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Section 1a: Clinical Document Architecture (CDA®)
Section 2: Clinical and Administrative Domains
Section 3: Implementation Guides

HL7 Version 3 Implementation Guide for CDA® R2 L3: Neonatal Care Reports (NCR), R1

DESCRIPTION

This implementation guide (IG) specifies a standard for electronic submission of neonatal care records (NCRs) in a Clinical Document Architecture (CDA), Release 2 (R2) format. This facilitates electronic extraction of a subset of the Children’s Hospitals Neonatal Consortium (CHNC) dataset using a standard reporting specification in the form of a Neonatal Care Report (NCR) to support performance improvement and research. 

ALTERNATIVE NAMES

HL7 Version 3 Implementation Guide for CDA® R2 L3: Neonatal Care Reports (NCR), R1 may also go by the following names or acronyms:

"HL7 IG for CDAR2L3: Neonatal Care Report, R1", CDAR2

TARGETS

  • Healthcare Providers
  • Software Developers
  • System Implementers
  • Neonatal Experts
  • Children’s Hospital Providers

BENEFITS

  • Develops reporting capabilities within the electronic health record (EHR and Pediatric EHR systems)
  • Process CDA NCR documents created according to this specification
  • Promotes systematic collection and analyses of clinical data on infants admitted to children’s hospital NICUs
  • Promotes benchmarking, quality improvement, and research initiatives that have not previously been possible in the patient population

IMPLEMENTATIONS/CASE STUDIES

  • In development

DEVELOPMENT BACKGROUND

CHNC and CHCA, a business alliance of 43 leading children’s hospitals in North America, envision this effort as a building block for more widespread use of the electronic medical record in place of manual data abstraction. The CHNC core data set contains around 700 data elements; this Draft Standard for Trial Use (DSTU) addresses a subset of approximately 60 data elements including 37 physiologic and laboratory elements for assessment of illness severity (Acuity indicator data generic organizer) and 21 base data elements found throughout the header and body of the NCR (e.g., name, medical record number, birth weight, and discharge head circumference).

 

This project supports reusability and ease of data collection through a standard data representation harmonized with work developed through Health Information Technology Expert Panel (HITEP), balloted through Health Level Seven (HL7), and/or recognized by the Health Information Technology Standards Panel (HITSP).

RELATED DOCUMENTS

HL7 Version 3 Implementation Guide for CDA® R2 L3: Neonatal Care Reports (NCR), R1

STU DOCUMENTS

HL7 Implementation Guide for Clinical Document Architecture, Release 2 – Level 3: Neonatal Care Report, DSTU Release 1 Expiration Jun 2012

(Download) (1.42 MB)

TOPIC

  • Patient Care

BALLOT TYPE

  • DSTU

STATUS DATE

2010-06-21

RESPONSIBLE WORK GROUP

Structured Documents

FAMILY

  • CDA

CURRENT STATE

  • Stable

REALM

  • US Realm
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