What is HL7v3 Standard?
The HL7v3 standard is basically a XML messaging format. Developed to bring in the complete medical record/history of a patient.The HL7v3 standard includes both messaging and document standards. The document standard for HL7 v3 is CDA.
What is Continuity of Care Record (CCR) ?
The CCR started out as a three-page paper document which was used in patient care referrals. It was created by the Massachusetts Department of Public Health, and included all the information that was necessary for providers to effectively continue care.
Relation Between CCR & CCD ?
Since CCR is very successful document in the transfer of care scenario, the Massachusetts Department of Public Health teamed up with ASTM and the Massachusetts Medical Society to create an electronic version of CCR That is nothing but CCD.
What is Continuity of Care Document (CCD) ?
CCD stands for Continuity of Care Document and it is based on the HL7 CDA architecture. CDA, or Clinical Document Architecture, is a document standard governed by the HL7 organization. The HL7v3 standard includes both messaging and document standards. The document standard for HL7 v3 is CDA, and one of the documents within the CDA architecture is CCD.
What Does CCD contain ?
A CCD document is not intended to give a complete medical history for a patient. It is intended to include only the information critical to effectively continue care. For example consider a patient is moving from one hospital to another for better treatment or care, then in that case what are all the details that the new facility needs to understand about the patient will be specified in CCD.
General 17 sections used in typical CCD document:
- Family history
- Social history
- Advance directives
- Medical equipment
- Vital signs
- Functional stats
- Plan of care
List of CCDA provided by HL7 standard:
- Continuity of Care Document
- Consultation Notes
- Discharge Summary
- Imaging Integration, and DICOM Diagnostic Imaging Reports
- History and Physical
- Operative Note
- Progress Note
- Procedure Note
- Unstructured Documents