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Clinical documents

Specifications, guidance and associated collateral applicable to all types of clinical documents.

The My Health Record allows different types of functionality including uploading of clinical documents and accessing targeted My Health Record views.

The following table describes the My Health Record functionalities and their relevance to various Healthcare sectors.

✓✓ Highly Recommended     ✓ Recommended

UploadingGP Pharmacy PathologyDiagnostic      
Imaging
Allied     
Health 
Shared Health Summary✓✓    
Event Summary✓✓  ✓✓
eHealth Prescription Record✓✓    
eHealth Dispense Record ✓✓   
eHealth Pathology Report  ✓✓  
eHealth Diagnostic Imaging Report   ✓✓ 
ViewingGPPharmacyPathologyDiagnostic     
Imaging
Allied     
Health
Health Record Overview✓✓
Medicare Overview✓✓✓✓
eHealth Pathology Report View✓✓✓✓✓✓
eHealth Diagnostic Imaging Report View✓✓✓✓✓✓
eHealth Prescription & Dispense View✓✓✓✓✓✓
eHealth Medicines View **✓✓✓✓✓✓

** The eHealth Medicines View is not a document that is uploaded by clinical information software. It can only be downloaded via the document list.

Related content

Developer guides

Clinical Documents Integration Toolkit

The Clinical Documents Integration Toolkit is a collection of integration tools and sample code resources available in both .NET and Java. The sample code and integration tools are used within the eHealth Reference Platform, forming part of the code library for tools and simulators.

Resources

Australian Immunisation Register v1.2

Product
EP-3433:2021
Status
Active
Version
1.2
The Australian Immunisation Register (AIR) captures vaccinations given to people of all ages in Australia through general practice and community clinics. This includes vaccines funded under the National Immunisation Program and privately funded vaccinations. The AIR is administered by the Department of Human Services. Since 30 September 2016 the AIR has…

Clinical Documents Integration Toolkit v1.9

Product
EP-3546:2021
Status
Active
Version
1.9
The eHealth integration toolkits are a collection of integration tools and sample code resources available in both .NET and Java. The sample code and integration tools are used within the eHealth Reference Platform, forming part of the code library for tools and simulators. Access to sample code and the eHealth Reference Platform’s online simulator…

Clinical Package Validator v3.3

Product
EP-3776:2023
Status
Active
Version
3.3
The Clinical Package Validator (Validator) provides software developers with enhanced capabilities to achieve a greater degree of automation and depth of their conformance tests of clinical documents, SMD messages and HL7 v2 messages. Before formally declaring conformance of a software product, developers need to perform additional tests to ensure full…

Common - Clinical Document v1.6

Product
EP-3435:2022
Status
Active
Version
1.6
Specifications, guidance and associated collateral applicable to all types of clinical documents. This specification references or contains excerpts of intellectual property (IP) owned by the Regenstrief Institute, IHTSDO, or HL7 International. Applicable IP constraints apply: This material contains content from LOINC (http://loinc.org). LOINC is copyright…

Common - Consumer Entered Information v1.2

Product
EP-1428:2013
Status
Withdrawn
Version
1.2
The Common - Consumer Entered Information end product component has been archived and the conformance points within that conformance profile have been republished in three different end products: Personal Health Summary Advance Care Document Custodian Personal Health Notes Please refer to these new profiles: Personal Health Summary - My Health Record…

Common - Continuity of Care v1.0.1

Product
EP-1458:2013
Status
Archived
Version
1.0.1
The Common - Continuity of Care end product has been archived. The remaining three components have been moved to Common - Clinical Documents. These are: FAQ Nullable Fields Guidance v1.1 FAQ Global Statements None Known v1.1 FAQ Undifferentiated Pathology and Radiology Results v1.3 Future updates to the FAQs will be published in Common - Clinical Document.

Core Level One Clinical Document v1.0

Product
EP-2648:2018
Status
Active
Version
1.0
The Core Level One Clinical Document is a CDA container for the electronic representation of clinical information provided by source systems. For example, documents in PDF format could be included in the CDA container so it can be accepted by the My Health Record. Although this Core Level One Clinical Document could ostensibly be used for any clinical…

Data Types in NEHTA Specifications v1.0

Product
EP-1135:2010
Status
Active
Version
1.0
This document supports the Agency's detailed clinical model specifications and structured content specifications. It details a set of data types as a profile of the ISO 21090 data type specification.

Detailed Clinical Model Library v4.5

Product
EP-2522:2017
Status
Active
Version
4.5
The Australian Digital Health Agency is actively engaging with the healthcare community to develop computable clinical content definitions known as detailed clinical models (DCMs). Each DCM is inclusive of all data attributes and potentially terminology bindings that are useful to describe a single, discrete clinical concept for use in a broad range of…

Discharge Summary v1.6

Product
EP-3415:2022
Status
Active
Version
1.6
Discharge Summary documents support the transfer of a patient from a hospital back to the care of their nominated primary healthcare provider. They capture details about the patient's hospital stay, including the diagnosis, diagnostic procedures performed, the prognosis, medications prescribed and follow-up actions recommended. The My Health Record system…

eDiagnostic Imaging v1.0

Product
EP-1147:2011
Status
Active
Version
1.0
eDiagnostic Imaging facilitates the development of a national approach to radiology services, creating more effective, efficient and safer patient care. This national approach will also promote greater continuity of care and enable increased responsiveness across the diagnostic imaging sector.