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: Subject (CDA Class)

The subject participant represents the primary target of the entries recorded in the document. Most of the time the subject is the same as the recordTarget, but need not be, for instance when the subject is a fetus observed in an obstetrical ultrasound.

The subject participant can be ascribed to a CDA section or a CDA entry. It propagates to nested components, unless overridden. The subject of a document is presumed to be the patient.

Usage:

• Use this Logical Model Profile: Act (CDA Class), Encounter (CDA Class), Observation (CDA Class), ObservationMedia (CDA Class)... Show 17 more, Organizer (CDA Class), Procedure (CDA Class), RegionOfInterest (CDA Class), Section (CDA Class), SubstanceAdministration (CDA Class), Supply (CDA Class), ADHA Act (CDA Class), ADHA Encounter (CDA Class), ADHA Observation (CDA Class), ADHA ObservationMedia (CDA Class), ADHA Organizer (CDA Class), ADHA Procedure (CDA Class), ADHA RegionOfInterest (CDA Class), ADHA Section (CDA Class), ADHA SubstanceAdministration (CDA Class), ADHA Supply (CDA Class) and ADHA extension controlAct

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
Subject			InfrastructureRoot	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId Instance of this type are validated by templateId Logical Container: ADHA ClinicalDocument (CDA Class)
@typeCode		0..1	cs	Binding: ParticipationTargetSubject (required) Fixed Value: SBJ
@contextControlCode		0..1	cs	Binding: CDAContextControl (required) Fixed Value: OP
awarenessCode		0..1	CE	Binding: TargetAwareness (example)
relatedSubject		1..1	RelatedSubject
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet / Code	URI
Subject.typeCode	required	Fixed Value: SBJ http://terminology.hl7.org/ValueSet/v3-ParticipationTargetSubject
Subject.contextControlCode	required	Fixed Value: OP http://hl7.org/cda/stds/core/ValueSet/CDAContextControl from this IG
Subject.awarenessCode	example	TargetAwareness http://terminology.hl7.org/ValueSet/v3-TargetAwareness

Name	Flags	Card.	Type	Description & Constraints
Subject		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	C	0..1	II	II-1: An II instance must have either a root or an nullFlavor.
@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: ParticipationTargetSubject (required) Fixed Value: SBJ
@contextControlCode		0..1	cs	Binding: CDAContextControl (required) Fixed Value: OP
awarenessCode		0..1	CE	Binding: TargetAwareness (example)
relatedSubject		1..1	RelatedSubject
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Subject.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
Subject.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
Subject.typeCode	required	Fixed Value: SBJ http://terminology.hl7.org/ValueSet/v3-ParticipationTargetSubject
Subject.contextControlCode	required	Fixed Value: OP http://hl7.org/cda/stds/core/ValueSet/CDAContextControl from this IG
Subject.awarenessCode	example	TargetAwareness http://terminology.hl7.org/ValueSet/v3-TargetAwareness

Constraints

Id	Grade	Path(s)	Details	Requirements
II-1	error	Subject.typeId	An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists()

Name	Flags	Card.	Type	Description & Constraints
Subject		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	C	0..1	II	II-1: An II instance must have either a root or an nullFlavor.
@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: ParticipationTargetSubject (required) Fixed Value: SBJ
@contextControlCode		0..1	cs	Binding: CDAContextControl (required) Fixed Value: OP
awarenessCode		0..1	CE	Binding: TargetAwareness (example)
relatedSubject		1..1	RelatedSubject
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Subject.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
Subject.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
Subject.typeCode	required	Fixed Value: SBJ http://terminology.hl7.org/ValueSet/v3-ParticipationTargetSubject
Subject.contextControlCode	required	Fixed Value: OP http://hl7.org/cda/stds/core/ValueSet/CDAContextControl from this IG
Subject.awarenessCode	example	TargetAwareness http://terminology.hl7.org/ValueSet/v3-TargetAwareness

Constraints

Id	Grade	Path(s)	Details	Requirements
II-1	error	Subject.typeId	An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists()

This structure is derived from InfrastructureRoot

Summary

Mandatory: 0 element(1 nested mandatory element)
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
Subject			InfrastructureRoot	XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId Instance of this type are validated by templateId Logical Container: ADHA ClinicalDocument (CDA Class)
@typeCode		0..1	cs	Binding: ParticipationTargetSubject (required) Fixed Value: SBJ
@contextControlCode		0..1	cs	Binding: CDAContextControl (required) Fixed Value: OP
awarenessCode		0..1	CE	Binding: TargetAwareness (example)
relatedSubject		1..1	RelatedSubject
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet / Code	URI
Subject.typeCode	required	Fixed Value: SBJ http://terminology.hl7.org/ValueSet/v3-ParticipationTargetSubject
Subject.contextControlCode	required	Fixed Value: OP http://hl7.org/cda/stds/core/ValueSet/CDAContextControl from this IG
Subject.awarenessCode	example	TargetAwareness http://terminology.hl7.org/ValueSet/v3-TargetAwareness

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Subject		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	C	0..1	II	II-1: An II instance must have either a root or an nullFlavor.
@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: ParticipationTargetSubject (required) Fixed Value: SBJ
@contextControlCode		0..1	cs	Binding: CDAContextControl (required) Fixed Value: OP
awarenessCode		0..1	CE	Binding: TargetAwareness (example)
relatedSubject		1..1	RelatedSubject
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Subject.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
Subject.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
Subject.typeCode	required	Fixed Value: SBJ http://terminology.hl7.org/ValueSet/v3-ParticipationTargetSubject
Subject.contextControlCode	required	Fixed Value: OP http://hl7.org/cda/stds/core/ValueSet/CDAContextControl from this IG
Subject.awarenessCode	example	TargetAwareness http://terminology.hl7.org/ValueSet/v3-TargetAwareness

Constraints

Id	Grade	Path(s)	Details	Requirements
II-1	error	Subject.typeId	An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Subject		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	C	0..1	II	II-1: An II instance must have either a root or an nullFlavor.
@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: ParticipationTargetSubject (required) Fixed Value: SBJ
@contextControlCode		0..1	cs	Binding: CDAContextControl (required) Fixed Value: OP
awarenessCode		0..1	CE	Binding: TargetAwareness (example)
relatedSubject		1..1	RelatedSubject
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Subject.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
Subject.typeId.nullFlavor	required	CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor from this IG
Subject.typeCode	required	Fixed Value: SBJ http://terminology.hl7.org/ValueSet/v3-ParticipationTargetSubject
Subject.contextControlCode	required	Fixed Value: OP http://hl7.org/cda/stds/core/ValueSet/CDAContextControl from this IG
Subject.awarenessCode	example	TargetAwareness http://terminology.hl7.org/ValueSet/v3-TargetAwareness

Constraints

Id	Grade	Path(s)	Details	Requirements
II-1	error	Subject.typeId	An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists()

This structure is derived from InfrastructureRoot

Summary

Mandatory: 0 element(1 nested mandatory element)
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