Common - Clinical Document v1.5

Common - Clinical Document v1.5

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 LOINCTM (http://loinc.org). The LOINC table, LOINC codes, and LOINC panels and forms file are copyright © 1995-2015, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and available at no cost under the license at http://loinc.org/terms-of-use. LOINC is a trademark of Regenstrief Institute, Inc., registered in the United States.
  • This material includes SNOMED Clinical TermsTM (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO). All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO, (http://www.ihtsdo.org).
  • This document includes excerpts of HL7TM International standards and other HL7 International material. HL7 International is the publisher and holder of copyright in the excerpts. The publication, reproduction and use of such excerpts is governed by the HL7 IP Policy (see http://www.hl7.org/legal/ippolicy.cfm) and the HL7 International License Agreement. HL7 and CDA are trademarks of Health Level Seven International and are registered with the United States Patent and Trademark Office.
End products superseded by

A new version has been released for this end product

Please refer to Common - Clinical Document v1.5.1 or refer to the Release History for all releases of this End Product.

Identifier: 
EP-2563:2017
Date: 
21-12-2017
Type: 
application/zip
SHA256 Checksum: 
1a2004d29569ddafa57f7fe49143d5eb6d4752b196db671f91599b5eca116760
Size: 
7.38 MB

Product Components

Product component
Identifier: 
NEHTA-1097:2011

This document provides advice for implementers with respect to coding common clinical concepts in Agency CDA documents, including e-Referral, Discharge Summary, Event Summary, Shared Health Summary, and Specialist Letter.

Product component
Identifier: 
NEHTA-1199:2012

This document:

Product component
Identifier: 
NEHTA-1226:2011

This specification defines a clinical package as a logical model of the data it contains. This model can be profiled to create data models for specific clinical data.

Product component
Identifier: 
NEHTA-1229:2011

This specification defines three logical models for clinical data that consists of a single CDA XML document and related byte streams. This specification also defines a possible serialised representation for those logical models.

Product component
Identifier: 
NEHTA-1255:2012

This FAQ answers the question: What is the appropriate use of date and date-time values in clinical documents?

Product component
Identifier: 
NEHTA-1270:2013

This FAQ describes an extension to these eDischarge Summary, eReferral and Specialist Letter that involves encapsulating the CDA package within an HL7 v2 MDM^T02 message (which covers the delivery of a document).

Product component
Identifier: 
NEHTA-1274:2013

A global exclusion statement is common in CDA clinical documents and has three possible values:

  • None known
  • Not asked
  • None supplied

This FAQ answers the question: What is the proper use of none known in global exclusion statements?

Product component
Identifier: 
NEHTA-1276:2013

The FAQs are guidance material for implementation. They should be used for clarification purposes and to support existing documentation.

Product component
Identifier: 
NEHTA-1328:2013

This document recommends a set of presentation guidelines for CDA® document authors. It complements the CDA® Rendering Specification and the CDA® implementation guides by describing:

Product component
Identifier: 
NEHTA-1459:2013

The CDA implementation guides that include diagnostic service reports (eReferral, Specialist Letter, Event Summary, and Discharge Summary) divide the reports into pathology and radiology.

Product component
Identifier: 
NEHTA-2063:2015

The conformance test specification contains test cases for assessing clinical information systems for conformance with the following PCEHR usability recommendations (published as part of the Clinical Usability Programme (CUP) Release 3):

Product component
Identifier: 
NEHTA-2065:2015

Specifies test cases for the assessment of conformance of clinical information systems with requirements related to CDA packaging.

Product component
Identifier: 
NEHTA-2189:2015

This conformance test specification supports the currently published My Health Record views specifications and their conformance requirements. It provides a targeted set of test cases, managed using a Microsoft Excel workbook.
 

Product component
Identifier: 
NEHTA-2064:2016

This version of Conformance Test Specification provides clarifications for many of the test cases, improves the readability of the document, and adds a number of test cases to support recently published Pathology Report and Diagnostic Imaging Report conformance profiles.

Product component
Identifier: 
NEHTA-2336:2016

The FAQs are guidance material for implementation. They are to be used for clarification purposes and to support existing documentation.

Product component
Identifier: 
DH-2267:2017

This document provides usability recommendations for clinical information systems authoring or rendering information contained in clinical documents and views exchanged with the My Health Record system.

Product component
Identifier: 
DH-2481:2017

This document provides conformance requirements applicable to all types of clinical documents. This includes references to other documents containing additional normative content.

Product component
Identifier: 
DH-2564:2017

This release of the Common - Clinical Document end product provides developers of systems generating CDA documents with important updates of:

Product component
Identifier: 
DH-2565:2017

This update of the Template Package Directory contains entries for new or updated template packages for the following document types:

Product component
Identifier: 
DH-2587:2017

This release of Conformance Test Specification for Authoring Systems includes updates to feature sets, improves the readability of the document, and addresses multiple issues raised during internal agency reviews.

Product component
Identifier: 
DH-2594:2017

This document provides guidance for the correct inclusion of qualifiers for structured clinical information contained in CDA documents.

Release history

By operation of the Public Governance, Performance and Accountability (Establishing the Australian Digital Health Agency) Rule 2016, on 1 July 2016, all the assets and liabilities of NEHTA will vest in the Australian Digital Health Agency. In this website, on and from 1 July 2016, all references to "National E-Health Transition Authority" or "NEHTA" will be deemed to be references to the Australian Digital Health Agency. PCEHR means the My Health Record, formerly the "Personally Controlled Electronic Health Record", within the meaning of the My Health Records Act 2012 (Cth), formerly called the Personally Controlled Electronic Health Records Act 2012 (Cth).

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