Clinical Document Architecture
Clinical Document Architecture (CDA)
Clinical Document Architecture (CDA) /ˈklɪnɪkəl ˈdɒkjʊmənt ɑːrˈkɪtɛktʃər/ is a markup standard developed by the HL7 International to define the structure of clinical documents such as discharge summaries and progress notes. The term originates from the combination of 'Clinical', referring to the medical context, and 'Document Architecture', referring to the structured format of the documents.
Overview
The CDA makes use of a XML-based markup standard and aims to specify the encoding, structure, and semantics of clinical documents for exchange. It is part of the HL7 standards which are widely used in healthcare to exchange clinical and administrative data.
Structure
A CDA document is a defined and complete information object that can include text, images, sounds, and other multimedia elements. It can be transferred within a message and can exist independently, outside the context of a message. The CDA structure contains a header and a body. The header includes patient information, author, and document type. The body contains the clinical information.
Levels
There are three levels of CDA to allow for varying degrees of semantic interoperability. Level One is the most basic, with a simple text note. Level Two adds some structure to the document. Level Three is fully structured, with coded entries for all parts of the document.
Usage
CDA is used in a variety of healthcare settings, including hospitals, clinics, and medical offices. It is used for a variety of clinical documents, such as discharge summaries, radiology reports, history and physical reports, and progress notes.
Related Terms
External links
- Medical encyclopedia article on Clinical Document Architecture
- Wikipedia's article - Clinical Document Architecture
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