HL7 CDA R2 AIS Implementation Guide

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HL7 Additional Information Specification Implementation GuideCDAR2AIS0000R030immunization, or evaluation and management. Service events are distinct from encounters.Although there is often a one to one relationship between the two, a service event may occuroutside the context of an encounter (e.g., review of laboratory results), or several service eventsmight occur within the context of a single encounter.George F CarsonMD2.5.1.22 (Optional)Added since this was in table. Need text.2.5.1.23 (Optional)Added since this was in table. Need text.2.5.1.24 (Optional)This element identifies the encounter or visit that is described by this clinical document. Not alldocuments are created as a result of an encounter with a patient (e.g., review of test results).2.5.2 The CDA BodyThe CDA body can be either unstructured or can be comprised of structured markup, includingnarrative text and structured and coded entries containing machine-readable information. EveryCDA document has exactly one body, which appears in the element following theCDA Header information.The element containing the body of a CDA document takes one of two forms.• It can be a single (e.g., an image or scanned image) element thatcontains a reference to an external file that provides the content for the body of thedocument. This is used when the entire attachment content is an image or other type ofexternally referenced file format. Note that the externally referenced file may bepackaged within the same X12 BIN Segment by using MIME. See section 3.5.2 for allallowable format types and section 2.4 for MIME packaging requirements of a type.Page 22March 2007Copyright © 1998-2007Health Level Seven, Inc. All rights reserved.Release 3.0 Draft Standard
HL7 Additional Information Specification Implementation GuideCDAR2AIS0000R030• Or it can contain a element containing one or more elements each with its own element. The following sub-sections detail therequirements and structure of the CDA body with sections.2.5.3 CDA Body with SectionsThe CDA body is just a set of containers for information. There are several levels. The outer-levelcontainer within the body is a "component" of the document. Each elementcontains a "section" that is represented by the element. Within a section the content isplaced in a element. Within the element may be containers that support alternativeways of arranging the information:• a element is a container for a block of text• a element is a container for a list of blocks of text• a element is a container for blocks of text arranged in rows and columns.For example, here is a fragment of a CDA document in the human-decision variant:PRINCIPAL DIAGNOSISBIPOLAR AFFECTIVE D/OIn this example the Principal Diagnosis section consists of one paragraph. It contains thediagnosis. Both the title and the text are intended to be read by a person.The CDA allows for human-readable text to be supplemented by discrete data elements thatwould assist a computer in processing the information in the document. Here is the samefragment with the supplementary information that is used for the computer-decision variant:PRINCIPAL DIAGNOSISBIPOLAR AFFECTIVE D/OCopyright © 1998-2007 Health Level Seven, Inc. All rights reserved.Release 3.0 Draft StandardPage 23March 2007
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HL7 CDA R2 AIS Implementation Guide

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