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The HL7 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange.In November 2000, HL7 published Release 1.0.
Progress Note - This template represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. [ 14 ] Transfer Summary - The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between ...
These documents must be capable of including data elements known as the "Common MU Data Set" that include: Patient name, sex, date of birth, race, ethnicity, preferred language, smoking status, problems, medications, medication allergies, laboratory tests, laboratory values/results, vital signs, care plan fields including goals and instructions ...
This template is used on approximately 7,000 pages and changes may be widely noticed. Test changes in the template's /sandbox or /testcases subpages, or in your own user subpage . Consider discussing changes on the talk page before implementing them.
A certificate of analysis (COA) is a formal laboratory-prepared document that details the results of (and sometimes the specifications and analytical methods for) one or more laboratory analyses, signed—manually or electronically—by an authorized representative of the entity conducting the analyses. This document gives assurances to the ...
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A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...