Clinical User Guide
CDA Documents

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

Event Summary

Specialist Letter

e-Referral

Individual
(patient details)

Author Details

Allergies

Medications

Medical History

Immunisations

Encounter Details
(start and end date)

Event Details

Diagnoses/ Interventions

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

Diagnostic Investigations

(sub components : pathology test results, requested services)

Outstanding requests

Recommendations

Narrative
(free text from the author)

Validity Period

 

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.