Clinical Document Architecture (CDA)
"The Health Level Seven (HL7) Clinical Document Architecture (CDA) is a document markup standard that specifies the structure and semantics of a clinical document (such as a discharge summary or progress note) for the purpose of exchange. A CDA document is a defined and complete information object that can include text, images, sounds, and other multimedia content. It can be transferred within a message and can exist independently, outside the transferring message. CDA documents are encoded in Extensible Markup Language (XML), and they derive their machine processable meaning from the RIM, coupled with terminology.
The CDA R2 model is richly expressive, enabling the formal representation of clinical statements (such as observations, medication administrations, and adverse events) such that they can be interpreted and acted upon by a computer. On the other hand, CDA R2 offers a low bar for adoption, providing a mechanism for simply wrapping a non-XML document with the
CDA header or for creating a document with a structured header and sections containing only narrative content. The intent is to facilitate widespread adoption, while providing a mechanism for incremental semantic interoperability" [[1]
Major Components
- "ClinicalDocument" element
- header: identifies and classifies the document, provides information on authentication, the encounter, the patient, and the involved providers
- "structuredBody" element
- body: clinical report, unstructured or structured markup.
References
- Dolin RH, Alschuler L, Boyer S, Beebe C, Behlen FM, Biron PV, Shabo Shvo A. HL7 Clinical Document Architecture, Release 2. J Am Med Inform Assoc. 2006 Jan-Feb;13(1):30-9. Epub 2005 Oct 12.
