View source for Clinical Document Architecture (CDA)

The '''Clinical Document Architecture (CDA)''' is a [[HL7|Health Level Seven (HL7)]] document markup standard that specifies the structure and semantics of a clinical document for the purpose of [[interoperability]].

== Introduction ==

A CDA document is a defined and complete information object that can include text, images, sounds, and other multimedia content. It can be transferred within a message and can exist independently, outside the transferring message. CDA documents are encoded in [[Extensible Markup Language (XML)]], and they derive their machine processable meaning from the RIM, coupled with terminology. <ref name=DolinEtAl>Dolin RH, Alschuler L, Boyer S, Beebe C, Behlen FM, Biron PV, Shabo Shvo A. <i>HL7 Clinical Document Architecture, Release 2</i>. J Am Med Inform Assoc. 2006 Jan-Feb;13(1):30-9. Epub 2005 Oct 12.http://www.ncbi.nlm.nih.gov/pubmed/16221939</ref>

HITSP, HL7, IHE, Health Story and other organizations worked together to prevent duplicate and conflicting implementation guides and agreed upon a new electronic clinical document creation standard called Consolidated Clinical Document Architecture (C-CDA), which is the only approved documentation for Meaningful use stage 2 EHR implementation in the USA. It has 9 document templates Continuity Care Document (CCD), Diagnostic Imaging Report, Discharge Summary, History and Physical, Operative notes, and Unstructured document, 60 section templates and 82 entry templates. <ref>Consolidated CDA Overview - (video presentations and PDF). http://www.healthit.gov/policy-researchers-implementers/consolidated-cda-overview</ref>

== Major Components ==

* "ClinicalDocument" element
* header: identifies and classifies the document, provides information on authentication, the encounter, the patient, and the involved providers
* "structuredBody" element 
* body: clinical report, unstructured or structured markup.
* more

== Implementations ==

[[Providing_Interoperability_to_a_Pervasive_Healthcare_System_Through_the_HL7_CDA_Standard|A. Brugués et al]] describe their implementation of CDS in a "pervasive healthcare" app, and discuss other implementations in the literature.
== References ==
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