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: LegalAuthenticator (CDA Class)

Represents a participant who has legally authenticated the document. The CDA is a standard that specifies the structure of exchanged clinical documents. In the case where a local document is transformed into a CDA document for exchange, authentication occurs on the local document, and that fact is reflected in the exchanged CDA document. A CDA document can reflect the unauthenticated, authenticated, or legally authenticated state. The unauthenticated state exists when no authentication information has been recorded (i.e., it is the absence of being either authenticated or legally authenticated). While electronic signatures are not captured in a CDA document, both authentication and legal authentication require that a document has been signed manually or electronically by the responsible individual. A legalAuthenticator has a required legalAuthenticator.time indicating the time of authentication, and a required legalAuthenticator.signatureCode, indicating that a signature has been obtained and is on file.

Usage:

• This Logical Model Profile is not used by any profiles in this Implementation Guide

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
LegalAuthenticator		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)
@typeCode		0..1	cs	Binding: CDAParticipationType (required) Fixed Value: LA
@contextControlCode		0..1	cs	Binding: CDAContextControl (required) Fixed Value: OP
time		1..1	TS
signatureCode	C	1..1	CS	Binding: CDASignatureCode (required) signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
sdtcSignatureText		0..1	ED	XML Namespace: urn:hl7-org:sdtc XML: signatureText (urn:hl7-org:sdtc)
assignedEntity		1..1	AssignedEntity
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet / Code	URI
LegalAuthenticator.typeCode	required	Fixed Value: LA http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType from this IG
LegalAuthenticator.contextControlCode	required	Fixed Value: OP http://hl7.org/cda/stds/core/ValueSet/CDAContextControl from this IG
LegalAuthenticator.signatureCode	required	CDASignatureCode http://hl7.org/cda/stds/core/ValueSet/CDASignatureCode from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
signature	warning	LegalAuthenticator.signatureCode	CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. : code.exists() implies code != 'X'

Name	Flags	Card.	Type	Description & Constraints
LegalAuthenticator		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)
@typeCode		0..1	cs	Binding: CDAParticipationType (required) Fixed Value: LA
@contextControlCode		0..1	cs	Binding: CDAContextControl (required) Fixed Value: OP
time		1..1	TS
signatureCode	C	1..1	CS	Binding: CDASignatureCode (required) signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
sdtcSignatureText		0..1	ED	XML Namespace: urn:hl7-org:sdtc XML: signatureText (urn:hl7-org:sdtc)
assignedEntity		1..1	AssignedEntity
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
LegalAuthenticator.typeCode	required	Fixed Value: LA http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType from this IG
LegalAuthenticator.contextControlCode	required	Fixed Value: OP http://hl7.org/cda/stds/core/ValueSet/CDAContextControl from this IG
LegalAuthenticator.signatureCode	required	CDASignatureCode http://hl7.org/cda/stds/core/ValueSet/CDASignatureCode from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
signature	warning	LegalAuthenticator.signatureCode	CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. : code.exists() implies code != 'X'

Name	Flags	Card.	Type	Description & Constraints
LegalAuthenticator		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
@typeCode		0..1	cs	Binding: CDAParticipationType (required) Fixed Value: LA
@contextControlCode		0..1	cs	Binding: CDAContextControl (required) Fixed Value: OP
time		1..1	TS
signatureCode	C	1..1	CS	Binding: CDASignatureCode (required) signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
sdtcSignatureText		0..1	ED	XML Namespace: urn:hl7-org:sdtc XML: signatureText (urn:hl7-org:sdtc)
assignedEntity		1..1	AssignedEntity
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
LegalAuthenticator.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
LegalAuthenticator.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
LegalAuthenticator.typeCode	required	Fixed Value: LA http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType from this IG
LegalAuthenticator.contextControlCode	required	Fixed Value: OP http://hl7.org/cda/stds/core/ValueSet/CDAContextControl from this IG
LegalAuthenticator.signatureCode	required	CDASignatureCode http://hl7.org/cda/stds/core/ValueSet/CDASignatureCode from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
signature	warning	LegalAuthenticator.signatureCode	CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. : code.exists() implies code != 'X'

This structure is derived from InfrastructureRoot

Summary

Mandatory: 0 element(3 nested mandatory elements)
Fixed: 2 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
LegalAuthenticator		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)
@typeCode		0..1	cs	Binding: CDAParticipationType (required) Fixed Value: LA
@contextControlCode		0..1	cs	Binding: CDAContextControl (required) Fixed Value: OP
time		1..1	TS
signatureCode	C	1..1	CS	Binding: CDASignatureCode (required) signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
sdtcSignatureText		0..1	ED	XML Namespace: urn:hl7-org:sdtc XML: signatureText (urn:hl7-org:sdtc)
assignedEntity		1..1	AssignedEntity
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet / Code	URI
LegalAuthenticator.typeCode	required	Fixed Value: LA http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType from this IG
LegalAuthenticator.contextControlCode	required	Fixed Value: OP http://hl7.org/cda/stds/core/ValueSet/CDAContextControl from this IG
LegalAuthenticator.signatureCode	required	CDASignatureCode http://hl7.org/cda/stds/core/ValueSet/CDASignatureCode from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
signature	warning	LegalAuthenticator.signatureCode	CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. : code.exists() implies code != 'X'

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
LegalAuthenticator		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)
@typeCode		0..1	cs	Binding: CDAParticipationType (required) Fixed Value: LA
@contextControlCode		0..1	cs	Binding: CDAContextControl (required) Fixed Value: OP
time		1..1	TS
signatureCode	C	1..1	CS	Binding: CDASignatureCode (required) signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
sdtcSignatureText		0..1	ED	XML Namespace: urn:hl7-org:sdtc XML: signatureText (urn:hl7-org:sdtc)
assignedEntity		1..1	AssignedEntity
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
LegalAuthenticator.typeCode	required	Fixed Value: LA http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType from this IG
LegalAuthenticator.contextControlCode	required	Fixed Value: OP http://hl7.org/cda/stds/core/ValueSet/CDAContextControl from this IG
LegalAuthenticator.signatureCode	required	CDASignatureCode http://hl7.org/cda/stds/core/ValueSet/CDASignatureCode from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
signature	warning	LegalAuthenticator.signatureCode	CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. : code.exists() implies code != 'X'

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
LegalAuthenticator		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
@typeCode		0..1	cs	Binding: CDAParticipationType (required) Fixed Value: LA
@contextControlCode		0..1	cs	Binding: CDAContextControl (required) Fixed Value: OP
time		1..1	TS
signatureCode	C	1..1	CS	Binding: CDASignatureCode (required) signature: CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'.
sdtcSignatureText		0..1	ED	XML Namespace: urn:hl7-org:sdtc XML: signatureText (urn:hl7-org:sdtc)
assignedEntity		1..1	AssignedEntity
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
LegalAuthenticator.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
LegalAuthenticator.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
LegalAuthenticator.typeCode	required	Fixed Value: LA http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType from this IG
LegalAuthenticator.contextControlCode	required	Fixed Value: OP http://hl7.org/cda/stds/core/ValueSet/CDAContextControl from this IG
LegalAuthenticator.signatureCode	required	CDASignatureCode http://hl7.org/cda/stds/core/ValueSet/CDASignatureCode from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
signature	warning	LegalAuthenticator.signatureCode	CDA Release One represented either an intended ('X') or actual ('S') authenticator. CDA Release Two only represents an actual authenticator, so has deprecated the value of 'X'. : code.exists() implies code != 'X'

This structure is derived from InfrastructureRoot

Summary

Mandatory: 0 element(3 nested mandatory elements)
Fixed: 2 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