This interim standard defines the metadata elements captured about every clinical document stored in a clinical data repository and accessed via clinical workstation or patient portal systems.
The purpose of this standard is to ensure that clinical assessments, test results, transfer of care summaries, operation notes and other common clinical document types can be identified, classified and indexed in a common way, enabling secure document sharing. While the standard is primarily about clinical documents, it can be extended to other models of information sharing too.
Metadata elements identify the patient, practitioner, facility, health specialty, document type and confidentiality level associated with each clinical document, as well as giving the document's repository location.