Canadian Health Information Management Association Practice Exam

What is the HL7 standard that specifies the structure of clinical documents for electronic exchange?

1. CDA.

2. CPOE.

3. ICD.

4. RFID.

The correct answer is: CDA.

The HL7 standard that specifies the structure of clinical documents for electronic exchange is the Clinical Document Architecture (CDA). CDA provides a framework that allows the encoding of documents such as discharge summaries, progress notes, and other clinical documents in a standardized format. This standard is essential for ensuring that electronic health records (EHRs) can share and interpret clinical documents effectively across different health information systems. CDA documents encapsulate both the content and the structure, facilitating interoperability, which means that different systems can understand and use the information contained within the documents regardless of the source. This standard plays a crucial role in health information exchange by providing a common understanding of clinical document elements such as patient information, author details, and relevant clinical data. In contrast, the other options serve different functions: CPOE (Computerized Provider Order Entry) refers to systems that enable health care providers to enter and manage orders for care electronically; ICD (International Classification of Diseases) is a classification system for diseases and health conditions that is used for coding diagnoses; RFID (Radio Frequency Identification) refers to technology used for tracking items or individuals, not for document structure. This differentiation highlights why CDA is the appropriate choice when discussing standards for electronic document exchange in healthcare.