformationHL7 Clinical Document Architecture （CDA）, Release 2.0 The CDA Specification is available from hl7.org.The HL7 Structured Documents Technical Committee maintains a listserv that hosts ongoing discussions on the implementation of CDA and related specifications. Implementers should subscribe to the list where they can post implementation questions and stay current with issues raised by others.ASIGHAIQRDACDA4CDTBefore You Begin Use of IDs and CodesThe CDA allows more than one type of