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: Encounter (CDA Class)

A derivative of the RIM PatientEncounter class, used to represent related encounters, such as follow-up visits or referenced past encounters.

NOTE: The EncompassingEncounter class in the CDA Header (see Header Relationships (§ 4.2.3 )) represents the setting of the clinical encounter during which the documented act occurred. The Encounter class in the CDA Body is used to represent other related encounters.

Usage:

• Use this Logical Model Profile: Entry (CDA Class), EntryRelationship (CDA Class) and OrganizerComponent (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
Encounter		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		1..1	cs	Binding: CDAActClass (required) Fixed Value: ENC
@moodCode		1..1	cs	Binding: XDocumentEncounterMood (2.0.0) (required)
id		0..*	II
code		0..1	CD	Binding: ActEncounterCode (example)
text		0..1	ED
statusCode		0..1	CS	Binding: ActStatus (required)
effectiveTime		0..1	IVL_TS
sdtcDischargeDispositionCode		0..1	CE	XML Namespace: urn:hl7-org:sdtc XML: dischargeDispositionCode (urn:hl7-org:sdtc)
priorityCode		0..1	CE	Binding: ActPriority (example)
subject		0..1	Subject
specimen		0..*	Specimen
performer		0..*	Performer2
author		0..*	Author
informant		0..*	Informant
participant		0..*	Participant2
entryRelationship		0..*	EntryRelationship
reference		0..*	Reference
precondition		0..*	Precondition
sdtcPrecondition2		0..*	Precondition2	XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc)
sdtcInFulfillmentOf1		0..*	InFulfillmentOf1	XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet / Code	URI
Encounter.classCode	required	Fixed Value: ENC http://hl7.org/cda/stds/core/ValueSet/CDAActClass from this IG
Encounter.moodCode	required	XDocumentEncounterMood http://terminology.hl7.org/ValueSet/v3-xDocumentEncounterMood|2.0.0
Encounter.code	example	ActEncounterCode http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.statusCode	required	ActStatus http://terminology.hl7.org/ValueSet/v3-ActStatus
Encounter.priorityCode	example	ActPriority http://terminology.hl7.org/ValueSet/v3-ActPriority

Name	Flags	Card.	Type	Description & Constraints
Encounter		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		1..1	cs	Binding: CDAActClass (required) Fixed Value: ENC
@moodCode		1..1	cs	Binding: XDocumentEncounterMood (2.0.0) (required)
id		0..*	II
code		0..1	CD	Binding: ActEncounterCode (example)
text		0..1	ED
statusCode		0..1	CS	Binding: ActStatus (required)
effectiveTime		0..1	IVL_TS
sdtcDischargeDispositionCode		0..1	CE	XML Namespace: urn:hl7-org:sdtc XML: dischargeDispositionCode (urn:hl7-org:sdtc)
priorityCode		0..1	CE	Binding: ActPriority (example)
subject		0..1	Subject
specimen		0..*	Specimen
performer		0..*	Performer2
author		0..*	Author
informant		0..*	Informant
participant		0..*	Participant2
entryRelationship		0..*	EntryRelationship
reference		0..*	Reference
precondition		0..*	Precondition
sdtcPrecondition2		0..*	Precondition2	XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc)
sdtcInFulfillmentOf1		0..*	InFulfillmentOf1	XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Encounter.classCode	required	Fixed Value: ENC http://hl7.org/cda/stds/core/ValueSet/CDAActClass from this IG
Encounter.moodCode	required	XDocumentEncounterMood http://terminology.hl7.org/ValueSet/v3-xDocumentEncounterMood|2.0.0
Encounter.code	example	ActEncounterCode http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.statusCode	required	ActStatus http://terminology.hl7.org/ValueSet/v3-ActStatus
Encounter.priorityCode	example	ActPriority http://terminology.hl7.org/ValueSet/v3-ActPriority

Name	Flags	Card.	Type	Description & Constraints
Encounter		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		1..1	cs	Binding: CDAActClass (required) Fixed Value: ENC
@moodCode		1..1	cs	Binding: XDocumentEncounterMood (2.0.0) (required)
id		0..*	II
code		0..1	CD	Binding: ActEncounterCode (example)
text		0..1	ED
statusCode		0..1	CS	Binding: ActStatus (required)
effectiveTime		0..1	IVL_TS
sdtcDischargeDispositionCode		0..1	CE	XML Namespace: urn:hl7-org:sdtc XML: dischargeDispositionCode (urn:hl7-org:sdtc)
priorityCode		0..1	CE	Binding: ActPriority (example)
subject		0..1	Subject
specimen		0..*	Specimen
performer		0..*	Performer2
author		0..*	Author
informant		0..*	Informant
participant		0..*	Participant2
entryRelationship		0..*	EntryRelationship
reference		0..*	Reference
precondition		0..*	Precondition
sdtcPrecondition2		0..*	Precondition2	XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc)
sdtcInFulfillmentOf1		0..*	InFulfillmentOf1	XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Encounter.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
Encounter.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
Encounter.classCode	required	Fixed Value: ENC http://hl7.org/cda/stds/core/ValueSet/CDAActClass from this IG
Encounter.moodCode	required	XDocumentEncounterMood http://terminology.hl7.org/ValueSet/v3-xDocumentEncounterMood|2.0.0
Encounter.code	example	ActEncounterCode http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.statusCode	required	ActStatus http://terminology.hl7.org/ValueSet/v3-ActStatus
Encounter.priorityCode	example	ActPriority http://terminology.hl7.org/ValueSet/v3-ActPriority

This structure is derived from InfrastructureRoot

Summary

Mandatory: 0 element(2 nested mandatory elements)
Fixed: 1 element

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
Encounter		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		1..1	cs	Binding: CDAActClass (required) Fixed Value: ENC
@moodCode		1..1	cs	Binding: XDocumentEncounterMood (2.0.0) (required)
id		0..*	II
code		0..1	CD	Binding: ActEncounterCode (example)
text		0..1	ED
statusCode		0..1	CS	Binding: ActStatus (required)
effectiveTime		0..1	IVL_TS
sdtcDischargeDispositionCode		0..1	CE	XML Namespace: urn:hl7-org:sdtc XML: dischargeDispositionCode (urn:hl7-org:sdtc)
priorityCode		0..1	CE	Binding: ActPriority (example)
subject		0..1	Subject
specimen		0..*	Specimen
performer		0..*	Performer2
author		0..*	Author
informant		0..*	Informant
participant		0..*	Participant2
entryRelationship		0..*	EntryRelationship
reference		0..*	Reference
precondition		0..*	Precondition
sdtcPrecondition2		0..*	Precondition2	XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc)
sdtcInFulfillmentOf1		0..*	InFulfillmentOf1	XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet / Code	URI
Encounter.classCode	required	Fixed Value: ENC http://hl7.org/cda/stds/core/ValueSet/CDAActClass from this IG
Encounter.moodCode	required	XDocumentEncounterMood http://terminology.hl7.org/ValueSet/v3-xDocumentEncounterMood|2.0.0
Encounter.code	example	ActEncounterCode http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.statusCode	required	ActStatus http://terminology.hl7.org/ValueSet/v3-ActStatus
Encounter.priorityCode	example	ActPriority http://terminology.hl7.org/ValueSet/v3-ActPriority

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Encounter		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		1..1	cs	Binding: CDAActClass (required) Fixed Value: ENC
@moodCode		1..1	cs	Binding: XDocumentEncounterMood (2.0.0) (required)
id		0..*	II
code		0..1	CD	Binding: ActEncounterCode (example)
text		0..1	ED
statusCode		0..1	CS	Binding: ActStatus (required)
effectiveTime		0..1	IVL_TS
sdtcDischargeDispositionCode		0..1	CE	XML Namespace: urn:hl7-org:sdtc XML: dischargeDispositionCode (urn:hl7-org:sdtc)
priorityCode		0..1	CE	Binding: ActPriority (example)
subject		0..1	Subject
specimen		0..*	Specimen
performer		0..*	Performer2
author		0..*	Author
informant		0..*	Informant
participant		0..*	Participant2
entryRelationship		0..*	EntryRelationship
reference		0..*	Reference
precondition		0..*	Precondition
sdtcPrecondition2		0..*	Precondition2	XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc)
sdtcInFulfillmentOf1		0..*	InFulfillmentOf1	XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Encounter.classCode	required	Fixed Value: ENC http://hl7.org/cda/stds/core/ValueSet/CDAActClass from this IG
Encounter.moodCode	required	XDocumentEncounterMood http://terminology.hl7.org/ValueSet/v3-xDocumentEncounterMood|2.0.0
Encounter.code	example	ActEncounterCode http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.statusCode	required	ActStatus http://terminology.hl7.org/ValueSet/v3-ActStatus
Encounter.priorityCode	example	ActPriority http://terminology.hl7.org/ValueSet/v3-ActPriority

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Encounter		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		1..1	cs	Binding: CDAActClass (required) Fixed Value: ENC
@moodCode		1..1	cs	Binding: XDocumentEncounterMood (2.0.0) (required)
id		0..*	II
code		0..1	CD	Binding: ActEncounterCode (example)
text		0..1	ED
statusCode		0..1	CS	Binding: ActStatus (required)
effectiveTime		0..1	IVL_TS
sdtcDischargeDispositionCode		0..1	CE	XML Namespace: urn:hl7-org:sdtc XML: dischargeDispositionCode (urn:hl7-org:sdtc)
priorityCode		0..1	CE	Binding: ActPriority (example)
subject		0..1	Subject
specimen		0..*	Specimen
performer		0..*	Performer2
author		0..*	Author
informant		0..*	Informant
participant		0..*	Participant2
entryRelationship		0..*	EntryRelationship
reference		0..*	Reference
precondition		0..*	Precondition
sdtcPrecondition2		0..*	Precondition2	XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc)
sdtcInFulfillmentOf1		0..*	InFulfillmentOf1	XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Encounter.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
Encounter.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
Encounter.classCode	required	Fixed Value: ENC http://hl7.org/cda/stds/core/ValueSet/CDAActClass from this IG
Encounter.moodCode	required	XDocumentEncounterMood http://terminology.hl7.org/ValueSet/v3-xDocumentEncounterMood|2.0.0
Encounter.code	example	ActEncounterCode http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.statusCode	required	ActStatus http://terminology.hl7.org/ValueSet/v3-ActStatus
Encounter.priorityCode	example	ActPriority http://terminology.hl7.org/ValueSet/v3-ActPriority

This structure is derived from InfrastructureRoot

Summary

Mandatory: 0 element(2 nested mandatory elements)
Fixed: 1 element

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