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VA Technical Reference Model v 20.8

Health Level Seven (HL7) Clinical Document Architecture (CDA) Release Two (R2) Implementation Guide: Consolidated CDA Templates for Clinical Notes
Health Level Seven (HL7) Clinical Document Architecture (CDA) Release Two (R2) Implementation Guide: Consolidated CDA Templates for Clinical Notes Standard or Specification

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Description: The Consolidated CDA (C-CDA) implementation guide contains a library of CDA templates, incorporating and harmonizing previous efforts from Health Level Seven (HL7), Integrating the Healthcare Enterprise (IHE), and Health Information Technology Standards Panel (HITSP). It represents harmonization of the HL7 Health Story guides, HITSP C32, related components of IHE Patient Care Coordination (IHE PCC), and Continuity of Care (CCD). C-CDA Release 1 included all required CDA templates in Final Rules for Stage 1 Meaningful Use and 45 CFR Part 170 ` Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology; Final Rule. This R2.1 guide was developed and produced by the HL7 Structured Documents Workgroup. It updates the C-CDA R2 (2014) guide to support `on-the-wire` compatibility with R1.1 systems C-CDA Release 2.1 implementation guide, in conjunction with the HL7 CDA Release 2 (CDA R2) standard, is to be used for implementing the following CDA documents and header constraints for clinical notes: Care Plan including Home Health Plan of Care (HHPoC), Consultation Note, Continuity of Care Document (CCD), Diagnostic Imaging Reports (DIR), Discharge Summary, History and Physical (H&P), Operative Note, Procedure Note, Progress Note, Referral Note, Transfer Summary, Unstructured Document, Patient Generated Document (US Realm Header).
Technology/Standard Usage Requirements: Users must ensure their use of this technology/standard is consistent with VA policies and standards, including, but not limited to, VA Handbooks 6102 and 6500; VA Directives 6004, 6513, and 6517; and National Institute of Standards and Technology (NIST) standards, including Federal Information Processing Standards (FIPS). Users must ensure sensitive data is properly protected in compliance with all VA regulations. Prior to use of this technology, users should check with their supervisor, Information Security Officer (ISO), Facility Chief Information Officer (CIO), or local Office of Information and Technology (OI&T) representative to ensure that all actions are consistent with current VA policies and procedures prior to implementation.
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Decision: View Decisions

Decision Source: TRM Mgmt Group
Decision Process: One-VA TRM v19.4
Decision Date: 04/18/2019
Aliases: C-CDA R2.1, Consolidated CDA Release 2.1, "HL7 IG for CDA R2: Consolidated CDA Templates for Clinical Notes, R1", "HL7 IG for CDAR2: IHE Health Story Consolidation, R1", Consolidated CDA, C-CDA, C-CDA R2, Consolidated CDA Release 2, CCDA
Introduced By: Enterprise Program Management Office (EPMO) TRM Team
Standards Body: HL7
- The information contained on this page is accurate as of the Decision Date (04/18/2019).