Dept. of Medical Informatics and Clinical Epidemiology
Oregon Health & Science University
As electronic medical record (EMR) adoption continues to increase, exchange of information between EMRs is increasingly important. Health Level Seven (HL7) standards were developed to facilitate that exchange by carrying information in a highly standardized format. Standardization allows for a minimum of customized interface between EMRs reducing cost and difficulty of implementing information exchange. Clinical information is transmitted electronically as messages or documents. Documentscan be constructed using Clinical Document Architecture, Release Two (CDA R2), one of the HL7 Version Three (HL7 V3) standards 1,2. CDA R2 is implemented with extensible markup language (XML) using tags defined in the HL7 V3 Reference Information Model (RIM) 2,4. CDA R2 is currently used to construct a variety of clinical documents after specifications are created for more specific purposes (implementation guides). An implementation guide for operative notes is available, but prior to this work there was no implementation guide for endoscopic, or any other non-operative, procedure note. This project describes the creation of a Procedure Note Implementation Guide, and as part of that, the construction of an endoscopy report example of a procedure note. The CDA R2 Procedure Note Implementation Guide was balloted by HL7 in January 2010, as a Draft Standard for Trial Use (DTSU), and included the XML example for endoscopy.
School of Medicine
Carr, Thomas A., "A standardized GI endoscopy procedure note, in extensible markup language, formatted using Health Level Seven (version 3) Clinical Document Architecture (release 2)" (2010). Scholar Archive. 394.