HL7 CDA R2 AIS Implementation Guide

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HL7 Additional Information Specification Implementation GuideCDAR2AIS0000R030• It can contain a element containing free text in XML elementsthat organize the material into sections, paragraphs, tables and lists as describedin the subsequent sections of this document.• The computer-decision variant (CDV) has the same content as the human-decisionvariant, but additional structured information and LOINC coded data is included so that acomputer could provide decision support based on the document. Attachments in theCDV can be rendered for human decisions using the same style sheet that HL7 providesfor rendering documents formatted according to the human-decision variant.These variants do not differ in functional content. All variants of the same attachment haverequired and optional content as specified in the Additional Information Specification documentfor that attachment. The variants only differ with regard to whether structured and coded data ismandated.Both variants place constraints upon what information must be present in the CDA to support theAttachment use case, described in Section 1.1 of each AIS document. Additional CDA structures(document sections, entries, etc.), may be present to support use cases other than those defined bythis implementation guide. Anything not explicitly prohibited by the AIS may be present in theCDA document to support use cases other than those defined therein.HL7 has provided one or more XML stylesheets as part of this implementation package;however, these are neither balloted standards, nor are they required for use under HIPAA. Use ofHL7 provided stylesheets is entirely up to the implementer.2.3 Certain XML TermsThis section informally introduces certain XML terms that are used extensively in thisimplementation guide. The reader can find them fully defined in Extensible Markup Language(XML) 1.0 (Fourth Edition) which is available at http://www.w3.org/TR/REC-xml. Latersections of this implementation guide provide more detail on the relevant terms and concepts usedin attachments and the example shown below.XML documents are composed of elements that can contain attributes, and text (which is calledparsable computer data (PCDATA). A well-formed XML document has a single element, theroot, which contains all other elements in the document. The following example is, by itself, awell-formed XML document, although it is only a portion of what constitutes a complete CDAdocument. The example contains several distinct kinds of elements, including: ,, , , , , , , , and . The element contains a LOINC code in its "code" attribute.Data is also conveyed as PCDATA within the and elements.PRIMARY DIAGNOSISbipolar affective disorderas of 26 March 2003Page 14March 2007Copyright © 1998-2007Health Level Seven, Inc. All rights reserved.Release 3.0 Draft Standard
HL7 Additional Information Specification Implementation GuideCDAR2AIS0000R0302.3.1 Use of XPathCompliance statements that refer to elements of a CDA document here are identified using thenotation defined in XML Path Language (XPath), which is available athttp://www.w3.org/TR/XPath. XPath expressions are also used in the AIS Value Tables to showhow each Attachment Component or Attachment Component Answer Part can be located withinthe clinical document.For example, a reference to/ClinicalDocument /code/@codewould be a reference to the code attribute of the element within the element.XPaths generally refer to a set of nodes. For example, the XPathsection/coderefers to all the elements that are direct descendants of any element.Copyright © 1998-2007 Health Level Seven, Inc. All rights reserved.Release 3.0 Draft StandardPage 15March 2007
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HL7 CDA R2 AIS Implementation Guide

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