Clinical Document Architecture
CDA (Clinical Document Architecture) conveys appropriate information to appropriate person. It is not only a document but also an architecture. CDA usually include text, sounds, images and other multimedia content. There exists variability in clinical notes, degree of semantic coding, use of standard healthcare terminologies and etc. Thus, it becomes difficult to store and exchange documents. CDA standard takes a step closer towards solving these variability. The CDA is a document markup standard that specifies structure and semantics of ‘clinical document’. The CDA is a part of HL7 Version 3 family of standards. The encoding is done in Extensible Markup Language (XML).A clinical document will exist as unchanged for a stipulated time period
which is defined by local and regulatory requirements.The clinical document is maintained by an organization or a person who has been entrusted with its responsibility.CDA is a clinical document which has information and needs authentication.the authentication can be applied to whole document and not just to parts of the document.The document should be human readable.Clinical documents have many requirements and uses. This include direct patient care, outcome research, public health reporting etc. The documents which are created by clinicians involved in direct patient care will be given first priority. The assumption is that the other users will be derivable.There exists many non-standardized clinical documents. The CDA brings about standardization of this documents. This is done by facilitating cost effective implementation across many systems, human readable documents between users are exchanged, by providing compatibility with different document creation application etc.The CDA documents can be exchanged via emails or on a floppy disc. They can be stored as an independent file or within a database. This signifies that CDA documents are application and platform-independent.An extensibility mechanism will be defined by CDA. This allows local implementers to represent information which cannot be represented in the standard.The CDA documents are platform and application independent. A huge number of tools can perform editing and can view information, at any time.Header: The CDA document is enclosed within a element. This contains header and body. The header is between and elements. The header helps in document identification and classification. It also provides information on authentication, patient, encounter, involved providers.
Body: This part contains the clinical report. It can consist of structured markup or unstructured blob.
Section: The document section of CDA is enclosed within section element. Sections helps in representing transaction. A narrative block (very important part and is human readable) can be a part of section. Also, section can have many CDA entries and external reference.
Examples of CDA document can be: discharge summary, diagnostic report, prescription, referral, clinical summary, history/physical examination.
which is defined by local and regulatory requirements.The clinical document is maintained by an organization or a person who has been entrusted with its responsibility.CDA is a clinical document which has information and needs authentication.the authentication can be applied to whole document and not just to parts of the document.The document should be human readable.Clinical documents have many requirements and uses. This include direct patient care, outcome research, public health reporting etc. The documents which are created by clinicians involved in direct patient care will be given first priority. The assumption is that the other users will be derivable.There exists many non-standardized clinical documents. The CDA brings about standardization of this documents. This is done by facilitating cost effective implementation across many systems, human readable documents between users are exchanged, by providing compatibility with different document creation application etc.The CDA documents can be exchanged via emails or on a floppy disc. They can be stored as an independent file or within a database. This signifies that CDA documents are application and platform-independent.An extensibility mechanism will be defined by CDA. This allows local implementers to represent information which cannot be represented in the standard.The CDA documents are platform and application independent. A huge number of tools can perform editing and can view information, at any time.Header: The CDA document is enclosed within a element. This contains header and body. The header is between and elements. The header helps in document identification and classification. It also provides information on authentication, patient, encounter, involved providers.
Body: This part contains the clinical report. It can consist of structured markup or unstructured blob.
Section: The document section of CDA is enclosed within section element. Sections helps in representing transaction. A narrative block (very important part and is human readable) can be a part of section. Also, section can have many CDA entries and external reference.
Examples of CDA document can be: discharge summary, diagnostic report, prescription, referral, clinical summary, history/physical examination.