Clinical Document Architecture with Australian Schema

Clinical Document Architecture with Australian Schema, published by Australian Digital Health Agency. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/AuDigitalHealth/cda-au-schema/ and changes regularly. See the Directory of published versions

• Content
• Detailed Descriptions
• Mappings
• XML
• JSON
• TTL

Logical Model: EncompassingEncounter (CDA Class)

This optional class represents the setting of the clinical encounter during which the documented act(s) or ServiceEvent occurred. Documents are not necessarily generated during an encounter, such as when a clinician, in response to an abnormal lab result, attempts to contact the patient but can't, and writes a Progress Note.

In some cases, the setting of the encounter is inherent in the ClinicalDocument.code, such as where ClinicalDocument.code is "Diabetes Clinic Progress Note". The setting of an encounter can also be transmitted in the HealthCareFacility.code attribute. If HealthCareFacility.code is sent, it should be equivalent to or further specialize the value inherent in the ClinicalDocument.code (such as where the ClinicalDocument.code is simply "Clinic Progress Note" and the value of HealthCareFacility.code is "cardiology clinic"), and shall not conflict with the value inherent in the ClinicalDocument.code, as such a conflict would constitute an ambiguous situation.

EncompassingEncounter.dischargeDispositionCode can be used to depict the disposition of the patient at the time of hospital discharge (e.g., discharged to home, expired, against medical advice, etc.).

Usage:

• Use this Logical Model Profile: ComponentOf (CDA Class)

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from InfrastructureRoot

Name	Flags	Card.	Type	Description & Constraints
EncompassingEncounter		1..1	InfrastructureRoot	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId Base for all types and resources Instance of this type are validated by templateId Logical Container: ADHA ClinicalDocument (CDA Class)
@classCode		0..1	cs	Binding: CDAActClass (required) Fixed Value: ENC
@moodCode		0..1	cs	Binding: CDAActMood (required) Fixed Value: EVN
id		0..*	II
code		0..1	CE	Binding: ActEncounterCode (example)
effectiveTime		1..1	IVL_TS
sdtcAdmissionReferralSourceCode		0..1	CE	XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
dischargeDispositionCode		0..1	CE	Binding: USEncounterDischargeDisposition (example)
responsibleParty		0..1	InfrastructureRoot
@typeCode		0..1	cs	Binding: CDAParticipationType (required) Fixed Value: RESP
assignedEntity		1..1	AssignedEntity
encounterParticipant		0..*	EncounterParticipant
location		0..1	InfrastructureRoot
@typeCode		0..1	cs	Binding: ParticipationTargetLocation (required) Fixed Value: LOC
healthCareFacility		1..1	HealthCareFacility
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet / Code	URI
EncompassingEncounter.classCode	required	Fixed Value: ENC http://hl7.org/cda/stds/core/ValueSet/CDAActClass from this IG
EncompassingEncounter.moodCode	required	Fixed Value: EVN http://hl7.org/cda/stds/core/ValueSet/CDAActMood from this IG
EncompassingEncounter.code	example	ActEncounterCode http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
EncompassingEncounter.dischargeDispositionCode	example	USEncounterDischargeDisposition http://terminology.hl7.org/ValueSet/v3-USEncounterDischargeDisposition
EncompassingEncounter.responsibleParty.typeCode	required	Fixed Value: RESP http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType from this IG
EncompassingEncounter.location.typeCode	required	Fixed Value: LOC http://terminology.hl7.org/ValueSet/v3-ParticipationTargetLocation

Name	Flags	Card.	Type	Description & Constraints
EncompassingEncounter		1..1	InfrastructureRoot	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId Base for all types and resources Instance of this type are validated by templateId Logical Container: ADHA ClinicalDocument (CDA Class)
@classCode		0..1	cs	Binding: CDAActClass (required) Fixed Value: ENC
@moodCode		0..1	cs	Binding: CDAActMood (required) Fixed Value: EVN
id		0..*	II
code		0..1	CE	Binding: ActEncounterCode (example)
effectiveTime		1..1	IVL_TS
sdtcAdmissionReferralSourceCode		0..1	CE	XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
dischargeDispositionCode		0..1	CE	Binding: USEncounterDischargeDisposition (example)
responsibleParty		0..1	InfrastructureRoot
@typeCode		0..1	cs	Binding: CDAParticipationType (required) Fixed Value: RESP
assignedEntity		1..1	AssignedEntity
encounterParticipant		0..*	EncounterParticipant
location		0..1	InfrastructureRoot
@typeCode		0..1	cs	Binding: ParticipationTargetLocation (required) Fixed Value: LOC
healthCareFacility		1..1	HealthCareFacility
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
EncompassingEncounter.classCode	required	Fixed Value: ENC http://hl7.org/cda/stds/core/ValueSet/CDAActClass from this IG
EncompassingEncounter.moodCode	required	Fixed Value: EVN http://hl7.org/cda/stds/core/ValueSet/CDAActMood from this IG
EncompassingEncounter.code	example	ActEncounterCode http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
EncompassingEncounter.dischargeDispositionCode	example	USEncounterDischargeDisposition http://terminology.hl7.org/ValueSet/v3-USEncounterDischargeDisposition
EncompassingEncounter.responsibleParty.typeCode	required	Fixed Value: RESP http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType from this IG
EncompassingEncounter.location.typeCode	required	Fixed Value: LOC http://terminology.hl7.org/ValueSet/v3-ParticipationTargetLocation

Name	Flags	Card.	Type	Description & Constraints
EncompassingEncounter		1..1	InfrastructureRoot	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId Base for all types and resources Instance of this type are validated by templateId Logical Container: ADHA ClinicalDocument (CDA Class)
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
realmCode		0..*	CS
typeId		0..1	II
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
@assigningAuthorityName		0..1	st
@displayable		0..1	bl
@root		1..1	oid, uuid, ruid	Fixed Value: 2.16.840.1.113883.1.3
@extension		1..1	st
templateId		0..*	II
@classCode		0..1	cs	Binding: CDAActClass (required) Fixed Value: ENC
@moodCode		0..1	cs	Binding: CDAActMood (required) Fixed Value: EVN
id		0..*	II
code		0..1	CE	Binding: ActEncounterCode (example)
effectiveTime		1..1	IVL_TS
sdtcAdmissionReferralSourceCode		0..1	CE	XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
dischargeDispositionCode		0..1	CE	Binding: USEncounterDischargeDisposition (example)
responsibleParty		0..1	InfrastructureRoot
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
realmCode		0..*	CS
typeId		0..1	II
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
@assigningAuthorityName		0..1	st
@displayable		0..1	bl
@root		1..1	oid, uuid, ruid	Fixed Value: 2.16.840.1.113883.1.3
@extension		1..1	st
templateId		0..*	II
@typeCode		0..1	cs	Binding: CDAParticipationType (required) Fixed Value: RESP
assignedEntity		1..1	AssignedEntity
encounterParticipant		0..*	EncounterParticipant
location		0..1	InfrastructureRoot
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
realmCode		0..*	CS
typeId		0..1	II
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
@assigningAuthorityName		0..1	st
@displayable		0..1	bl
@root		1..1	oid, uuid, ruid	Fixed Value: 2.16.840.1.113883.1.3
@extension		1..1	st
templateId		0..*	II
@typeCode		0..1	cs	Binding: ParticipationTargetLocation (required) Fixed Value: LOC
healthCareFacility		1..1	HealthCareFacility
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
EncompassingEncounter.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
EncompassingEncounter.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
EncompassingEncounter.classCode	required	Fixed Value: ENC http://hl7.org/cda/stds/core/ValueSet/CDAActClass from this IG
EncompassingEncounter.moodCode	required	Fixed Value: EVN http://hl7.org/cda/stds/core/ValueSet/CDAActMood from this IG
EncompassingEncounter.code	example	ActEncounterCode http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
EncompassingEncounter.dischargeDispositionCode	example	USEncounterDischargeDisposition http://terminology.hl7.org/ValueSet/v3-USEncounterDischargeDisposition
EncompassingEncounter.responsibleParty.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
EncompassingEncounter.responsibleParty.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
EncompassingEncounter.responsibleParty.typeCode	required	Fixed Value: RESP http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType from this IG
EncompassingEncounter.location.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
EncompassingEncounter.location.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
EncompassingEncounter.location.typeCode	required	Fixed Value: LOC http://terminology.hl7.org/ValueSet/v3-ParticipationTargetLocation

This structure is derived from InfrastructureRoot

Summary

Mandatory: 0 element(3 nested mandatory elements)
Fixed: 4 elements

Structures

This structure refers to these other structures:

• cs: Coded Simple Value (http://hl7.org/cda/stds/core/StructureDefinition/cs-simple)

Differential View

This structure is derived from InfrastructureRoot

Name	Flags	Card.	Type	Description & Constraints
EncompassingEncounter		1..1	InfrastructureRoot	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId Base for all types and resources Instance of this type are validated by templateId Logical Container: ADHA ClinicalDocument (CDA Class)
@classCode		0..1	cs	Binding: CDAActClass (required) Fixed Value: ENC
@moodCode		0..1	cs	Binding: CDAActMood (required) Fixed Value: EVN
id		0..*	II
code		0..1	CE	Binding: ActEncounterCode (example)
effectiveTime		1..1	IVL_TS
sdtcAdmissionReferralSourceCode		0..1	CE	XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
dischargeDispositionCode		0..1	CE	Binding: USEncounterDischargeDisposition (example)
responsibleParty		0..1	InfrastructureRoot
@typeCode		0..1	cs	Binding: CDAParticipationType (required) Fixed Value: RESP
assignedEntity		1..1	AssignedEntity
encounterParticipant		0..*	EncounterParticipant
location		0..1	InfrastructureRoot
@typeCode		0..1	cs	Binding: ParticipationTargetLocation (required) Fixed Value: LOC
healthCareFacility		1..1	HealthCareFacility
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet / Code	URI
EncompassingEncounter.classCode	required	Fixed Value: ENC http://hl7.org/cda/stds/core/ValueSet/CDAActClass from this IG
EncompassingEncounter.moodCode	required	Fixed Value: EVN http://hl7.org/cda/stds/core/ValueSet/CDAActMood from this IG
EncompassingEncounter.code	example	ActEncounterCode http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
EncompassingEncounter.dischargeDispositionCode	example	USEncounterDischargeDisposition http://terminology.hl7.org/ValueSet/v3-USEncounterDischargeDisposition
EncompassingEncounter.responsibleParty.typeCode	required	Fixed Value: RESP http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType from this IG
EncompassingEncounter.location.typeCode	required	Fixed Value: LOC http://terminology.hl7.org/ValueSet/v3-ParticipationTargetLocation

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
EncompassingEncounter		1..1	InfrastructureRoot	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId Base for all types and resources Instance of this type are validated by templateId Logical Container: ADHA ClinicalDocument (CDA Class)
@classCode		0..1	cs	Binding: CDAActClass (required) Fixed Value: ENC
@moodCode		0..1	cs	Binding: CDAActMood (required) Fixed Value: EVN
id		0..*	II
code		0..1	CE	Binding: ActEncounterCode (example)
effectiveTime		1..1	IVL_TS
sdtcAdmissionReferralSourceCode		0..1	CE	XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
dischargeDispositionCode		0..1	CE	Binding: USEncounterDischargeDisposition (example)
responsibleParty		0..1	InfrastructureRoot
@typeCode		0..1	cs	Binding: CDAParticipationType (required) Fixed Value: RESP
assignedEntity		1..1	AssignedEntity
encounterParticipant		0..*	EncounterParticipant
location		0..1	InfrastructureRoot
@typeCode		0..1	cs	Binding: ParticipationTargetLocation (required) Fixed Value: LOC
healthCareFacility		1..1	HealthCareFacility
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
EncompassingEncounter.classCode	required	Fixed Value: ENC http://hl7.org/cda/stds/core/ValueSet/CDAActClass from this IG
EncompassingEncounter.moodCode	required	Fixed Value: EVN http://hl7.org/cda/stds/core/ValueSet/CDAActMood from this IG
EncompassingEncounter.code	example	ActEncounterCode http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
EncompassingEncounter.dischargeDispositionCode	example	USEncounterDischargeDisposition http://terminology.hl7.org/ValueSet/v3-USEncounterDischargeDisposition
EncompassingEncounter.responsibleParty.typeCode	required	Fixed Value: RESP http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType from this IG
EncompassingEncounter.location.typeCode	required	Fixed Value: LOC http://terminology.hl7.org/ValueSet/v3-ParticipationTargetLocation

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
EncompassingEncounter		1..1	InfrastructureRoot	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId Base for all types and resources Instance of this type are validated by templateId Logical Container: ADHA ClinicalDocument (CDA Class)
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
realmCode		0..*	CS
typeId		0..1	II
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
@assigningAuthorityName		0..1	st
@displayable		0..1	bl
@root		1..1	oid, uuid, ruid	Fixed Value: 2.16.840.1.113883.1.3
@extension		1..1	st
templateId		0..*	II
@classCode		0..1	cs	Binding: CDAActClass (required) Fixed Value: ENC
@moodCode		0..1	cs	Binding: CDAActMood (required) Fixed Value: EVN
id		0..*	II
code		0..1	CE	Binding: ActEncounterCode (example)
effectiveTime		1..1	IVL_TS
sdtcAdmissionReferralSourceCode		0..1	CE	XML Namespace: urn:hl7-org:sdtc XML: admissionReferralSourceCode (urn:hl7-org:sdtc)
dischargeDispositionCode		0..1	CE	Binding: USEncounterDischargeDisposition (example)
responsibleParty		0..1	InfrastructureRoot
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
realmCode		0..*	CS
typeId		0..1	II
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
@assigningAuthorityName		0..1	st
@displayable		0..1	bl
@root		1..1	oid, uuid, ruid	Fixed Value: 2.16.840.1.113883.1.3
@extension		1..1	st
templateId		0..*	II
@typeCode		0..1	cs	Binding: CDAParticipationType (required) Fixed Value: RESP
assignedEntity		1..1	AssignedEntity
encounterParticipant		0..*	EncounterParticipant
location		0..1	InfrastructureRoot
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
realmCode		0..*	CS
typeId		0..1	II
@nullFlavor		0..1	cs	Binding: CDANullFlavor (required)
@assigningAuthorityName		0..1	st
@displayable		0..1	bl
@root		1..1	oid, uuid, ruid	Fixed Value: 2.16.840.1.113883.1.3
@extension		1..1	st
templateId		0..*	II
@typeCode		0..1	cs	Binding: ParticipationTargetLocation (required) Fixed Value: LOC
healthCareFacility		1..1	HealthCareFacility
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
EncompassingEncounter.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
EncompassingEncounter.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
EncompassingEncounter.classCode	required	Fixed Value: ENC http://hl7.org/cda/stds/core/ValueSet/CDAActClass from this IG
EncompassingEncounter.moodCode	required	Fixed Value: EVN http://hl7.org/cda/stds/core/ValueSet/CDAActMood from this IG
EncompassingEncounter.code	example	ActEncounterCode http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
EncompassingEncounter.dischargeDispositionCode	example	USEncounterDischargeDisposition http://terminology.hl7.org/ValueSet/v3-USEncounterDischargeDisposition
EncompassingEncounter.responsibleParty.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
EncompassingEncounter.responsibleParty.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
EncompassingEncounter.responsibleParty.typeCode	required	Fixed Value: RESP http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType from this IG
EncompassingEncounter.location.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
EncompassingEncounter.location.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
EncompassingEncounter.location.typeCode	required	Fixed Value: LOC http://terminology.hl7.org/ValueSet/v3-ParticipationTargetLocation

This structure is derived from InfrastructureRoot

Summary

Mandatory: 0 element(3 nested mandatory elements)
Fixed: 4 elements

Structures

This structure refers to these other structures:

• cs: Coded Simple Value (http://hl7.org/cda/stds/core/StructureDefinition/cs-simple)

Other representations of profile: CSV, Excel