HL7 CDA R2 AIS Implementation Guide

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HL7 Additional Information Specification Implementation GuideCDAR2AIS0000R0302.5 The Structure of a CDA DocumentThis section introduces some basic concepts of the HL7 CDA, and how these relate to attachmentimplementation. This summary does not mention features of the CDA that are not germane to theuse of CDA documents as attachments. For example, in our simplified approach to using theCDA Standard, we found it necessary to describe only a few dozen of the 500 XML elements inthe CDA Standard. Much more detail is provided in the CDA Standard, available from HL7.The root element in a CDA Release 2.0 document instance is always . Thiselement is logically broken up into a Header and a Body.2.5.1 The CDA HeaderThe header contains information about the patient, the event being documented, the healthcareproviders who have documented the event, and other administrative data. This header informationis always provided in discrete XML elements. The following sub-sections provide a briefdescription of the required CDA Header elements relevant to attachments, with examples foreach. Table 2.5-1 below shows the required and optional header elements. Please see HL7Clinical Document Architecture Release 2.0 for a more complete list of header elements andtechnical details on their representation in a CDA document.[Need to add more to table, and add more sub-sections that were in table but not described.Either the order of the table or the subsections needs to be sorted differently – see multiple ballotcomments.]Header ElementTable 2.5-1 CDA Header ElementsReq/OptHeader ElementReq/Opt R O R R R O R 5 O R O R O O R 6 O O O O R O R O[Add parentDocument and authenticator, since they appear in paragraphs below.]O5 This implementation guide requires that all clinical documents to have a human readable title.6 This implementation guide requires that all clinical documents record the attachment control number in this headerelement.Page 18March 2007Copyright © 1998-2007Health Level Seven, Inc. All rights reserved.Release 3.0 Draft Standard
HL7 Additional Information Specification Implementation GuideCDAR2AIS0000R0302.5.1.1 (Required)This is an identifier that indicates the Clinical Document conforms to the CDA Release 2.0specification. Future releases of CDA will use a different value for this element. This elementmust appear exactly as follows:2.5.1.2 (Required)This is a user assigned identifier unique to the Clinical Document being re-used or created. Thisidentifier should not be confused with the provider's Patient Account Number or Medical RecordNumber. The extension typically contains the institution assigned identifier. The root is an OIDthat identifies the assigner of the identifier. Each revision of a clinical document is assigned adistinct identifier. See section 2.5.6 for a description of OIDS and their use in attachments andfor more information on how to obtain a list of OIDs that have been registered with HL7.2.5.1.3 (Attachment Type Identifier) (Required)This is a LOINC code that classifies the clinical document attachment type (vs. the actualattachment data components) associated with the clinical information in the CDA. For example,if you are sending the psychiatric treatment plan, the value in this header element would be18594-2, which identifies the clinical document as the psychiatric rehabilitation attachment type.2.5.1.4 (Attachment Type Name) (Required)This is the human readable name of the clinical document. [See MLB-3 and DAF comments]Psychiatric Rehabilitation Attachment2.5.1.5 (Required)This is the date (and time) when this revision of the clinical document was created.2.5.1.6 (Required)This code defines the level of confidentiality assigned to the clinical document.Note that the receiver is not obligated to give the document any special handling beyond itsnormal policies for dealing with personally identifiable health information, regardless of the valueplaced in . [MLB-4 Add codes but review Keith's 6/26 email.]2.5.1.7 (Optional)Added since this was in table. Need text.2.5.1.8 (Optional)Added since this was in table. Need text.Copyright © 1998-2007 Health Level Seven, Inc. All rights reserved.Release 3.0 Draft StandardPage 19March 2007
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HL7 CDA R2 AIS Implementation Guide

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