As part of the ongoing effort to enable more consistent and accurate clinical data exchange, the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) Draft Standard for Trial Use Release 2 continues to build on the library of CDA R2 templates consolidated within the first release. The updated template library for Clinical Notes includes refinements to previously harmonized templates, along with new templates representing data supporting additional use cases. These additions within the sophomore release expand the applicability of electronic, interoperable clinical documentation beyond the ambulatory and inpatient care settings.
Notable refinements and additions in C-CDA for Clinical Notes R2 are:
- Clarified template conformance and guidance supporting Meaningful Use Stage 2 requirements
- Robust examples to guide implementers and supplementary examples to address ambiguities
- New Care Plan document facilitating care planning amongst patient care providers
- New Transfer Summary document supporting patient care transitions between health care settings
- New Referral Note document informing consulting providers
- Updated Consultation Note document informing referring providers
- New Patient-Generated Document header for documents created by the patient
The two-volume implementation guide is being vetted through the HL7 September ballot cycle. To submit comments, HL7 voting members must join the ballot pool by Monday, September 9, 2013. Votes and comments are due Monday, September 16. Information on the balloting process and getting plugged-in is available here.