- How is a CDA document structured?
- Common CDA Document Level Templates
- Additional Information
Before you dive in, let’s quickly review some CDA basics!
- CDA uses the HL7 Reference Information Model (RIM) and HL7 Version 3 Datatypes
- CDA documents are encoded in XML and can contain both text and multimedia content
- CDA documents can be transferred within an HL7 message
- CDA documents can also exist independently, outside of a message
- CDA documents often contain encoded data intended for computer processing
- CDA documents are governed by very specific rules and must be created correctly to pass validation
How is a CDA document structured? [top]
A CDA document consists of two major sections:
The CDA header contains important metadata which identifies the document type, patient, provider, etc. Our solution provides a pre-built header with most of this information already in place. You only need to add and popluate the user-specific elements and attributes. You can also customize our CDA header’s template, behind the scenes.
The CDA body contains the clinical data being shared. The body can be one of two types:
- A non-XML body can contain any document composed of either text content or a MIME encoded BLOB (e.g., *.doc, *.pdf, *.tif). This makes it easy to share clinical documents in any form: text, picture, pdf, word document, etc.
- A structured XML body is composed of sections that contain entries. Each entry has a mandatory, human-readable narrative block and an optional encoded portion. The narrative block contains the complete content, either as XML or any MIME encoded BLOB (e.g., *.doc, *.pdf, *.tif). This human-readable block makes it easier to meet CDA standards as encoding is not required. The encoded portion, if present, contains entries that encode the data from the narrative block. These entries duplicate the information in the Narrative Block and can be safely ignored by recipients unable to process them.
With our solution, creating and populating the body of your CDA document can be as easy as simply adding a few lines of code to your script.
About Document Level Templates
Document Level Templates are used to define specialized CDA documents by applying restrictions to the generic CDA R2 model. A Document Level Template will make some sections/entries mandatory while excluding others. The three most commonly used templates are the Unstructured Document (C62), the Continuity of Care Document or CCD (C32), and the IHE Lab Report (C37).
What is a RIM class?
The CDA standard uses HL7’s Reference Information Model (RIM) for the following reasons:
- To represent health concepts
- To give data a clinical or administrative context
- To express how pieces of data are connected
The Reference Information Model consists of a generic set of classes from which more specific health classes are derived. For example, the “Act” RIM class represents actions that are executed and documented as health care management/provision. The “Participation” RIM class expresses the context of this act (who performed it, who received the care, where it was done, and so forth).
Want to know more? Check out the RIM standards here.
But, what’s with all these codes?
The CDA standard also relies on coding systems to identify, connect, and define health-related content. These include such systems as Systematized Nomenclature of Medicine — Clinical Terms (SNOMED CT) and Logical Observation Identifiers Names and Codes (LOINC). Our modules make applying these codes much easier by including helpful lookup capabilities.
About CDA Compliance
To be CDA compliant, your document must to meet the following criteria:
- All documents must comply with the base CDA R2 standard
- Specialized documents must comply with the appropriate Document Level Template
We recommend using the NIST CDA validation page to check that your document is compliant. The process is easy, but be careful not to upload confidential information!
There are are variety of external resources that specialize in CDA standards. If you need brushing up on your knowledge, check out the following links:
Common CDA Document Level Templates [top]
This page lists some of the common CDA Document Level Templates in use today.
When the CDA R2 was initially released, various organizations (HITSP, IHE, etc.) created many Document Level Templates to extend the standard. This created some inconsistency in how data is represented, since the same data can be encoded differently, in different templates. Because of this, the Heath Story Project was created to standardize the CCD and eight of the most common clinical documents. The result is the Consolidated Clinical Document Architecture (CCDA).
Document Level Template Examples
CCDA Document Level Templates from the HL7’s IHE Health Story Project:
|Continuity of Care Document (CCD)||C32||Continuity of Care Document (CCD)||Core data set of the most relevant patient healthcare data, covering one or more encounters.|
|Consultation Note||C84||Consultation Note||Supports consultations (request for advice) from one provider to another.|
|Diagnostic Imaging Report||Provides a specialist’s interpretation of image data. It conveys the interpretation to the referring (ordering) physician and becomes part of the patient’s medical record.|
|Discharge Summary||C48||Discharge Summary||Summarizes a patient’s admission to a hospital; it provides pertinent information for the continuation of care following discharge.|
|History and Physical (H&P) Note||C84||History and Physical (H&P) Note||Supports hospital admission, preoperative review, and initial ambulatory patient assessments.|
|Operative Note||Documents a surgical procedure. The operative note should be sufficiently detailed to support diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.|
|Procedure Note||Procedure Note||Documents non-operative procedures including interventional cardiology, interventional radiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields.|
|Progress Note||Progress Note||Documents a patient’s ongoing progress and clinical status during a hospitalization or outpatient visit.|
|Unstructured Document||C62||Unstructured Document||Documentation captured in an unstructured format encapsulated within an image or unstructured text file.|
Document Level Templates defined by HITSP:
|Lab Result Message||C35||A message containing laboratory results|
|Lab Report Document||C37||A clinical laboratory report containing the complete set of final results produced by a clinical laboratory in fulfillment of one or more test orders for a patient|
|Patient Level Quality Data Document||C38||A Patient Level Quality Data Document Using IHE Medical Summary (XDS-MS)|
|Encounter Message||C39||Contains data for a patient encounter (excluding laboratory results and radiology reports)|
|Radiology Result Message||C41||A message containing radiology result data|
|Resource Utilization Message||C47||A message containing content necessary to report utilization and status of health provider resources to public health agencies|
|Immunization Message||C72||A message containing the information required to update a patient’s vaccination record|
|Labor and Delivery Report||C152||Documents the course of labor and delivery of a mother and her fetus(es)|
- The CDA R2 page on the HL7 website
- Consolidated Clinical Document Architecture (CCDA)
- The IHE Health Story Project
- These are some of the organizations involved with the CDA