# Use Cases - Clinical Note Document v26.0.0

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# Clinical Note Document

26.0.0
AU

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* [**Table of Contents**](toc.md)
* [**Guidance**](guidance.md)
* **Use Cases**

## Use Cases

This section outlines typical scenarios that lead to the creation of Clinical Note Documents. It aims to provide readers with context and background to help them understand the purpose, usage, and potential future applications of Clinical Note Documents.

This section is not exhaustive and does not include deviations or fringe examples but is provided to better position the reader on the potential application of Clinical Note Documents.

### Clinical Note Document created in the residential aged care home (RACH)

Dr Randal has an agreement to attend a RACH on a regular basis and consults with multiple residents there. On this occasion Dr Randal visits Mr Peterson for a routine consult. During the consultation, Dr Randal takes notes regarding Mr Peterson’s weight and blood pressure.

After finishing her rounds, Dr Randal enters the notes from the consultation into Mr Peterson’s electronic record in the RACH CIS.

Dr Randal needs to send the notes to her GP CIS. Dr Randal includes a narrative and selects an optional sub-type (e.g. summary note). Dr Randal then authors the Clinical Note Document on the RACH CIS and sends the authored Clinical Note Document to her GP CIS using existing point-to-point transfer mechanisms.

#### Structured Scenario

| | |
| :--- | :--- |
| Step 1 | Dr Randal completes a consultation with patient Mr Peterson and produces notes during the consult. |
| Step 2 | Dr Randal enters the notes into the RACH CIS. |
| Step 3 | Dr Randal selects an optional sub type. |
| Step 4 | Dr Randal authors the Clinical Note Document in the RACH CIS. |
| Step 5 | Dr Randal sends the authored Clinical Note Document to her GP CIS using existing point-to-point transfer mechanisms. |

Figure 1: Clinical Note Document created in the residential home
### Author Clinical Note Document with a PDF attachment in a GP CIS

Dr Randal has an agreement to attend a RACH on a regular basis. Dr Randal consults with multiple residents and has a routine consultation with Mr Peterson. During the consultation, Dr Randal takes notes regarding Mr Peterson’s weight and blood pressure.

After finishing her rounds, Dr Randal returns to her GP clinic and enters the notes from Mr Peterson’s consultation into her GP CIS.

Dr Randal needs to send the notes to the RACH CIS at Mr Peterson's RACH. Dr Randal authors the Clinical Note Document on the GP CIS and attaches a PDF, and then, using existing point-to-point transfer mechanisms, sends the authored Clinical Note Document to the RACH CIS.

#### Structured Scenario

| | |
| :--- | :--- |
| Step 1 | Dr Randal completes a consultation with patient Mr Peterson. |
| Step 2 | Dr Randal takes notes during the consultation. |
| Step 3 | Dr Randal enters the notes into her GP CIS. |
| Step 4 | Dr Randal authors the Clinical Note Document in her GP CIS. |
| Step 5 | Dr Randal attaches a PDF to the Clinical Note Document. |
| Step 6 | Dr Randal sends the authored Clinical Note Document (with PDF attachment) to the RACH CIS using existing point-to-point transfer mechanisms. |

Figure 2: Author Clinical Note Document with a PDF attachment in a GP CIS
### Clinical Note Document created and sent to multiple providers

Dr Randal visits the RACH and attends to Mr Peterson as part of a multidisciplinary care plan review. During the consultation, Dr Randal takes notes regarding Mr Peterson’s weight and blood pressure.

Dr Randal then enters the notes from Mr Peterson’s consultation into the RACH CIS.

Dr Randal needs to send the notes to her GP CIS and to Dr Smith as part of a multidisciplinary care plan. Dr Randal authors the Clinical Note Document on the RACH CIS. Then using existing point-to-point transfer mechanisms sends the authored Clinical Note Document to Dr Smith and her own GP CIS.

#### Structured Scenario

| | |
| :--- | :--- |
| Step 1 | Dr Randal completes a multidisciplinary care plan review with patient Mr Peterson. |
| Step 2 | Dr Randal takes notes during the consultation. |
| Step 3 | Dr Randal enters the notes into the RACH CIS. |
| Step 4 | Dr Randal authors the Clinical Note Document in the RACH CIS. |
| Step 5 | Dr Randal sends the authored Clinical Note Document to her clinic using existing point-to-point transfer mechanisms. |
| Step 6 | Dr Randal sends the authored Clinical Note Document to Dr Smith’s clinic using existing point-to-point transfer mechanisms. |

Figure 3: Clinical Note Document created and sent to multiple providers
### Clinical Note Document created for a patient transfer

Mr Peterson has a planned transfer from his current RACH to another RACH closer to where his daughter lives. Bill is a nurse at the RACH and is the responsible staff member on duty. He reviews the clinical information in the RACH CIS to send to Mr Peterson's new RACH. Bill includes Mr Peterson's recent clinical information and his strict dietary needs.

Bill authors the Clinical Note Document on the RACH CIS and attaches any relevant information associated with the transfer e.g. dietary requirements, medication charts and recent blood test results. Bill uses existing point-to-point transfer mechanisms to send the Clinical Note Document to the receiving RACH system. Bill also sends the authored Clinical Note Document to Mr Peterson’s usual GP.

#### Structured Scenario

| | |
| :--- | :--- |
| Step 1 | Mr Peterson has a planned transfer to another residential aged care organisation. |
| Step 2 | Bill, the responsible staff member on duty, reviews clinical information in the RACH CIS. |
| Step 3 | Bill authors the Clinical Note Document and attaches relevant information associated with the transfer. |
| Step 4 | Bill sends the authored Clinical Note Document and attachments to the receiving RACH CIS using existing point-to-point transfer mechanisms. |
| Step 5 | Bill sends the authored Clinical Note Document and attachments Mr Peterson’s usual GP using existing point-to-point transfer mechanisms. |

Figure 4: Clinical Note Document created for a patient transfer
### Clinical Note Document created for a telehealth consultation

Mr Peterson requires an after-hours consultation with a GP. The responsible staff member on duty facilitates a phone call with Dr George, an after-hours GP that Mr Peterson has not seen before. Mr Peterson attends a telehealth consultation with Dr George. During the consult, Dr George takes notes regarding Mr Peterson’s health.

Dr George enters the notes from Mr Peterson’s telehealth consultation into his GP CIS.

Dr George needs to send his notes to the RACH CIS and to Mr Peterson’s usual GP. Dr George authors the Clinical Note Document on the GP CIS then, using existing point-to-point transfer mechanisms, sends the authored Clinical Note Document to the RACH CIS and to Mr Peterson’s usual GP.

Bill is the responsible staff member on duty at the RACH and reviews the Clinical Note Document received from Dr George and feels confident in actioning documented instructions that confirm those discussed in the telehealth consultation.

#### Structured Scenario

| | |
| :--- | :--- |
| Step 1 | Dr George completes an after-hours phone consultation with Mr Peterson. |
| Step 2 | Dr George takes notes during the consultation. |
| Step 3 | Dr George enters the notes into his GP CIS. |
| Step 4 | Dr George authors the Clinical Note Document in his GP CIS. |
| Step 5 | Dr George sends the authored Clinical Note Document to the RACH CIS and Mr Peterson’s usual GP using existing point-to-point transfer mechanisms. |
| Step 6 | Bill, the responsible staff member on duty at the RACH, reviews and actions the Clinical Note Document received. |

Figure 5: Clinical Note Document created for a telehealth consultation

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IG © 2026+ [Australian Digital Health Agency](https://www.digitalhealth.gov.au). Package au.gov.digitalhealth.cnd#26.0.0 based on [FHIR 4.0.1](http://hl7.org/fhir/R4/). Generated 2026-06-19

Links: [Table of Contents](toc.md) | [QA Report](qa.md) | [Version History](https://fhir.digitalhealth.gov.au/dh/history.html) | [Report an issue or propose a change](mailto:help@digitalhealth.gov.au) 

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