Clinical Document Architecture (CDA)

The Clinical Document Architecture (CDA) is a Health Level Seven (HL7) document markup standard that specifies the structure and semantics of a clinical document for the purpose of interoperability.

Introduction

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. [1] HITSP, HL7, IHE, Health Story and other organizations worked together to prevent duplicate and conflicting implementation guides and agreed upon a new electronic clinical document creation standard called Consolidated Clinical Document Architecture (C-CDA), which is the only approved documentation for Meaningful use stage 2 EHR implementation in the USA. It has 9 document templates Continuity Care Document (CCD), Diagnostic Imaging Report, Discharge Summary, History and Physical, Operative notes, and Unstructured document, 60 section templates and 82 entry templates.