REQUIRED:
HL7 Consolidated Clinical Document Architecture Release 2.1 (C-CDA R2) KEY REQUIRED GUIDE
C-CDA is a collection of CDA implementation guides for 12 document types. It contains the required and optional section templates and data elements for each document type.
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).
This HL7 Standard was recommended by NCVHS for adoption under HIPAA. This HL7 Standard is the same standard used for the exchange of electronic health records.
C-CDA (HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes - US Realm)
HL7 CDA® R2 Attachment Implementation Guide: Exchange of C-CDA Based Documents, Release 2 – US Realm (STU) (HL7 Guide) KEY REQUIRED GUIDE
This guide applies additional constraints onto the HL7 C-CDA standards in common use for clinical documentation, by defining requirements for sending and receiving systems for attachment request and response messages. It provides additional information on the Attachment process for Structured/Unstructured and Solicited/Unsolicited.
This HL7 Standard was recommended by NCVHS for adoption under HIPAA.
HL7 CDA® R2 Attachment Implementation Guide: Exchange of C-CDA Based Documents, Release 2
OPTIONAL:
HL7 CDA® Release 2 Implementation Guide: Additional CDA R2 Templates – Clinical Documents for Payers Set 1, Release 1 – US RealmHL7 Clinical Documents for Payers Set 1 (CDP1)
The purpose of this implementation guide (IG) is to provide guidance on a standardized, implementable, interoperable electronic solution to reduce the time and expense related to the exchange of clinical and administrative information between and among providers and payers. This guide describes structured documentation templates that meet requirements for documentation of medical necessity and appropriateness of services to be delivered or that have been delivered in the course of patient care.
These document templates are designed for use when the provider needs to exchange more clinical information than is required by the C-CDA R2 document-level templates and/or must indicate why information for specific section-level or entry-level templates is not included. For example, payer policy may allow providers to submit any information they feel substantiates that a service is medically necessary and appropriate under the applicable coverage determination rules. The ability to submit any supporting documentation is a provider’s right under these rules as is the ability to declare that specific information is not available or not applicable.
This guide is recommended for adoption under HIPAA as an optional use.
HL7 CDA® R2 Implementation Guide: Exchange of C-CDA Based Documents; Periodontal Attachment, Release 1 - US Realm.
The Periodontal attachment is used to convey information about periodontal related services. This includes the business use of claims attachments, prior authorization and pre-determinations. It may also be used for other clinical data exchange functions as needed. The items defined for electronic supporting documentation were developed by the Standards Committee on Dental Informatics of the American Dental Association (ADA).
HL7 CDA® R2 IG: C-CDA Templates for Clinical Notes R1 Companion Guide, Release 1HL7 Companion Guide for C-CDA R2
The Companion Guide to Consolidated Clinical Document Architecture (C-CDA) provides supplemental guidance to the Health Level Seven (HL7) CDA® R2 IG: C-CDA Templates for Clinical Notes STU Release 2.1 in support of the ONC 2015 Edition Health IT Certification Criteria (2015 Edition) Certified Electronic Health Record Technology requirements.
This guide provides additional technical clarification and practical guidance to assist implementers to support best practice implementations of the 2015 Edition Health Information Technology (Health IT) Certification Criteria, 2015 Edition Base Electronic Health Record (EHR) Definition, and ONC Health IT Certification. The guide is intended to:
Explain basic CDA concepts that are important to understand, prior to implementing the 2015 Edition Health IT Certification Criteria.
Provide guidance on the 2015 Edition Health IT Certification Criteria and data representation in the C-CDA format, including the mapping of CCDS data definitions (170.102) and the “additional data” defined in 170.315(g)(6) CCDA creation performance to the CDA templates included in the C-CDA Implementation Guide.
Highlight that guidance where it is optional in context of the certification program.
Highlight additional guidance and resources relevant to the 2015 Edition Health Information Technology (Health IT) Certification Criteria, 2015 Edition Base Electronic Health Record (EHR) Definition, and ONC Health IT Certification.
HL7 CDA® R2 IG: C-CDA Templates for Clinical Notes R1 Companion Guide, Release 1
HL7 Implementation Guide for CDA® Release 2: Digital Signatures and Delegation of Rights, Release 1HL7 Digital Signatures and Delegation of Rights Release 1
The Digital Signature and Delegation of Rights Implementation Guides provide a standardized method of applying Digital Signatures to CDA documents. The standard provides for multiple signers, signer’s declaration of their role, declaration of purpose of the signature, long-term validation of the Digital Signatures and data validation of the signed content.
HL7 Implementation Guide for CDA® Release 2: Digital Signatures and Delegation of Rights, Release 1
HL7 Implementation Guidance for Unique Object Identifiers (OIDs), Release 1
What are Unique Object Identifiers? And why are they used?
HL7 Implementation Guidance for Unique Object Identifiers (OIDs), Release 1
Guidance on Implementation of Standard Electronic Attachments for Healthcare Transactions
Attachment Collaboration Project (ACP) – Overview for implementing Attachments X12, HL7 and WEDI.
Guidance on Implementation of Standard Electronic Attachments for Healthcare Transactions
Quick Start Guide for CDA R2
The purpose of this Quick Start Guide is to aid implementers in developing applications that produce simple CDA documents.
Quick Start Guide for Simple CDA Release 2.0 Documents
LOINC HIPAA Tab for Attachments
For information related to LOINC codes in general and those used to request and response for additional documentation