http://www.loc.gov/mods/v3 http://www.loc.gov/standards/mods/v3/mods-3-2.xsd
Clinical documentation is used throughout healthcare to describe care provided to a patient, communicate essential information between healthcare providers and maintain medical records. The CDA Book describes the HL7 Clinical Document Architecture Release 2.0 standard, a standard format for clinical documentation. It is thus intended for Healthcare Informaticists and IT developers, analysts and architects developing Healthcare applications working with all types of clinical documents. “The Clinical Document Architecture (CDA) is a common container for assembly of structured and unstructured information that does not require creating numerous standards for individual document types. What has been missing to date is the educational materials to make CDA accessible to everyone. This book contains the documentation, samples, and guidance needed to successfully implement CDA in real world applications. It will accelerate adoption of CDA as a means to exchange structured data elements that not only capture the thought process of the encounter for care coordination but also can be stored as individual data elements for population health, research, and decision support.” John D. Halamka MD, Chief Information Officer at Harvard Medical School.
Introduction -- Acknowledgements -- Acronyms and Abbreviations.-Preface -- Organization of this Book -- Section I: Introduction -- Section II: Data Types -- Section III: CDA Modeling Section IV: Implementing CDA -- 1. Clinical Documentation -- 1.1 Properties of Clinical Documents -- 1.2 The 6 Characteristics of Clinical Documents -- 2. The HL7 Clinical Document Architecture2.1 History of the Clinical Document Architecture -- 2.2 CDA is based on XML -- 2.3 Structure of a CDA Document -- 2.4 Levels of CDA -- Summary -- 3. Extensible Markup Language -- 3.1 The XML Declaration -- 3.2 Namespaces -- 3.3 XML Schema Language -- 3.4 Parsing the CDA XML -- Summary -- 4 Basic Data Types -- 4.1 ANY -- 4.2 Booleans -- 4.3 Quantities -- Summary -- 5 Text and Multimedia -- 5.1 BIN Binary -- 5.2 ED Encapsulated Data -- 5.3 ST String -- Summary -- 6 Demographic Data -- 6.1 ADXP Address Part -- 6.2 AD Address Mixed Content Models -- 6.3 ENXP Entity Name Part -- 6.4 EN Entity Name -- 6.5 ON Organization Name -- 6.6 PN Person Name -- 6.7 TN Trivial Name -- 6.8 II Instance Identifier -- Stupid Geek Tricks -- 6.9 TEL Telecommunications Address -- Summary -- 7 Codes and Vocabularies -- 7.1 Concepts -- 7.2 Codes -- 7.3 Coding Systems -- 7.4 Pre- and Post-Coordination -- 7.5 Value Sets -- Summary -- 8 Codes -- 8.1 CD Concept Descriptor -- 8.2 CE Coded With Equivalents -- 8.3 CV Coded Value -- 8.4 CO Coded Ordinal -- 8.5 CS Coded Simple -- Summary -- 9 Dates and Times -- 9.1 TS Time Stamp -- 9.2 IVL_TS -- Interval of Time -- 9.3 PIVL_TS Periodic Interval of Time -- 9.4 EIVL_TS Event-Related Periodic Interval of Time -- 9.5 GTS Generic Timing Specification -- 9.6 Use of Time Data Types with Medications -- Summary -- 10 Collections -- 10.1 BAG Bag -- 10.2 SET Set -- 10.3 IVL Interval -- 10.4 LIST List -- Summary -- 11 HL7 Version 3 Modeling -- 11.1 The RIM Backbone Classes -- 11.2 HL7 Modeling and UML -- Summary -- 12 Clinical Document Infrastructure -- 12.1 <ClinicalDocument> -- 12.2 Infrastructure Elements -- Summary -- 13 The CDA Header -- 13.1 Clinical Document RIM Attributes -- 13.2 Acts -- 13.3 Participations and Roles in the Document Context Co-occurrence -- 13.4 People, Organizations and Devices -- Summary -- 14 The CDA Body.-14.1 Unstructured Narrative -- 14.2 Structured Narrative -- 14.3 The Narrative Block -- 14.4 Subject Participation -- 14.5 Other Rendering Options -- Summary -- 15 Clinical Statements in the CDA -- 15.1 Act classes in the CDA Clinical Statement Model.-15.2 EntryRelationship -- 15.3 Participants -- Summary -- 16 HL7 Version 2 to CDA Release 2 -- 16.1 HL7 Version 2 Data Type Mappings -- 16.2 Converting Codes and Assigning Authorities -- 16.3 Observation (OBX) -- 16.4 Transcription Document Header (TXA) -- 16.5 Patient Identifier (PID) -- 16.6 Patient Visit Information (PV1) -- 16.7 Additional Patient Visit Information (PV2) -- 16.8 Next of Kin (NK1) -- 16.9 Message Header (MSH) and Event (EVN) Segments -- 16.10 Common Order Segment (ORC) -- 16.11 Observation Request Segment (OBR) -- 16.12 Note (NTE) -- 16.13 Specimens (SPM) -- Summary -- 17 Extracting Data from a CDA Document -- 17.1 Data Extraction -- 17.2 XPath Searching through Context -- Summary -- 18 Templates -- 18.1 Building Implementation Guides using Templates -- 18.2 CDA Extensions -- Summary -- 19 Validating the Content of a CDA Document -- 19.1 Using the CDA Schemas -- 19.2 ISO Schematron -- 19.3 Model Based Validation -- 19.4 Validating when CDA Extensions are Used -- 19.5 Validating Narrative -- Summary -- 20 Implementation Guides on CDA -- 20.1 Claims Attachments (HL7) -- 20.2 Electronic Medical Summary (British Columbia / Vancouver Island Health Authority) -- 20.3 Care Record Summary (HL7) -- 20.4 Volet Médical (DMP) -- 20.5 Cross Enterprise Sharing of Medical Summaries (IHE) -- 20.6 The Continuity of Care Document -- 20.7 Exchange of Personal Health Records -- 20.8 Laboratory Reports -- 20.9 Smart Open Services for European Patients -- 20.10 Unstructured Documents -- Summary.