CDA Documents

 

Clinical Document Architecture (CDA) is an XML-based markup standard for specifying the encoding, structure and semantics of clinical documents for exchange. CDA-based documents are saved to the Letters tab of a patient's clinical record, along with other correspondence such as letters. When you open a CDA document, it is opened in the CDA Viewer.

 

Content Used for CDA Documentation:

Core Components

CDA Documents

 

Shared Health Summary

Event Summary

Specialist Letter

e-Referral

Individual
(patient details)

Mandatory

Mandatory

Mandatory

Mandatory

Author Details

Mandatory

Mandatory

Mandatory

Mandatory

Allergies

Conditional

Optional

Conditional

Conditional

Medications

Conditional

Optional

Conditional

Conditional

Medical History

Conditional

N/A

Conditional

Conditional

Immunisations

Conditional

Optional

N/A

N/A

Encounter Details
(start and end date)

N/A

Mandatory

N/A

N/A

Event Details

N/A

Optional

N/A

N/A

Diagnoses/ Interventions

(sub components : problem/ diagnoses, procedure, medical history item)

N/A

Optional

Conditional

Conditional

Diagnostic Investigations

(sub components : pathology test results, requested services)

N/A

Optional

Conditional

Conditional

Outstanding requests

N/A

N/A

Conditional

Conditional

Recommendations

N/A

N/A

Conditional

N/A

Narrative
(free text from the author)

N/A

Optional

Mandatory

Mandatory

Validity Period

N/A

N/A

N/A

Optional

 

Mandatory: The component labeled 'Mandatory' must be completed to send the letter.

Conditional: The component labeled 'Conditional' will be auto-populated if there is relevant data  present in the patient's record ,if not an exclusion statement will be provided against the component as to why the data is not available. Also, the user has an option to delete individual line items from each component.

Optional: The component labeled 'Optional' can be left blank.

N/A: This component is not available for the CDA document.