When is a Document a Document?
The HL7 standard for Structured Documents Section describes the document vs. message distinction as follows “A document is designed to be persistent for long periods of time, whereas messages are more often expected to be transient. There is a place for both of these constructs in healthcare.” HL7 characterizes a document by the following properties:
- Persistence – Documents are persistent over time. The content of the document does not change from one moment to another. A document represents information stored at a single instance in time.
- Wholeness - A document is a whole unit of information. Parts of the document may be created or edited separately, or may also be authenticated or legally authenticated, but the entire document is still to be treated as a whole unit.
- Stewardship - A document is maintained over its lifetime by a custodian, either an organization or a person entrusted with its care.
- Context - A clinical document establishes the default context for its contents
- Potential for authentication - A clinical document is an assemblage of information that is intended to be legally authenticated.
What is a document vs a Document?
FHIR-Document is a Document
What is this document?
- Current Medications
- Current Allergies
- Current Problems
- Current Immunizations