HL7 Implementation Guide for CDA Release 2: Operative Note
Draft Standard for Trial Use
Published March 2009
For the purpose of this Implementation Guide, the operative note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies. It is created immediately following a surgical or other high-risk procedure and records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.
The audience for this draft standard includes software developers and consultants responsible for implementation of U.S. realm Electronic Health Record (EHR) 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 (CDA) documents created according to this specification.
Also included below are files containing the Schematron schema for the HL7 Operative Note DSTU, as well pre-generated XSLT files that can be used to generate validation reports on Op Note compliant CDA instances. This schema is intended to be used in addition to the CDA.xsd XML Schema file that is included with the CDA base specification.