Appendix

Editing tips and notes

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1 CDA Overview

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2 Introduction to CDA Technical Artifacts

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3 CDA Document Exchange in HL7 Messages

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4 CDA Templating

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5 CDA R-MIM

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6 CDA Hierarchical Description

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7 CDA XML Implementation

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8 Appendix A. Samples

8.1 Sample Document

This file is not included in the wiki form of the CDA standard.

8.2 Sample CDA Instance

This is a valid and conformant CDA instance based on the sample document above.

NOTE: Readers should be aware of the evolving "Using SNOMED CT in HL7 Version 3" implementation guide, currently in a draft state. The guide, co-developed by HL7 and the College of American Pathologists, will be balloted by HL7 as an Informative Document. Recommendations in the final published guide should usurp patterns of SNOMED CT usage found in this sample instance

Open the Sample File

8.3 Sample CDA Style Sheet

This is a sample CDA XSLT style sheet that can be used to transform a CDA instance into HTML. It is provided as a convenient starting point for local style sheet development, and has several known limitations, including:

• Local implementations may have different requirements for rendering the CDA header.
• Does not support RegionOfInterest rendering.
• Does not support rendering of inline multimedia (e.g. multimedia that is Base 64 encoded within the CDA document).
• Does not support rendering of deleted text within the CDA Narrative Block.

Open the Sample Style Sheet

9 Appendix B. Implementation Notes

9.1 Creating CDA Documents

Introduction

There are an ever-increasing variety of tools and techniques for creating CDA documents:

1. Transcription: most clinical documents are created through a voice interface. CDA is available as an output from transcription vendors large and small today. Some are integrating natural language processing to provide coded structures within dictated CDAs.
2. EMR/EHR: many electronic medical record vendors have CDA output capability, although they provide it on-demand, not as a standard feature. For EMRs, CDA is relatively simple type of report.
3. XML forms: a new generation of XML tools for forms generation can create CDA on output.
4. Knowledge base: at least one major US provider has built a CDA editor on top of a knowledge base for guided, structured entry.
5. Dynamic query: dynamic assembly of CDA documents is used in some distributed applications to prepopulate documents from existing data stores, such as lab result databases. This method can be used in conjunction with any of the others.

This appendix considers not the specific tools and technologies, but is intended as a general guide to use of CDA in document creation.

Before you start: RIM compliance

• structures, vocabulary, datatypes

Creating a CDA-compliant instance, by definition, means that the information contained within is defined by the HL7 RIM. Regardless of your starting point or method of document generation, when you are done, the computable semantics of the document will derive their meaning from the relationship between RIM classes, controlled vocabulary and the V3 RIM datatypes. Any CDA-generation implementation must start with an examination of how document requirements relate to the RIM, the datatypes and vocabulary.

The RIM, however, is a highly abstract model and recognizes many extensive vocabulary domains. While RIM-mapping is a necessary condition for CDA generation, it is not sufficient to determine the method of generation or to drive a user interface for document creation.

An exchange specification, not an authoring specification

• CDA is not deterministic for document creation

CDA is a specification for the exchange form of a clinical document. A CDA schema can validate many of the conformance requirements, but will be too general for most authoring applications. In general, standards for interoperability and broadbased exchange will not directly drive an authoring GUI. Given the extent of the CDA domain – clinical care – the requirements for generalized exchange overlap with, but don’t match, the requirements for driving an authoring interface.

For example, the CDA requirement for human readability demands that a single stylesheet render the authenticated clinical content of any CDA document. If CDA elements were defined in the generic schema that corresponds to the sections of a document, <historyOfPresentIllness> or <Subjective>, for example, a stylesheet would need to recognize each of these tags as section-level tags and render them accordingly. The CDA approach, defining <section> and asserting the type of section through coded vocabulary means that not only is the CDA extensible through the externally-maintained vocabulary domains, but that document designers have the flexibility to create hierarchies of sections and to name and tag them according to local requirements, while maintaining compatibility for the exchange context. Thus, while specific tagging that makes it easier to drive a GUI is fine locally, where practice can be more tightly constrained, CDA needs to take a more general approach.

Both sets of requirements, for authoring and for exchange, should be recognized. Within a defined community of interest, such as a single business enterprise, a professional society or in some cases, local and regional health authorities, there can be tight agreement on the form of a document so that the authoring definitions and the exchange definitions coincide. Unless and until there is universal agreement, there can be no universal exchange unless the diversity of local requirements is acknowledged. This is a long-winded way of saying that CDA will remain a general exchange standard, and other approaches must be available to define data entry and document creation validation requirements.

General approaches: constrain or transform

• constrain: emit valid CDA directly from the authoring system using a schema that isn’t CDA
• transform: example - emit local XML, map to CDA

Given that CDA is not an authoring schema, there are two logical alternatives to creating valid CDA instances.

The first is to add constraints to the CDA schema so that the resulting specification defines a particular document type (see the following exhibit "Creating a CDA through a local schema"). There are several technologies available for adding constraints. One approach is to modify the CDA schema itself to a local variant (local.cda.xsd below). Modifications could include limiting the levels of nesting; constraining vocabulary and sequence, for example requiring that a section with a LOINC code for "Subjective" initiate the document body and be followed by a section coded "Objective". These modifications could be expressed in W3C Schema or as Xpath statements within the local schema. Instances that validate against this constrained, local version of CDA are, by definition, also valid CDA instances.

Link to wide graphic (opens in a new window)

Templates are one type of constraint. HL7 is in the process of defining a formal template mechanism (see The "A" in "CDA").

The second approach is to create a local schema and then transform the local XML instance to CDA

Link to wide graphic (opens in a new window)

9.2 LOINC Document Codes

The following table is drawn from LOINC, version 2.14, December 2004, and equals the subset whose scale = "DOC" (and whose status <> "DEL"). The LOINC document model includes a component for "type of service" (conveyed in the Component field), "setting" (conveyed in the System field), "subject matter domain" (conveyed in the Method_Type field), and "training / professional level" (also conveyed in the Method_Type field).

The type of service characterizes the kind of service or activity that was provided to/for the patient (or other subject of the service) as described in the note. Common subclasses of service would be examinations, evaluations, and management. The notion of time sequence, e.g. at the beginning (admission) at the end (discharge) and is subsumed in the axis.

The setting is a modest extension of the Centers for Medicare and Medicaid Services (CMS) coarse definition of settings. Setting is not equivalent to location, which typically has more locally defined meanings.

The subject matter domain characterized the subject matter or clinical categorization of a note. The training / professional level characterizes the training or professional level of the author of the document.

Table X: LOINC document codes

LOINC_NUM	COMPONENT (Type of Service)	SYSTEM (Setting)	METHOD_TYPE (Subject Matter Domain and/or Training / Professional Level)
34862-3	ADMISSION EVALUATION NOTE	INPATIENT	ATTENDING PHYSICIAN.GENERAL MEDICINE
34744-3	ADMISSION EVALUATION NOTE	{SETTING}	NURSING
34873-0	ADMISSION EVALUATION NOTE	{SETTING}	SURGERY
34094-3	ADMISSION HISTORY AND PHYSICAL NOTE	HOSPITAL	CARDIOLOGY
34763-3	ADMISSION HISTORY AND PHYSICAL NOTE	{SETTING}	GENERAL MEDICINE
28615-3	AUDIOLOGY STUDY	{SETTING}
18743-5	AUTOPSY NOTE	{SETTING}	{PROVIDER}
33720-4	BLOOD BANK CONSULT	{SETTING}
34095-0	COMPREHENSIVE HISTORY & PHYSICAL NOTE	{SETTING}	{PROVIDER}
34096-8	COMPREHENSIVE HISTORY AND PHYSICAL	NURSING HOME
34098-4	CONFERENCE EVALUATION NOTE	{SETTING}	{PROVIDER}
34097-6	CONFERENCE EVALUATION NOTE	NURSING HOME	{PROVIDER}
24611-6	CONFIRMATORY CONSULTATION NOTE	OUTPATIENT	{PROVIDER}
34807-8	CONSULTATION NOTE	{SETTING}	OPHTHALMOLOGY
34100-8	CONSULTATION NOTE	CRITICAL CARE UNIT	{PROVIDER}
34810-2	CONSULTATION NOTE	{SETTING}	OPTOMETRY
34812-8	CONSULTATION NOTE	{SETTING}	OROMAXILLOFACIAL SURGERY
34814-4	CONSULTATION NOTE	{SETTING}	ORTHOPEDICS
34831-8	CONSULTATION NOTE	{SETTING}	RADIATION ONCOLOGY
34761-7	CONSULTATION NOTE	{SETTING}	GASTROENTEROLOGY
34099-2	CONSULTATION NOTE	{SETTING}	CARDIOLOGY
34833-4	CONSULTATION NOTE	{SETTING}	RECREATIONAL THERAPY
34820-1	CONSULTATION NOTE	{SETTING}	PHARMACY
34822-7	CONSULTATION NOTE	{SETTING}	PHYSICAL MEDICINE AND REHABILITATION
34835-9	CONSULTATION NOTE	{SETTING}	REHABILITATION
34824-3	CONSULTATION NOTE	{SETTING}	PHYSICAL THERAPY
34826-8	CONSULTATION NOTE	{SETTING}	PLASTIC SURGERY
34764-1	CONSULTATION NOTE	{SETTING}	GENERAL MEDICINE
34837-5	CONSULTATION NOTE	{SETTING}	RESPIRATORY THERAPY
34803-7	CONSULTATION NOTE	{SETTING}	OCCUPATIONAL HEALTH
34816-9	CONSULTATION NOTE	{SETTING}	OTORHINOLARYNGOLOGY
34783-1	CONSULTATION NOTE	{SETTING}	KINESIOTHERAPY
34756-7	CONSULTATION NOTE	{SETTING}	DENTISTRY
34788-0	CONSULTATION NOTE	{SETTING}	PSYCHIATRY
34102-4	CONSULTATION NOTE	HOSPITAL	PSYCHIATRY
34791-4	CONSULTATION NOTE	{SETTING}	PSYCHOLOGY
34103-2	CONSULTATION NOTE	{SETTING}	PULMONARY
34795-5	CONSULTATION NOTE	{SETTING}	NEPHROLOGY
34758-3	CONSULTATION NOTE	{SETTING}	DERMATOLOGY
34760-9	CONSULTATION NOTE	{SETTING}	DIABETOLOGY
34798-9	CONSULTATION NOTE	{SETTING}	NEUROSURGERY
34800-3	CONSULTATION NOTE	{SETTING}	NUTRITION+DIETETICS
34749-2	CONSULTATION NOTE	OUTPATIENT	ANESTHESIA
34781-5	CONSULTATION NOTE	{SETTING}	INFECTIOUS DISEASE
34828-4	CONSULTATION NOTE	{SETTING}	PODIATRY
34101-6	CONSULTATION NOTE	OUTPATIENT	GENERAL MEDICINE
34104-0	CONSULTATION NOTE	HOSPITAL	{PROVIDER}
34785-6	CONSULTATION NOTE	{SETTING}	MENTAL HEALTH
34805-2	CONSULTATION NOTE	{SETTING}	ONCOLOGY
34797-1	CONSULTATION NOTE	{SETTING}	NEUROLOGY
34879-7	CONSULTATION NOTE	{SETTING}	ENDOCRINOLOGY
34839-1	CONSULTATION NOTE	{SETTING}	RHEUMATOLOGY
34779-9	CONSULTATION NOTE	{SETTING}	HEMATOLOGY+ONCOLOGY
34777-3	CONSULTATION NOTE	{SETTING}	GYNECOLOGY
34776-5	CONSULTATION NOTE	{SETTING}	GERONTOLOGY
34855-7	CONSULTATION NOTE	{SETTING}	OCCUPATIONAL THERAPY
34853-2	CONSULTATION NOTE	{SETTING}	VASCULAR SURGERY
34771-6	CONSULTATION NOTE	{SETTING}	GENERAL SURGERY
34841-7	CONSULTATION NOTE	{SETTING}	SOCIAL WORK
34845-8	CONSULTATION NOTE	{SETTING}	SPEECH THERAPY+AUDIOLOGY
11488-4	CONSULTATION NOTE	{SETTING}	{PROVIDER}
34847-4	CONSULTATION NOTE	{SETTING}	SURGERY
34851-6	CONSULTATION NOTE	{SETTING}	UROLOGY
34849-0	CONSULTATION NOTE	{SETTING}	THORACIC SURGERY
34865-6	COUNSELING NOTE	{SETTING}	PSYCHIATRY
34866-4	COUNSELING NOTE	{SETTING}	PSYCHOLOGY
34872-2	COUNSELING NOTE	{SETTING}	SOCIAL WORK
34869-8	COUNSELING NOTE	{SETTING}	PHARMACY
34864-9	COUNSELING NOTE	{SETTING}	MENTAL HEALTH
28622-9	DISCHARGE ASSESSMENT NOTE	{SETTING}	NURSING
28574-2	DISCHARGE NOTE	{SETTING}	{PROVIDER}
11490-0	DISCHARGE SUMMARIZATION NOTE	{SETTING}	PHYSICIAN
28655-9	DISCHARGE SUMMARIZATION NOTE	{SETTING}	ATTENDING PHYSICIAN
18842-5	DISCHARGE SUMMARIZATION NOTE	{SETTING}	{PROVIDER}
34105-7	DISCHARGE SUMMARIZATION NOTE	HOSPITAL	{PROVIDER}
29761-4	DISCHARGE SUMMARIZATION NOTE	{SETTING}	DENTISTRY
34745-0	DISCHARGE SUMMARIZATION NOTE	{SETTING}	NURSING
34106-5	DISCHARGE SUMMARIZATION NOTE	HOSPITAL	PHYSICIAN
34902-7	EDUCATION NOTE	OUTPATIENT	GERONTOLOGY
34897-9	EDUCATION NOTE	{SETTING}	DIABETOLOGY
34895-3	EDUCATION NOTE	{SETTING}	{PROVIDER}
34107-3	EDUCATION PROCEDURE NOTE	HOME HEALTH	{PROVIDER}
34108-1	EVALUATION AND MANAGEMENT	OUTPATIENT	{PROVIDER}
34836-7	EVALUATION AND MANAGEMENT NOTE	{SETTING}	REHABILITATION
34111-5	EVALUATION AND MANAGEMENT NOTE	EMERGENCY DEPARTMENT	{PROVIDER}
34834-2	EVALUATION AND MANAGEMENT NOTE	{SETTING}	RECREATIONAL THERAPY
34759-1	EVALUATION AND MANAGEMENT NOTE	{SETTING}	DERMATOLOGY
34842-5	EVALUATION AND MANAGEMENT NOTE	{SETTING}	SOCIAL WORK
34113-1	EVALUATION AND MANAGEMENT NOTE	NURSING HOME	{PROVIDER}
34762-5	EVALUATION AND MANAGEMENT NOTE	{SETTING}	GASTROENTEROLOGY
34840-9	EVALUATION AND MANAGEMENT NOTE	{SETTING}	RHEUMATOLOGY
34757-5	EVALUATION AND MANAGEMENT NOTE	{SETTING}	DENTISTRY
34112-3	EVALUATION AND MANAGEMENT NOTE	INPATIENT	{PROVIDER}
34746-8	EVALUATION AND MANAGEMENT NOTE	{SETTING}	NURSING
34754-2	EVALUATION AND MANAGEMENT NOTE	{SETTING}	CRITICAL CARE
34772-4	EVALUATION AND MANAGEMENT NOTE	{SETTING}	GENERAL SURGERY
34753-4	EVALUATION AND MANAGEMENT NOTE	OUTPATIENT	CARDIOLOGY
34752-6	EVALUATION AND MANAGEMENT NOTE	{SETTING}	CARDIOLOGY
34832-6	EVALUATION AND MANAGEMENT NOTE	{SETTING}	RADIATION ONCOLOGY
34750-0	EVALUATION AND MANAGEMENT NOTE	{SETTING}	ANESTHESIA
34773-2	EVALUATION AND MANAGEMENT NOTE	{SETTING}	ATTENDING PHYSICIAN.GENERAL SURGERY
34830-0	EVALUATION AND MANAGEMENT NOTE	{SETTING}	PULMONARY
34778-1	EVALUATION AND MANAGEMENT NOTE	{SETTING}	GYNECOLOGY
34838-3	EVALUATION AND MANAGEMENT NOTE	{SETTING}	RESPIRATORY THERAPY
34780-7	EVALUATION AND MANAGEMENT NOTE	{SETTING}	HEMATOLOGY+ONCOLOGY
34109-9	EVALUATION AND MANAGEMENT NOTE	{SETTING}	{PROVIDER}
34854-0	EVALUATION AND MANAGEMENT NOTE	OUTPATIENT	VASCULAR SURGERY
34765-8	EVALUATION AND MANAGEMENT NOTE	{SETTING}	GENERAL MEDICINE
34819-3	EVALUATION AND MANAGEMENT NOTE	{SETTING}	PATHOLOGY
34801-1	EVALUATION AND MANAGEMENT NOTE	{SETTING}	NUTRITION+DIETETICS
34823-5	EVALUATION AND MANAGEMENT NOTE	{SETTING}	PHYSICAL MEDICINE AND REHABILITATION
34825-0	EVALUATION AND MANAGEMENT NOTE	{SETTING}	PHYSICAL THERAPY
34827-6	EVALUATION AND MANAGEMENT NOTE	{SETTING}	PLASTIC SURGERY
34829-2	EVALUATION AND MANAGEMENT NOTE	{SETTING}	PODIATRY
34846-6	EVALUATION AND MANAGEMENT NOTE	{SETTING}	SPEECH THERAPY+AUDIOLOGY
34848-2	EVALUATION AND MANAGEMENT NOTE	{SETTING}	SURGERY
34815-1	EVALUATION AND MANAGEMENT NOTE	{SETTING}	ORTHOPEDICS
34852-4	EVALUATION AND MANAGEMENT NOTE	{SETTING}	UROLOGY
34817-7	EVALUATION AND MANAGEMENT NOTE	{SETTING}	OTORHINOLARYNGOLOGY
34856-5	EVALUATION AND MANAGEMENT NOTE	{SETTING}	ANTICOAGULATION
34857-3	EVALUATION AND MANAGEMENT NOTE	{SETTING}	SUBSTANCE ABUSE
34858-1	EVALUATION AND MANAGEMENT NOTE	{SETTING}	PAIN MANAGEMENT
34859-9	EVALUATION AND MANAGEMENT NOTE	{SETTING}	HYPERLIPIDEMIA
34860-7	EVALUATION AND MANAGEMENT NOTE	{SETTING}	HYPERTENSION
34861-5	EVALUATION AND MANAGEMENT NOTE	{SETTING}	DIABETOLOGY
34878-9	EVALUATION AND MANAGEMENT NOTE	{SETTING}	EMERGENCY MEDICINE
34898-7	EVALUATION AND MANAGEMENT NOTE	{SETTING}	ENDOCRINOLOGY
34905-0	EVALUATION AND MANAGEMENT NOTE	{SETTING}	NEUROLOGY
34850-8	EVALUATION AND MANAGEMENT NOTE	OUTPATIENT	THORACIC SURGERY
34792-2	EVALUATION AND MANAGEMENT NOTE	{SETTING}	PSYCHOLOGY
34766-6	EVALUATION AND MANAGEMENT NOTE	OUTPATIENT	GENERAL MEDICINE
34767-4	EVALUATION AND MANAGEMENT NOTE	{SETTING}	MEDICAL STUDENT.GENERAL MEDICINE
34768-2	EVALUATION AND MANAGEMENT NOTE	{SETTING}	NURSE.GENERAL MEDICINE
34769-0	EVALUATION AND MANAGEMENT NOTE	{SETTING}	ATTENDING PHYSICIAN.GENERAL MEDICINE
34782-3	EVALUATION AND MANAGEMENT NOTE	{SETTING}	INFECTIOUS DISEASE
34784-9	EVALUATION AND MANAGEMENT NOTE	{SETTING}	KINESIOTHERAPY
34786-4	EVALUATION AND MANAGEMENT NOTE	{SETTING}	MENTAL HEALTH
34821-9	EVALUATION AND MANAGEMENT NOTE	{SETTING}	PHARMACY
34789-8	EVALUATION AND MANAGEMENT NOTE	{SETTING}	PSYCHIATRY
34813-6	EVALUATION AND MANAGEMENT NOTE	{SETTING}	OROMAXILLOFACIAL SURGERY
34802-9	EVALUATION AND MANAGEMENT NOTE	{SETTING}	OCCUPATIONAL HEALTH
34811-0	EVALUATION AND MANAGEMENT NOTE	{SETTING}	OPTOMETRY
34808-6	EVALUATION AND MANAGEMENT NOTE	{SETTING}	OPHTHALMOLOGY
34806-0	EVALUATION AND MANAGEMENT NOTE	{SETTING}	ONCOLOGY
34804-5	EVALUATION AND MANAGEMENT NOTE	{SETTING}	OCCUPATIONAL THERAPY
34794-8	EVALUATION AND MANAGEMENT NOTE	{SETTING}	MULTIDISCIPLINARY
34110-7	EVALUATION AND MANAGEMENT NOTE	OUTPATIENT	DIABETOLOGY
34799-7	EVALUATION AND MANAGEMENT NOTE	{SETTING}	NEUROSURGERY
34796-3	EVALUATION AND MANAGEMENT NOTE	{SETTING}	NEPHROLOGY
34787-2	GROUP COUNSELING NOTE	{SETTING}	MENTAL HEALTH
34790-6	GROUP COUNSELING NOTE	{SETTING}	PSYCHIATRY
34843-3	GROUP COUNSELING NOTE	{SETTING}	SOCIAL WORK
34114-9	GROUP COUNSELING NOTE	HOSPITAL	{PROVIDER}
34793-0	GROUP COUNSELING NOTE	{SETTING}	PSYCHOLOGY
34774-0	HISTORY & PHYSICAL NOTE	{SETTING}	GENERAL SURGERY
28626-0	HISTORY & PHYSICAL NOTE	{SETTING}	PHYSICIAN
11492-6	HISTORY & PHYSICAL NOTE	HOSPITAL	{PROVIDER}
34116-4	HISTORY & PHYSICAL NOTE	NURSING HOME	PHYSICIAN
34115-6	HISTORY & PHYSICAL NOTE	HOSPITAL	MEDICAL STUDENT
34117-2	HISTORY AND PHYSICAL NOTE	{SETTING}	{PROVIDER}
18841-7	HOSPITAL CONSULTATIONS	{SETTING}
28572-6	INITIAL EVALUATION NOTE	{SETTING}	DENTISTRY
28654-2	INITIAL EVALUATION NOTE	{SETTING}	ATTENDING PHYSICIAN
18735-1	INITIAL EVALUATION NOTE	{SETTING}	PHYSICAL THERAPY
18736-9	INITIAL EVALUATION NOTE	{SETTING}	PHYSICIAN
18737-7	INITIAL EVALUATION NOTE	{SETTING}	PODIATRY
18738-5	INITIAL EVALUATION NOTE	{SETTING}	PSYCHOLOGY
18739-3	INITIAL EVALUATION NOTE	{SETTING}	SOCIAL SERVICE
18734-4	INITIAL EVALUATION NOTE	{SETTING}	OCCUPATIONAL THERAPY
28581-7	INITIAL EVALUATION NOTE	{SETTING}	CHIROPRACTOR
29753-1	INITIAL EVALUATION NOTE	{SETTING}	NURSING
28636-9	INITIAL EVALUATION NOTE	{SETTING}	{PROVIDER}
28635-1	INITIAL EVALUATION NOTE	{SETTING}	PSYCHIATRY
28621-1	INITIAL EVALUATION NOTE	{SETTING}	NURSE PRACTITIONER
18763-3	INITIAL EVALUATION NOTE	{SETTING}	CONSULTING PHYSICIAN
18740-1	INITIAL EVALUATION NOTE	{SETTING}	SPEECH THERAPY
34120-6	INITIAL EVALUATION NOTE	OUTPATIENT	{PROVIDER}
34119-8	INITIAL EVALUATION NOTE	NURSING HOME	{PROVIDER}
34118-0	INITIAL EVALUATION NOTE	HOME HEALTH	{PROVIDER}
34121-4	INTERVENTIONAL PROCEDURE NOTE	{SETTING}
34896-1	INTERVENTIONAL PROCEDURE NOTE	{SETTING}	CARDIOLOGY
34899-5	INTERVENTIONAL PROCEDURE NOTE	{SETTING}	GASTROENTEROLOGY
34903-5	NOTE	{SETTING}	MENTAL HEALTH
34906-8	NOTE	{SETTING}	PASTORAL CARE
11536-0	NOTES	{SETTING}	NURSING
34871-4	OPERATIVE NOTE	{SETTING}	PODIATRY
34874-8	OPERATIVE NOTE	{SETTING}	SURGERY
34877-1	OPERATIVE NOTE	{SETTING}	UROLOGY
34870-6	OPERATIVE NOTE	{SETTING}	PLASTIC SURGERY
34868-0	OPERATIVE NOTE	{SETTING}	ORTHOPEDICS
34818-5	OPERATIVE NOTE	{SETTING}	OTORHINOLARYNGOLOGY
34122-2	PATHOLOGY PROCEDURE NOTE	{SETTING}	PATHOLOGY
34880-5	POST-OPERATIVE EVALUATION AND MANAGEMENT NOTE	{SETTING}	NURSE.SURGERY
34875-5	POST-OPERATIVE EVALUATION AND MANAGEMENT NOTE	{SETTING}	SURGERY
34863-1	POST-OPERATIVE EVALUATION AND MANAGEMENT NOTE	{SETTING}	GENERAL SURGERY
34867-2	POST-OPERATIVE EVALUATION AND MANAGEMENT NOTE	OUTPATIENT	OPHTHALMOLOGY
34881-3	PRE-OPERATIVE EVALUATION AND MANAGEMENT NOTE	{SETTING}	NURSE.SURGERY
34123-0	PRE-OPERATIVE EVALUATION AND MANAGEMENT NOTE	HOSPITAL	ANESTHESIA
34775-7	PRE-OPERATIVE EVALUATION AND MANAGEMENT NOTE	{SETTING}	GENERAL SURGERY
34876-3	PRE-OPERATIVE EVALUATION AND MANAGEMENT NOTE	{SETTING}	SURGERY
34751-8	PRE-OPERATIVE EVALUATION AND MANAGEMENT NOTE	{SETTING}	ANESTHESIA
34809-4	PRE-OPERATIVE EVALUATION AND MANAGEMENT NOTE	{SETTING}	OPHTHALMOLOGY
34747-6	PRE-OPERATIVE EVALUATION AND MANAGEMENT NOTE	{SETTING}	NURSING
28570-0	PROCEDURE NOTE	{SETTING}	{PROVIDER}
28625-2	PROCEDURE NOTE	{SETTING}	PODIATRY
28577-5	PROCEDURE NOTE	{SETTING}	DENTISTRY
11505-5	PROCEDURE NOTE	{SETTING}	PHYSICIAN
28575-9	PROGRESS NOTE	{SETTING}	NURSE PRACTITIONER
28580-9	PROGRESS NOTE	{SETTING}	CHIROPRACTOR
18744-3	STUDY REPORT	RESPIRATORY SYSTEM	BRONCHOSCOPY
11510-5	SUBSEQUENT EVALUATION NOTE	{SETTING}	PSYCHOLOGY
11508-9	SUBSEQUENT EVALUATION NOTE	{SETTING}	PHYSICAL THERAPY
11509-7	SUBSEQUENT EVALUATION NOTE	{SETTING}	PODIATRY
11506-3	SUBSEQUENT EVALUATION NOTE	{SETTING}	{PROVIDER}
11507-1	SUBSEQUENT EVALUATION NOTE	{SETTING}	OCCUPATIONAL THERAPY
11512-1	SUBSEQUENT EVALUATION NOTE	{SETTING}	SPEECH THERAPY
15507-7	SUBSEQUENT EVALUATION NOTE	EMERGENCY DEPARTMENT	{PROVIDER}
18733-6	SUBSEQUENT EVALUATION NOTE	{SETTING}	ATTENDING PHYSICIAN
34904-3	SUBSEQUENT EVALUATION NOTE	{SETTING}	MENTAL HEALTH
34901-9	SUBSEQUENT EVALUATION NOTE	OUTPATIENT	GENERAL MEDICINE
18764-1	SUBSEQUENT EVALUATION NOTE	{SETTING}	NURSE PRACTITIONER
34129-7	SUBSEQUENT EVALUATION NOTE	HOME HEALTH	{PROVIDER}
34132-1	SUBSEQUENT EVALUATION NOTE	OUTPATIENT	PHARMACY
34131-3	SUBSEQUENT EVALUATION NOTE	OUTPATIENT	{PROVIDER}
28656-7	SUBSEQUENT EVALUATION NOTE	{SETTING}	SOCIAL SERVICE
34130-5	SUBSEQUENT EVALUATION NOTE	HOSPITAL	{PROVIDER}
28617-9	SUBSEQUENT EVALUATION NOTE	{SETTING}	DENTISTRY
34128-9	SUBSEQUENT EVALUATION NOTE	OUTPATIENT	DENTISTRY
34127-1	SUBSEQUENT EVALUATION NOTE	OUTPATIENT	DENTAL HYGIENIST
34126-3	SUBSEQUENT EVALUATION NOTE	CRITICAL CARE UNIT	{PROVIDER}
34900-1	SUBSEQUENT EVALUATION NOTE	{SETTING}	GENERAL MEDICINE
34125-5	SUBSEQUENT EVALUATION NOTE	HOME HEALTH CARE	CASE MANAGER
28569-2	SUBSEQUENT EVALUATION NOTE	{SETTING}	CONSULTING PHYSICIAN
18762-5	SUBSEQUENT EVALUATION NOTE	{SETTING}	CHIROPRACTOR
34124-8	SUBSEQUENT EVALUATION NOTE	OUTPATIENT	CARDIOLOGY
28627-8	SUBSEQUENT EVALUATION NOTE	{SETTING}	PSYCHIATRY
28623-7	SUBSEQUENT EVALUATION NOTE	{SETTING}	NURSING
34133-9	SUMMARIZATION OF EPISODE NOTE	{SETTING}	{PROVIDER}
34134-7	SUPERVISORY NOTE	OUTPATIENT	ATTENDING PHYSICIAN
34135-4	SUPERVISORY NOTE	OUTPATIENT	ATTENDING PHYSICIAN.CARDIOLOGY
34136-2	SUPERVISORY NOTE	OUTPATIENT	ATTENDING PHYSICIAN.GASTROENTEROLOGY
28624-5	SURGICAL OPERATION NOTE	{SETTING}	PODIATRY
28573-4	SURGICAL OPERATION NOTE	{SETTING}	PHYSICIAN
11504-8	SURGICAL OPERATION NOTE	{SETTING}	{PROVIDER}
28583-3	SURGICAL OPERATION NOTE	{SETTING}	DENTISTRY
34137-0	SURGICAL OPERATION NOTE	OUTPATIENT	{PROVIDER}
34138-8	TARGETED HISTORY AND PHYSICAL NOTE	{SETTING}	{PROVIDER}
34139-6	TELEPHONE ENCOUNTER NOTE	{SETTING}	NURSING
34844-1	TELEPHONE ENCOUNTER NOTE	OUTPATIENT	SOCIAL WORK
34748-4	TELEPHONE ENCOUNTER NOTE	{SETTING}	{PROVIDER}
34140-4	TRANSFER OF CARE REFERRAL NOTE	{SETTING}	{PROVIDER}
34770-8	TRANSFER SUMMARIZATION NOTE	{SETTING}	GENERAL MEDICINE
18761-7	TRANSFER SUMMARIZATION NOTE	{SETTING}	{PROVIDER}
28651-8	TRANSFER SUMMARIZATION NOTE	{SETTING}	NURSING
28616-1	TRANSFER SUMMARIZATION NOTE	{SETTING}	PHYSICIAN
34755-9	TRANSFER SUMMARIZATION NOTE	{SETTING}	CRITICAL CARE
28568-4	VISIT NOTE	EMERGENCY DEPARTMENT	PHYSICIAN
28653-4	VISIT NOTE	{SETTING}	SOCIAL SERVICE
28618-7	VISIT NOTE	{SETTING}	DENTISTRY
28579-1	VISIT NOTE	{SETTING}	PHYSICAL THERAPY
28578-3	VISIT NOTE	{SETTING}	OCCUPATIONAL THERAPY
28571-8	VISIT NOTE	{SETTING}	SPEECH THERAPY
28628-6	VISIT NOTE	{SETTING}	PSYCHIATRY

9.3 CDA and Semantic Interoperability

A long term objective of CDA and other specifications in the V3 family is to achieve increasingly greater and greater "semantic interoperability", which might be defined as the ability of two applications to share data, with no prior negotiations, such that decision support within each application continues to function reliably when processed against the received data.

CDA seeks to achieve the highest level of constraint that can exist in an international standard. Where international consensus is lacking, and where uses cases in different realms currently preclude consensus, CDA will need to be necessarily inclusive. In such areas, ongoing harmonization and consensus building will further enable semantic interopability, which will be reflected in future iterations of CDA.

While the framework provided by the RIM and by CDA and by the shared HL7 Clinical Statement Model are a critical component of semantic interoperability, they are not currently sufficient, particularly given the lack of global terminology solution, and the fact that each terminology overlaps with the RIM in different ways. Such terminology solutions are outside the scope of CDA, and will need to be addressed in various national and international forums.

9.4 Changes from CDA Release 1

CDA, Release One became an ANSI-approved HL7 Standard in November, 2000, representing the first specification derived from the HL7 Reference Information Model (RIM). Since then, the RIM has matured, as has the methodology used to derive RIM-based specifications. In addition, early adopters are posing new use cases for incorporation.

The basic model of CDA, Release Two is essentially unchanged. A CDA document has a header and a body. The body contains nested sections. These sections can be coded using standard vocabularies, and can contain "entries". CDA, Release One entries included such things as character data, hyperlinks, and multimedia.

The main evolutionary steps in CDA, Release Two are that both header and body are fully RIM-derived, and there is a much richer assortment of entries to use within CDA sections. CDA, Release Two enables clinical content to be formally expressed to the extent that is it modeled in the RIM.

CDA, Release Two takes advantage of HL7’s growing expertise in creating model-based XML standards. Given the evolution of the RIM and the HL7 development methodology since November 2000, there are a number of changes between the new and the old CDA.

9.4.1 Deprecated Components

The following components are retained for backwards compatibility with CDA, Release One, and have been deprecated:

• ClinicalDocument/copyTime.
• ClinicalDocument/authenticator/signatureCode/@code="X".
• ClinicalDocument/legalAuthenticator/signatureCode/@code="X".
• ClinicalDocument/assignedAuthor/assignedAuthoringDevice/MaintainedEntity.
• ClinicalDocument/recordTarget/patientRole/patient/id.
• linkHtml.name.
• table.border, table.cellspacing, table.cellpadding.

Further use of these components is discouraged.

9.4.2 CDA R1 to CDA R2 Correspondence

This table is not included in the wiki form of the CDA standard. For a comparison of CDA R2 to CDA R2.1, use the wiki revision history functionality.