HL7 Implementation Guide for CDA Release 2: Consultation Notes
Draft Standard for Trial Use
Published July 16, 2008
For the purpose of this Implementation Guide, a consultation visit is defined by the evaluation and management guidelines for a consultation established by the Centers for Medicare and Medicaid Services. A sample Consultation Note was provided by the Association for Healthcare Documentation Integrity (AHDI) and used as a test against the design of this HL7 Draft Standard for Trial Use.
The audience for this draft standard includes software developers and consultants responsible for implementation of Electronic Health Record (EHR) systems, Electronic Medical Record (EMR) systems, Personal Health Record (PHR) systems, dictation/transcription systems, document management applications, and local, regional and national health information exchange networks who wish to create and/or process HL7 Clinical Document Architecture documents created according to this specification.
The Consultation Note and History & Physical standards are referenced by the Healthcare Information Technology Standards Panel (HITSP) in document C/84, "Consult & History & Physical Note Component." They are also referenced in this regard by the Certification Commission for Healthcare Information Technology (CCHIT) in the current Health Information Exchange work group roadmap criteria, Road.HIE.157, "The HIE shall provide the ability to receive and forward a HITSP C/84 document," slated for 2011 certification.