Polish National Implementation of HL7 CDA (plcda-)

eZdrowie - Projekt P1

Rules for creation of medical documentation in electronic form (version: 1.2)

Release date: 2017-02-07T00:00:00

Introduction

This release of the Polish National Implementation of HL7 CDA (called also "Implementation Guide" [IG]) covers two groups of document types: (1) eDrugPrescription, eReferral and eMedicalEquipmentPrescription, which are going to be processed on P1 Platform and (2) Consultation Note, Discharge Summary, Laboratory Report, Diagnostic Note, Admissions Refusal Note, Nursing Patient History Note, Nursing Patient Status Assessment Note, Nursing Discharge Prescriptions Note, Nursing Report, Immunization Card Item and Surgical Operation Protocol, which are not going to be processed on P1 Platform, but will only be indexed there.

This work aims at ensuring interoperable standardization of those documents in an extent allowing their processing in accordance to the requirements defined for P1 Project as well as in information systems of medical providers, including their safe exchange between parties.

The major change from the previous version is to allow alternative form of clinical documents (in accordance to HL7 CDA standard) i.e. files containing header and content for machine-processing – in the XML format and human readable content – in another format (PDF or graphic).

Change log for version 1.2

The Polish National Implementation of HL7 CDA is a refinement of HL7® CDA™ (Clinical Document Architecture) standard, Release 2. All copyrights to HL7® CDA™ standard belong to HL7® International.

Conventions of business rules

In business rules there has been used one of the four levels of requirement for each business rule:

Expression „MUST” or „IS REQUIRED” means unconditional requirement: Failing to comply means always that the electronic clinical document does not fulfil the requirements defined in the Implementation Guide.

Expression „SHOULD” means operational requirement: Systems and processes must be designed in such way, that the rule may be fulfilled. If required information is operationally available in the particular situation, then it must be written down in the document.

Expression „MAY” means indication of the proper way of writing down some optional data. It does not mean that only those data may be contained in the document.

Expression „MUST NOT” means unconditional prohibition. Violation implies lack of compliance with the requirements defined in the Implementation Guide.

Recommendations regarding standard implementation in central systems in respect to the current release

Registration of ISO OID nodes

Any code system, which is not owned or maintained by CSIOZ, should be registered in agreement with its owner or maintainer.