HL7 CDA R2 AIS Implementation Guide

More documents

Recommendations

Info

HL7 Additional Information Specification Implementation GuideCDAR2AIS0000R030In this example the and elements provide the supplementary information,which in this case includes the ICD-9-CM Diagnosis code associated with the principal diagnosis.2.5.3.1 SubsectionsAny CDA Section can have further subsections. These are represented in additional elements of the CDA Section. Subsections follow entries within the CDA structure(see section 2.5.4 below on Entries). The following is an example of a component with multipleanswer parts in the human decision variant (HDV).PRINCIPAL DIAGNOSISBIPOLAR AFFECTIVE D/ODATE OF FIRST ONSET OR EXACERBATION2006-03-062.5.4 CDA EntriesCDA Entries are used to store the computer processable information in the computer decisionvariant of attachments. There are several different kinds of entries that may be used within aCDA Document. Each entry represents some sort of clinical statement about the care that isbeing provided to the patient. This implementation guide discusses the most common types ofentries used in the Additional Information Specifications. Additional Information Specificationswill describe other kinds of entries as they become necessary.To support reuse of existing CDA documents being returned in response to a claims attachmentrequest, additional CDA data elements may be present within an entry used in a claimsattachment. These data elements must conform to the CDA Release 2.0 specification. Receiversare encouraged to not reject transactions with these additional data elements to promote the re-useof existing CDA documents, but need not process them, unless otherwise specifically indicated inan Additional Information Specification. At this point, no Additional Information Specificationrequires data elements other than those listed below.2.5.4.1 Entry ClassesThis section explains how the Claims Attachment AIS makes use of HL7 Version 3 classes in theCDA document to represent information. For more detail on how these classes are represented inan attachment see the HL7 Clinical Document Architecture Release 2.0 standard, or relatedstandards.HL7 Version 3 standards partition information into four basic class types: information aboutPage 24March 2007Copyright © 1998-2007Health Level Seven, Inc. All rights reserved.Release 3.0 Draft Standard
HL7 Additional Information Specification Implementation GuideCDAR2AIS0000R030intentional acts, the participations in those acts, the role that a participant plays, and the entities(persons, organizations, locations or substances) taking on those roles. The type of class used torepresent the information appears in the AIS value tables for each attachment component andattachment component answer part. An example and explanation of the value tables and theirstructure can be found in section 2.9 of this implementation guide.Compliance statements and other details about the entry classes are found in section 3.6 and itssub-sections.2.5.4.1.1 ActsMost of the information requested by an AIS will appear in some form of act class, representedusing the , , , , or elements, corresponding to ACT, PROC, ENC, OBS, SBADM, or SPLY values in theAIS data tables.2.5.4.1.2 Persons and OrganizationsInformation about persons and organizations will be through the participation class, and will beindicated by the value PART in the AIS data table. CDA uses the following participationelements to represent the participation of various people or organizations: , ,, , , , , ,, , , , ,and . Answer parts will appear in the appropriate participation element, orone of its contained classes based on the kind of information being requested.Each participant has an associated role. For example, the participant has a role. The participation element will often carry the time that participation started in the element, and may include other information, relevant to the participation (e.g., a signaturecode).The role carries the identifiers of the person or organization in one or more contained elements. Addresses and contact information for persons are stored on the role, because thiscontact information may vary with the role.Each role has an at least one associated entity, which may be a person or organization, or both,depending upon the type of role. For example, the role can have an entity, as well as a entity.Entities carry the names of people or organizations. Enties representing organizations also carrythe address and contact information for the organization.2.5.4.1.3 SubstancesActs related to substances ( and ) have other participants,which are the substances being administered (through the element), or supplied(via the element). The product is acting in the role, and thesubstance detail appears mainly in the entities represented by the or elements.Copyright © 1998-2007 Health Level Seven, Inc. All rights reserved.Release 3.0 Draft StandardPage 25March 2007
Page 1 and 2: CDAR2AIS0000R030HL7 Additional Info
Page 4 and 5: HL7 Additional Information Specific
Page 31: HL7 Additional Information Specific
Page 82 and 83:
HL7 Additional Information Specific
Page 84:
HL7 Additional Information Specific
show all

HL7 CDA R2 AIS Implementation Guide

Create successful ePaper yourself

Delete template?

Save as template?