Health Story: Integrating Narrative Notes and the EHR
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Procedure Note

HL7 Implementation Guide for CDA R2
Procedure Note
Draft Standard for Trial Use
Published August 2010

This project designed a basic procedure note in XML as a constraint on HL7 version 3 Clinical Document Architecture Release 2. The note is basic enough to be used for all procedures and includes a sample note for endoscopy. To promote standardization and acceptance, it was closely modeled on the current HL7 CDA Operative Note. Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (JCAHO) requirements, with specialty group input, was used to choose the contents. CMS and JCAHO, the primary regulators, requirements dictated the minimum content standards. Implementer institutions were given opportunity for input as to compatibility with current/planned systems.

The Health Story Project collaborated with the American Society of Gastrointestinal Endoscopy (ASGE) with strong volunteer support from Oregon Health & Science University. Within HL7, the project was sponsored by the Structured Documents Work Group.

» Project Wiki Site

» Access Procedure Note DSTU

» Download Procedure Note Validating Rule Set (xpath/Schematron)

» Access HL7 CDA Release 2 through the Clinical Document Architecture section of the HL7 online store