Technical Specification
Track updates
SA TS 90007.2:2014
[Current]Consumer entered information, Part 2: CDA implementation guide
A guide to implementing the logical model detailed by SA TS 90007.1 as an HL7 Clinical Document Architecture Release 2 (CDA) XML document. Contains descriptions of both constraints on the CDA and, where necessary, custom extensions to the CDA, for the purposes of fulfilling the requirements for Australian implementations of consumer entered information in the form of consumer entered health summaries and consumer entered notes. Also presents conformance requirements against which implementers can attest the conformance of their systems.
Published: 29/08/2014
Pages: 196
Table of contents
Cited references
Content history
Table of contents
Header
About this publication
Preface
Foreword
1 Scope and general
1.1 Scope and application
1.2 Intended audience
1.3 Normative references
1.4 Terms, definitions and acronyms
1.4.1 Terms and definitions
1.4.2 Consumer entered health summary
1.4.3 Consumer entered notes
1.4.4 Acronyms
1.5 Interpretation of normative language
1.6 Conformance
1.7 Known issues
2 Guide for use
2.1 General
2.2 Clinical Document Architecture Release 2
2.3 Mapping interpretation
2.3.1 General
2.3.2 CDA R-MIM representation
2.3.3 CDA mapping (normative)
2.3.3.1 Mapping requirements
2.3.3.2 Example mapping table
2.3.3.3 Interpretation of example mapping
2.3.4 Example XML fragment
2.4 CDA extensions
2.5 Australian CDA schema
2.6 Schematron
2.7 Implementation strategies
3 Consumer Entered Health Summary data hierarchy
4 Administrative observations
4.1 Introduction
4.2 CDA R-MIM representation
4.3 CDA mapping
4.4 Example of administrative observations XML fragment
5 CDA header—Consumer entered health summary
5.1 Introduction
5.2 ClinicalDocument
5.2.1 Identification
5.2.2 Relationships
5.2.3 CDA R-MIM representation
5.2.4 CDA mapping
5.2.5 Example of ClinicalDocument Body XML fragment
5.3 LegalAuthenticator
5.3.1 Identification
5.3.2 Relationships
5.3.3 CDA R-MIM representation
5.3.4 CDA mapping
5.3.5 Example of LegalAuthenticator XML fragment
5.4 Custodian
5.4.1 Identification
5.4.2 Relationships
5.4.3 CDA R-MIM representation
5.4.4 CDA mapping
5.4.5 Example of Custodian Body XML fragment
6 Context data specification—CDA mapping for Consumer Entered Health Summary
6.1 Consumer Entered Health Summary
6.1.1 Identification
6.1.2 Relationships
6.1.3 CDA R-MIM representation
6.1.4 CDA mapping
6.1.5 Example of Consumer Entered Health Summary Context XML fragment
6.2 Document author
6.2.1 Identification
6.2.2 Relationships
6.2.3 CDA R-MIM representation
6.2.4 CDA mapping
6.2.5 Example of Document Author XML fragment
6.3 Subject of care
6.3.1 Identification
6.3.2 Relationships
6.3.3 CDA R-MIM representation
6.3.4 CDA mapping
6.3.5 Example of Subject of Care XML fragment
7 Content data specification—CDA mapping for Consumer Entered Health Summary
7.1 Consumer Entered Health Summary
7.1.1 Identification
7.1.2 Relationships
7.1.3 CDA R-MIM representation
7.1.4 CDA mapping
7.1.5 Example of Consumer Entered Health Summary Body XML fragment
7.2 Allergies and adverse reactions
7.2.1 Identification
7.2.2 Relationships
7.2.3 CDA R-MIM representation
7.2.4 CDA mapping
7.2.5 Example of Adverse Reactions XML fragment
7.3 Adverse reaction
7.3.1 Identification
7.3.2 Relationships
7.3.3 CDA R-MIM representation
7.3.4 CDA mapping
7.3.5 Example of Adverse Reaction XML fragment
7.4 Medications
7.4.1 Identification
7.4.2 Relationships
7.4.3 CDA R-MIM representation
7.4.4 CDA mapping
7.4.5 Example of Medications XML fragment
7.5 Medication
7.5.1 Identification
7.5.2 Relationships
7.5.3 CDA R-MIM representation
7.5.4 CDA mapping
7.5.5 Example of Medication Instruction XML fragment
8 Consumer Entered Notes data hierarchy
9 CDA header—Consumer entered notes
9.1 Introduction
9.2 ClinicalDocument
9.2.1 Identification
9.2.2 Relationships
9.2.3 CDA R-MIM representation
9.2.4 CDA mapping
9.2.5 Example of ClinicalDocument Body XML fragment
9.3 LegalAuthenticator
9.3.1 Identification
9.3.2 Relationships
9.3.3 CDA R-MIM representation
9.3.4 CDA mapping
9.3.5 Example of LegalAuthenticator XML fragment
9.4 Custodian
9.4.1 Identification
9.4.2 Relationships
9.4.3 CDA R-MIM representation
9.4.4 CDA mapping
9.4.5 Example of Custodian Body XML fragment
10 Context data specification—CDA mapping for Consumer Entered Notes
10.1 Consumer entered notes
10.1.1 Identification
10.1.2 Relationships
10.1.3 CDA R-MIM representation
10.1.4 CDA mapping
10.1.5 Example of Consumer Entered Notes Context XML fragment
10.2 Document author
10.2.1 Identification
10.2.2 Relationships
10.2.3 CDA R-MIM representation
10.2.4 CDA mapping
10.2.5 Example of Document Author XML fragment
10.3 Subject of care
10.3.1 Identification
10.3.2 Relationships
10.3.3 CDA R-MIM representation
10.3.4 CDA mapping
10.3.5 Example of Subject of Care XML fragment
11 Content data specification—CDA mapping for Consumer Entered Notes
11.1 Consumer Entered Notes
11.1.1 Identification
11.1.2 Relationships
11.1.3 CDA R-MIM representation
11.1.4 CDA mapping
11.1.5 Example of Consumer Entered Notes Body XML fragment
11.2 Note
11.2.1 Identification
11.2.2 Relationships
11.2.3 CDA R-MIM representation
11.2.4 CDA mapping
11.2.5 Example of Note XML fragment
Appendix A
A1 Code
A1.1 General
A1.2 Example of code
A2 ID
A2.1 General
A2.2 Example of ID
A3 Time
A3.1 General
A3.2 Example of Simple timestamp
A3.3 Example of Low time
A3.4 Example of Interval timestamp 1
A3.5 Example of Interval timestamp 2
A3.6 Example of Width time
A4 Entity Identifier
A4.1 CDA mapping
A4.2 Example of Entity Identifier XML fragment
A5 Person Name
A5.1 CDA mapping
A5.2 Example of Person Name
A6 Address
A6.1 CDA mapping
A6.2 Example of Address XML fragment
A7 Electronic Communication Detail
A7.1 CDA mapping
A7.2 Example of Electronic Communication Detail
Appendix B
B1 Introduction
B2 ClinicalDocument.CompletionCode
B3 EntityIdentifier
B4 Entitlement
B5 Multiple Birth
B6 Administrative Gender Code
B7 Birth Time
B8 Deceased Time
B9 Qualifications
Appendix C
C1 General
C1.1 Context
C1.2 Example of All values
C1.3 Example of One value
C2 Australian State/Territory Identifier—Postal value set
C3 Health care client electronic communication medium value set
C4 Health care client electronic communication usage code
C5 Health care client identifier address purpose
C6 Health care client identifier date accuracy indicator value set
C7 Health care client identifier geographic area value set
C8 Health care client name usage value set
C9 Health care client sex value set
C10 Health care client source of death notification value set
C11 Health care provider organization name usage value set
C12 HL7 V3 CDA: ActMoodCode
C13 HL7 V3 CDA: ObservationInterpretationNormality
C14 HL7 V3 CDA: RelatedDocument.TypeCode
C15 HL7 V3: TelecommunicationAddressUse
C16 NCTIS: Change Type Values
C17 NCTIS: Admin codes—Document status
C18 NCTIS: Admin codes—Entitlement type
C19 NCTIS: Admin codes—Global statement values
C20 NCTIS: Admin codes—Recommendation or change values
C21 NCTIS: Admin codes—Result status
C22 METeOR 291036: Indigenous status
C23 OIDs
Appendix D
Bibliography
Cited references in this standard
Content history
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