Clinical Document (HL7 clinical document)
Clinical document (CD) is a written, printed or electronic record that provides evidence of medical care. Clinical documents use an XML markup standard developed by Health Level 7 International (HL7), an organization dedicated to developing standards for the exchange of electronic health information. The standard, which is known as the Clinical Document Architecture (CDA), defines the structure of many common clinical documents such as admission or discharge records.
The HL7 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. CDA is an ANSI-certified standard from Health Level Seven International (HL7.org). Release 1.0 was published in November, 2000 and Release 2.0 was published with the HL7 2005 Normative Edition.
CDA specifies the syntax and supplies a framework for specifying the full semantics of a clinical document. It defines a clinical document as having the following six characteristics:
- Potential for authentication
- Human readability
A CDA can contain any type of clinical notes. Typical CDA document types include Discharge Summary, Imaging Report, History & Physical, and Pathology Report. An XML element in a CDA supports unstructured text, as well as links to composite documents encoded in pdf, docx, or rtf, as well as image formats like jpg and png.
It was developed using the HL7 Development Framework (HDF) and it is based on the HL7 Reference Information Model (RIM) and the HL7 Version 3 Data Types.
The CDA specifies that the content of the document consists of a mandatory textual part (which ensures human interpretation of the document contents) and optional structured parts (for software processing). The structured part relies on coding systems (such as from SNOMED and LOINC) to represent concepts.