CDA Documents

Creating Event Summaries in v3.15 Creating an Event Summary Running Time: 03:18

Creating Shared Health Summaries in v3.15 Creating Shared Health Summaries in v3.15 Running Time: 03:38

Clinical Document Architecture is an XML-based markup standard for specifying the encoding, structure and semantics of clinical documents for exchange. CDA-based documents are saved to the Letters tab of a patient's clinical record, along with other correspondence such as letters. When you open a CDA document, it is opened in the CDA Viewer.

Content Used for CDA Documentation:

Core Components CDA Documents
Shared Health Summary Event Summary Specialist Letter e-Referral
Individual (patient details) Mandatory Mandatory Mandatory Mandatory
Author Details Mandatory Mandatory Mandatory Mandatory
Allergies Conditional Optional Conditional Conditional
Medications Conditional Optional Conditional Conditional
Medical History Conditional N/A Conditional Conditional
Immunisations Conditional Optional N/A N/A
Encounter Details (start and end date) N/A Mandatory N/A N/A
Event Details N/A Optional N/A N/A
Diagnoses/ Interventions

(sub components : problem/ diagnoses, procedure, medical history item)

 N/A Optional Conditional Conditional
Diagnostic Investigations

(sub components : pathology test results, requested services)

 N/A Optional Conditional Conditional
Outstanding requests N/A N/A Conditional Conditional
Recommendations N/A N/A Conditional N/A
Narrative (free text from the author) N/A Optional Mandatory Mandatory
Validity Period N/A N/A N/A Optional

Mandatory: The component labeled 'Mandatory' must be completed to send the letter.

Conditional: The component labeled 'Conditional' will be auto-populated if there is relevant data present in the patient's record ,if not an exclusion statement will be provided against the component as to why the data is not available. Also, the user has an option to delete individual line items from each component.

Optional: The component labeled 'Optional' can be left blank.

N/A: This component is not available for the document.