About CDA Documents

CDA Documents

See also:

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.

&lt;p&gt;&amp;#160;&lt;/p&gt;