Aged Care Clinical Note

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Conformance

This page outlines the essential conformance guidelines for implementers of the Aged Care Clinical Note document. Adhering to these guidelines improves the chances that both sending and receiving systems meet mutual expectations, thereby enhancing interoperability. Before reading this page, implementers are advised to be familiar with FHIR Conformance Rules and the FHIR standard requirements in general.

FHIR Clinical Document

This Implementation Guide has a direct dependency on the FHIR Clinical Documents Implementation Guide. The Bundle and Composition profiles defined in this IG are derived from those defined in the FHIR Clinical Documents. Hence, all conformance rules and guidelines for FHIR Clinical Documents apply to the Aged Care Clinical Note. Implementers are expected to specifically follow the requirements defined in the what-is-a-fhir-clinical-document section that describes the common characteristic of a clinical document. Additionally, Human readability and rendering FHIR Clinical Documents section describes some necessary conformance requirements.

AU Core and AU Base

This Implementation Guide has direct dependencies on the two key Australian FHIR Implementation Guides, AU Base and AU Core. This Implementation Guide at the current stage doesn't define any interaction and doesn't constraint the Aged Care Clinical Note to be shared and discovered in one way or another. Hence, a Profile Support + Interaction Support conformance to AU Core is not required to meet the minimum requirements of conformance to the Aged Care Clinical Note. That is also to say that Profile Only Support for AU Core profiles used in this IG is a requirement to meet the minimum requirements of conformance to the Aged Care Clinical Note. Those profiles are AU Core Organization, AU Core Medication, AU Core Practitioner and AU Core PractitionerRole.

Mandatory and Must Support Elements

Mandatory elements are those with minimum cardinality > 0. Source systems of the Aged Care Clinical Note SHALL populate these elements to ensure conformance. If a mandatory element can't be populated by the source system, implementers are advised to follow the Missing Data guidance from AU Core. However, in this scenario the resource remains non-conformant to this implementation guide and how the receiving system handles the resource can't be predicted.

Throughout this Implementation Guide, some elements have been marked as Must Support. Special attention and care are to be given to Must Support elements whether they are mandatory or not. The general expectations for a non-mandatory Must Support element is that it SHOULD be populated by the source system if data is available while the receiving system SHALL NOT error whether it is populated or not. If a Must Support element is also mandatory, it follows the guidelines of the mandatory elements in the beginning of this section.

Actors, CapabilityStatement, and Exchange Patterns

At this stage, this Implementation Guide is only concerned with the structure of an Aged Care Clinical Note. It defines a set of FHIR artefacts that when conformed with promotes the safe and consistent representation of the document without enforcing a particular approach to sharing it. Hence, this Implementation Guide doesn't define any Actors, CapabilityStatements, or interactions. This may change in the future based on feedback from the community. The sending and receiving system need to agree on a technical approach to sharing the Aged Care Clinical Note document, e.g. RESTful interaction, secure messaging, file transfer, etc…