HL7 CDA R2 AIS Implementation Guide

HL7 Additional Information Specification Implementation GuideCDAR2AIS0000R030• Laboratory results• Medications.In addition, a specification is available that enumerates the use of LOINC codes in modifying thescope of requests in the ASC X12 277 transaction.anesthesiaarthroscopybronchoscopecardiac catheterizationcolonoscopyconsultation noteconsultation requestcytologyTable 1.2-1. Sample Clinical report topics.diagnostic imaging flexible sigmoidoscopydischarge notehistory and physicalecho heartnotesEEG braininitial assessmentEKGnursingelectromyelogram OB echoendoscopyoperative noteexercise stress test procedure noteprogress noteradiologyspirometrysurgical pathologytemperature chart totaltriage notevisit note1.3 Authority, Organization and Scope of this DocumentThis Implementation Guide is based on the HL7 Clinical Document Architecture (ANSI/HL7CDA R2-2005), an ANSI-accredited American National Standard. The HL7 Membership in aletter ballot, using the procedure for publishing HL7 Recommendations, has approved thisImplementation Guide.The organization of this specification is described below:• Section 1 is this introduction.• Section 2 provides foundational information on the CDA and the general approach toCDA-based attachments.• Section 3 provides the rules for constructing a CDA document that conforms to thisspecification for attachments.• Section 4 describes non-normative supplementary information that is included in thepublication package. Non-normative data is data supplied for informational purposes tofurther explain or clarify some text on concept. Users may choose to use this nonnormativedata.• Section 5 contains a subset of the Unified Code for Units of Measure (UCUM) table.This is a large table of units of measures used in attachment documents. To conservespace in the individual AIS documents, it has been included in this implementation guideand will not be repeated in each of the AIS documents.Those sections of this document that are normative are explicitly identified by including the word"Normative" in the section title. Sections not so marked are not normative. See also, thedefinition of "Normative" in section 3.1.1.4 Health Level Seven OrganizationFounded in 1987, Health Level Seven, Inc. (http://www.HL7.org) is a not-for-profit, ANSIaccreditedstandards developing organization dedicated to providing a comprehensive frameworkand related standards for the exchange, integration, sharing, and retrieval of electronic healthinformation that supports clinical practice and the management, delivery and evaluation of healthservices.Copyright © 1998-2007 Health Level Seven, Inc. All rights reserved.Release 3.0 Draft StandardPage 7March 2007