Clinical User Guide
Creating CDA e-Health Documents

See also:

CDA e-Health documents cannot be accessed from outside a patient's record, nor can their templates be modified. When creating any CDA document, data marked as confidential, or data under the Surgical Audit Tool tab will not be included on the CDA form.

As CDA documents can be shared between registered practitioners via systems such as MDExchange and My Health Record, it is important that you understand that as an author of a CDA document, you are responsible for its content.

CDA documents that display Past History items require that you have recorded the History items using a valid date format;

The Date field in a CDA eHealth document displays;

  • As blank if the date and year are not recorded for the Past History item

  • The year only, if the year is present but no date has been recorded, or if the year is present but the date field contains text which is not in a recognised date format, or is not a month (or abbreviation of) in the Past History item.

  • A date, if no year is present but the date is present in the Past History item.

  • Month and year, if month and year are recorded but no date is present in the Past History item.

 

1.      Ensure you have opened a patient's record.

2.      Within Letter Writer, select File > New.

3.      From the New dialogue box, select the e-Health tab and then double-click the CDA e-Health template you wish to use.

 

4.      Select from the following supplied templates:

o      e-Referral

o      Event Summary

o      Shared Health Summary

o      Specialist Letter

See CDA Documents to view the different components/sections of each CDA Document type.

 

5.      A new CDA e-Health document is generated for you to complete. Complete it as desired.

o      If you wish to indicate that a document contains sensitive information:

•       In an e-Referral, type 'Sensitive Information' into the Reason for Referral field of the document.

•       In a Specialist Letter, type 'Sensitive Information' into the Response Narrative field of the document.

 

6.      You can then send the document;

o      Via MDExchange, by clicking   Use this method if you wish to send the document directly to another user. Note that if you select this method you can also upload the document to My Health Record (as explained following, at Step 10).  See Sending Messages via MDExchange for the remaining steps for sending a CDA Document via this method.

o      Via an External Transport method by clicking  Note that if you select this method you can also upload the document to My Health Record (as explained following, at Step 10).

o      Via My Health Record by clicking (uploaded to the My Health Record system where it can then be accessed by the recipient). Note that this button is only available to selected templates. If this button is not available, you can still upload the document to My Health Record, as explained following.

 

7.      The Select Addressee window appears.

 

8.      From the list of available addressees (taken from your Address Book), select the recipient you wish to send the letter to.

9.      Select a Data Transfer Configuration from the associated drop-down list.

A Data Transfer Configuration is essentially the indication of a location on your computer where the resulting file will be deposited, to be collected by your third-party transport software (as opposed to using MedicalDirector's MDExchange system). If you are unsure of which configuration to select, or cannot see your desired configuration in the list, please contact your Systems Administrator for assistance. Data Transfer Configurations are managed via Clinical's Manage Communications utility.

(Optional) Tick the Save as Default check box to save your selected Data Transfer Configuration as the default.

 

10.   (Optional) Tick the Send to MyHealthRecord check box to simultaneously upload this letter to the My Health Record system.

11.   Once you have selected a recipient and Data Transfer Configuration, click Send to send the e-Health document, after which Letter Writer will close and you will be returned to the patient's Clinical Window.

Note that as the author of the CDA document, you are responsible for its content.